Physical Therapy Management in Shoulder

Instabilities
The term ‘shoulder instability’ is used to refer to the inability to maintain
the humeral head in the glenoid fossa.

Shoulder instability is a lack of control of the glenohumeral joint that can

occur from several causes such as :

(1) Static Stabilizers (ligament, capsule, non contractile tissues)

(2) Dynamic stabilizers (Muscle tendon unit)

(3) Sensorimotor system (joint mechanoreceptors, proprioception,

kinaesthesia, joint position sense.

Shoulder instability is typically described in relation to the direction of

the instability event: anterior, posterior, and multidirectional.

Anterior instability

 It is the most common manifestation of unidirectional instability,

comprising more than 90% of shoulder dislocations.
 This type of injury most commonly occurs as the result of a one-
time traumatic episode to a shoulder in a vulnerable position of
combined abduction and external rotation.
 The injury may involve an avulsion of the anteroinferior labrum
from the glenoid, commonly referred to as the Bankart lesion.
Occasionally a fragment of the underlying glenoid rim also may
be fractured off; this lesion is referred to as a bony Bankart lesion.
 Other lesions can also present with symptoms of anterior
instability, including subscapularis tears, humeral avulsions of the
glenohumeral ligament (HAGL), superior labrum anterior to
posterior (SLAP) injuries, and rotator interval lesions.

Posterior Instability

 It is far less common than anterior instability, accounting for 2% to

10% of shoulder dislocations.
  Posterior dislocations are often associated with axial loads applied
to the adducted arm and are classically associated with
electrocution and seizures.
 Structural changes associated with posterior instability include
avulsions of the posterior labrum (a reverse Bankart lesion), which
may be associated with a posterior glenoid rim fracture.
 Injuries to the SGHL, the posterior band of the IGHL, the
subscapularis muscle, and the coracohumeral ligament (CHL) can
also be seen in posterior instability.
 The most common form of posterior instability is recurrent
posterior instability, usually resulting in a posterior labral tear and
postero-inferior capsular stretch resulting from repetitive loading
with the arm in flexion and internal rotation (i.e., the bench press
exercise).

Multidirectional instability (MDI)

 It is not typically associated with traumatic episodes. Instead, the

primary dysfunction here involves either congenital or acquired
capsuloligamentous laxity.
 Presenting pathology typically consists of symptomatic, abnormal
humeral head translation in more than one direction, which
may include recurrent subluxations or even dislocations with
minimal trauma.

MECHANISM OF INJURY

Traumatic

The most common glenohumeral dislocation occurs anteriorly, usually

as a result of sporting accidents or falls, particularly when the upper
extremity is in 90° abduction and external rotation.

Posterior dislocations most commonly result from seizures, shock and

falls.

Atraumatic

Chronic Recurrent caused by repetitive extreme external rotation with

the humerus abducted and extended (i.e.pitching motion). Instability
may be caused by gradual weakening of the anterior and inferior static
restraints. The humeral head will tend to move away from shortened
structures. For example: posterior shoulder capsular tightness will
cause the humeral head to shift anteriorly, resulting in a loss of
integrity of all anterior structures. Commonly associated with
participation in sports such as gymnastics, baseball, softball, tennis,
swimming, and weight training.

Concomitant Causes:

Bankart lesion: It is a lesion of the anterior part of the glenoid

labrum of the shoulder. This injury is caused by repeated
anterior shoulder subluxations.

Hill-Sachs lesion: This is a depression on the humeral head in

postero-lateral quadrant, caused by impingement by the anterior edge
of the glenoid on the head as it dislocates.

SLAP lesion (Superior labrum anterior posterior): A SLAP

tear or SLAP lesion is an injury to the glenoid labrum
(fibrocartilaginous rim attached around the margin of the glenoid
cavity). Tears of the superior labrum near to the origin of the long
head of biceps.

HAGL lesion (Humeral Avulsion of Glenohumeral

Ligaments): It is an injury to the inferior glenohumeral ligament
causing instability and/or pain.

