PATIENTGUIDETOSHOULDERINSTABILTY

What is shoulder instability ?

Shoulder instability is a cause of shoulder pain.The shoulder can dislocate(the ball comes completely out of the socket) or sub-luxate(the ball comes partially out of the socket).Shoulder instability is a result of damage to the shoulder labrum that help keep the ball within the socket.

How does shoulder instabilityoccur?

Many times,the labrum(where the shoulder ligaments attach) which acts as a restraint tears from single violent injury such as football tackle or a motor vehicle accident. However, they can also be stretched from repeated strenuous use.

Is thereotherdamageto shoulder incaseofin stability?

The labrum (where the shoulder ligaments attach) is usually torn in cases of shoulder instability.This is known as Bankart’slesion. In addition,there are sometimes fractures of the ball or socket of the shoulder, known as Hill-sachslesion. Rarely,there is also a rotator cuff tear in cases of instability.

What are the treatment options for shoulder instability?

The treatment primarily depends on the patients’s age ,activity level ,and number of dislocations of the shoulder. For patients who first dislocated their shoulder, can commonly be treated in a sling with early rehabilitation.However, patients with repeated episodes of instability, the usual treatment is surgery to fix the torn labrum.

How is the shoulder instability treated with surgery?

Shoulder instability is usually repaired with arthroscopic techniques .The arthroscope is a small fiber optic instrument that is placed into the joint through a small incision. A camera is attached to the arthroscope and the image is viewed on a TV monitor.The arthroscope allows a complete evaluation the entire shoulder joint,including the ligaments, the rotator cuff, and the cartilage surface. Small instruments ranging from 3-5 mm in size are inserted through additional small incisions so that any injury can be diagnosed, and damaged tissue can be repaired reconstructed or removed. The damaged labrum and ligaments are identified and then repaired back to the socket using suture anchors to sew the ligaments back in place.in most cases, bio-absorbable anchor is used.

What are some of the possible complications?

  • Stiffness of the shoulder after surgery
  • Recurrent instability
  • Infection
  • Bleeding
  • Nerve damage

The use of arthroscopic techniques attempts to limit these complications.

REHABILITATION

Post-operative rehabilitation is essential after arthroscopic shoulder repair. The initial phase will focus on protection and progressive range of motion exercises to ensure proper healing of the repaired anatomical structures. This will be followed by several phases focused on restoring and enhancing the strength and function of the rotator cuff and scapular muscles.

PHASE I(0-4 WEEKS)

The rehabilitation guidelines below are presented in a criterion based progression.

PHASE I(0-6 WEEKS POST SURGERY)

Rehabilitation goals

  • Protect the post-surgical shoulder
  • Activate the stabilizing muscles of the gleno-humeral and scapula-thoracic joints
  • Full active and passive range of motion for shoulder flexion,abduction,internal rotation and external rotation to neutral.

Precautions

  • Sling immobilization required for soft tissue healing for 3-4 weeks.
  • No shoulder external rotation with abduction for 6 weeks to protect repaired tissues.
  • Full active and passive range of motion for shoulder flexion,abduction,internal rotation and external rotation to neutral.

Suggested therapeutic exercises

  • Beginweek3,sub maximal shoulder isometrics .
  • Active assisted to passive ROM for shoulder flexion,abduction,internal rotation and external rotation to neutral,progressing to active ROM at week 5..
  • Hand gripping.
  • Elbow, forearm and wrist active ROM
  • Postural exercises.

Progression criteria

  • Full active ROM in all cardinal planes. 5/5 rotators strength at 0` shoulder abduction.

PHASE II (begin after meeting phase I criteria,usually after 6 weeks of surgery)

Rehabilitation goals

  • Full shoulder active ROM in all cardinal planes.
  • Progress shoulder external rotation ROM gradually to prevent overstressing the repaired anterior tissues of the shoulder.
  • Strengthen shoulder and scapular stabilizers in protected positions(0-45`).

Precautions

  • Avoidpassive and forceful movements into shoulder external rotation,extension and horizontal abduction.

Suggested therapeutic exercises

  • Active assisted and active ROM in all cardinal planes-assessing scapular rhythm.
  • Gentle shoulder mobilizations as needed.
  • Rotator cuff strengthening in non-provocative positions.
  • Scapular strengthening and dynamic neuromuscular control.
  • Cervical spine and scapular ROM.
  • Postural exercises.
  • Core strengthening .

Precautions

  • Full shoulder active ROM
  • 5/5 shoulder internal and external rotator strength at 45’ abduction

PHASE III (begin after meeting phase II criteria,usually 10-11 weeks after surgery)

Rehabilitation goals

  • Full shoulder active ROM in all cardinal planes with normal scapula humeral movements
  • 5/5 rotator cuff strength at 90 abduction in the scapular plane.

Precautions

  • All exercise and activities to remain non provocative and low to medium velocity.
  • Avoid activities where there is a higher risk of falling or outside forces to be applied to the arm.
  • No swimming,throwing or sports.

Suggestedtherapeuticexercises

  • Posterior glides if posterior capsule is tight
  • Flexion and horizontal abduction in prone and full can exercises.
  • Theraband,dumbbell (light resistance/high rep)internal and external rotation in 90 abduction and rowing.

Progression criteria

  • When all the above mentioned goals are met with no signs of impingement and apprehension.

PHASE V (usually after 20 weeks of surgery)

Rehabilitation goals

  • Patient to demonstrate stability with higher velocity movements and change of direction movements that replicate sport specific patterns.
  • No apprehension or instability with high velocity overhead movements.
  • Work capacity cardiovascular endurance for specific sport or work demands.

Precautions

  • Progress gradually into sport specific movement patterns.

Suggested therapeutic exercises

  • Initiate sport specific programs depending on the athlete’s sport.
  • High velocity strengthening and dynamic control,such as inertial,plyometrics,rapid theraband drills.

Suggested therapeutic exercises

  • Patient may return to sport after receiving clearance from the orthopedic surgeon and physiotherapist.