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Shoulder Instability and Dislocation
Shoulder Instability by Jon Tobey
This is when there is a complete separation of the glenohumeral joint caused by direct or indirect forces applied to the shoulder. This type of injury usually occurs when there is a blow to the humerus while it is in a position of external rotation and abduction. Weak stability of structures including the subscapularis, glenohumeral ligament and the long head of the biceps can predispose this joint to dislocation or a significant blow to the are may damage them along with the attachment of the anterior capsule and glenoid labrum. (Colby & Kisner, 350)
There are usually two types of shoulder dislocations. Traumatic posterior shoulder dislocation and recurrent dislocation. Traumatic posterior shoulder dislocation is the less common type. The mechanism of this type of injury is a force applied to the humerus that combines flexion adduction and internal rotation. This usually involves the subacromial, although subglenoid or subspinous posterior dislocations occur. Recurrent dislocation with significant ligamentous and capsule laxity, unidirectionsl or multidirectional recurrent subluxations or dislocations may occur with any movement that reproduces the abduction and external rotation forces. The group in which this reoccurring dislocation is seen the most is the younger population less than 30 years of age, due to their high level of activity. (Colby & Kisner 351)
Some symptoms after an acute traumatic dislocation injury may include pain and muscle guarding from bleeding and inflammation. When a dislocation is associated with a rotor cuff tear there is an inability to abduct the humerus against gravity. The posterior and anterior capsule may be tight and after healing there could be adhesions. (Colby & Kisner, 351) These are some of the tests performed that will show signs of shoulder instability. Apprehension and relocation. Patients who have recurrent instability will often have a positive apprehension test. The classic apprehension maneuver is performed by placing the affected arm in abduction, extension, and external rotation, then applying a gentle anterior translational force (figure 2A). The apprehension of impending instability is relieved by the relocation test (figure 2B). If the patient complains of pain alone, then other diagnoses, such as internal impingement, should be considered. (Blaine, Levine & Park, 2002)
Translation. With the patient supine, anteroposterior (AP) translation is evaluated in 45 degrees of abduction with the shoulder in the plane of the scapula, 30 degrees of flexion, and neutral rotation. An axial force is applied with the examining hand centering the humeral head in the glenoid fossa. The other hand then applies a gentle anterior force to evaluate translation. (Blaine, Levine & Park, 2002)
Normal translation is 50 percent of the width of the glenoid surface anteriorly and posteriorly. Translation to the glenoid rim is graded as 1plus. Grade 2plus occurs when the head subluxates beyond the rim but self-reduces when the force is released. Grade 3plus entails head dislocation that does not spontaneously reduce. [ 19] (Blaine, Levine & Park, 2002)
Inferior stability is assessed with the sulcus test by applying an inferior force to the humerus with the arm at the side. The sulcus exists between the acromion and the inferiorly subluxated humeral head. Translations of 1 cm, 2 cm, or greater than 2 cm are graded as 1plus, 2plus, and 3plus, respectively.[ 19] (Blaine, Levine & Park, 2002)
Laxity. Ligamentous laxity is determined by evaluating hyperextension of the elbows, wrists, thumbs, and metacarpophalangeal joints. Assessing ligamentous laxity is critical, because patients who have positive signs may not be appropriate candidates for arthroscopic repair. ( Blaine, T. Levine, W. Park, M. (2002) Physician and Sports medicine) (Blaine, Levine & Park, 2002)
Non-operative management includes three management phases. Phase one protection phase after closed reduction of anterior dislocation. A sling is worn in this phase for three to four weeks after the incident and is only removed for exercise. Exercises in this phase use protected range of motion (ROM), intermittent muscle setting of the rotor cuff, deltoid, biceps brachii and grade two joint techniques. Phase two is controlled motion phase after closed reduction of anterior dislocation. In this phase the patient increases shoulder mobility, stability and strengthens the rotor cuff and scapular muscles by using isometric and closed chain exercises. The patient continues to wear a sling for three weeks and they slowly increase the amount of time that the sling remains off. The last non-operative phase is return to function phase after anterior shoulder dislocation. In this phase the patient will restore functional capacity and return to maximum function. After this phase the patient should continue to protect the arm and work on increasing their limited ROM. (Colby & Kisner, 351)
