Rehab of the Unstable Shoulder

1. Rehab of the Unstable Shoulder Chris Sawyer, PT Children’s Mercy Hospital

2. Epidemiology • Shoulder is a joint evolved for mobility • Instability is usually defined as a clinical syndrome that occurs when laxity produces symptoms • Dislocation & subluxation of GH joint occurs relatively frequently in athletes

3. Epidemiology • Rowe found a bimodal distribution of shoulder dislocation with peaks in the 2nd and 6th decades with 98% of those cases being anterior dislocations • Hovelius found traumatic injury to be the most common cause of shoulder instability, accounting for 95% of anterior dislocations

4. Epidemiology • Rowe found that 70% of those that experience a dislocation can expect a recurrent dislocation within 2 years of the initial injury • Recurrence is highly age-dependent • In patients younger than 20 years of age, recurrent dislocations rates have been reported as high as 90% in the athletic population

5. Anatomical Considerations

6. Anatomical Considerations Middle glenohumeral ligament • Primarily effective at 45° abduction • Helps limit external rotation, inferior and anterior humeral tranlsation. Superior glenohumeral ligament • Plays minor role in preventing anterior instability • Primarily limits inferior translation and external rotation of the adducted arm

7. Anatomical Considerations Inferior glenohumeral ligament • Heavily involved in maintaining shoulder stability • With an anterior and posterior band, it supports the humeral head like a hammock • Primary stabilizer limiting anterior, posterior & inferior humeral translation at 90° abduction • Detachment of anterior band from glenoid and labrum is known as the Bankart Lesion.

8. Anatomical Considerations

9. Anatomical Considerations Rotator Cuff • EMG Studies show that all (with deltoid) are active throughout full ROM of flexion, abduction and elevation • Co-contraction helps hold humeral head in center of glenoid throughout arc of motion • Create GH compressive force that helps stabilize joint

10. Anatomical Considerations • Scapulothoracic stability has been emphasized as an important component of GH stability. • Dysfunction can lead to failure of scapular rotation beneath the humeral head, permitting abnormal translation • Trapezius, serratus anterior and rhomboids all influence scapular movements

11. Patient Evaluation • History • Traumatic vsAtraumatic dislocation • Symptoms • General laxity • Party Trick?

12. Patient Evaluation • Physical Exam • Muscle atrophy and scapular winging • ROM assessment • Special tests • Sulcus Sign • Load and Shift • Apprehension Test

13. Rehabilitation • No scientific studies available to support one specific rehab regimen in preference to another • Key to pain-free shoulder function for sporting activities is functional stability or a balance between stabilizers of the shoulder and forces applied to the shoulder • Rehab should aim to optimize the performance of the dynamic stabilizers

14. Rehabilitation • Dynamic compression—1st mechanism of functional stability • Sub-scapularis co-contracts with infraspinatus and teres minor to center and compress humeral head into glenoidfossa • Interior fibers of rotator cuff co-contract with anterior deltoid to help keep head centered in fossa

15. Rehabilitation • Dynamic ligament tension—2nd mechanism of functional stability • Rotator cuff tendons blend with shoulder capsule at their point of insertion and serve to tighten capsule on contraction • Reactive neuromuscular control—3rd mechanism of functional stability • Involves exercising the unstable shoulder in positions that maximally challenge dynamic stabilizers---Plyometrics helps to retrain neuromuscular control

16. Rehabilitation • Provision of stable platform under humeral head requires the scapula and humerus to move in synchrony and allows orientation of glenoid to adjust in responses to changes in arm position • Trapezius and serratus anterior contribute to 2 importan force couples that produce scapular elevation

17. Exercises • Subscapularis • Internal rotation activities • Isometric against wall, sidelying, prone, standing • Infraspinatus • External rotation activities • Isometric against wall, sidelying, prone, standing • Teres Minor • External rotation activities • Isometric against wall, sidelying, prone, standing

18. Exercises • Anterior deltoid • Forward flexion exercises • Supine, prone, standing forward flexion-thumb up • Push ups---wall, counter, floor • Serratus Anterior • Serratus punches, push up plus, rows • LatissimusDorsi • Lat pulls, seated press ups • Rhomboids • Rows, scap squeezes, standing horizontal abd

19. Exercises • “Other” strengthening ex’s • PNF patterns---active-assisted, wall wash, t-band • Ceiling swiss ball walks • Ball walk outs • Shoulder geometry, alphabets • Standing abduction with forearms pressed against wall

20. Evidenced Based Practice • Postacchini et al • 92% rate of recurrence with a mean of 7 re-dislocations in patients who had a traumatic dislocation at the age of 14-17 • 86% rate of recurrence with a mean of 2.3 re-dislocations in patients who had an atraumatic dislocation between 14-16 • Bankart lesion found in 80% of cases—each of these patients had a tramautic primary dislocation at the age of 14-17

21. Evidenced Based Practice • Postacchini et al (cont) • 7/28 patients had surgery (5 traumatic, 2 atraumatic)—all 5 traumatic dislocators reported no issues of recurrence and had stable shoulder on exam, both atraumaticdislocators continued to have recurrence issues and were unstable on exam • 21/28 did not have surgery---all reported issues with recurrence and/or had clinical signs indicating anterior or multidirectional instability

22. Evidenced Based Practice • Burkhead et al • 140 shoulders in 115 patients that had a dx of traumatic or atraumatic recurrent anterior, posterior or multidirectional instability were treated with specific set of strengthening exercises • 12/74 (16%) that had traumatic subluxation had good or excellent results from exercise regimen • 53/66 (80%) that had atraumaticsubluxation had good or excellent results with exercise regimen

23. Evidenced Based Practice • Hovelius et al & DeBerardino et al • 300 patients with anterior dislocations who did not have surgery • Follow up 8-10 years after initial dislocation • 55% rate of recurrence • Combo of multiple studies from 1996-2000 • 120 patients with anterior dislocations who undwent open bankart repair • Follow up 2.5-12 years after initial dislocation • 6% rate of recurrence

24. References • Bahu, M., Trentacosta, N., Vorys, G., Covey, A., Ahmad, C.: Multidirectional Instability: Evaluation and Treatment Options. Clinics in Sports Med., 27: 671-689, Oct. 2008 • Bonci, C., Sloan, B., Middleton, K.: Nonsurgical/Surgical Rehabiliation of the Unstable Shoulder. Journal of Sport Rehabilitation. 1:146-171. 1992 • Burkhead, W., Rockwood, C.: Treatment of Instability of The Shoulder with an Exercise Program. Journal of Bone and Joint Surgery. 74A: 890-896. 1992 • Dodson, C., Cordasco, F.: Anterior Glenohumeral Joint Dislocations. Orthopedic Clin N AM. 39: 507-518. 2008

25. References • Mallon, W., Speer, K.: Multidirectional Instability: Current Concepts. Journal of Shoulder and Elbow Surgery. 4: 54-64. 1995. • Postacchini, F., Gumina, S., Cinotti, G.: Anterior Shoulder Dislocation in Adolescents. Journal of Shoulder and Elbow Surgery. 9: 470-474. 2000. • Walton, J., Paxinos, A., Tzannes, A., Callanan, M., Hayes, K., Murrell, G.: The Unstable Shoulder in the Adolescent Athlete. The American Journal of Sports Medicine. 30:758-767. 2002 • Wang, R., Arciero, R.: Treating the Athlete with Anterior Shoulder Instability. Clinical Sports Medicine. 27: 631-648. 2008