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Rehabilitation of the In-Season and Postoperative Athlete

Kevin E. Wilk, PT, DPT and Lenny Macrina, MSPT, SCS, CSCS

Shoulder instability is a common pathology seen in athletes and in active individuals. The glenohumeral joint is the most commonly dislocated major joint in the human body. This is probably due to the inherent laxity and tremendous range of motion (ROM) exhibited by individuals along with the large amounts of stress applied to the shoulder joint. Thus, the glenohumeral joint is inherently unstable in many individuals. Mannava et al¹ reported 15% of all players reporting to the National Football League Combine exhibited labral tears. Brophy et al^2,3 stated it was the fourth most common procedure seen at the Combine. Furthermore, it is the fourth most common procedure performed in college football players.⁴

Following injury or surgery, we believe appropriate well-designed rehabilitation is essential to a successful outcome. The rehabilitation must be based on numerous factors (we will discuss those later), but perhaps the most important factor is a team approach to the rehabilitation program. The physician and the physical therapist must communicate regarding the type of surgery performed, concomitant procedures or lesions, and the surgeon’s overall impression regarding the rate of progression based on tissue quality, bone quality, etc. The specific factors will be discussed in this chapter.

In this chapter we will discuss the postoperative rehabilitation guidelines following specific surgical procedures such as Bankart repairs, Latarjet procedures, and remplissage procedure. In addition, we will discuss our return-to-play criteria for patients returning to sports and higher-level functional activities.

REHABILITATION FACTORS

There are 9 key factors that should be considered when designing a rehabilitation program for a patient with shoulder instability (Table 14-1). We will briefly discuss these factors and their significance to the rehabilitation program.

Onset of Pathology

The first factor to consider in the rehabilitation of a patient with shoulder instability is the onset of the pathology. Shoulder instability may result from an acute event, a traumatic event, or from chronic recurrent episodes. The goal of the rehabilitation program may vary greatly based on the onset and mechanism of injury.

Following a traumatic subluxation or dislocation, the patient typically presents with significant tissue trauma, pain, muscle guarding, and apprehension. The first-time dislocation episode is generally more painful than recurrent episodes.

Conversely, a patient presenting with atraumatic or chronic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks.

Degree of Instability

The second factor is the degree of instability present in the patient and its effect on his or her function. Varying degrees of shoulder instability exist such as a subtle subluxation to gross (uncontrollable) instability.

Speer et al5 has reported that for a shoulder dislocation to occur, a Bankart lesion must be present. Furthermore, soft-tissue trauma must be present on both sides of the glenohumeral joint capsule. Thus, an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid (Bankart lesion) and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept” as described by Warren et al.⁶

Frequency

The next factor to influence the rehabilitation program is the frequency of dislocation or subluxation. The primary traumatic dislocation is most often treated conservatively with immobilization in a sling and early controlled passive ROM (PROM) exercises, especially with first-time dislocations. The incidence of recurrent dislocation ranges from 17% to 96% with a mean of 67% in patient populations between ages 21 and 30 years.^7–18 Therefore, the rehabilitation program should progress cautiously in young, athletic individuals.

It should be noted that Hovelius et al^26–29 has demonstrated that the rate of recurrent dislocations is based on the patient’s age and is not affected by the length of postinjury immobilization. Individuals between ages 19 and 29 years are the most likely to experience multiple episodes of instability. Hovelius et al^10,19–21 noted patients in their 20s exhibited a recurrence rate of 60% whereas patients in their 30s to 40s had less than a 20% recurrence rate. In adolescents, the recurrence rate is as high as 92%²² and 100% with an open physes.²³

Chronic subluxations, as seen in the atraumatic, unstable shoulder, may be treated more aggressively because of the lack of acute tissue damage, less muscular guarding, and inflammation. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities. The goal is to return the patient’s ROM, enhance strength, proprioception, dynamic stability, and neuromuscular control. This is especially true in the specific points of motion or direction that results in instability complaints.

