Glenohumeral internal rotation deficit is common. In addition, a good rehabilitation program includes core strengthening, proprioceptive training, scapular stabilization, plyometrics and, for overhead throwers, ultimately a throwing program that increases flexibility and helps the player regain full range of motion without tenderness or pain, he said.
Furthermore, success rates are better than that among patients who present before they develop a labral tear, he said. Well, easy answer — leave it alone. By Susan M. Source: Duralde XA.
Disclosures: Duralde reports no relevant financial disclosures. Read next. January 11, Receive an email when new articles are posted on. Open chain exercises are performed with no support to the hand and have increased loading at the shoulder due to the weight of the arm and the effect of gravity.
Initially RC exercises should be performed with a stable body posture and the weight of the arm supported on a table, floor or wall to encourage muscular co-activation and scapula stability without increasing shear forces across the shoulder joint.
Such positions may also provide guidance and reassurance to the patient as to where the shoulder feels more stable. In addition closed chain exercises have been shown to encourage recruitment of the scapula thoracic muscles, so if specific weakness has been found in middle and lower trapezius and or serratus anterior such exercises can be beneficial [ 28 ]. Early isometric RC exercises should also be encouraged Fig.
In those patients who are unable to gain selective RC recruitment due to poor trunk stability and poor scapula position, exercises to improve postural tone may be beneficial. Destabilising the base of support and challenging their postural muscles such as sitting on a Swiss ball standing on one leg or on a wobble board may encourage postural muscles to engage and reduce inappropriate over-activity of muscles such as Latissimus Dorsi Fig.
A downwardly rotated scapula is commonly seen in patients with inferior or postero-inferior instability, encouraging scapula elevation in the movement pattern can be helpful in alleviating the instability [ 29 ].
In addition if RC and deltoid activation as a symptom modification test improves the stability, exercises to improve the recruitment of these muscles through the movement can be beneficial. Examples can be where the patient pushes outwards against a wall as they elevate the arm or pulling outwards against the resistance of theraband as they elevate the arm Fig.
Previous studies have investigated the importance of the kinetic chain in shoulder function and it has been postulated that there is a correlation between lower limb and upper limb function [ 13 ]. Therefore if there is poor recruitment of the RC then a more stable base needs to be provided to optimise its recruitment pattern. This may be achieved by initially focussing on improving posture to stabilise the trunk and lower limbs. Specific rehabilitation of scapula muscles would be required if selective weakness is identified and this appears to be the primary driver to the glenohumeral instability.
Scapula imbalance is widely recognised in shoulder pathology and selective activation of the weaker muscle parts with minimal activity in the hyperactive muscles is key in resolving symptoms [ 28 ]. Observations found in overhead athletes with internal impingement and occult anterior instability have indicated dominance of upper trapezius activation in relation to middle, lower and serratus anterior function [ 29 ].
The work done by Cools et al. Based on their EMG analysis these exercises were side lying external rotation, side lying forward flexion, prone horizontal abduction with external rotation. However in those patients who present with a drooping scapula and poor upward rotation increased activation of upper trapezius may be desirable. If increased upper trapezius recruitment improves the instability then exercises with the arm above shoulder height in prone and side lying positions may be more preferable.
In addition the modified scapula shrug exercise where the patient is encouraged to upwardly rotate the scapula in 30 degrees abduction compared to 0 degrees abduction encourages more upper trapezius activation and can be more effective in patients with multi-directional instability [ 31 ]. The exercise can be performed with the arm in weight bearing positions on a table or in four point kneeling, the patient is encouraged to push their chest away from the floor inorder to encourage scapula protraction activating serratus anterior in its inner range.
The EMG recruitment of serratus anterior and trapezius can alter dependant on whether the exercise is performed on a stable or unstable base [ 33 ]. It has been suggested that performing the exercise on an unstable base encourages increased activation of trapezius where as a stable base encourages activation of serratus anterior.
