Introduction
- Bryan Warme, MD
- Scott A. Rodeo, MD
Epidemiology
- •
Multidirectional instability (MDI) of the shoulder has various definitions in the literature. Shoulder instability can be categorized into anterior, posterior, or inferior directions. Generally speaking, instability in any two or more of these directions or combination of directions supports a diagnosis of MDI. Furthermore, instability without associated trauma is a characteristic of MDI.
Age
- •
MDI is a relatively rare condition, and it is unknown whether there is a specific age of an athlete during which there is increased vulnerability to manifesting the associated symptoms. This condition appears to be more common in younger individuals.
Sex
- •
It has been suggested that atraumatic MDI may be more common in female athletes, but this anecdotal evidence is not supported by formal studies.
Sport
- •
Swimming has been associated with a higher percentage of athletes with MDI than other sports. There may be a degree of acquired laxity that develops over time in swimmers due to repetitive overhead activity. There is likely also an element of congenital, underlying generalized ligamentous laxity in these athletes ( Figure 3-1 ). Athletes with increased shoulder laxity may have a mechanical advantage in various swimming strokes, thus leading to selection for swimming.
FIGURE 3-1
Generalized laxity in a swimmer demonstrated by bilateral knee hyperextension.
Position
- •
Swimming strokes that require extremes of range of motion may increase the likelihood of having athletes with MDI.
Pathophysiology
Intrinsic Factors
- •
MDI is a complex shoulder condition that remains poorly understood. The underlying pathology is capsular laxity.
- •
Systematic connective tissue disorders can predispose an athlete to MDI. Examples of this include Ehlers-Danlos and Marfan syndromes.
- •
Abnormal muscle activation patterns of the deltoid and periscapular musculature adversely affect the dynamic shoulder stabilizers, leading to scapulothoracic dyskinesis and resultant abnormal kinematics, thereby contributing to MDI.
Extrinsic Factors
- •
It is unclear whether there is an etiologic relationship between competitive swimming and MDI, although it is possible that repetitive overhead activity can lead to glenohumeral laxity. Swimming is a unique sport in that there is constant shoulder motion against resistance (water) at extremes of shoulder motion.
Traumatic Factors
- •
Shoulder instability in general has a spectrum of causes from purely traumatic to completely atraumatic. MDI lies on the atraumatic end of the spectrum, but traumatic causes can underlie shoulder instability in more than one direction.
- •
Matsen developed the “TUBS” and “AMBRI” acronyms to describe the two ends of this instability spectrum: Traumatic vs. MDI.
| Traumatic | Atraumatic |
|---|---|
| Unidirectional | Multidirectional |
| Bankart lesion | Bilateral |
| Surgical stabilization | Rehabilitation |
| Inferior capsular shift |
Classic Pathological Findings
- •
Patulous, redundant, or dysfunctional capsule
- •
Scapular dyskinesis, which may be primary or secondary
Clinical Presentation
History
- •
Classically, there is no traumatic etiology underlying shoulder instability.
- •
A history of asymptomatic shoulder laxity may become symptomatic without an apparent traumatic event.
- •
The typical complaint is pain, although some athletes will report a sense that the shoulder “slips” or “feels loose.”
Physical Examination
Abnormal Findings
- •
2+ Instability (symptomatic laxity) in more than a single direction (anterior, posterior, or inferior). The shoulder should translate to and over the rim of the glenoid with testing and reproduce symptoms of “instability.”
- •
Bilateral shoulder instability without a traumatic etiology.
- •
Sulcus sign suggesting inferior laxity ( Figure 3-2 ).
FIGURE 3-2
Physical examination of a shoulder with MDI demonstrating a positive “Sulcus Sign,” indicative of inferior instability.
(From Altchek DW, Warren RF, Skyhar MJ, Ortiz G: T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am 73:105–112, 1991.)
- •
Jerk test suggesting posterior instability.
- •
Apprehension suggesting anterior instability.
