Introduction
- Ellen Shanley, PhD, PT, OCS
- Charles A. Thigpen, PhD, PT, ATC
- Richard J. Hawkins, MD
- Charles A. Thigpen, PhD, PT, ATC
Epidemiology
Overall Incidence
- •
Estimates of the initial incidence of anterior glenohumeral instability in the general population range from 8.2 occurrences per 100,000 person years in the rural United States to as high as 24 occurrences per 100,000 person years in Scandinavian countries.
- •
In NCAA athletes the instability incidence at the glenohumeral joint was calculated as 0.12 injuries per 1000 athletic exposures (AE).
- •
The frequency of instability episodes in a military population over 1 year was calculated as 2.8%.
- •
The overall injury rate, including both initial and recurrent episodes of shoulder instability, has been documented to significantly increase the total number of episodes.
Age
- •
Owens et al. reported that 80% of shoulder dislocations occur in younger patients. Forty seven percent of patients presenting to U.S. emergency departments with traumatic dislocations were between the age of 15 and 29. A Scandinavian population study reported that the overall peak incidence of shoulder dislocations in males occurred between the ages 21 and 30 and in females between the ages of 61 and 80. Recurrent instability has been reported at highest frequencies in patients younger than 20 years old (66% to 94%).
Gender
- •
Male collegiate athletes (0.15/1000 AE) were 2.7 times more likely to sustain a shoulder instability episode than female (0.06/ 1000 AE) collegiate athletes. In the military, male cadets had a slightly higher frequency of shoulder instability than their female counterparts with 2.9% and 2.5% documented over a 1-year study period, respectively.
Sport
- •
In collegiate athletes, the rate of shoulder instability was greatest in Spring football at 0.40/1000 AE followed by wrestling (0.21/1000 AE), women’s ice hockey (0.18/1000 AE) and fall football (0.18/1000 AEs).
- •
In high school athletes, dislocations were reported to be higher in male sports (38%) than female sports (29%). However, female basketball players sustained more shoulder dislocations than male basketball players (proportion ratio = 2.7).
- •
Injuries were sustained more in games (0.31/1000 AE) than practices (0.09/1000 AE) and NCAA athletes were 3.5 times more likely to sustain an injury in games than in practice.
Position
- •
In football, linebackers, wide receivers, and running backs most frequently sustained dislocations.
- •
Outside hitters reported the highest percentage of shoulder dislocation amongst volleyball players
Pathophysiology
Intrinsic Factors
- •
Several anatomic factors have been theorized to increase the potential for anterior instability of the glenohumeral joint. Capsular redundancy, patulousness of the inferior glenohumeral capsule, variations in the capsular and ligament insertion to the glenoid, and laxity of the rotator interval have been identified as risk factors for initial and recurrent instability. The glenoid labrum is a static stabilizer of the joint and disruption of this structure yields a decrease in the stability of approximately 10% in all directions. Generalized joint hypermobility ( Figure 1-1 ), as measured by the Beighton scale, has been associated with a 2.5 times increased risk of having reported an episode of glenohumeral instability.
FIGURE 1-1
Hyperlaxity of the wrist (A) and elbow (B). (Courtesy of Drs. Baujat and Finidori, Necker Hospital, Genetics Department and Pediatric Orthopaedic Surgery Department, Paris, France.)
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 481) Fig 42-10 and 42-11.
- •
The loss of osseous integrity by altered inclination or version, as well as bone loss on the glenoid or humeral side of the joint, may affect anterior and inferior joint stability. There is the concept of bone loss inferiorly which may suggest, if significant, a bone block operation rather than an arthroscopic Bankart type of repair.
- •
Following failure of an arthroscopic procedure, an open procedure going through the subscapularis might be considered.
- •
There may be associated pathology that requires attention such as a superior labrum anterior to posterior (SLAP) lesion. Most surgeons in doing a Bankart repair in the presence of a SLAP, also repair the SLAP for added stability.
- •
There is a relationship of the presence of SLAP tears and increased strain on the anterior inferior glenoid humeral ligament. Thus it is related to instability.
- •
- •
Dynamic stability of the shoulder is dependent on concavity-compression. This phenomenon is related to the centering forces produced by coordinated contraction of the rotator cuff musculature combined with proper position and stabilization of the scapula. A lack of neuromuscular control secondary to interruption of descending neural input, rotator cuff inhibition or decreased integrity, or scapular dyskinesis can lead to shoulder instability.
Extrinsic Factors
- •
The initial incidence of shoulder dislocation was greater in those involved in sport and recreational activities as compared with sedentary individuals in the general population. Also, the frequency of recurrent dislocation was greater in athletes (> 80%) than the general population (33%).
- •
Contact has been documented as the most common mechanism of shoulder dislocation. In full to partial contact sports, contact with another participant was the most frequent cause of dislocation. Another common mechanism for injury was player contact with equipment and playing surfaces.
- •
In the general population, especially older women, falls on the outstretched arm have been theorized as a frequent cause of dislocation.
Traumatic Factors
- •
Bankart described the mechanism for shoulder dislocation as a fall on the extended arm causing a forceful extension of the humerus resulting in anterior-inferior dislocation.
- •
More recently, contact or externally applied energy to the distal upper extremity while the arm is abducted and externally rotated, forcing the shoulder beyond the limits of normal range of motion, has been documented in weight lifters and rugby players sustaining anterior shoulder dislocations.
Classic Pathological Findings
- •
Intraarticular pathology, including disruption of the anterior inferior capsule and labrum associated with anterior dislocation has been classically documented by Perthes ( Figure 1-2 ). Bankart has been credited with describing a shearing disruption of the glenoid labrum naming this the “essential lesion” of any anterior glenohumeral dislocation ( Figure 1-3 ). Previously, Flower in 1861 and Caird in 1887, described the relationship of a defect in the head of the humerus as an associated injury suffered with anterior dislocation.
FIGURE 1-2
Axial MRI scan of a Perthes lesion: Incomplete tear of nondisplaced anteroinferior labrum that remains attached to the glenoid neck only through periosteal fibers (arrow) .
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 98.) Fig 8-10.
FIGURE 1-3
The axial CT image and associated 3-D reconstruction demonstrate a large Hill-Sachs lesion of the posterosuperolateral humeral head and evaluation of the anterior glenoid rim reveals loss of normal contour consistent with a compression type glenoid injury.
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 251.) Fig 21-4.
- •
Bony injury to the glenoid has been documented as a frequent concomitant injury suffered during a high energy dislocation. The presence of a bony Bankart lesion in association with a Hill-Sachs lesion (often termed an engaging Hill-Sachs lesion) is a risk factor for recurrent dislocation.
