SHOULDER DISLOCATION & INSTABILITY Rehabilitation Considerations

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1 SHOULDER DISLOCATION & INSTABILITY Rehabilitation Considerations Meagan Pehnke, MS, OTR/L, CHT, CLT March 1 st, 2019 Philadelphia Surgery & Rehabilitation of the Hand: Pediatric Pre-course

2 OUTLINE Discuss concepts of shoulder stability Discuss general rehabilitation guidelines for: Non-operative multi-directional instability Post-operative Bankart lesion repair Application of principles to general pediatric population 2

3 WHAT IS SHOULDER STABILITY? Glenohumeral joint stabilization = complex interaction: 1. Static stabilizers: glenoid, labrum, cartilage, glenohumeral ligaments, negative intra-articular pressure 2. Dynamic stabilizers: rotator cuff, long head of biceps tendon, periscapular Proprioception ST control Strength GH control 3

4 Shoulder Pathology: Algorithm AMBRII Atraumatic Multidirectional Bilateral Rehabilitation Inferior capsular shift Rotator interval TUBS Traumatic Unidirectional Bankart lesion Surgery 4

5 5 NON-OPERATIVE REHABILITATION: SHOULDER MULTI DIRECTIONAL INSTABILITY

6 GOAL OF REHABILITATION Retrain static stabilizers Strengthen and retrain dynamic stabilizers Improve active control of shoulder 6

7 EVALUATION KEY POINTS Understand direction of instability Guarding & apprehension Posture & asymmetries Scapula, shoulder, pelvic & UE position Strength- influence of posture Hypermobility- Beighton scale 7

8 GOALS OF REHAB PROGRAM Restore confidence in movement Scapula and glenohumeral control- static stabilizers Maintain scapular and humeral head control through all stages Strengthen dynamic stabilizers Normalize kinematics, motor control and proprioception 8

9 KEY CONSIDERATIONS Initial focus is NOT rotator cuff or deltoid strengthening Sequence of progression 1. Stability and control of ST & GH Carry over throughout progression 2. Initiation dynamic activities Proprioception important for healthy movement Slow progression Non-provocative -> overhead Symptom free current exercise Scapula/GH control with isometric hold new position 9

10 STAGES OF STRENGTHENING Step 1 Scapula and glenohumeral control Step 2 Posterior musculature- periscapular & rotator cuff Step 3* Progress glenohumeral elevation Isolated deltoid strengthening Step 4 Functional/ sports specific exercise Part & whole practice function & sport participation 10 *Must maintain scapula and HH control to progress >step 2

11 STEP 1: SCAPULA AND GLENOHUMERAL CONTROL Normalize arthrokinematics of GH & ST Humeral head centering, neutral position Restore confidence in movement Avoid provocative positions Supine -> upright Supported ROM Body mechanics, posture & UE alignment 11

12 12 Shoulder suction : contract agonist & antagonist, find neutral position (supine -> upright)

13 STEP 2: POSTERIOR MUSCULATURE Shoulder girdle strength & control Humeral head centering Avoid excessive deltoid contribution Posterior musculature Rotator cuff Periscapular Isometric & closed chain Rhythmic stabilization, manual resistance 13

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15 STEP 3: ELEVATION & ISOLATED DELTOID Criteria: must demonstrate ST & GH control Motor control training Scapulohumeral rhythm Dynamic strengthening: Progressive ROM Isolated deltoid strengthening Isotonic & open chain Demonstrate control in elevation: <90 degrees At shoulder level >90 degrees 15

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17 STEP 4: FUNCTIONAL & SPORTS SPECIFIC EXERCISE Optimize proprioception, coordination & dynamic stabilization Posture, scapular, glenohumeral Functional activities & sports specific training Part & whole practice Integrate trunk stability and kinetic chain Open chain plyometrics 17

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19 19 POST-OPERATIVE REHABILITATION: BANKART LESION

20 BANKART LESION REPAIR Anterior/inferior glenoid labrum tear secondary to anterior dislocation 20 Thompson, J. C., & Netter, F. H. (2010). Netter's concise orthopaedic anatomy. Philadelphia, PA: Saunders Elsevier.

