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 2 nd and 6 th 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. 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. 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 vs Atraumatic 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—1 st 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

15. Rehabilitation Dynamic ligament tension—2 nd 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—3 rd 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 Latissimus Dorsi  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 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

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 atraumatic subluxation 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