OBJECTIVES. Therapists Management of Shoulder Instability SHOULDER STABILITY SHOULDER STABILITY WHAT IS SHOULDER INSTABILITY? SHOULDER INSTABILITY

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Brittney Lucas
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1 Therapists Management of Shoulder Instability Brian G. Leggin, PT, DPT, OCS Lead Therapist, Penn Therapy and Fitness at Valley Forge Adjunct Assistant Professor, Department of Orthopaedics, University of Pennsylvania, Perelman School of Medicine OBJECTIVES Brief overview of shoulder stability and instability Non-operative management of various forms of instability Post-operative management following surgical stabilization SHOULDER STABILITY SHOULDER STABILITY Static Stabilizers Bony configuration Cartilage Capsule Ligaments Dynamic Stabilizers Musculature around shoulder Kinetic Chain Scapula Trunk Lower Extremities Extreme ranges of motion: Capsuloligamentous structures taut (static stabilizers) Mid ranges of motion: Static stabilizers not taut dynamic stabilizers, articular surfaces, labrum, intra-articular pressure provide stability WHAT IS SHOULDER INSTABILITY? Spectrum of disorders including: Laxity Normal motion necessary for function Subluxation Partial dislocation Dislocation Abnormal symptomatic translation of humeral head relative to the glenoid Often requiring reduction to restore normal alignment Traumatic TUBS (Traumatic, Unidirectional, Bankart Lesion, Surgery) Atraumatic AMBRI (Atraumatic, Multidirectional, Bilateral, Rehabilitation, Inferior Capsular Shift) Congenital Born Loose or Torn Loose Brian G. Leggin, PT, DPT, OCS 1

TRAUMATIC INSTABILITY Recurrence Rates Result of high-velocity uncontrolled end range

40 = 94% recurrence rate 79% recurrence rate 50% recurrence rate 14% recurrence rate

$recurrence rate Osseous Defects/Deficiency Humeral Side Impression fracture (Hill-Sachs$ (hypoplastic glenoid) Hill-Sachs lesions Common problem Recurrent instability-100% 1 o

(hypoplastic glenoid) Hill-Sachs lesions Common problem Recurrent instability-100% 1 o

25 35 years old < 25 up to 3 weeks with sling Passive range of motion to promote

strengthening at 6 weeks 1 3 weeks sling Passive range of motion Restrict to waist

2 TRAUMATIC INSTABILITY Recurrence Rates Result of high-velocity uncontrolled end range force Traditionally in abduction/er 85-95% are anterior Rowe < 20 = = = > 40 = 94% recurrence rate 79% recurrence rate 50% recurrence rate 14% recurrence rate % Bankart lesion Method or length of immobilization has little effect on recurrence rate Osseous Defects/Deficiency Humeral Side Impression fracture (Hill-Sachs lesion) Humeral version Glenoid Side Bone loss Boney Bankart or compression Congenital (hypoplastic glenoid) Hill-Sachs lesions Common problem Recurrent instability-100% 1 o Anterior instability-80% Anterior shoulder subluxation- 25% What should we do? years old < 25 up to 3 weeks with sling Passive range of motion to promote functional healing Restrict to waist level activities Rotator cuff, deltoid, scapular strengthening at 6 weeks 1 3 weeks sling Passive range of motion Restrict to waist level activities Begin rotator cuff strengthening at 4 weeks Outcome depends on activity level Brian G. Leggin, PT, DPT, OCS 2

> 35 years old Role of Exercise Sling for comfort Look for signs of rotator cuff tear Early range of motion exercises Rotator cuff,

shoulders in 115 patients with traumatic and atraumatic instability Treated with rotator cuff & deltoid strengthening exercises

Results 12 of 74 (16%) shoulders with traumatic instability good/excellent 53 of 66 (80%) shoulders with atraumatic instability

anterior instability Atraumatic Instability Laxity at multiple joints Ehrlos Danlos?