- •
Generalized laxity can suggest underlying connective tissue disorder (e.g., elbow hyperextension or the ability to touch the thumb to the forearm).
Pertinent Normal Findings
- •
Normal neurological and vascular exams (which can be compromised during episodes of instability).
- •
Patient is not able to voluntarily dislocate.
Imaging
- •
Bony injuries such as Hill-Sachs or bony Bankart lesions seen on plain film suggest a traumatic etiology rather than atraumatic MDI.
- •
Magnetic resonance imaging (MRI) can show a “patulous” capsule in MDI. MRI may also show capsular thickening, which reflects adaptive remodeling due to repetitive episodes of plastic deformation of the capsule ( Figure 3-3 ).
FIGURE 3-3
Capsular remodeling as seen on MRI can reflect repetitive plastic deformation.
Arthroscopic Examination
- •
Capsular redundancy and a positive “drive through” sign are hallmarks of MDI on diagnostic arthroscopy ( Figure 3-4 ).
FIGURE 3-4
Postive “drive through” sign on arthroscopy indicative of shoulder laxity.
Differential Diagnosis
- •
Traumatic unidirectional instability—look for traumatic lesions on radiographs and instability in only one direction.
- •
Posterior shoulder dislocation due to seizure/convulsion—again, confirm instability only in the posterior direction.
- •
Voluntary dislocation with or without underlying psychiatric condition—these patients may have MDI, but these underlying diagnoses can make it difficult to achieve a stable outcome, regardless of treatment modality.
Treatment
Nonoperative Management
- •
Rehabilitation is the mainstay of treatment for MDI. Most treating physicians recommend a minimum of 6 to 12 months of rehabilitation before considering any surgical intervention in MDI.
- •
Pain-relieving modalities such as nonsteroidal antiinflammatory drugs (NSAIDs) and selective use of injections can be used adjunctively with rehabilitation if necessary.
- •
Exercises aimed at improving coordination of shoulder muscle activation can improve dynamic shoulder stability.
- •
Ultimately, activity modification may be necessary to exclude those shoulder positions for which subluxation events are most likely.
Guidelines for Choosing among Nonoperative Treatments
- •
Proprioception training and scapular stabilization exercises are important when the athlete is unable to actively control the humeral head concentrically on the glenoid.
- •
Cessation of the offending sport is at the discretion of the athlete.
- •
Pain-relieving modalities should be used conservatively, and opioid pain medication should only be used in acute settings for short periods of time.
Surgical Indications
- •
There are no absolute indications for surgical stabilization of MDI.
- •
Relative indications for surgery are failure of extended rehabilitation and trials of activity modification and/or cessation of the affecting sport.
- •
Ultimately, surgery for MDI is less predictable than for traumatic, unidirectional instability. The athlete must be an informed patient, appreciating the unpredictability of the surgery and the potential complications. Furthermore, the surgeon must be confident that improved stability can be achieved through an operation if surgery is to be indicated.
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
History of voluntary dislocation, especially in the setting of an underlying psychiatric condition, predicts a poor surgical outcome. In these cases, treatment should consist of rehabilitation exclusively. If the underlying psychiatric condition resolves, then surgery can be considered if extended rehabilitation has failed to improve stability.
- •
If there is a traumatic injury underlying MDI, earlier surgical intervention can be considered to concomitantly address the traumatic injury (e.g., Bankart lesion) and the MDI (e.g., patulous capsule).
Aspects of Clinical Decision Making When Surgery is Indicated
- •
The directions of instability are important to surgical planning. Although both open and arthroscopic techniques have been described for MDI, open techniques have traditionally been the mainstay of surgical intervention for MDI. The direction of instability influences the decision to open the shoulder either anteriorly or posteriorly. Most surgical repairs are now done arthroscopically.
- •
A combination of open and arthroscopic approaches can be used if both anterior and posterior instability are present to limit the open aspect of the surgery to a single incision. Alternatively, both anterior and posterior incisions can be used to allow open stabilization of both anterior and posterior stabilization ( Figures 3-5, 3-6, and 3-7 ).