Direction of Instability

The fourth factor is the direction of instability present. The 3 most common forms include anterior, posterior, and multidirectional. Anterior instability is the most common traumatic type of instability seen in the general orthopedic population. It has been reported that this type of instability represents approximately 90% to 95% of all traumatic shoulder instabilities.¹⁵ However, the incidence of posterior instability appears to be dependent on the patient population.²⁴ For example, in professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen because of the pushing methods employed during the blocking motion. Mair et al²⁵ reported on 9 athletes with posterior instability, 8 of 9 of whom were linemen and 7 of whom were offensive linemen. Often, these patients require surgery, as Mair and colleagues²⁵ also reported 75% required surgical stabilization. Kaplan and colleagues⁴ reported in a study of collegiate football players with shoulder instability that 78% required surgical stabilization. Overhead athletes undergoing a posterior labral repair are less likely to return to their preinjury levels of sport compared with contact athletes or the overall athletic population.²⁶

Multidirectional instability (MDI) can be identified as shoulder instability in more than one plane of motion. Patients with MDI often have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule. Furthermore, Rodeo et al²⁷ reported that this type of patient exhibits a greater concentration of elastin compared to collagen and also smaller-diameter collagen fibrils. The authors consider an inferior displacement of greater than 8 to 10 mm during the sulcus maneuver (Figure 14-1) with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity.²⁸

Owing to the atraumatic mechanism and lack of acute tissue damage, ROM is often normal to excessive. Patients with recurrent shoulder instability due to MDI generally have weakness in the rotator cuff, deltoid, and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers.

The fifth factor involves considering other tissues that may have been affected and the premorbid status of the tissue. Disruption of the anterior capsulolabral complex from the glenoid commonly occurs during a traumatic injury resulting in an anterior Bankart lesion. Often osseous lesions may be present, such as a concomitant Hill-Sachs lesion caused by an impaction of the posterolateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation. This has been reported in up to 80% of dislocations.29–31 Conversely, a reverse Hill-Sachs lesion may be present on the anterior aspect of the humeral head due to a posterior dislocation.³² Also, glenoid bone loss of approximately 20% to 25% after a dislocation is considered significant and may contribute to long-term instability episodes for the patient. Recent studies show that not even 15% to 17% glenoid bone loss may be a critical level, as well.^33–35

Occasionally, a bone bruise may be present in individuals who have sustained a shoulder dislocation thereby restricting upper extremity weight-bearing activities early on in the rehabilitation process. In rare cases of extreme trauma, the brachial plexus may become involved as well.³⁶ Burkhart and De Beer³⁷ reported some patients exhibited a bony defect or inverted-pear–shaped glenoid resulting in recurrent instability if not accurately identified or properly treated. Other common injuries in the unstable shoulder may involve the superior labrum (SLAP lesion) such as a type V SLAP lesion characterized by a Bankart lesion of the anterior capsule extending into the anterior superior labrum.³⁸ Injuries to the rotator cuff may also be observed and significantly affect the rehabilitation progression and long-term function of the patient. These concomitant lesions will affect the rehabilitation significantly to protect the healing tissue.

Neuromuscular Control

The sixth factor to consider is the patient’s level of neuromuscular control, particularly at end range. Neuromuscular control may be defined as the efferent, or motor output in reaction to an afferent, or sensory input.^13,28 The afferent input is the ability to detect the glenohumeral joint position and motion in space with resultant efferent response by the dynamic stabilizers as they blend with the joint capsule to assist in stabilization of the humeral head. Injury with resultant insufficient neuromuscular control could result in deleterious effects to the patient. As a result, the humeral head may not center itself within the glenoid, thereby compromising the surrounding static stabilizers. The patient with poor neuromuscular control may exhibit excessive humeral head migration with the potential for injury, an inflammatory response, and reflexive inhibition of the dynamic stabilizers.

Several authors have reported that neuromuscular control of the glenohumeral joint may be negatively affected by joint instability. Lephart et al¹³ compared the ability to detect passive motion and the ability to reproduce joint positions in normal, unstable, and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared both to normal shoulders and shoulders undergoing surgical stabilization procedures. Smith and Brunolli³⁹ reported a significant decrease in proprioception following a shoulder dislocation. Blasier and colleagues⁴⁰ reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity. Zuckerman et al⁴¹ noted that proprioception is affected by the patient’s age, with older patients exhibiting diminished more proprioception than a comparably younger population. Thus, the patient presenting with traumatic or acquired instability may present with poor proprioception and neuromuscular control.