- •
Researchers documenting the prevalence of specific tissue injury after primary and recurrent anterior dislocations reported anterior labrum periosteal sleeve avulsion (ALPSA) ( Figure 1-4 ) lesions (27%) occurred with greater frequency than Bankart lesions (24%) during primary dislocation.
FIGURE 1-4
Axial MRA demonstrating an ALPSA lesion (arrow) .
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 72.) Fig 6-5A.
Clinical Presentation
History
- •
Depending on the timing of presentation, patients presenting for evaluation often complain of pain after an initial episode of traumatic anterior instability. The pain and muscle spasm may accompany prolonged dislocation with a delay in reduction.
- •
The individual may report impaired sensation, loss of motion, and impaired strength.
- •
Commonly, patients report feelings of apprehension and instability.
Physical Examination
Abnormal Findings
- •
Positive anterior apprehension test (+/− relocation test) ( Figure 1-5 ) is suggestive of anterior instability. The relocation test ( Figure 1-6 ) must not be confused with a positive relocation for reduction of pain which would be suggestive of internal impingement.
FIGURE 1-5
Performance of the anterior apprehension test. An examination is positive when the patient expresses “apprehension” or the feeling of their shoulder slipping out of socket when in this abducted externally rotated position.
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 26.) Fig 2-8A.
FIGURE 1-6
Performance of the anterior relocation test. The addition of a posteriorly directed force to the anterior proximal arm results in relief of patient apprehension in the abducted, externally rotated position.
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 26.) Fig 2-10.
- •
Positive results for the combination of all three provocative (apprehension, relocation, and surprise) tests, was highly specific for the presence of anterior instability.
- •
The athlete may complain of popping or clicking in the shoulder on movement.
- •
Neurologic assessment including sensory and motor exam might demonstrate impaired sensation over the deltoid and decreased strength for abduction and external rotation . These symptoms are usually found in an individual requiring eduction of the dislocation. Symptoms may be related to neuropraxia and are usually transient axillary nerve injury. There is rarely decreased strength related to a true persistent neurological injury.
Pertinent Normal Findings
- •
The patient with anterior instability will demonstrate normal to near normal single plane range of motion after an initial recovery.
- •
Strength will return after a brief period of recovery barring neurological involvement.
- •
The patient will resume participation at a high level of play with the exception of overhead activities and activities requiring the arm to extend behind the body or adopt a position of abduction and external rotation.
- •
The provocative position for anterior instability is the maximal cocking position for a thrower.
Imaging
- •
Radiographic studies routinely consist of a true AP (right angle to the scapula) ( Figure 1-7 ), a lateral scapula, and an axillary view. They often demonstrate the presence of a Hill-Sachs lesion of the humeral head and may demonstrate a loss of bone at the anterior surface of the glenoid. There can be specialized X-rays such as a west point view ( Figure 1-8 ) to determine anterior glenoid bone involvement and specialized views to identify a Hill-Sachs lesion.
- •
Magnetic resonance imaging ( Figure 1-9 ) may demonstrate tearing of the anterior inferior glenoid labrum and with less frequency the anterior capsule and anterior aspect of the inferior glenohumeral ligament. Increased signals denoting structural deficits and tissue inflammation are noted on the T2-weighted images. The concomitant rotator cuff tear, in an older patient, can be diagnosed with an MRI.
FIGURE 1-9
Axial MR arthrogram demonstrating an anterior labral tear. Note fluid interposed between anterior labrum and glenoid (arrow) .
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 71.) Fig 6-4A.
- •
Commuted tomography (CT) is utilized to identify bone defects in two dimensions.
- •
CT reconstructions are three-dimensional studies ( Figure 1-10 ) and are used to quantify bone defects on both the humeral and glenoid surfaces when standard X-ray images fail to specifically define the lesion. These images are used sparingly as they deliver a fair amount of radiation exposure to the patient.
FIGURE 1-10
Three-dimensional CT: Arrow indicates the bone fragment detached from the anterior glenoid rim.
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 96.) Fig 8-7A.
FIGURE 1-7
True anteroposterior (Grashey) radiographic view demonstrating intact glenoid rim.
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 90.) Fig 8-2C.
FIGURE 1-8
West Point view. Red dots outline glenoid bone loss (about 15%) (white arrow) .
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 173.) Fig 14-2B.
- •
Differential Diagnosis
- •
Multidirectional instability of the glenohumeral joint may be confused with anterior glenohumeral joint instability. The differential diagnosis is made by history (chronic episodes of subluxation/dislocations and often laxity in multiple joints), unwanted translation in two or more directions (always inferior and either anterior, or posterior), and positive sulcus sign. Additionally, the athlete may present with decreased dynamic stability and poor muscle control in multiple planes of motion.
- •
Posterior instability may be misdiagnosed as anterior instability. Patients with decreased force couple/concavity compression, and altered positioning of the humeral head in the glenoid fossa can be misdiagnosed with anterior instability. These patients will appear to have increased anterior translation on examination if the humeral head is not centered prior to conducting the load shift test. The differential diagnosis begins with recognizing the presenting symptoms. The patient will often complain of an inability to bring their arm across their body especially when weight is applied to the distal portion of the upper extremity.
- •
Superior labrum from anterior to posterior (SLAP) lesions have been documented in patients complaining of anterior instability. Patients with complaints of anterior instability have been documented to present with a variety of labral and bony lesion (ALPSA).
Treatment
Nonoperative Management
- •
Bracing: Itoi et al. have shown that traumatic anterior instability can be placed in a sling ( Figure 1-11 ) with pillow at 45° to 60° of external rotation (ER) and the injury heals. However, compliance and long-term success seem to be problematic, based on follow-up studies.
FIGURE 1-11
Commercially available external rotation sling that can be used for immediate postreduction immobilization.
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach. Philadelphia, 2011, Elsevier (Saunders), p. 103.) Fig 9-3.
- •
A criterion-based, progressive exercise program is thought to be effective for short-term management of traumatic anterior shoulder instability coupled with bracing when the athlete returns to sport. This program focuses on rotator cuff and scapular stability as well as maximizing shoulder proprioception/kinetic awareness in higher ranges of elevation and ER.
Guidelines for Choosing Among Nonoperative Treatments
- •
Patients with initial, unidirectional, capsular injuries may be appropriate for immediate bracing in slight abduction and ER.
- •
A progressive rehabilitation program works well for many patients to ensure success.
Surgical Indications
- •
Disability related to recurrent dislocations.