FIGURE 3-5
Open inferior capsular shift, as proposed by Neer.
(Redrawn from Neer CS 2nd, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am 62:897–908, 1980.)
FIGURE 3-6
T-plasty modification of the inferior capsular shift, as proposed by Altchek.
(Redrawn from Altchek DW, Warren RF, Skyhar MJ, Ortiz G: T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am 73:105– 112, 1991.)
FIGURE 3-7
Arthroscopic capsular placation ( A ) and rotator interval closure ( B ).
Evidence
Multiple-Choice Questions
- QUESTION 1.
MRI of a shoulder with MDI often reveals:
- A.
Fatty infiltration of the rotator cuff
- B.
Bone edema adjacent to a Hill-Sachs lesion
- C.
Concomitant acromioclavicular (AC) joint arthrosis
- D.
Patulous capsule
- A.
- QUESTION 2.
According to Matsen et al., two factors that are more closely associated with MDI than traumatic shoulder instability include:
- A.
Bankart and Hill-Sachs lesions
- B.
Multidirectionality and bilaterality
- C.
Traumatic etiology and unidirectionality
- D.
Shoulder weakness and paresthesias
- A.
- QUESTION 3.
Which of the following patient attributes predicts a poor surgical outcome after MDI stabilization?
- A.
Age less than 20
- B.
Smoking history
- C.
Underlying psychiatric condition
- D.
BMI greater than 35
- A.
- QUESTION 4.
The mainstay of treatment for MDI should be:
- A.
Surgical stabilization
- B.
Rehabilitation
- C.
Pain medication
- D.
Benign neglect
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Clinical Presentation )
- QUESTION 2.
Correct answer: B (see Clinical Presentation and Evidence)
- QUESTION 3.
Correct answer: C (see Treatment )
- QUESTION 4.
Correct answer: B (see Treatment )
Nonoperative Rehabilitation of Multidirectional Shoulder Instability
- John T. Cavanaugh, PT, MEd, ATC, SCS
- Scott A. Rodeo, MD
- •
Communicate with referring physician
- •
Treat patient as an individual
- •
Consider physiological healing restraints
- •
Develop strong base of support: Scapular strengthening
- •
Identify direction of greatest instability
- •
Incorporate exercises high in neuromuscular activation
- •
Functional progression
- •
Patients referred for physical therapy with the diagnosis of MDI often present with varied symptoms. Some patients may present acutely following an episode of instability, whereas others present relatively asymptomatic with full range of motion (ROM) and normal strength on physical examination.
- •
Throughout the rehabilitation course an emphasis is placed on neuromuscular training to train the shoulder’s dynamic stabilizers to engage when needed to aid in stability. These neuromuscular exercises are encouraged as early as deemed appropriate in the rehabilitation program.
- •
The patient needs to be treated as an individual and treated based on information gained from their history, subjective complaints, radiographic imaging, physical examination, and the direction of the referring physician.
Phase I (weeks 0 to 8)
- •
A thorough physical examination can identify deficits in ROM, flexibility, laxity, and strength. Scapular dyskinesis, winging, and atrophy can also be observed. Apprehension and stability testing provide the rehabilitation specialist with valuable information as it pertains to the direction of greatest instability ( Figure 3-8 ).
FIGURE 3-8
Load and shift laxity testing.
- •
Patients may very well present with only symptoms in overhead sports activities; e.g., baseball and swimming. These patients may present on initial examination with full ROM and normal strength and scapulohumeral rhythm. Their laxity exam along with subjective complaints and history confirm their diagnosis.
- •
These patients begin their rehabilitation program at a more advanced level, incorporating exercise and activities found in Phases II and III of the general guideline.
| PHASE I (weeks 0 to 8) | PHASE II (weeks 8 to 14) | PHASE III (weeks 14 to 20) |
|---|---|---|
|
|
|
Protection
- •
During the first phase of rehabilitation, care is taken to allow for healing and recovery from trauma (if applicable). The patient/athlete who complains of microinstability is treated predominantly based on symptoms.