Medical treatment is used if necessary including reoccurring episodes of dislocations, which impairs functional activities. These procedures improve stability while maintaining normal rotation of the GH joint. There are several procedures which can be performed including: capsulorrhaphy, electrothermally assisted capsulorrhaphy, bankart reconstruction, soft tissue transfers, bony procedures, repair of a slap lesion, posterior capsulorrhaphy. Capsulorrhaphy is a tightening of the capsule to reduce capsular redundancy and overall capsular volume by incising, overlapping and then suturing the lax or overstretched portion of the capsule. Electrothermally assisted capsulorrhaphy is an arthroscopic procedure that uses thermal energy to shrink and tighten loose capsuloligamentous structures. Bankart reconstruction is an open or arthroscopic repair of a bankart lesion (a detachment of the capsulolabral complex from the anterior rim of the glenoid). Soft tissue repairs are open transfers and realignment of the subscapularis tendon to stabalize the anterior capsule. Bony procedures are an open transfer of the tip of the coracoid process to the anterior glenoid rim to form a bony block. Repair of a slap lesion is a tear of the proximal attachment of the biceps and superior labrum, which is classified as a SLAP. The lesion is debrided arthroscopically and the torn portion of the superior labrum and biceps anchor are reattached with tacks or suture anchors. Last a posterior capsulorrhaphy is managed with an open or arthroscopic stabilization procedure to tighten the capsule if the capsule is lax. (Colby & Kisner, 353)
Another method used is the scapula manipulation technique. This technique is used to reposition the glenoid fossa in order to reduce the risk of traumatic shoulder dislocations. This method has a success rate of 90 percent and is used often due to the high rate of success with out the use of sedatives. (Tindale, 2005)
The first post-operative phase is the maximum protection phase. This phase will protect the tightened capsule for about six weeks. This phase is used to control pain, prevent or correct postural malalignment, prevent losses of mobility in the involved upper extremity, develop control and strength of the scapulothoracic elbow, wrist and hand musculatures and prevent inhibition and atrophy of GH musculature. Exercises and techniques used in this phase include: self assisted ROM, wand exercises, isometric and dynamic strengthening exercises and multiple angle, multiple setting exercises of the GH joints and musculature.
Phase two is the moderate protection/ controlled motion phase. This phase begins six to eight weeks post-operative and will continue until 12-16 weeks. The focus is to develop normal ROM of the shoulder and strength and endurance as well. The goal in this phase is to restore full, pain free ROM of the shoulder to continue to increase strength, endurance, stability and control of the shoulder musculature. Stretching and grade three mobilizations in positions that do not provoke instability are used in this phase, also progressions through dynamic strengthening to overhead positions are used if strength of dynamic stabilizers is adequate.
Phase three is the minimum protection/ return to function phase. This phase usually begins as early as 10-12 weeks post-operative or as late as 16-18 weeks. This phase usually lasts six months post-operative until work related and sport related activities can adequately be performed. This phase will focus on returning full ROM, strength and stability in the GH joint and musculature. Also the patient should be able to participate in normal activities. (Colby & Kisner, 356)
Exercise Program
Cardiovascular:
Intensity: Begin at 50% of maximum heart rate and increase up to 80% of maximum heart rate (MHR)
Time: Begin at 15 min and increase up to 30 min
Type: Rowing machine and upper body ergometer.
Rowing instructions: Make sure to be seated on a commercial row if possible, use legs and arms together in a smooth, rythmatic motion. Make sure to emphasize on the use of the scapula muscles. Otherwise follow directions on machine.
Ergometer instructions: Make sure to sit up right on the machine, use your arms to move the mill. Try less resistance to start in order to build up cardiovascular endurance. Also make sure to place emphasis on the backward motions of the ergometer.
Flexibility/ Range of motion
Hold: 20 seconds
Rest: 10 seconds
Sets: 2x through
External Rotation with stick: While standing use a light weight stick and put right arm at 90 degree angle with fingers pointing up. Then grab the stick with your right arm and the stick should be behind your right tricep. Then grab the stick with your left arm and pull forward/upward while keeping your right arm at a 90-degree angle. Then repeat with the left arm.