- •
First-time dislocations with combinations of specific pathologies (e.g., an older patient with combined dislocation and rotator cuff tear).
- •
Selected patients presenting with acute dislocation and combined bone loss (humeral and glenoid).
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
Number of dislocations
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Severity of dislocation
- •
Was anesthesia required?
- •
Was it a “locked” dislocation?
- •
- •
Labral involvement
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Bony avulsion
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Percentage glenoid bone loss
- •
Residual neurological or vascular symptoms
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Rotator cuff involvement
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Concomitant SLAP repair
Aspects of Clinical Decision-Making When Surgery is Indicated
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Number of dislocations and the resultant disability are considered when planning for surgery.
- •
Patient age and overall health.
- •
Patients presenting with apprehension concerns are examined carefully to define the size and location of the lesion.
- •
Patients with engaging lesions require consideration to determine if the engagement occurs prior to attainment of the 90-90 positions.
- •
Patients presenting to the orthopedic surgeon reporting recurrent dislocations with difficult reduction.
- •
Sport and occupational requirements (i.e., position played, contact, ROM requirements).
- •
Associated complications (i.e., axillary nerve or rotator cuff involvement).
- •
Previous failed reconstruction.
Evidence
Multiple-Choice Questions
- QUESTION 1.
Overall in high school athletes, males are at a higher risk of sustaining at traumatic anterior shoulder dislocation when compared to females. However, when comparing which two sports females are at higher risk than males:
- A.
Boys’ baseball to girls’ softball
- B.
Boys’ to girls’ basketball
- C.
Boys’ to girls’ ice hockey
- D.
Boys’ to girls’ soccer
- A.
- QUESTION 2.
Generalized joint hypermobility, as measured by the Beighton scale, has been associated with a ____ times increased risk of having reported an episode of glenohumeral instability.
- A.
1.5
- B.
2.0
- C.
2.5
- D.
3.0
- A.
- QUESTION 3.
When documenting specific tissue injury after primary and recurrent anterior dislocations, researchers have reported:
- A.
ALPSA lesions occurred with greater frequency than Bankart lesions during primary dislocation
- B.
Concomitant intraarticular pathology occurs with increasing frequency with recurrent dislocations
- C.
Bony Bankart lesions occurred with greater frequency than Hill-Sachs lesions during recurrent dislocation
- D.
Glad lesions occurred with greater frequency than Bankart lesions during primary dislocation
- A.
- QUESTION 4.
Which of the following modalities is the best choice for an older patient presenting after initial dislocation episode presenting with complaints of weakness and inability to lift their arm overhead?
- A.
Computed tomography
- B.
Computed tomography with 3D reconstruction
- C.
Magnetic resonance imaging
- D.
Specialized radiographs (West Point view)
- A.
- QUESTION 5.
Neuropraxic symptoms in a patient presenting after anterior dislocation are most often related to:
- A.
Axillary nerve injury
- B.
Musculocutaneous nerve injury
- C.
Radial nerve injury
- D.
Suprascapular nerve injury
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Overall Incidence — Sport )
- QUESTION 2.
Correct answer: C (see Pathophysiology )
- QUESTION 3.
Correct answer: A (see Pathophysiology )
- QUESTION 4.
Correct answer: C (see Clinical Presentation )
- QUESTION 5.
Correct answer: A (see Clinical Presentation )
Nonoperative Rehabilitation Following Anterior Capsulolabral Injury
- Charles A. Thigpen, PhD, PT, ATC
- Ellen Shanley, PhD, PT, OCS
- Richard J. Hawkins, MD
- Ellen Shanley, PhD, PT, OCS
Overview of Goals, Important Milestones, and Guidelines
- •
Conservative management of anterior shoulder instability is often considered for patients diagnosed with traumatic anterior shoulder instability.
- •
The rehabilitation process is not dependent on time as clearance for return to sport is not based on assumed tissue healing.
- •
The rate of recurrence following traumatic anterior shoulder instability is significant and should be considered during the counseling and rehabilitation process. In general, the younger the patient and the more tissues involved (capsule/ligament, labrum, glenoid), the greater the recurrence rate. Therefore, we recommend limiting the number of recurrent episodes as they may lead to increased incidence of intrarticular pathology and long-term complications.
- •
Rehabilitation following traumatic anterior instability is therefore based on criteria alone with a strong emphasis on maximizing dynamic stability about the shoulder girdle.
- •
The suggested treatment progressions should be constantly within the context of risk of reinjury based on age, sport, and involved pathology.
- •
Gradual, pain-free restoration of range of motion (ROM) avoiding the sensation of instability
- •
Muscle guarding/spasm must first be resolved before dynamic stability can be restored
- •
Correct application of manual techniques and therapeutic exercises to promote static balance in glenohumeral joint mobility and optimum dynamic stabilization from the rotator cuff and associated shoulder girdle muscles.
- •
Return to sport is not appropriate until the athlete demonstrates dynamic stability in the functional ROM in which they are expected to participate.
Phase I
Goals
- •
Educate the patient about restrictions, pain management, and activities of daily living (ADLs).
- •
Protect the anterior shoulder by avoiding positions/movements that are likely to increase stress on the anterior/inferior capsulolabral structures.
- •
Minimize shoulder pain to normalize muscle tone.
- •
Gradually restore frontal plane elevation, abduction, and external rotation (ER) above 45°, as suggested in Table 1-1 .
Table 1-1
Staged Range of Motion Goals Following Arthroscopic Anterior Capsulolabral Injury
PFE
PER at 20° abd
PER at 90° abd
AFE
Phase I
90°
10°–30°
Contraindicated
NA
Phase II
155°
50°–65°
75°
145°
Phase III
WFL
WFL
WFL
WFL
AFE , Active forward elevation in the scapular plane; NA , not appropriate; PER , passive external rotation; PFE , passive forward elevation; WFL , within functional limits.
- •
Restore scapular control.
- •
Modalities and soft tissue mobilization are often helpful to decrease guarding and allow gradual increase in muscle function.
- •
Restore isometric, then positional, isometric muscle function before progressing to full ROM concentric activities
| PHASE I | PHASE II | PHASE III |
|---|---|---|
|
|
|
Protection
- •
We recommend initial sling use for dislocations with gradual progression to no sling based on pain, available ROM, muscle performance, and activity level.
Management of Pain and Swelling
- •
Oral pain medications as needed
- •
Electrical stimulation (Transcutaneous Electrical Neural Stimulation, TENS) is recommended to manage pain and muscle guarding.