- •
For the first-time dislocator, sling immobilization may be indicated for up to 4 weeks after an instability episode.
- •
Immobilization for less than 2 weeks for patients who report an episode of subluxation or recurrent dislocation.
- •
Patient/athlete is advised to avoid symptomatic positions that provoke apprehension.
- •
Modification of daily activities is emphasized: i.e., no heavy lifting or overhead activities of daily living (ADL).
Management of Pain and Swelling
- •
During the posttraumatic period the daily use of cryotherapy and antiinflammatory medication are recommended.
- •
Electrical stimulation in the form of transcutaneous electrical nerve stimulation (TENS) can be used to assist in pain control.
- •
NSAIDs as needed.
Techniques for Progressive Increase in Range of Motion
- •
ROM deficits are addressed with respect to the direction of instability and the timetable set forth by the referring physician. For example, for patients whose recent episode entailed an anterior subluxation, external rotation (ER) will be initially limited to 30° and forward flexion (scapular plane) limited to 90°. Full ROM should be restored by 8 weeks after trauma.
Manual Therapy Techniques
- •
Gentle active assisted range of motion (AAROM) in scapular plane (if needed).
Soft Tissue Techniques
- •
Soft tissue massage: scapular musculature.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
ER is regained via a supine wand exercise.
- •
Forward flexion by supine active-assistive exercise, at first with the assistance of the noninvolved upper extremity, progressing to using a wand.
- •
Internal rotation (IR) via a towel-pass exercise while the patient attempts to pass a towel around his/her back. IR is then progressed to a towel-stretch exercise.
Other Therapeutic Exercises
- •
Core-stability exercises.
- •
Lower-extremity strengthening without use of upper extremity.
- •
Distal upper-extremity strengthening (forearm, wrist, hand) exercises.
Activation of Primary Muscles Involved
- •
Exercises are performed for the following muscle groups:
- •
Serratus anterior, rhomboids
- •
Trapezius muscles
- •
Levator scapulae
- •
Deltoid muscles
- •
Rotator cuff musculature
- •
Humeral positioners
- •
Sensorimotor and Neuromuscular Dynamic Stability Exercises
- •
Manual humeral head control exercises where the patient needs to react to the direction of force provided by the rehabilitation specialist (perturbation exercises) attempt to reestablish neuromuscular pathways to provide dynamic stability of the glenohumeral joint ( Figure 3-9 ).
FIGURE 3-9
Neuromuscular dynamic stability exercises.
Open and Closed Kinetic Chain Exercises
- •
Closed kinetic chain (CKC) stabilization exercises using a physioball are included for patients whose symptomatic direction of instability is anterior ( Figure 3-10 ).
FIGURE 3-10
CKC stabilization exercises using a physioball.
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Deltoid isometrics are initiated as symptoms allow.
- •
Early scapular strengthening is initiated as soon as these exercises are asymptomatic. Specific techniques used include manual resistance and rhythmic stabilization to scapular musculature. This technique can be started early on with the patient sidelying and the involved upper extremity supported in a neutral rotated position ( Figure 3-11 ).
FIGURE 3-11
Manual scapular stabilization exercises performed sidelying with the humerus positioned in neutral rotation.
- •
As symptoms subside during this phase, scapular retraction isometrics and isotonic exercises are introduced as supine “serratus” punches ( Figure 3-12 ).
FIGURE 3-12
Serratus anterior exercise performed supine.
- •
When scapulothoracic rhythm normalizes, scapular plane elevation “scaption” is performed and advanced in a progressive resistive exercise (PRE) fashion ( Figure 3-13 ).
FIGURE 3-13
Forward elevation in the scapular plane (“scaption”).
- •
IR and ER isometrics are initiated in a modified neutral position and performed submaximally.