3 > 35 years old Role of Exercise Sling for comfort Look for signs of rotator cuff tear Early range of motion exercises Rotator cuff, deltoid, scapular muscle strengthening Allow gradual return to activity Recommend modifications Burkhead & Rockwood JBJS shoulders in 115 patients with traumatic and atraumatic instability Treated with rotator cuff & deltoid strengthening exercises Followed patients at six to eight week intervals until better or surgery Average rehabilitation time = 14 weeks Burkhead & Rockwood Results 12 of 74 (16%) shoulders with traumatic instability good/excellent 53 of 66 (80%) shoulders with atraumatic instability good/excellent 29 of 33 (88%) shoulders with multidirectional instability good/excellent Posterior instability patients did better than anterior instability Atraumatic Instability Laxity at multiple joints Ehrlos Danlos? PRESENTATION Atraumatic Instability Improve dynamic stability and control Rotator cuff and scapular muscle strength Gradually work into functional positions Deltoid, biceps, triceps Brian G. Leggin, PT, DPT, OCS 3

4 Rotator Cuff Strength MANUAL RESISTANCE Phase I ER IR Extension PHASE II MANUAL RESISTANCE Begin when at GREEN for all Phase I exercises Abduction to 60º Forward elevation ER at 45º supported PHASE I SCAPULAR MUSCLE FOREHAND BACKHAND Brian G. Leggin, PT, DPT, OCS 4

5 Phase II SCAPULAR MUSCLE SCAPULAR MUSCLE PHASE III PHASE III - IV PHASE III 45 Brian G. Leggin, PT, DPT, OCS 5

6 PHASE III - IV PHASE III - IV Kinetic Chain Evaluation KINETIC CHAIN EXERCISES KINETIC CHAIN EXERCISES FUNCTIONAL SCAPULAR Brian G. Leggin, PT, DPT, OCS 6

REHABILITATION FOLLOWING ARTHROSCOPIC INSTABILITY REPAIR The

Rehabilitation Guideline Gaunt et al, JOSPT, March 2010

stabilization No subscap repair Motion returns sooner Need

Educate patient Sling immobilization (surgeon preference)

Control pain and inflammation Initiate AAROM/PROM Phase I FE

full PROM FE Add Phase II ROM Begin rotator cuff

7 REHABILITATION FOLLOWING ARTHROSCOPIC INSTABILITY REPAIR The American Society of Shoulder & Elbow Therapists Consensus Rehabilitation Guideline Gaunt et al, JOSPT, March 2010 POST-OP INSTABILITY REHAB First 6 Weeks Arthroscopic stabilization No subscap repair Motion returns sooner Need to protect repair Respect ER ROM Emphasize dynamic stability Educate patient Sling immobilization (surgeon preference) Permit healing of capsuloligamentous complex and labrum Control pain and inflammation Initiate AAROM/PROM Phase I FE and ER ER below 45º 6 12 Weeks 6 12 Weeks Gradual return to full PROM FE Add Phase II ROM Begin rotator cuff strengthening and integrate scapula Phase I strengthening ER, IR, Ext. Manual resistance Start in supported position Alternating isometric (ER/IR) Gradually progress to unsupported positions Brian G. Leggin, PT, DPT, OCS 7

Rotator Cuff Strength PHASE II Phase I ER IR Extension Begin when at GREEN for

Beyond 12-16 Weeks FOREHAND Increase strength of rotator cuff & deltoid in

scapular muscle strength Total arm strengthening Increase endurance Gradual

8 Rotator Cuff Strength PHASE II Phase I ER IR Extension Begin when at GREEN for all Phase I exercises Abduction to 60º Forward elevation ER at 45º supported Beyond Weeks FOREHAND Increase strength of rotator cuff & deltoid in functional positions Manual resistance in functional positions Increase scapular muscle strength Total arm strengthening Increase endurance Gradual return to sporting activities BACKHAND Phase II SCAPULAR MUSCLE Brian G. Leggin, PT, DPT, OCS 8

9 SUMMARY Arthroscopic Instability Repair Rehab Arthroscopic repair needs protection Go slow regaining ROM Progress strengthening exercises into stress positions slowly THANK YOU!! Brian G. Leggin, PT, DPT, OCS 9

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