- •
Intermittent cryotherapy for pain and inflammation reduction
- •
Patient positioning: patients are encouraged to use pillows or bolsters to find a “position of comfort,” usually slightly abducted (20° to 30°) in a neutral or slight internal rotation (IR), especially at night. This position is recommended to reduce stress on repaired structures as well as to “unload” the surrounding muscles.
Techniques for Progressive Increase in Range of Motion
- •
The initial phase is resolving pain, decreasing swelling, and allowing the acute, postinjury shoulder to recover.
- •
Supported Codman’s pendulum exercises for gentle motion and joint distraction, supported forward elevation (FE) (<90°), and ER to 0° at the side (<20° abduction) can be performed immediately to maintain joint mobility but should not reproduce symptoms. We suggest all of these motions be performed with support to minimize rotator cuff activity due to incorrect technique.
Manual Therapy Techniques
- •
Gentle joint distraction and grade I-II joint oscillations may be helpful before performing supervised passive/active assisted range of motion (P/AAROM) by the rehabilitation professional to decrease muscle guarding and prepare the joint for ROM exercise. We recommend these treatments to be performed in the scapular plane in approximately 30° of elevation, and neutral rotation to limit the stress on the capsulolabral injury.
Soft Tissue Techniques
- •
Shortening, parallel techniques (such as positional release/strain-counterstrain) may be helpful to reduce protective guarding especially for the subscapularis, posterior rotator cuff, teres major, latissimus dorsi, and pectoralis major/minor.
Stretching/Flexibility Techniques for the Musculo-Tendinous Unit
- •
Stretching/flexibility exercises are not recommended at this time due the need to protect the repair. Cervico-thoracic, elbow, hand, and wrist.
Other Therapeutic Exercises
- •
Lower extremity and cardiovascular exercises may begin immediately as long as there is no reproduction of instability symptoms. This is crucial especially for the in-season management with the goal to return to play in season.
Activation of Primary Muscles Involved
- •
Isometric exercises may begin day 1 as tolerated. We recommend performing these exercises in the “safe zone” of 20° to 30° abduction in the plane of the scapula in neutral rotation first with the elbow supported then gradually removing support.
- •
Gradual progression to positional isometrics can begin day 1.
Open and Closed Kinetic Chain Exercises
- •
Closed chain activities are often less painful and help to provide compression of the GH joint, thereby increasing the static stability of the joint ( Figure 1-12 ).
FIGURE 1-12
Closed kinetic chain perturbations in quadruped. Patient is positioned in quadruped loading affected arm as tolerated. Perturbations can then be applied manually or using an unstable surface.
Neuromuscular Dynamic Stability Exercises
- •
Exercises to emphasize rotator cuff balance and co-contraction should be emphasized during Phase I ( Figure 1-13 ).
FIGURE 1-13
Cuff co-contraction during elevation: A, B, Patient squeezes ball into internal rotation/adduction while elevating arm as tolerated. C-E, Patient maintains ER while elevating arm as tolerated.
Milestones for Progression to the Next Phase
- •
Minimal to moderate pain (Numeric Pain Rating Scale [NPRS]: 2 to 4/10) with minimal pain at rest (2/10)
- •
Stage I ROM goals achieved but not significantly exceeded
Phase II
Goals
- •
Minimize shoulder pain (<2/10)
- •
Achieve staged ROM goals to normalize passive ROM and active ROM.
- •
Normalize rotator cuff guarding and neuromuscular control
- •
Normalize scapular position and control
- •
Normalize subscapularis muscle function to provide dynamic stability for the anterior shoulder.
- •
Avoid scapular protraction with coronal plane shoulder motion to limit stress on the anterior capsulolabral structures.
- •
Follow up soft tissue work with proprioceptive neuromuscular facilitation (PNF), positional isometrics, and proprioceptive activities to maximize neuromuscular facilitation during early phases after injury.
Patient-Oriented Outcomes
- •
Best clinical practice uses patient-rated measures of function and disability to comprehensively assess patient response to treatment.
- •
There are many available scales for measuring functional loss and disability in patients with instability and one measure is likely not superior to another.
- •
We recommend two measures, a general measure of shoulder function that includes pain, function, and patient satisfaction similar to the American Shoulder and Elbow Surgeons’ (ASES), the Pennsylvania Shoulder Score (PSS) and a measure specifically for instability, such as the Western Ontario Instability Index (WOSI).
Protection
- •
Treatment for pain/analgesia oral pain medications
- •
Electrical stimulation (TENS) is recommended to manage pain and muscle guarding. TENS units at home are often helpful to control pain, especially shortly after surgery.
- •
Intermittent cryotherapy for pain and inflammation reduction. We recommend 20 minutes per hour for the first week following surgery.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Gentle joint distraction and grade I-III joint oscillations may be helpful before performing supervised PROM by the rehabilitation professional to decrease muscle guarding, restore capsular balance, and prepare the joint for ROM exercise. Anterior-inferior or inferior glides should not be performed. We recommend these positions to be performed in the scapular plane in approximately 30° of elevation, and neutral rotation to limit the stress on the capsulolabral repair.
Soft Tissue Techniques
- •
Shortening, parallel techniques such as (Positional Release/Strain-Counterstrain) may be helpful to reduce protective guarding especially for the subscapularis, posterior rotator cuff, teres major, latissimus dorsi, and pectoralis major/minor.
- •
Passive ROM and active assist ROM exercises may be initiated after POW 2 for ER and FE (see Table 1-1 ).
Stretching/Flexibility Techniques for the Musculo-Tendinous Unit
- •
Should not be performed as these are end ROM exercises.
Other Therapeutic Exercises
- •
Gradual introduction of total body strengthening (TBS), total leg strength (TLS), core stability, uninvolved total arm strength (TAS), and cardiovascular conditioning can be initiated with attention to the safety of the activity. All exercises should be performed so that the patient does not have symptoms of instability during activity.
Activation of Primary Muscles Involved
- •
Scapular retraction and proprioceptive neuromuscular facilitation (PNF) patterns should be emphasized and positions based on patient tolerance. We recommend first achieving stability in a retracted position then progressing to scapular protraction to minimize increased stress on the anterior capsulolabral structures. Although scapular elevation and retraction are safe we suggested limited resistance because of the load placed through the glenohumeral joint for most exercises.
- •
Active ROM and rotator cuff strengthening within the staged ROM goals in Table 1-1 . The recommended procedure is to begin with submaximal isometric strengthening of the shoulder and elbow with the arm adducted to the side in neutral rotation first, then to progressively increase the angle of arm elevation and ER. As the patient demonstrates improved rotator cuff endurance and absence of pain or other symptoms it is recommended to progress to dynamic isometrics, then concentric/eccentric exercises, then AROM exercises within the ROM restrictions.