- •
Upper-body ergometer (as symptoms allow).
Milestones for Progression to the Next Phase
- •
Full AROM and passive ROM.
- •
Scapulohumeral rhythm normalized throughout AROM as measured by visual observation, assuring symmetry, lack of dynamic scapula winging, and hiking.
- •
Sufficient scapular strength base: Demonstration of strength gains via PRE in proportion to body type/size.
- •
5/5 Manual muscle testing throughout involved upper extremity (scapular muscles, humeral head positioners, and rotator cuff muscles).
Phase II (weeks 8 to 14)
- •
Many patients/athletes with MDI may very well enter their rehabilitation program at an advanced level as described here in Phase II. This advanced phase emphasizes the need to clinically evaluate the athlete to properly challenge the shoulder complex.
- •
Dynamic neuromuscular control about the glenohumeral joint is crucial for optimal performance in sports. EMG studies have demonstrated that patients with MDI exhibit altered functioning of the humeral head positioners and dynamic stabilizers of the glenohumeral joint during functional and complicated movements.
- •
Because ROM and muscle strength have been normalized before this phase is entered, a greater emphasis is placed on training the neuromuscular structures throughout the shoulder complex during this phase.
Protection
- •
Activity modification in ADL, avoiding motions that bring on symptoms (pain, instability) e.g., overhead movements.
Management of Pain and Swelling
- •
Ice and electrical stimulation (TENS) as needed.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Continue humeral head control/rhythmic stabilization exercises.
- •
Proprioceptive neuromuscular facilitation (PNF) patterns with manual resistance (D1, D2) ( Figure 3-14 ).
FIGURE 3-14
Manual resistance with PNF D2 pattern.
Soft Tissue Techniques
- •
Soft tissue massage to scapular musculature.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Address inflexibility issues on an individual basis: e.g., pectoralis minor tightness, glenohumeral IR deficits (GIRD) (thixotrophy of the infraspinatus and teres minor).
Other Therapeutic Exercises
- •
Lower-extremity strengthening program, running, plyometrics specific to sport.
- •
Core-stability program.
- •
Wrist and elbow strengthening, especially for throwing athletes.
Activation of Primary Muscles Involved
- •
Scapular stabilizers (serratus anterior; rhomboids; upper, middle, and lower trapezius; levator scapulae).
- •
Glenohumeral stabilizers (deltoid, humeral head positioners, rotator cuff musculature).
Sensorimotor and Neuromuscular Dynamic Stability Exercises
- •
Rhythmic stabilization.
- •
Humeral head control exercises.
- •
PNF exercises.
- •
Scapular stabilization exercises, CKC using a physioball on wall: bilateral → unilateral → manual perturbations.
- •
Bodyblade (below horizontal).
Techniques to Increase Muscle Strength, Power, and Endurance
Open and Closed Kinetic Chain Exercises
- •
IR/ER TheraBand (modified neutral).
- •
IR/ER isokinetics (modified neutral).
- •
Scaption with weights (PRE).
- •
Ball stabilization on wall.
- •
Serratus “punches” (PRE).
- •
Prone “hitch-hiker” (middle trapezius muscle strengthening).
- •
Prone lower-trapezius strengthening (PRE).
- •
Biceps/triceps (PRE).
- •
Row machine (PRE).
- •
Chest press machine (PRE) (limit arc) to symptom-free ROM.
- •
Latissimus dorsi pulldown machine (PRE) (limit arc) to symptom-free ROM.
- •
Upper-body ergometer.
Functional Exercises
- •
D1/D2 PNF patterns with TheraBand or resistance exercise machines.
- •
Resistance exercise machine or pulley system: reciprocal flexion.
Plyometrics
- •
Two-handed chest press toss vs. plyoback.
Sport-Specific Exercises
- •
Baseball, tennis, volleyball, golf: scaption, trunk rotation exercises seated on physioball.