Arm Dominance

The seventh factor to consider in the nonoperative rehabilitation of the unstable shoulder is the arm dominance and the desired activity level of the patient. If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball, or a throwing sport, then the rehabilitation program should include sport-specific dynamic stabilization exercises, neuromuscular control drills, and Plyometric exercises in the overhead position once full, pain-free ROM, and adequate strength has been achieved. Patients whose functional demands involve below-shoulder–level activities will follow a progressive exercise program to return full ROM and strength. The success rates of patients returning to overhead sports after a traumatic dislocation of their dominant arm are extremely low.^42,43 Arm dominance can also significantly influence the successful outcome. The recurrence rates of instabilities vary based on age, activity level, and arm dominance. In athletes involved in collision sports, the recurrence rates have been reported between 86% and 94%.^8,44–47

The next factor is the age of the patient. Younger patients (ages 17 to 24 years) tend to exhibit a lesion different from older patients (older than 40 years). Younger patients usually exhibit a Bankart lesion, and some may even exhibit a humeral avulsion of the glenohumeral ligament lesion. Conversely, older patients may exhibit an anterior labral periosteal avulsion lesion.48 The patient’s age is a significant prognostic factor for recurrent instability and generally a very important consideration for treatment.

Patient Goals

The ninth, and maybe the most critical factor, is the activity level and type of activities the patient desires to return to once full ROM and strength are obtained. Patients who desire to return to strenuous and aggressive activities, especially overhead or involving contact sports, should undergo surgical repair if a capsulolabral lesion is present. In contrast, inactive patients or patients with low-risk activities may be able to be treated successfully without surgery.

NONOPERATIVE REHABILITATION GUIDELINES

Patients may be classified into 2 common forms of shoulder instability: traumatic and atraumatic. Specific guidelines to consider in the rehabilitation of each patient population will be outlined. A 4-phase rehabilitation program will be discussed for traumatic shoulder instability, followed by an overview of variations and key rehabilitation principles for atraumatic (congenital) laxity.

Traumatic Shoulder Instability

Phase I, Acute Phase

Following a first-time traumatic shoulder dislocation or subluxation, the patient often presents in considerable pain, muscle spasm, and an acute inflammatory response. Patients usually self-limit their motion by guarding the injured extremity in an internally rotated and adducted position against the side of their body to protect the injured shoulder. The goals of the acute phase are to 1) diminish pain, inflammation, and muscle-guarding; 2) promote and protect healing soft tissues; 3) prevent the negative effects of immobilization; 4) reestablish baseline dynamic joint stability; and 5) prevent further damage to the glenohumeral joint capsule (Table 14-2).

We allow immediate limited and controlled motion following a traumatic dislocation in some patients (ages 18 to 28 years) but immobilize patients ages 29 to 45 years. However, motion is restricted so as not to cause further tissue attenuation. A short period of immobilization in a sling to control pain and to allow scar tissue to form for enhanced stability may be necessary for 7 to 14 days although no long-term benefits regarding recurrence rates and immobilization have been made in patients ages 17 to 29 years.^10,49 Individuals older than 29 years are usually immobilized for 2 to 4 weeks to allow scarring of the injured capsule. The ideal position in which to immobilize the glenohumeral has traditionally been in internal rotation with the arm close to the body. Potential complications with immobilization may include a decrease in joint proprioception, muscle disuse and atrophy, and a loss of ROM in specific age groups. Therefore, prolonged use of immobilization following a traumatic dislocation may not be recommended in all patients.

PROM is initiated in a restricted and protected range based on the patient’s symptoms. Early motion is intended to promote healing, enhance collagen organization, stimulate joint mechanoreceptors, and aid in decreasing the patient’s pain through neuromuscular modulation.^17,50–52 Pain-free active-assisted ROM (AAROM) exercises such as pendulums and external/internal rotation at 45 degrees of abduction using an L-bar (Breg Corp) may also be initiated. PROM exercises are also performed in a pain-free arc of motion. In addition, passive/active joint positioning is also performed in a restricted motion. Modalities such as ice, low-level laser, or transcutaneous electrical nerve stimulation may also be beneficial to decrease pain, inflammation, and muscle guarding.

Strengthening exercises are initially performed through submaximal, pain-free isometric contractions to initiate muscle recruitment and retard muscle atrophy. Electrical stimulation of the posterior cuff musculature may also be incorporated to enhance this muscle-fiber–recruitment process early on in the rehabilitation process and also in the next phase when the patient initiates isotonic strengthening activities (Figure 14-2). Reinold et al⁵³ stated that the use of electrical stimulation may improve force production of the rotator cuff, particularly the external rotators, immediately after an acute injury.

