PFATS Articles
In-season Management of the Unstable Shoulder
Reggie Scott MS, ATC, PES, Assistant Athletic Trainer Carolina Panthers
The glenohumeral joint is inherently unstable and exhibits the greatest amount of motion found in any joint in the body.1 Due to this mobility, it’s susceptible to various injuries. The purpose of this case study was to look at in-season management of glenohumeral instability.
Overview of Glenohumeral Joint Stabilization
Shoulder stability is achieved through a synergy of dynamic and static stabilizers which centralize the humeral head in the glenoid fossa. Dynamic stabilizers:
- Joint compression -- co-contraction/co-activation centralizes and compresses the humeral head in the glenoid fossa
- Dynamic ligament tension – muscle contraction produces capsule tension due to the anatomical blend of the rotator cuff with the capsule
- Scapular concavity effect
- Neuromuscular control
- Osseous structures
- The glenoid labrum
- Capsular structures
- Negative intra-articular pressure
- A co-efficient of friction
When injury occurs and static stabilizers are compromised, clinicians must develop a thorough and comprehensive program that targets the dynamic stabilizers without causing further irritation of the shoulder joint.
Injuries from anterior instability are most commonly triggered through abduction and external rotation of the shoulder or by an anterior force through a direct blow. Injuries associated with posterior instability typically include forward flexion of the shoulder with internal rotation or a posterior load. Acquired instability can occur from various overuse mechanisms such as throwing or improper lifting.
Case
This case study follows an outside linebacker with no previous history of shoulder pathology. In early September of the ’06-’07 NFL season while making a tackle, the player made ground contact with his shoulder and experienced a posterior load. He was diagnosed with a left shoulder posterior subluxation and did not return to play. An MRI performed the following day found a posterior labral tear, superior labral lesion, a humeral head bone bruise and intra-articular loose bodies.
Treatment considerations
In regard to in-season cases, the non-operative management approach should be thoroughly evaluated with heavy communication between the athlete and medical staff. Considerations such as position demands, concomitant injuries, severity of injury, acute/chronic issues, as well as, other conditions should be a part of your assessment. Also, it is important to understand the conservative options compared to surgical intervention. Recent research shows that surgery following first-time dislocations in someone younger than 25 is unnecessary in 50% of patients2.
Phases of Rehabilitation
EARLY PHASE:
Initially, rehabilitation goals should focus on controlling pain, initiating early pain free ROM and beginning pain-free isometric strengthening. Immobilization may result in an increase in episodes of functional instability due to a decrease in dynamic stability through rotator cuff inhibition and loss of neuromuscular control.1 However, early motion and strengthening programs have not shown to increase the incidence of recurrent instability>1, so immobilization would only be indicated for comfort. The athlete was not immobilized but was instructed to avoid any type of posterior loading and horizontal adduction.
Pain Management consisted of:
- Cryotherapy (Gameready®, Ice)
- Modalities (IFC, Hi Volt)
- NSAIDS
Range Of Motion:
During ROM exercises, consideration must be taken for the “bone bruise” of the shoulder as the athlete suffered a posterior glenoid and anteromedial humeral head bone bruise. Scapular plane motion was initiated to avoid overloading the articulation with the bone bruise. Scapula retraction is another important component during ROM which can be inhibited with supine table exercises. This can cause a compression of the scapula along the rib cage which subsequently causes improper shoulder movement. The numerous muscles that attach to the scapula are intricate in allowing the entire kinetic chain to work in synergy and allow for proper movement.
- Active, passive and assisted ROM:
- Let pain be an early guide
- Start with successful movements
- Use caution with posterior load & horizontal adduction
- Standing scapular plane motion:
- Palpate and mobilize scapula
- Internal and external rotation:
- Limit internal rotation to neutral
- Do not limit external rotation
- Elbow flexion and extension
Early in the rehabilitation program, it is important to work isometrics in the scapular plane for protection of injured structures. As progression continues multi-angle/planes can be initiated.
- Internal and external rotation
- Use scapular plane holds (bent elbow, shorten lever arm)
- Use multi-angle, tri-plane motion
Criteria for progression to the intermediate phase were based on a decrease in pain level, improved range of motion (scapula reaction), good strength and no setbacks
INTERMEDIATE PHASE:
Key components to this phase included initiating functional exercises that incorporated all three planes of motion. Various drivers such as gravity, tubing, dumbbells and body blade were used to strengthen in these planes. During this phase of rehabilitation, the lower extremity, trunk and pelvis were incorporated.
Range Of Motion:
- Upper body ergometer
- Seated
- Standing
- Interval (cardio)
- Wand
- Tri-plane movements
- Tri-plane stretching
- True stretch station
Strengthening
- Tubing
- External rotation
- Internal rotation
- Scaption
- Rows
Dumbbell
- Frontal plane punches
- Front raise (180 degrees)
- Lateral raise
Particular attention should be paid to the transformational zones. The dynamic stabilizers must be able to decelerate an eccentric movement, absorb the potential energy, and accelerate to the opposite direction. If these dynamic stabilizers are not trained to load and explode, stress will be placed on static stabilizers and osseous structures.
Criteria for progression to the advanced phase consisted of full pain-free ROM, improved strength and no apprehension on exam.
ADVANCED PHASE:
Key components during this phase included closing the chain, ballistic training and preparing for return of activity.
Strengthening:
- Powerplate
- Weight shift laterally
- Staggered hand position
- Internal rotation/external rotation hand placement
- Akrowheels
- 3-way reach in push up position
- Bodyblade
- Internal/ external rotation
- D1-D2 Patterns
- Scaption
- Push up w/ rotation
- Monster Walks
- Against wall
- Push up position on ground with 3-way reach.
- Medball Throws
- Front oblique throws
- Side oblique throws
- Overhead throws
Sports Specific Drills:
- Warm-up drills
- Walking lunges with upper extremity reaches (rotational, overhead, oblique)
- Lateral shuffle
- Buttkicks
- Carioca
- Backpedaling
- Sport-specific drills
- Change of direction drills
- Upper extremity drills (engage in sled, ball throws, fumble simulation)
- Cardiovascular conditioning
- Half-gassers
To return to activity, the athlete needed to exhibit full range of motion, normal or near normal strength. Additionally, he needed to be relatively pain free and have a good clinical exam for clearance by the team physician.
BRACING:
Various shoulder braces are available. Most importantly, it is important to choose a brace that is tolerated by the athlete and limits the desired motion.
Bracing options include types with pads (simply stable harness) and those without (shoulder spica wrap or sully shoulder harness)
WEEKLY MAINTENANCE SCHEDULE
A weekly maintenance schedule was designed to maintain strength, neuromuscular control and ROM throughout the season. This program was modified periodically based on schedule and pain level.
Monday
- Pain management
- ROM (variable)
- Intermediate strength training
- Tubing series
- Advance phase
- Supplement w/ workout
- Advance phase
- Supplement w/ workout
- Intermediate strength training
- Rest
ACKNOWLEDGEMENT:
I would like to thank Ryan Vermillion, Dr. Pat Connor and Mark Shermansky for their valuable input and support.References:
1. Andrews, J. Arrigo, C. Wilk, K. Current Concepts: The Stabilizing Structures of the Glenohumeral Joint. JOSPT. Volume 25, Number 6. June 1997.2. Hovelius, L. Incidence of shoulder dislocation in Sweden. Clin Orthop Relat Res. 1982 Jun;(166): 127-31.