- •
Swimming: prone PRE exercises; e.g., lower trapezius, “hitch-hiker,” shoulder extension on physioball ( Figure 3-15 ).
FIGURE 3-15
“Hitch-hiker” exercise performed prone on physioball.
Milestones for Progression to the Next Phase
- •
Lack of apprehension with overhead movements.
- •
IR/ER isokinetic test greater than 75% limb symmetry.
- •
0/10 pain in all ADL.
Phase III (weeks 14 to 20)
- •
With the athlete relatively asymptomatic and having achieved a sufficient strength base, he/she is now ready to challenge the shoulder complex with more demanding exercises that mimic the demands of their individual sport.
- •
During this phase, emphasis is placed on increasing strength, power, and endurance as well as a gradual return to sport.
- •
Valuable information can be gained from isokinetic testing, so that any deficits or muscle imbalances across the glenohumeral joint can be addressed in the final phase of rehabilitation.
- •
Intensity and volume should be structured and closely monitored to avoid overuse symptoms from developing.
Management of Pain and Swelling
- •
Ice and electrical stimulation (TENS) as needed.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Continue humeral head control/rhythmic stabilization exercises.
- •
PNF patterns with manual resistance (D1, D2).
Soft Tissue Techniques
Continue soft tissue massage to upper extremity as needed.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Continue to address inflexibility issues on an individual basis: e.g., pectoralis minor tightness, GIRD (thixotrophy of the infraspinatus and teres minor).
Other Therapeutic Exercises
- •
Lower-extremity strengthening program, running, plyometrics specific to sport.
- •
Core-stability program.
- •
Wrist and elbow strengthening, especially for throwing athletes.
Activation of Primary Muscles Involved
- •
Scapular stabilizers (serratus anterior; rhomboids; upper, middle, and lower trapezius; levator scapulae), glenohumeral stabilizers (deltoid, humeral head positioners, rotator cuff musculature).
Sensorimotor and Neuromuscular Dynamic Stability Exercises
- •
Rhythmic stabilization.
- •
Humeral head control exercises (give some specific examples of exercises to accomplish this).
- •
PNF exercises.
- •
Scapular stabilization exercises, CKC using a physioball on wall: unilateral with manual perturbations.
- •
Bodyblade (above horizontal).
- •
BOSU ball upper-extremity stabilization, bilateral → unilateral with perturbations ( Figure 3-16 ).
FIGURE 3-16
Upper-extremity stabilization using BOSU ® ball (foot taps for perturbations).
Techniques to Increase Muscle Strength, Power, and Endurance
Open and Closed Kinetic Chain Exercises
- •
IR/ER TheraBand (modified neutral and 90°/90°).
- •
IR/ER isokinetics (modified neutral).
- •
Scaption with weights (PRE).
- •
Unilateral ball stabilization on wall.
- •
Serratus “punches” (PRE).
- •
Prone “hitch-hiker” (middle trapezius).
- •
Prone lower-trapezius strengthening (PRE).
- •
Biceps/triceps (PRE).
- •
Row machine (PRE).
- •
Chest press machine (PRE).
- •
Latissimus dorsi pulldown machine (arc) (PRE).
- •
Military press (PRE).
- •
Bench press (wide grip).
- •
Upper-body ergometer.
Plyometrics
- •
Advance to overhead “soccer throw,” diagonal toss (overhead) vs. plyoback.
- •
D2 deceleration with plyoball off wall (throwers).
- •
Unilateral plyoball toss: supine → standing (90/90) vs. plyoback.
Functional Exercises
- •
D1/D2 PNF patterns with TheraBand or resistance exercise machines.
- •
Resistance exercise machine or pulleys system: reciprocal flexion.
Sport-Specific Exercises
- •
Baseball, tennis, volleyball, golf: Scaption, military press, trunk rotation exercises seated on physioball.
- •
Swimming: Prone PRE exercises; e.g., lower trapezius, “hitch-hiker,” shoulder extension on physioball.