Sensorimotor Exercises
- •
Angular reposition, rhythmic stabilization, and repeated contractions within staged ROM limits may be implemented during Phase II.
Open and Closed Kinetic Chain Exercises
- •
Closed kinetic chain (CKC) exercises may be implemented below 90° of elevation during Phase II. These exercises should begin in a modified weight-bearing position and progressed to full weight-bearing as tolerated.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
See above w/AROM
Milestones for Progression to the Next Phase
- •
Appropriate healing of the surgical repair by adhering to the precautions and immobilization guidelines.
- •
Staged ROM goals achieved but not significantly exceeded
- •
Minimal to no pain (NPRS: 0—2/10) with ROM
- •
PSS greater than 60% and WOSI less than 50%. These are estimates based on reported normative data and our experience. This combined with other objective criteria provides clear communication between the patient and medical professionals on how the patient perceives their shoulder function, and gives potential insight as to how care can be improved upon.
Phase III
Goals
- •
Achieve staged ROM goals to normalize passive ROM and active ROM. DO NOT significantly exceed especially for ER at 90° of abduction
- •
Minimize shoulder pain (0/10 at rest and <2/10 following exercises or activity)
- •
Begin to increase strength and endurance
- •
Increase functional activities as evidenced by PSS > 80% and WOSI < 30%.
- •
Nearly full active elevation in the plane of the scapula should be achieved before progressing to elevation in other planes or initiating resistive elevation exercises.
- •
Ensuring posterior rotator cuff performance and scapular stability below 90° of abduction before progressing to higher elevation and difficulty of exercises.
- •
Posterior-inferior glides are often helpful to gain full ER and FE. Addition of posterior shoulder flexibility exercises in conjunction with these mobs before and after exercise is helpful in the stiff shoulder.
- •
In our opinion, rapid gain of ER towards 90° of abduction should be avoided (before 8 weeks). If the athlete must return to overhead, throwing sports and the involved shoulder is their throwing arm, then more aggressive stretching of ER towards 90° of abduction may begin at 8 weeks.
- •
Functional exercises may begin toward the end of this phase. Simple patient instruction to “keep their hands where they can see them” will allow the patient to resume desired activities without risking reinjury.
Protection
- •
No sling use
- •
Avoid positions of max ER towards 90° of abduction, especially with a posteriorly directed load. (e.g., NO push-ups, bench press, pectoral flys)
Management of Pain and Swelling
- •
Pain should not be a limiting factor at this point. If pain is limiting progression of activities rest and reevaluation of all aspects of the shoulder should be performed in consultation with the referring surgeon
- •
Cryotherapy as needed.
- •
NSAIDS as needed.
Patient Education
- •
Counsel about using the upper extremity for appropriate ADLs in the pain-free ROM (starting with waist level activities and progressing to shoulder level and finally to overhead activities over time)
- •
Continue education regarding avoidance of heavy lifting or quick sudden motions
- •
Education to avoid positions which place stress on the anterior inferior capsule during ADLs
Techniques for Progressive Increase in Range of Motion
- •
FE should be progressed from active-assistive exercises (e.g., rope and pulley, wall walks), to active, to resistive upright exercises, then finally to prone exercises as per reported electomyography (EMG) activity of the shoulder. Although protection of the rotator cuff is not needed, the EMG activity reflects overall stress to the shoulder and is a good guide to exercise progression.
Manual Therapy Techniques
- •
Grade I-III joint mobilizations (up to tissue resistance) are most often all that is required especially for anterior/inferior directions. If ROM is greater than 50% less than staged ROM goals as compared with the uninvolved extremity then gentle joint mobilizations may be performed. However they should be done only into the limited directions and only until staged ROM goals are achieved. It is crucial in the patients that appear “tight” to discern if there is capsuloligamentous tightness/stiffness, musculotendinous, pain limitation, or some combination.
Soft Tissue Techniques
- •
Deeper soft tissue techniques may be initiated during this phase. More aggressive techniques such as Active Release ® or other instrumented soft tissue mobilizations to normalize muscle tone and extensibility. Particular attention should be paid to the subscapularis, latissimus, pectorals, teres major, and posterior rotator cuff. In our experience these techniques often allow for gradual return consistent with the staged goals without aggressive joint mobilizations or excessive end range stretching.
Stretching/Flexibility Techniques for the Musculo-Tendinous Unit
- •
Total upper quarter mobility should be evaluated with restoration of cervical, thoracic, and scapulothoracic mobility to facilitate optimal return upper extremity ROM.
- •
End range flexibility exercises may begin in particular for posterior shoulder (horizontal adduction and sleeper stretch beginning at 60° to 70° of elevation on side. Pectoralis minor flexibility can begin with attention not to increase stress on anterior shoulder as these have been shown to be effective at increasing pectoralis minor length ( Figure 1-14 ). Gradual introduction of latissimus, posterior shoulder, and FE stretches as needed ( Figure 1-15 ).
FIGURE 1-14
A, The pectoralis major and minor are stretched by placing the arm at 90° of abduction then leaning forward and rotating away from affected arm while keeping the elbow in line with the scapula and thorax. The patient should report feeling a “stretch” along the anterior shoulder and pectorals, not glenohumeral joint discomfort. B, The pectoralis major and minor are stretched by placing the arm at 120° of abduction then leaning forward and rotating away from affected arm the while keeping the elbow in line with the scapula and thorax. The patient should report feeling a “stretch” along the anterior shoulder and pectorals, not glenohumeral joint discomfort. C, D, Pectoralis minor flexibility can begin with attention not to increase stress on anterior shoulder as these have been shown to be effective at increasing pectoralis minor length.
FIGURE 1-15
Latissimus and posterior shoulder flexibility on ball: (A) Patient actively rolls ball away from body and sits back on buttocks maintaining neutral spine then (B) adding trunk rotation away from affected side to change angle of stretch from distal latissimus to posterior cuff and teres major.
Other Therapeutic Exercises
- •
Address core stability deficits as needed beginning in the sagittal plane and progressing to frontal and transverse plane exercises.
- •
Total leg strengthening exercises may be progressed as tolerated but high loads should be avoided on the shoulder in activities such as power clean, dead lifts, and back squats should be avoided. Front squats during this phase are recommended to allow for safe positioning of the shoulder with large loads.
- •
It is also recommended to use this phase of rehabilitation to address kinetic chain deficits using basic functional screens such as the overhead squat, single leg squat, or more in-depth approaches such as the Functional Movement Screen. These approaches will provide areas for improvement for the athlete allowing for total body and lower extremity kinematic chain assessment.