21 PRECAUTIONS GUIDELINE Understand details of operation ROM progression- tissue quality Associated injuries Congenital laxity Inflammation 21

22 PHASE SUMMARY Phase I 0-6 weeks Phase II 7-12 weeks Phase III weeks Phase IV 16+ weeks Home program Controlled ROM, basic scapular training Progress ROM Scapular stabilization & proprioception Progress to functional, overhead activities Scapulohumeral rhythm Maximize strength & endurance Return to sports 22

23 PHASE I: 0-6 WEEKS Sling immobilization 4-6 weeks Capsule-ligamentous-labral healing Intervention goals: Minimize effects of immobilization Control post-op pain and inflammation Use of ice as needed 23

24 INTERVENTION No formal therapy Home exercise program: Pendulums Basic scapular training Scapular retractions Elbow and wrist ROM Gentle grip strengthening 24

25 PHASE 2: 7-12 WEEKS Initiate formal therapy program Intervention goals: Normalize arthrokinematics of GH & ST joints Full shoulder ROM by week 10 Improve shoulder girdle strength and proprioception Decrease pain and inflammation 25

Thrower s Ten Non-provocative proprioceptive neuromuscular facilitation Scapular and UE patterns Rhythmic

26 INTERVENTION Scapular stabilization Shoulder ROM (gradually work towards ER at 90 to 90 ; Forward Elevation to 180 ) Progressive resistance shoulder strengthening Non-provocative positions -> provocative positions by weeks Thrower s Ten Non-provocative proprioceptive neuromuscular facilitation Scapular and UE patterns Rhythmic Stabilization LB & core strengthening Week 10: Full weight-bearing/closed kinetic chain Non-provocative double-arm open chain plyometrics 26

27 PHASE 3: WEEKS Full Shoulder A/PROM Without compensation or apprehension Normalize scapulohumeral rhythm Improve muscular strength and endurance Initiation of functional activities & return to sports 27

28 INTERVENTION Single-arm open chain plyometrics Sport specific drills Strengthening: ER/IR at 90 abduction Functional and overhead Criteria to initiate

28 28 INTERVENTION Single-arm open chain plyometrics Sport specific drills Strengthening: ER/IR at 90 abduction Functional and overhead Criteria to initiate interval throwing program: Normal arthrokinematics of GH and ST joint Symmetrical total arc of rotational motion +clinical exam Strength >90% contralateral side

29 PHASE 4: 16+ WEEKS Gradual return to full unrestricted sport activities Maintain ROM, stability and neuromuscular control Achieve maximal strength and endurance Intervention, continue to address: ROM deficits Upper quadrant strength, endurance and control 29

30 CRITERIA TO DISCHARGE FOR RETURN TO FULL SPORT ACTIVITIES Normal arthrokinematics of GH and ST joint Symmetrical total arc of rotational motion Satisfactory clinical exam and negative impingement testing Strength testing >90% contralateral side Subjective scoring (Penn Shoulder Score >90 points)(dash<15) Completion of both interval and positional specific throwing program 30

31 APPLICATION TO PEDIATRICS Laxity does not indicate instability Consider functional impact of generalized joint hypermobility Important to assess Static vs dynamic stability Posture and UE position Asymmetries Compensations Incorporate appropriate functional strength and stability activities Teach neutral position, emphasis on improving posture and alignment Address body mechanics Proprioceptive awareness Muscle co-contractions due to weak musculature/laxity Normalize movement 31

32 REFERENCES Bateman, M., Jaiswal, A., Tambe, A. A. (2018). Diagnosis and management of atraumatic shoulder instability. Journal of Arthroscopy and Joint Surgery, 5, Brogan, K., Baxter, J. A., Tennent, D. (2018). Managing patients with shoulder instability. Orthopaedics and Trauma, 32(3), D Addesi, L. L, Dantuluri, P. K. Shoulder Instability. In: Skirven, T. M., Osterman, A. L., Fedorczyk, J.M., Amadio, P.C., eds. Rehabilitation of the Hand and Upper Extremity. Vol 6. Philadelphia, PA: Elsevier Mosby; 2011: Leggin, B. G., Gaunt, B. W., Shaffer, M. A. Rehabilitation of Shoulder Instability. In: Skirven, T. M., Osterman, A. L., Fedorczyk, J.M., Amadio, P.C., eds. Rehabilitation of the Hand and Upper Extremity. Vol 6. Philadelphia, PA: Elsevier Mosby; 2011: Warby, S. A., Watson, L., Ford, J. J., Pizzari, T. (2017). Multidirectional instability of the glenohumeral joint: Etiology, classification, assessment, and management. Journal of Hand Therapy, 30, Watson, L., Balster, S., Lenssen, R., Hoy, G., Pizzari, T. (2017). The effects of a conservative rehabilitation program for multidirectional instability of the shoulder. Journal of Shoulder and Elbow Surgery, 27, Watson, L., Warby, S., Balster, S., Lenssen, R., & Pizzari, T. (2016). The treatment of multidirectional instability of the shoulder with a rehabilitation program: Part 1. Shoulder & Elbow, 8(4), Watson, L., Warby, S., Balster, S., Lenssen, R., & Pizzari, T. (2017). The treatment of multidirectional instability of the shoulder with a rehabilitation programme: Part 2. Shoulder & Elbow, 9(1),

33 33 THANK YOU!

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

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