Therefore challenging the base of support i. If weakness is identified in some or all of the RC muscles, rehabilitation should be directed at activating and strengthening the weaker muscles.
Exercises can be performed in lying, sitting or standing postures dependent upon the ability of the patient. If patients present with RC weakness in the outer range, or demonstrate scapula winging, lying supine is the preferred starting position to stabilise the trunk and scapula. With the elbow flexed to 90 degrees the patient is asked to rotate their arm though internal and external rotation, with the arm supported against gravity to reduce apprehension or anxiety and permit the arm to be moved through a wide arc of rotation with improved control.
Once the patient can perform the exercise well, it should be repeated to the point of fatigue. In time, this exercise is gradually made more demanding by increasing the weight of the arm by either removing the underlying support, or by moving the arm into increasing degrees of abduction.
These rotational exercises can be performed whilst lying prone again using towels to support the weight of the arm. This position improves inner range function of the RC but does require reasonable scapula control Fig. Placing towels under the arm can provide extra support. If the elbow is elevated above the level of the shoulder, this decreases the weight of the limb and enhances compression of humeral head into the glenoid, therefore improving proprioception and confidence.
It also encourages the patient to actively control the arm in positions that previously would have caused apprehension. Once the patient can control the weight of their own arm through a reasonable arc of rotation external loads can be added. There is no evidence to guide treatment in terms of load, frequency or repetition [ 21 ].
It is recommended to empower the patient to determine these parameters in consultation with the therapist taking into account fatigue, pain and effort. The exercise needs to be achievable for the patient to perform, but not too easy so that it does not improve RC recruitment pattern.
The focus should be on gaining stability in the deficient range with low loads rather than high loads in the competent range. It is better to perform 2 exercises twice a day properly rather than several exercises badly. Practice and repetition is more likely to enhance and maintain motor control function. An example of a common exercise prescribed for anterior instability is placing the patient in prone lying with the arm fully supported and encouraging recruitment of the external rotators in inner range, as these muscles are often weaker in isometric testing.
It also follows that these muscles primary role is to help prevent anterior displacement of the glenohumeral joint in elevation [ 7 ]. Once the patient has achieved good activation and balance of the rotator cuff muscles, task specific functional exercises should be performed. Combining upper limb control with lower limb stability can start to incorporate patterns of muscle recruitment.
Task specific activities have been shown to be effective in cognitive motor retraining [ 34 ]. Ultimately the patient needs to be challenged to regain confidence, if this is lacking the patient is at risk of developing compensatory strategies increasing the risk of re-injury.
If the patient is struggling to do basic exercises then 3 further modalities can be used; elastic therapeutic tape, biofeedback and functional electrical stimulation. The use of tape remains controversial on its therapeutic effect and whether it alters proprioception but it is used widely in the clinical setting [ 35 ,36].
It can either be used to support the shoulder girdle providing the patient with a more secure feeling of the shoulder and therefore provide confidence and an ability to move or it can be used to help correct posture and position of the scapula providing feedback to the patient. When the patient moves out of the supported corrected position the tape can either become taut or slack depending on the method of taping guiding the patient on whether they are moving correctly or not.
Surface electromyography to provide biofeedback can be another method to help guide the patient on which muscle groups they are using. For example a skin electrode overlying on the infraspinatus muscle and another on Latissimus Dorsi and through a visual display on a screen or audible feedback the patient can be encouraged to activate or inhibit one group of muscles over another. This form of real time biofeedback with repetitive practice has been shown to be effective in shoulder instability [37,38].
Functional electrical stimulation where muscles are directly stimulated by a muscle stimulator machine have been widely used to help restore more normal movement patterns particularly in the field of stroke and spinal cord rehabilitation however there is a paucity of evidence to their true efficacy and benefit in management of shoulder instability.
It can be particularly effective in patients with more ingrained movement patters or with a degree of neurological injury.