Active internal rotation: While standing put your arm at a 90-degree angle this time with your fingers facing the ground. Have your partner grab your elbow and your hand and push your hand in the direction behind you while keeping your arm at a 90-degree angle. Repeat with other arm.
Pectoralis Major active stretch: Seated Indian style put your hands on the back of your head with your palms on your head. Have your partner gently pull on your elbows toward your back until a slight stretch is felt. (Shoulder Stretching)
Rhomboid/ mid-trap stretch: While standing grab onto a pole in front of you with your arms and allow your shoulder blades to pull forward. Once a slight stretch is felt hold for 20 seconds.
Strength and Muscular Endurance
When strengthening the shoulder musculature it is extremely important to work on scapular range of motion and strength also. This will help prevent the shoulder from dislocating by allowing the scapula to move along with the shoulder.
Internal Rotation: Using a piece of elastic tubing attach the tubing to a fixed structure at mid-torso height. Grasp the tubing and walk out until the tubing begins to have resistance. While keeping your elbow on your hip, and with your arm at a 90-degree angle rotate at the GH joint internally so the hand is going towards your inside. (15-20 reps)
External Rotation: Using a piece of elastic tubing attach the tubing to a fixed structure at mid-torso height. Grasp the tubing and walk out until the tubing begins to have resistance. While keeping your elbow on your hip, and with your arm at a 90-degree angle rotate at the GH joint externally so the hand holding the tubing is turning out away from your body and the tubing should be crossing your front midsection. (15-20 reps)
Horizontal Abduction: Have the patient lie on a table prone, and extend arms to the side. The patient will push off therapist with palms facing down and hold for 5 seconds for 10 reps.
Scapular Adduction: Tie elastic tubing around a fixed object. Have the patient grab on to the tubing with both hands and while standing bring the shoulder blades together. Try to emphasize on the patient not bringing the elbows in but more on just isolating the shoulder blades and creating a notch in the center of their back. (15-20 reps)
Improvement in balance/proprioception and function
Window washing: Have the patient use a cloth on a smooth surface. Have them perform 30 circles with each arm focusing on isolating the shoulder. The patient will complete 30 circles clockwise then 30 counter clock wise in each arm.
Ball wall push off: Have the patient use a medicine ball and place it on the wall holding it up against the wall with one hand. Then have the patient move the body so the shoulder joint is isolated and have them focus on stabilizing the shoulder while the body moves creating an unstable surface. (15 seconds each arm)
Ball side catch off wall: With the patient standing have them toss the ball from the side of them into the wall and then catch the ball with the same arm. This will form a repetitive motion like an axe chop. Make sure that the patient moves the torso and bends their legs with each throw and catch. This will help with coordination of the shoulder.
Prevention of Future Reoccurrences
Have the patient continue to stretch in order to keep full range of motion in both GH joints. Have the patient perform rotor cuff exercises as a warm up for any upper body exercises in order to keep the rotor cuff strong and tight. Also inform the patient to avoid overusing the shoulder joint by constantly performing shoulder exercises and putting additional unnecessary stress on the shoulder joint. Inform the client to stay away from activities that involve overhead throwing or activities that dislocations seem to occur for them. Also have the subjects be aware of how they sleep and make sure they are not putting their shoulders in awkward positions. Last instruct the patient to see a certified personal trainer or therapist regularly to ensure that they are performing exercises properly and their technique is good. For more information on personal training go to http://jontobeyfitness.com/ .
References
Blaine, T. Levine, W. Park, M. (2002) Physician and Sportsmedicine: Shoulder dislocation in young athletes.
Colby, L.A. Kisner, C (2002) Therapeutic Exercise foundations and Techniques. F.A. Davis Co. Philadelphia.
Shoulder stretching guides http://www.bodybuilding.com/fun/stretches.php?MainMuscle=Shoulders
Tindale, Rabina (2005) Emergency Nurse: Shoulder Dislocation. V.13 (3) p.6
About the Author
Jon Tobey is a Certified Personal Trainer and Nutrition Coach at the Salem Athletic Club in Salem, NH. He specializes in Weight Loss, Toning and group training including: Boxing Boot Camp and regular Boot Camp Training.
http://www.sac-nh.com/specialized_programs.php
http://www.sac-nh.com/contact_tobey.php
Chris Rea – Soft Top, Hard Shoulder
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