ALPSA lesion (Anterior Labroligamentous Periosteal Sleeve

Avulsion): It is similar to a Bankart lesion, in that it too is usually due
to anterior shoulder dislocation and involves the anterior inferior labrum

Clinical Presentation

In Anterior instability:

 Clicking
 Pain
 Complain of dead arm with throwing
 Pain posteriorly
 Possible subacromial or internal impingement signs
 The patient may have a positive apprehension test, relocation
test, and/or anterior release test
  Increased joint accessory motion particularly in the anterior
direction

In Posterior instability

 Possible subacromial or internal impingement

 Glenohumeral internal rotation deficit (GIRD) may be present
 Pain
 Clicking
 Increased joint accessory motion particularly in the posterior
direction

In Multidirectional instability

 Antero-inferior laxity most commonly presents with global

shoulder pain, cannot pinpoint to a specific location
 May have a positive sulcus sign, apprehension/relocation test,
anterior release tests
 Secondary rotator cuff impingement can be seen with
microtraumatic events caused during participation in sports
such as gymnastics, swimming and weight training
 Increased joint accessory motion in multiple planes.

TREATMENT

Medical and Surgical Management

The treatment invariably is surgical. Although a large number of surgical

operations have been described, the following operations are performed
commonly:

a) Putti-Platt operation: Double-breasting of the subscapularis

tendon is performed in order to prevent external rotation and
abduction, thereby preventing recurrences.
b) Bankart's operation: The glenoid labrum and capsule are re-
attached to the front of the glenoid rim. This is a technically
demanding procedure, but has become simpler with the use of
special fixation devices called anchors.
c) Bristow's operation: In this operation, the coracoid process, along
with its attached muscles, is osteotomized at its base and fixed to
lower-half of the anterior margin of the glenoid. The muscles
 attached to the coracoid provide a dynamic anterior support to the
head of the humerus.
d) Arthroscopic Bankart repair: With the development of
arthroscopic techniques, it has become possible to stabilise a
recurrently unstable shoulder arthroscopically.

Physical Therapy Management

Phase I : (0-4 weeks) Acute post injury or post surgical

 Rest and immobilization

 Medications and modalities are used for ain control
 Immobilization is done using a sling or a brace.
 Muscle activation of the surrounding muscles in rest of the
kinematic chain can be implemented.
 Sensorimotor system training can be initiated.
 Neuromuscular dynamic stability training can be performed.

Phase II: (4-8 weeks) Sub acute post injury or post surgical

 Sling/brace is usually removed and a progressive increase in ROM

occurs, continuing to protect the healing structures as they are
undergoing the maturation and remodeling phases.
 Muscle activation for the muscles involved in the surgery is usually
initiated in a shortened ROM to protect the continued healing
process. The other muscles in the kinematic chain are involved in a
therapeutic exercise program to increase their muscle strength,
power, and endurance.
 Sensorimotor exercises are continued using both open and closed
kinetic chain exercises to activate the joint mechanoreceptors.
Basic functional exercises are also begun during this time of the
rehabilitation program.

Phase III: (8-12 weeks) Chronic post injury or post surgical

 Increased emphasis is placed on increasing muscle strength,

power, and endurance in the shoulder complex and the entire
kinematic chain including the scapulothoracic muscles,
glenohumeral muscles, rotator cuff, and total arm strength (TAS).
  The sensorimotor system training using open kinetic chain and
closed kinetic chain exercises are implemented into functional
patterns.
 Incorporating neuromuscular dynamic stability training is oriented
to functional training and performance enhancement.

Phase IV: (>12 weeks) functional post injury or post surgical

 ROM activities are continued as a maintenance program to keep

the full ROM allowed by the surgical stabilization procedure.
 The therapeutic exercise program is oriented to specificity of
performance depending on the demands of the patient, whether it
is to return to work or sports.
 Various functional tests can be used to reassess the patient's
performance for specificity of training and criteria for discharge
back to activity and document their outcomes.