By placing direct muscle stimulation on underactive muscles it provides the feedforward sensory input the patient can then perceive and join in with. However, there is a lack of guidance or consensus on where and how such modalities should be applied. Clinically these techniques have been shown to have positive effects to help those patients who lack sensory awareness of their shoulder in space and in relation to the rest of their body or where abnormal habitual patterns of movement have been established.
Poor posture, weak core stability and dysfunctional motor control of the rotator cuff muscles or surrounding shoulder girdle muscles can compromise stability at the GHJ. An appreciation of the impact of both physical and psychosocial factors that affect motor control strategies in the presence of pain and injury is required to avoid inappropriate management and risk of chronicity.
A carefully managed progression of control of the kinetic chain, scapula position and GHJ movement offers the best solution for improving and sustaining outcomes in patients with shoulder instability. The authors would like to thank Hazel Brown and Jan Letocha for their help in preparing the photographs and the Royal National Orthopaedic Hospital, Stanmore UK for their support in production of this article.
The authors confirm that this article content has no conflict of interest. National Center for Biotechnology Information , U. Journal List Open Orthop J v. Open Orthop J. Published online Aug Author information Article notes Copyright and License information Disclaimer.
This is an open access article distributed under the terms of the Creative Commons Attribution 4. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
This article has been cited by other articles in PMC. Abstract Background: The shoulder relies predominantly on dynamic muscular control to provide stability. Method: A systematic outline is provided to guide the clinician on how to identify muscular insufficiencies both local to the shoulder joint and global muscles that can influence shoulder instability.
Results: The Stanmore classification helps to correctly diagnose the type of instability and prioritise management. Conclusion: Physical and psychosocial factors can influence motor control in the presence of pain and injury. Open in a separate window.
Muscles that Control Shoulder Movement Muscles that control shoulder movement may be grouped into 3 distinct categories as listed below: Muscles that Control Scapular Movement Peri-scapular muscles include the upper fibres of trapezius, levator scapulae, which elevate the scapula, rhomboids major and minor which retract the scapula, lower fibres of trapezius which depresses the scapula, serratus anterior and pectoralis minor which protract the scapula.
Early stage - Managing Apprehension and Pain Pain, anxiety, fear and avoidance of movement are natural emotional reactions to shoulder instability,but are not necessarily correlated to severity of structural damage. Rehabilitation of the Scapular Muscles Specific rehabilitation of scapula muscles would be required if selective weakness is identified and this appears to be the primary driver to the glenohumeral instability.
Rehabilitation of the Rotator Cuff If weakness is identified in some or all of the RC muscles, rehabilitation should be directed at activating and strengthening the weaker muscles. Adjuncts to Motor Control Processing If the patient is struggling to do basic exercises then 3 further modalities can be used; elastic therapeutic tape, biofeedback and functional electrical stimulation.
Lewis A. The second factor is the degree of instability present in the patient and the effect on their function.
Varying degrees of shoulder instability exist such as a subtle subluxation or gross instability. The term subluxation refers to the complete separation of the articular surfaces with spontaneous reduction. Conversely, a dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint, resulting in underlying capsular tissue trauma.
The degree of trauma to the soft tissue of the glenohumeral joint with a shoulder subluxation is can be quite extensive. Speer et al 3 has reported that in order for a shoulder dislocation to occur, a Bankart lesion and soft tissue trauma must be present on both sides of the glenohumeral joint capsule.
Thus, in the situation of 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. The rate of progression of the rehabilitation program will vary based upon the degree of instability and persistence of symptoms. For example, a patient with mild subluxations and muscle guarding may initially tolerate strengthening exercises and neuromuscular control drills more than a patient with a significant amount of muscular guarding.
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 range of motion ROM exercises, especially with first time dislocations. It should be noted that Hovelius et al 8 , 16 , 17 has demonstrated that the rate of recurrent dislocations is based on the patient's age and not affected by the length of post-injury immobilization.
Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability.
Chronic subluxations, as seen in the atraumatic, unstable shoulder may be treated more aggressively due to the lack of acute tissue damage and less muscular guarding and inflammation. Rotator cuff and periscapular strengthening activities should be initiated while ROM exercises are progressed. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.
The goal is to enhance strength, proprioception, dynamic stability and neuromuscular control, especially in the specific points of motion or direction which results in instability complaints. The fourth factor is the direction of instability present. The three most common forms include anterior, posterior, and multidirectional.
Following a traumatic event in which the humeral head is forced into extremes of abduction and external rotation, or horizontal abduction, the glenolabral complex and capsule may become detached from the glenoid rim resulting in anterior instability.
This type of detachment is referred to a Bankart lesion. Figure 1 Baker et al 20 have identified four types of Bankart lesions based on the size and the degree of tissue involvement.
Conversely, rarely will a patient with atraumatic instability due to capsular redundancy dislocate their shoulder. It is the author's opinion that these patients are more likely to repeatedly sublux the joint without complete separation of the humerus from the glenoid rim. Capsular avulsions can occur on the glenoid side Bankart lesion or on the humeral head side referred to as a HAGL lesion humeral avulsion of the inferior glenohumeral ligament.
Drawing illustrating a Bankart lesion. The arrow denotes the avulsed capsule from the glenoid. CT arthrogram of a bony Bankart lesion. The large arrow shows the dye that has leaked out of the capsule. The small arrow shows the bony lesion which has pulled away from the glenoid rim. However, patients with significant atraumatic laxity may complain of posterior instability especially with shoulder elevation, horizontal adduction and excessive internal rotation due to the strain placed on the posterior capsule in these positions.
In professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen. Mair et al 26 reported on nine athletes with posterior instability in which eight of nine were linemen and seven were offensive linemen. Multidirectional instability MDI can be identified as shoulder instability in more than one plane of motion. Patients with MDI have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule.
Furthermore, Rodeo et al 28 reported that this type of patient turns over collagen at a faster rate. The authors consider an inferior displacement of greater than mm during the sulcus maneuver Figure 2 with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity. Due 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 muscle, and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers.
Initially, the focus of the rehabilitation program is on maximizing dynamic stability, scapula positioning, proprioception, and improving neuromuscular control in mid ROM. Also, rehabilitation should focus on improving the efficiency and effectiveness of glenohumeral joint force couples through co-contraction exercises, rhythmic stabilization, and neuromuscular control drills.
Isotonic strengthening exercises for the rotator cuff, deltoid muscle, and scapular muscles are also emphasized to enhance dynamic stability. The authors noted the most significant difference was in the deltoid muscles compared to the rotator cuff muscles in their groups.
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 Sach's lesion caused by an impaction of the postero-lateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation.
In rare cases of extreme trauma, the brachial plexus may become involved as well. 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.
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 al 10 compared the ability to detect passive motion and the ability to reproduce joint positions in patients with normal, unstable, and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared to both normal shoulders and shoulders undergoing surgical stabilization procedures.
Smith and Brunoli 36 reported a significant decrease in proprioception following a shoulder dislocation. Blasier et al 37 reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.
Zuckerman et al 38 noted that proprioception is affected by the patient's age with older subjects exhibiting diminished proprioception than a comparably younger population. Thus, the patient presenting with traumatic or acquired instability may present with poor neuromuscular control.
The final factor to consider in the non-operative 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. The recurrence rates of instabilities vary based on age, activity level, and arm dominance.
Patients may be classified into two common forms of shoulder instability - traumatic and atraumatic. Specific guidelines to consider in the rehabilitation of each patient population will be outlined. A four-phase rehabilitation program will be discussed for traumatic shoulder instability, followed by an overview of variations and key rehabilitation principles for atraumatic shoulder instability congenital and acquired laxity.
