When designing a rehabilitation program for a patient with shoulder instability (glenohumeral instability), it is important to consider the following key factors:[1]
SHOULDER REHABILITATION PROTOCOLS
- Onset of pathology
- The degree of instability and its impact on function
- Dislocation frequency (chronic vs acute)
- Unstable orientation (back-to-front or multi-directional)
- Accompanying pathology (Bankart lesion Hill sachs lesion a reverse Hill sachs lesion…)
- End range neuromuscular control
- Activity level
When considering all seven key factors, each patient will have a different non-surgical rehabilitation program structure.
The rehabilitation program will be divided into two categories: traumatic and non-traumatic. It is important to discuss this traumatic and nontraumatic dislocation regimen to make it better.
Traumatic
The length of this traumatic dislocation protocol will vary for each individual based on the seven key factors and the desired goals and activities of the arm dominance. 1
Phase 1 - The acute motion phase
The glenohumeral joint will be fixed in a pronated and adducted position (2-4 weeks to allow for scarring of the injured joint capsule and 7-14 days in young adults). There is some discussion about fixed positions. Several studies have concluded that external rotation fixation Significantly reduces the recurrence rate of instability in first dislocations and chronic dislocations. [1][2]
The goals of this phase are to: reduce pain, inflammation, and muscle spasm; re-establish dynamic stability and pain-free range of motion; delay muscle wasting; improve proprioception and protect the healing capsule. To achieve this goal, the following aspects will be implemented:
- decrease pain and inflammation
- Range of motion (ROM) exercises: active-passive and active, with some help
- Strengthening/Proprioception Exercises: Isometric Movement of Arms on the Side
- Rhythmic stabilization
Before a patient can move on to the next stage, he must meet certain criteria, which include:
1) Fully functional ROM 2) Minimal pain and reduced inflammation 3) Adequate static stability and 4) Adequate neuromuscular control.
Phase 2 - Intermediate phase
The goals of this phase are to: enhance proprioceptive motor and dynamic stability; restore and improve muscle strength and neuromuscular control; and normalize joint kinematics. To achieve this, the following aspects will be implemented:[1]
- 90 Degree Abduction ROM Progression (Painless)
- Initiate Isotonic Strengthening: Emphasize External Rotation and Scapular Strengthening
- Neuromuscular control of the shoulder complex: initiation of proprioceptive motor rhythm stabilization training
- As needed: Continue ice therapy
Before a patient can enter stage 3, he must meet certain criteria, which include:
1) Minimal pain and tenderness 2) Symmetrical range of motion of the joint capsule 3) Completely pain-free ROM and 4) Good strength tolerance and dynamic stability of the upper extremity and scapula pectoralis tissue.
Phase 3 - Advances strengthening phase
The goals of this phase are to: improve neuromuscular control strength and endurance; enhance dynamic stability; and prepare the patient or athlete for activity. To achieve this, the following aspects will be implemented:[1]
- As needed: Continue ice or electrotherapy
- Continues isotonic strengthening, but now with increased resistance
- Emphasize PNF (45,90 and 145 degrees)
- When Working With Athletes: Advanced Neuromuscular Control Training
- Endurance training: increase the length of the exercise, more repetitions, more exercise time
- Initiate plyometric training
Before a patient can enter stage 4, he must meet certain criteria, which include:
1) Fully functional ROM 2) Static and dynamic stability and 3) Sufficient strength and endurance.
Phase 4 - Return to activity phase
The goal of this phase is to: (gradually) increase the activity level to prepare the patient or athlete for a functional return to his activity or sport. To achieve this, the following aspects will be implemented:[1]
- Exercise as in phase 3
- Do isotonic strengthening exercises
- An interval sport program
- Brace considering contact motion (stabilizing the glenohumeral joint)
Follow up:
- Isokinetic testing (external and internal rotation; ab- and adduction)
- a progress interval training
- Maintain the exercise program
1.↑E. Wilk, K., C. Macrina, L., M. Reinold, M., ‘Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability’, North amarican journal of sports physical therapy, VOL. 1 (2006), februari, nr. 1, p. 16-31
2.Cutts, S., Prempeh, M., Drew, S., ‘Anterior shoulder dislocation’, Ann R coll Surg Engl, VOL. 91 (2009), p. 2-7 (Level of evidence 2A)
3. E. Wilk, K., C. Macrina, L., M. Reinold, M., ‘Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability’, North american journal of sports physical therapy, VOL. 1 (2006), februari, nr. 1, p. 16-31
4. Cutts, S., Prempeh, M., Drew, S., ‘Anterior shoulder dislocation’, Ann R coll Surg Engl, VOL. 91 (2009), p. 2-7 (Level of evidence 2A)