Activation of Primary Muscles Involved
- •
Elbow flexion/extension strengthening with elbow by the side can begin in this phase
- •
Exercises and functional activities should be pain free and performed without substitutions or aberrant movement patterns (shrugging, thoracic extension)
- •
Balanced rotator cuff strengthening to maintain the humeral head centered within the glenoid fossa during progressively more challenging activities
- •
Should be initially performed in a position of comfort with low stress to the glenohumeral joint such as less than 45° elevation in the plane of the scapula (e.g., elastic band or dumbbell ER, IR, FE)
- •
Exercises should be progressive in terms of shoulder elevation (e.g., start with exercises performed at waist level progressing to shoulder level and finally overhead activities)
- •
Depending upon the goals of the exercise (control versus strengthening), rehabilitation activities may also be progressive in terms of speed once the patient demonstrates proficiency at slower speeds
Sensorimotor Exercises
- •
Activities to improve neuromuscular control of the rotator cuff and shoulder girdle such as use of unstable surfaces, body blade, and manual resistance exercises in conjunction with auditory, visual, or tactile cues or biofeedback.
- •
PNF patterns are particularly effective for restoring muscle balance and proper coordination patterns. This manual feedback is preferable, especially early during this phase because the clinician controls the load to the extremity and is able to best match the patient’s level of performance.
Open and Closed Kinetic Chain Exercises
- •
Strengthen scapular retractors and upward rotators
- •
Weight-bearing exercises with a fixed distal segment. Examples: quadruped position while working to maintain proper position of the scapula, quadruped with scapula protraction, progressing from quadruped to tripod position, no push-ups
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Exercises should be progressive in terms of muscle demand. It is suggested to use activities that have muscle activity levels documented with EMG. In general, increasing elevation increases deltoid and supraspinatus activity, whereas increasing ER at lower levels of elevation increases posterior rotator cuff EMG. The subscapularis is most active during forward punches (combined scapular protraction and glenohumeral IR) and should be performed at lower and higher levels of elevation.
- •
Exercises should be progressive in terms of adding stress to the anterior capsule, gradually working towards a position of 90° of ER and 90° of abduction by 12 weeks.
- •
Rehabilitation should include isolated and complex movement patterns progressing from isolated to complex movement patterns.
- •
The rotator cuff and scapula stabilizer strengthening program should emphasize high repetitions (typically 30 to 50 reps) and relatively low resistance (typically 1 to 2 kg) during this phase.
- •
General shoulder strengthening exercises (front/side raises, shoulder presses) may be initiated as full AROM is achieved and rotator cuff and scapular stabilizer strength is adequate for normal movement patterns. This is usually a late Phase III exercise and should begin with 3 to 5 kg and similar reps (15 to 20 for 3 to 4 sets).
Neuromuscular Dynamic Stability Exercises
- •
Development of dynamic stability is crucial during this phase of rehabilitation following stabilization procedure. Rhythmic stabilization starting at 45° of abduction in the scapular plane in neutral rotation and gradually increasing in elevation and ER as performance increases. Four to five bouts for 30 seconds are recommended before progressing the difficulty of exercises.
- •
CKC push up plus progression are important exercises as it promotes rotator cuff and scapular stabilizer co-contraction needed for dynamic stability.
Plyometrics
- •
No heavy lifting or plyometrics should be performed during this stage.
Functional Exercises
- •
Functional exercises may be initiated toward the end of Phase III (weeks 9 to 12); however, we strongly recommend avoiding undue stress on the anterior shoulder.
- •
Multi-planar exercises should be progressed in a similar fashion as previously described, emphasizing rotational control across each plane of elevation.
Milestones for Progression to the Next Phase
- •
Staged active ROM goals achieved with minimal to no pain (NPRS 0 to 2/10) and without substitution patterns
- •
Appropriate scapular posture at rest and dynamic scapular control during ROM and strengthening exercises
- •
Strengthening activities completed with minimal to no pain (NPRS 0 to 2/10)
- •
<20% deficit using isokinetic or hand held dynamometer for ER, IR, abduction, and elevation.
- •
Able to complete 20 hand-taps during modified Davies CKC upper extremity (UE) test. We recommend modifying the Davies test by using biacromial width as in our experience a standard 36″ is too wide for many patients.
- •
Able to complete 30 reps of ER at <20° of abduction in 30 seconds (1 rep/sec).
Phase IV
- •
The length of Phase IV will vary dependent upon sport participation. For noncontact sports it may be as simple as a gradual return to sport. For contact athletes it may require a more gradual return to activity in a braced condition.
Goals
- •
No complaints of pain at rest and minimal to no pain (NPRS 0 to 2/10) following activities
- •
No or minimal sensation of instability with activities
- •
Normalize strength, endurance, neuromuscular control, and power as evidenced by:
- •
<10% deficit using isokinetic or hand held dynameter for ER, IR, abduction, and elevation.
- •
30 reps in 30 seconds with blue Thera-Band at 0° and 90° abduction
- •
Able to complete 90 hand-taps during modified Davies CKC UE test in 60 seconds.
- •
Gradual demonstration of confidence and performance in sports specific positions.
- •
Functional improvement in ADLs and sport as evidenced by PSS > 90% and WOSI < 20%.
- •
- •
A balance of posterior and anterior rotator cuff strength (ER:IR ratio) of 66% before beginning return to sport training is recommended.
- •
Progression of presport training activities should be monitored, re-evaluating the athlete’s pain and strength (no >10% advancement as compared to presport).
- •
We recommend soreness rules avoiding activity postsoreness for 24 to 48 hours.
Management of Pain and Swelling
- •
Pain should not be a limiting factor at this point. If pain is limiting progression of activities rest and reevaluation of all aspects of the shoulder should be performed in consultation with the referring surgeon
- •
Cryotherapy as needed
- •
NSAIDS as needed
Patient Education
- •
Counsel about using the upper extremity for appropriate ADLs in the pain-free ROM (starting with waist level activities and progressing to shoulder level and finally to overhead activities over time)
- •
Continue education regarding avoidance of heavy lifting or quick sudden motions
- •
Education to avoid positions which place stress on the anterior inferior capsule during ADLs
Other Therapeutic Exercises
- •
Progressing from Phase III there are no limitations to TBS/TLS or TAS. However, unless end range of motion is required for the athlete’s sport then we strongly recommend avoiding training that stresses the shoulder in the ABER position as the risk of developing recurrent instability outweighs the benefits of training.