Following a first time traumatic shoulder dislocation or subluxation, the patient often presents in considerable pain, muscle spasm, and an acute inflammatory response. The patient usually self-limits 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 re-establish baseline dynamic joint stability, and 5 prevent further damage to glenohumeral joint capsule.
Appendix 1. Immediate limited and controlled motion is allowed following a traumatic dislocation in patients between the ages of years but immobilize patients between the ages of years old. However, motion is restricted so as to 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 days although no long-term benefits regarding recurrence rates and immobilization have been made in younger patients between the ages of years old.
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. The ideal position to immobilize the glenohumeral has traditionally been in internal rotation with the arm close to the body.
Recent studies by Itoi et al 44 , 45 examined positional differences of immobilization and compared the rates of recurrent dislocations. The authors concluded that immobilization in external rotation significantly reduced the recurrence rate of instability in chronic and first-time dislocators. Itoi et al 45 has recommended immobilization with the arm in 30 degrees of abduction and external rotation, compared to a group of patients immobilized in internal rotation. The authors stated that the resultant Bankart lesion had improved coaptation to the glenoid rim with immobilization in external rotation versus conventional immobilization in a sling.
Passive ROM is initiated in a restricted and protected range based on the patient's symptoms. The early motion is intended to promote healing, enhance collagen organization, stimulate joint mechanoreceptors, and aid in decreasing the patient's pain through neuromuscular modulation. Vista, CA may also be initiated. Passive ROM exercises are also performed in a painfree arc of motion. Modalities such as ice, transcutaneous electrical nerve stimulation TENS , and high voltage stimulation may also be beneficial to decrease pain, inflammation, and muscle guarding.
Strengthening exercises are initially performed through submaximal, painfree isometric contractions to initiate muscle recruitment and retard muscle atrophy.
Electrical stimulation of the posterior cuff musculature may also be incorporated to enhance the muscle fiber recruitment process early on in the rehabilitation process and also in the next phase when the patient initiates iso-tonic strengthening activities. Figure 3 Reinold et al 49 believe that the use of electrical stimulation may improve force production of the rotator cuff particularly the external rotators immediately after an acute injury.
Electrical stimulation to the posterior rotator cuff during exercise activity to improve muscle fiber recruitment and contraction. Dynamic stabilization exercises are also performed to re-establish 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 painfree angles which do not compromise the healing capsule.
Rhythmic stabilization for flexion and extension may also be performed with the shoulder at 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 is present. During the intermediate phase, the program emphasizes regaining full ROM along with progressing strengthening exercises of the rotator cuff, and re-establishing muscular balance of the glenohumeral joint, scapular stabilizers, and surrounding shoulder muscles. Before the patient enters Phase II, certain criteria must be met which include diminished pain and inflammation, satisfactory static stability, and adequate neuromuscular control.
To achieve the desired goals of this phase, passive ROM is performed to the patient's tolerance with the goal of attaining nearly full ROM. External rotation at 90 degrees of abduction is generally limited to degrees to avoid overstressing the healing anterior capsuloligamentous structures for approximately weeks but eventually increasing ROM to full motion as the patient tolerates. 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 re-establish muscular balance following the injury. Kibler 1 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, isotonic exercises are progressed to emphasize rotator cuff and scapulothoracic muscle strength. 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 4. Sidelying manual external rotation while the clinician imparts rhythmic stabilization drills at end range. Closed kinetic chain exercises are progressed to include a hand on the wall stabilization drills in the plane of the scapular at shoulder height as the patient tolerates.
Figure 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 stabilization to the involved and uninvolved upper extremity along with the trunk to integrate dynamic stability and core strengthening tilt board, ball, etc.
Figure 6 Caution should be placed while performing closed kinetic chain exercises in patients with posterior instability for weeks at allow for adequate healing and strength gains. Furthermore, patients with significant scapular winging should perform push-ups 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. Exercises such as tubing with manual resistance and end range rhythmic stabilization drills are also performed.
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