Dynamic stabilization exercises are also performed to reestablish dynamic joint stability. The patient maintains a static position as the rehabilitation specialist performs manual rhythmic stabilization drills to facilitate muscular co-contractions. These manual rhythmic stabilization drills are performed for the shoulder internal and external rotators in the scapular plane at 30 degrees of abduction and are performed at pain-free angles that do not compromise the healing capsule. Rhythmic stabilizations for flexion and extension may also be performed with the shoulder at 100 degrees of flexion and 10 degrees of horizontal abduction. Strengthening exercises are also performed for the scapular retractors and depressors to reposition the scapula in its proper position. Scapula strengthening is critical for successful rehabilitation.

Closed kinetic-chain exercises such as weight-shifting on a ball are performed to produce a co-contraction of the surrounding glenohumeral musculature and to facilitate joint mechanoreceptors to enhance proprioception. Weight shifts are usually able to be performed immediately following the injury unless posterior instability or an articular cartilage lesion (bone bruise) is present.

During the intermediate phase, the program emphasizes regaining full ROM along with progressing strengthening exercises of the rotator cuff, reestablishing the muscular balance of the glenohumeral joint, scapular stabilizers, and surrounding shoulder muscles. Before the patient enters phase II certain criteria must be met, including diminishing pain and inflammation, satisfactory static stability, and adequate neuromuscular control.

Isotonic strengthening exercises are also initiated during this phase. Emphasis is placed on increasing the strength of the internal and external rotators and scapular muscles to maximize dynamic stability. The ultimate goal of the strengthening phase is to reestablish muscular balance following the injury. Kibler et al12 noted that scapular position and strength deficits have been shown to contribute to glenohumeral joint instability. Exercises initially include external and internal rotation with exercise tubing at 0 degrees of abduction along with sidelying external rotation and prone rowing. During the latter part of this phase, exercises are progressed to include the “Progressive isotonic strengthening program” (Table 14-3) to emphasize rotator cuff and scapulothoracic muscle strength (Figure 14-3). Manual resistive exercises such as sidelying external rotation and prone rowing may also prove beneficial by having the clinician vary the resistance throughout the ROM. Incorporating manual concentric and eccentric manual exercises and rhythmic stabilization drills at end range to enhance neuromuscular control and dynamic stability is also recommended (Figure 14-4).

Closed kinetic-chain exercises are progressed to include hand on the wall stabilization drills in the plane of the scapular at shoulder height as the patient tolerates (Figure 14-5). Push-ups are performed first with hands on a table then progressed to a push-up on a ball or unstable surface while the rehabilitation specialist performs rhythmic stabilizations to the involved and uninvolved upper extremity along with the trunk to integrate dynamic stability and core strengthening (tilt board, ball, etc) (Figure 14-6). Caution should be taken while performing closed kinetic-chain exercises in patients with posterior instability for 6 to 8 weeks to allow for adequate tissue healing and strength gains. Furthermore, patients with significant scapular winging should perform push-ups with a plus⁵⁴ until adequate scapular strength is accomplished. Core stabilization drills should also be performed to enhance scapular control. Additionally, strengthening exercises may be advanced in regards to resistance, repetitions, and sets as the patient improves. End range rhythmic stabilization drills with the arm at 0 degrees of adduction or at 45 degrees of abduction are also performed. We refer to these exercises as perturbation drills. Exercises such as tubing with manual resistance and end-range rhythmic stabilization drills are also performed (Figure 14-7). The goal of these exercise drills is to improve proprioception and neuromuscular control at end range. Often these exercises are performed seated on a stability ball to recruit core, hip, and scapular muscles as the patient attempts to maintain good stability and posture.

Related posts:

Decision Making in Surgical Treatment of Athletes With First-Time vs Recurrent Shoulder Instability Special Considerations for Return to Play in Collision Athletes (Hockey, Football, and Rugby) Open Treatment of Anterior Instability Special Considerations for Multidirectional Instability Management of the Aging Athlete With the Sequelae of Shoulder Instability Arthroscopic Anterior Shoulder Instability in the Athlete

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