Open and Closed Kinetic Chain Exercises
- •
Progression of OKC and CKC consistent with principles previously outlined.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
During this phase the focus of exercises should progress from endurance to strength and power. This will require increasing loads, speed of movements, and type of contraction.
- •
Loads —loads now may be increased appropriate to sport and body weight beginning with 3 to 5 sets of 10 and progressing to 3 to 5 sets of 4 to 6 reps over the next 8 to 10 weeks consistent with a traditional strength training program.
- •
Speed of movement —concentric movements are challenged first beginning with IR, then ER, then punches and complex movements. Punches are last as this as scapular protraction places increased stress on the capsulolabral complex and is a common mode of dislocation.
- •
Type of contraction —eccentric loads can now be initiated beginning with ER (towards IR) and abduction (towards adduction) first then progressing to IR and abduction in preparation for plyometric exercises.
- •
It is recommended to gradually progress to positions of high stress during this phase as needed. For example, to progress back to bench press begin with the athlete performing a dumbbell bench press on the floor, then barbell on the floor, then dumbbell ( Figure 1-16 ).
FIGURE 1-16
A, B, The bench press progression begins with dumbbells and the athlete on the floor. The arms are shoulder level then the weight is pushed up finishing with scapular protraction. When the athlete can complete 3 sets of 15 without pain or soreness the barbell bench on the floor can be considered. C, The barbell progression is performed in the same manner as dumbbell bench press on the floor completing the exercise with full scapular protraction. D, Traditional bench press should begin after completing the floor progression. Hands should be shoulder width apart and the elbows should not go behind the body when the bar is to the chest to protect the anterior repair. A towel roll or other que can be used on the chest to help the athlete modify the exercise.
Neuromuscular Dynamic Stability Exercises
- •
Integration of higher loads and greater perturbations are important in particular for athletes returning to sport.
- •
For football players clap pushups on foam or Dynadisc
- •
For throwers repeated ER yo-yos (with 1-kg weight on band)
Plyometrics
- •
Because of the explosive nature of this type of exercise, emphasis of plyometric exercises should be on quality not quantity. Additionally, 2 to 3 weeks of tolerance to high speed multi-planar activities is recommended, which progressively mimics functional demands before initiating plyometric exercises.
- •
Perform two to three times/week and utilize moderate reps (e.g., 3 to 5 sets of 15 to 20 reps).
- •
Begin with unweighted balls and progress to lightly weighted balls (Plyoballs).
Functional Exercises
- •
Continue as per Phase III.
Sport-Specific Exercises
- •
Med ball throws against a wall, for distance for OKC sports.
- •
UE fitter/stepper in prone position for CKC sports ( Figure 1-17 ).
FIGURE 1-17
Hand Walks on Box: Patient “walks” one hand at a time up on box and back down maintaining scapular stability without shrugging and remaining symptom free for 1 rep/sec (both hands up and down) for 30 to 60 seconds.
- •
Dribbling on wall or rebounding with one hand.
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Clearance from physician.
- •
PSS > 90% and WOSI < 10%.
- •
No complaints of pain at rest and minimal to no pain (NPRS 0 to 2/10) following activities.
- •
No or minimal sensation of instability with activities.
- •
Restoration of sufficient ROM to perform desired activities.
- •
Maintenance of strength and endurance as evidence by the following:
- •
<10% deficit using isokinetic or hand held dynameter for ER, IR, abduction, and elevation.
- •
30 repetitions in 30 seconds with blue Thera-Band at 0° and 90° abduction
- •
Able to complete 90 hand-taps during modified Davies CKC UE test in 60 seconds.
- •
Phase V: Return to Sport Progression
- •
Similar to Phase IV, the length will vary dependent upon sport participation.
- •
The timing of this phase will be greatly impacted by risk of reinjury and timing relative to competition requirements.
- •
As risk of reinjury increases, a more conservative approach in return to competition is recommended.
- •
As maturity of the athlete and level of competition increase athlete education becomes imperative allowing the sports medicine team (athlete, PT, ATC, and MD) to reach the best decision for that athlete.
Goals
- •
No complaints of pain at rest and minimal to no pain (NPRS 0 to 2/10) following activities
- •
No or minimal sensation of instability with activities
- •
Maintenance of sufficient ROM to perform desired activities
- •
Maintenance of shoulder strength and endurance as previously described with minimal to no pain (NPRS 0 to 2/10) or difficulty
- •
Soft tissue and joint mobilizations (once or twice per week) will prevent loss in ROM during the return to sport progression. Careful attention to maintenance of ROM and flexibility will allow for long-term successful return to sport.
- •
Begin sessions with a complete dynamic warm-up including rotator cuff before complex, functional, and plyometric exercises.
- •
Continued strengthening of the rotator cuff and scapular stabilization exercises to fatigue should be performed once or twice per week.
Protection
- •
Use of either a Sully or Donjoy (formerly SaWa) brace is recommended during initial return to sport, in particular for contact athletes. We prefer the SaWa brace-9 (lace up/strap brace) for contact athletes as it is the only brace demonstrated to limit ER and abd ROM. The Sully (neoprene) is recommended for all others as it has been shown to increase proprioception and kinesthetic awareness which are altered in shoulders with anterior instability.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
As previously described PRN.
Soft Tissue Techniques
- •
As previously described PRN.
Stretching/Flexibility Techniques for the Musculo-Tendinous Unit
- •
Regular assessment of ROM/flexibility during the return to sport progression and after return to sport is important for long-term shoulder function.
Other Therapeutic Exercises
- •
As previously described.
Open and Closed Kinetic Chain Exercises
- •
As previously described.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Care should be taken to ensure that the athlete maintains shoulder-strengthening and dynamic strengthening exercises. We recommend 3 days for 20 to 30 minutes of focused rotator cuff and scapular stabilizing exercises in addition to TBS and TAS that may be apart from normal athletic activities.
Plyometrics
- •
PRN as previously described.
Sport-Specific Exercises
- •
PRN as previously described.
Criteria for Return to Sport
- •
PSS > 95% and WOSI < 10%.
- •
No complaints of pain at rest and minimal to no pain (NPRS 0 to 2/10) following activities.
- •
No or minimal sensation of instability with activities.
- •
Maintenance of sufficient ROM to perform desired activities.
- •
Maintenance of strength and endurance as evidenced by the following:
- •
<10% side-to-side deficit using isokinetic or hand held dynameter for ER, IR, abduction, and elevation.
- •
<33% unilateral ER:IR ratio
- •
30 repetitions in 30 seconds with blue Thera-Band at 0° and 90° abduction
- •
Able to complete 90 hand-taps during modified Davies CKC UE test in 60 seconds.
