Rehab of the Unstable Shoulder
Chris Sawyer, PT
Children’s Mercy Hospital
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
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
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
Anatomical Considerations
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
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.
Anatomical Considerations
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
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
Patient Evaluation
• History
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Traumatic vs Atraumatic dislocation
Symptoms
General laxity
Party Trick?
Patient Evaluation
• Physical Exam
▫ Muscle atrophy and scapular winging
▫ ROM assessment
▫ Special tests
 Sulcus Sign
 Load and Shift
 Apprehension Test
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
Rehabilitation
• Dynamic compression—1st mechanism of
functional stability
▫ Sub-scapularis co-contracts with infraspinatus
and teres minor to center and compress humeral
head into glenoid fossa
▫ Interior fibers of rotator cuff co-contract with
anterior deltoid to help keep head centered in
fossa
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
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
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
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
• Latissimus Dorsi
 Lat pulls, seated press ups
• Rhomboids
 Rows, scap squeezes, standing horizontal abd
Exercises
• “Other” strengthening ex’s
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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
Evidenced Based Practice
• Postacchini et al
▫ 92% rate of recurrence with a mean of 7 redislocations in patients who had a traumatic
dislocation at the age of 14-17
▫ 86% rate of recurrence with a mean of 2.3 redislocations 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
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 atraumatic dislocators 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
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 atraumatic subluxation had
good or excellent results with exercise regimen
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
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
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: 631648. 2008