- •
Resistance exercise machine or pulley system to replicate sport-specific movements: e.g., forehand/backhand tennis, polling cross-country skiing movement.
- •
Interval throwing program (baseball).
- •
Tennis: ground strokes → overhead volleys/serving (monitor volume).
- •
Volleyball: Overhead serving/spiking (monitor volume).
- •
Swimming: breaststroke → freestyle before advancing to backstroke/butterfly (monitor volume).
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Asymptomatic (apprehension/pain) with overhead sport-specific ovements.
- •
IR/ER isokinetic test greater than 90% limb symmetry.
- •
Independent with home/gym therapeutic exercise program for maintenance and progression of strength, power, endurance gains made in physical therapy.
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Continued pain, apprehension, or complaints of instability during ADL and/or sport-specific exercises and movements.
- •
Poor compliance with rehabilitation resulting in continued symptoms.
Tips and Guidelines for Transitioning to Performance Enhancement
- •
Care is taken to avoid overtraining and incorporating rest and cross training into the treatment regimen.
- •
The athlete should take note to initially avoid combining weight training and sport-specific training, e.g., throwing, swimming, tennis strokes on the same day. As symptoms allow, sport-specific training can be performed on consecutive days.
- •
Communication with the athlete’s strength and conditioning coach or whoever will be responsible for the continuation of care is vital to ensure a safe, noncomplicated return to sport.
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
It is vital to communicate with the athlete’s coach that upon to return to team practice, the athlete returning from injury is not be treated the same as team players who are otherwise deemed healthy.
- •
Volume and repetitions need to be modified for the individual who has returned to the team following his/her course of rehabilitation.
- •
Bracing for sports such as football and lacrosse may be recommended by the physician on an individual basis ( Figure 3-17 ).
FIGURE 3-17
Shoulder stabilizer brace (Breg Inc., Vista, CA).
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Asymptomatic (apprehension/pain) with overhead sport-specific movements.
- •
IR/ER isokinetic test > 90% limb symmetry (muscular strength, power, and endurance).
- •
Isokinetic test: ER to IR ratio > 70%.
- •
Independent with home/gym therapeutic exercise program for maintenance and progression of strength, power, and endurance gains made in physical therapy.
- •
Physician clearance.
Evidence
Multiple-Choice Questions
- QUESTION 1.
For athletes who have sustained a recurrent episode of instability, sling immobilization should be used for no greater than:
- A.
2 weeks
- B.
4 weeks
- C.
6 weeks
- D.
8 weeks
- A.
- QUESTION 2.
For athletes who have sustained an episode of anterior instability, which motion will initially be limited?
- A.
IR
- B.
ER
- C.
Horizontal adduction
- D.
Flexion to 45°
- A.
- QUESTION 3.
All of the following exercises strengthen in isolation one of the scapular muscles, except:
- A.
Supine “punch”
- B.
Prone “hitch-hiker”
- C.
Shrugs
- D.
CKC ball stabilization on wall
- A.
- QUESTION 4.
In determining strength assessment for return to sport, IR/ER isokinetic testing should reveal a limb symmetry of:
- A.
70%
- B.
80%
- C.
90%
- D.
100%
- A.
- QUESTION 5.
Toward the latter stages of rehabilitation, an athlete transitions into a sport-specific training (throwing, swimming, etc.) program. Such training should initially be performed.
- A.
Every day
- B.
Every other day
- C.
Every 3 days
- D.
Once a week
- A.
Answer Key
- QUESTION 1.
Correct answer: A (see Phase I )
- QUESTION 2.
Correct answer: B (see Phase I )
- QUESTION 3.
Correct answer: D (see Phase II )
- QUESTION 4.
Correct answer: C (see Phase III )
- QUESTION 5.
Correct answer: B (see Phase III )
Related posts:
Adhesive Capsulitis and Glenohumeral Arthritis
Patellar Instability
Midfoot Strains and Sprains and Lisfranc Injuries
Triangular Fibrocartilage Complex Injuries
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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