- •
Evidence
Multiple-Choice Questions
- QUESTION 1.
Recurrent episodes following traumatic anterior shoulder instability generally increase
- A.
The older a patient and less tissues involved.
- B.
The younger a patient and more tissues involved.
- C.
The older a patient and more tissues involved.
- D.
The younger a patient and less tissues involved.
- A.
- QUESTION 2.
Rotator cuff exercises in Phase I are best tolerated
- A.
In the “safe zone” of 20° to 30° abduction in the plane of the scapula.
- B.
In neutral abduction and rotation.
- C.
In supported elevation at 90° of abduction.
- D.
In 45° of abduction and 20° of IR.
- A.
- QUESTION 3.
Which statement best describes the rationale of why recurrent instability is worrisome?
- A.
Clearance for return to sport isn’t based on number of recurrent episodes.
- B.
Contact athletes are at risk for rotator cuff tears with recurrent instability.
- C.
There is no evidence that recurrent instability increases injury risk or long-term disability.
- D.
Recurrent instability episodes may lead to increased incidence of intraarticular pathology and early onset osteoarthritis.
- A.
- QUESTION 4.
Criteria for initiating resistance exercises above shoulder height include
- A.
Pain free at rest, full AROM in abduction and ER.
- B.
Pain free at rest, PROM within functional limits, and negative apprehension test.
- C.
Pain free after exercise, AROM within functional limits, and tolerance of Phase 2 exercises.
- D.
Pain free at rest, AROM within functional limits, and tolerance of Phase 2 exercises.
- A.
- QUESTION 5.
A 16-year-old linebacker is 4 weeks s/p a right shoulder dislocation without labral or bony injuries confirmed by MRI. What criteria should they meet to return to play?
- A.
No sense of instability at end ROM, < 50% ER:IR strength ratio, and 60 hand-taps during CKC UE test.
- B.
No sense of instability at end ROM, < 50% ER:IR strength ratio, and 90 hand-taps during CKC UE test.
- C.
Minimal sense of instability at end ROM, < 33% ER:IR strength ratio, and 60 hand-taps during CKC UE test.
- D.
Minimal sense of instability at end ROM, < 33% ER:IR strength ratio, and 90 hand-taps during CKC UE test.
- A.
Answer Key
- QUESTION 1.
Correct answer: B . (see Overview)
- QUESTION 2.
Correct answer: A . (see ROM Guidelines Phase I )
- QUESTION 3.
Correct answer: D . (see Overview/Return to Sport- Phase IV )
- QUESTION 4.
Correct answer: C . (see Phases II and III )
- QUESTION 5.
Correct answer: D . (see Phase IV -Return to Sport)
Postoperative Rehabilitation after Arthroscopic Anterior Shoulder Stabilization
- Charles A. Thigpen, PhD, PT, ATC
- Ellen Shanley, PhD, PT, OCS
- Richard J. Hawkins, MD
- Ellen Shanley, PhD, PT, OCS
Indications for Surgical Treatment
- •
Disability related to recurrent shoulder instability.
- •
Following first time dislocation selected patients combined with certain pathologies (e.g., full thickness rotator cuff tear following dislocation in older patient, large glenoid or humeral defect).
Brief Summary of Surgical Technique
Major Surgical Steps
- •
Examination under anesthesia for translation in all directions and range of motion.
- •
Positioning in lateral decubitus or sitting (beach chair) position ( Figures 1-18 and 1-19 ). Either requires some lateral distraction.
FIGURE 1-18
The lateral decubitus position. (A) Operative setup. The arm is usually abducted between 45 and 60 degrees. (B) Final balanced suspension setup with the arm abducted about 50 degrees and a lateral strap is used to facilitate the visualization of the glenohumeral joint. Care must be taken to ensure the lateral suspension strap is around a padded arm sleeve.
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach, Philadelphia, 2011, Elsevier (Saunders), p. 37.) Fig. 3-10B and 3-12.
FIGURE 1-19
Beach chair position. Final positioning with the arm reduced to a pneumatic arm positioner. It is easier to reduce the arm to the arm holder that has been previously placed on the pneumatic arm positioner.
(From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach, Philadelphia, 2011, Elsevier (Saunders), p. 41.) Fig. 3-20C.
- •
Prepping and draping protecting vulnerable areas and insuring sterility and accessibility.
- •
Insertion of scope for visualization (establish outflow when necessary) ( Figures 1-20 and 1-21 ).
FIGURE 1-20
Surgical skin landmarks. A, Initial skin markings showing landmarks. Note lateral position of anticipated portal posteriorly. B, Shows portals.
(From Reider B, et al: Operative techniques: sports medicine surgery, Philadelphia, 2010, Elsevier (Saunders) ) Fig. 11-14A and B.
FIGURE 1-21
Outside picture demonstrating arthroscope posterior and 18-gauge needles placed in outside-in fashion. Note anterosuperior portal is adjacent to anterior acromion and anterior mid-glenoid portal is adjacent to coracoid.
From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach, Philadelphia, 2011, Elsevier (Saunders), p. 135.) Fig. 11-15.
- •
Identify pathology and determine approach.
- •
Prepare anterior glenoid surface.
- •
Mobilize labrum and capsule ( Figures 1-22 and 1-23 ).
FIGURE 1-22
Preparation of anterior labrum. A, Arthroscopic view from anterosuperior portal in a right shoulder showing anterior-inferior capsulolabral avulsion. B, Right shoulder showing mobilization of anterior capsulolabral avulsion with subscapularis muscle visible deep to labrum.
From Provencher MT, Romeo AA, editors: Shoulder instability: a comprehensive approach, Philadelphia, 2011, Elsevier (Saunders), pp.136 and 137.) Fig. 11-20 and 11-22.
FIGURE 1-23
Mobilization of labrum and capsule. Sequence of performing plication posteroinferiorly as part of the initial phase of the repair in a right shoulder; viewing portal is anterosuperior. A, A suture shuttling device pierced capsule about 10 mm lateral to labrum at 6 o’clock position. B, The needle is then brought through the labrum and a monofilament suture (0 or No. 1) is passed and retrieved out of the anterior mid-glenoid portal. C, A nonabsorbable suture (No. 2) is tied to the monofilament suture outside the anterior mid-glenoid portal, and the monofilament suture acts to shuttle the nonabsorbable suture. D, Steps are repeated to shuttle the other limb of the nonabsorbable suture through labrum and capsule. E, Mattress plication suture in place posteroinferiorly. F, Mattress plication suture tied; note reduction of posteroinferior redundancy.Related posts:
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