S H O U L D E R INSTABILITIES

NONOPERATIVE MANAGEMENT
RELATE D PATHOLOGIE S AND
M EC H A N I S M S OF
I N J U RY
Glenohumeral joint hypermobility

Atraumatic Traumatic
hypermobility, hypermobility

A single or
Instability, can be
sequence of high
due to generalized
force events that
connective tissue
compromise the
laxity or from
integrity of the
microtrauma
stabilizing
related to
structures, often
repetitive
dislocating the G H
activities
joint.
 Atraumatic Hypermobility

Multidirectional
Unidirectional instability
instability

Anterior instability Stability is

compromised in more
than one direction
Posterior instability

Inferior instability
UNIDIRECTIONAL INSTABILITY
 ANTERIOR INSTABILITY
• Forces against the arm when
it is in an abducted and
externally rotated position
• Resulting in anterior
humeral head translations
• Throwing athletes
• Apprehension, load and
shift, and anterior drawer
tests should be positive
GRADES OF GLENOHUMERAL
TRANSLATION
 POSTERIOR INSTABILITY
• Less common
• Repetitive forces against a forward-flexed and medial rotation while the shoulder is
under a compressive load
• Translating the humeral head posteriorly
• Posterior drawer sign should be positive.
 INFERIOR INSTABILITY

• Result of rotator cuff weakness/paralysis is frequently seen

• Repetitively reach overhead (workers or swimmers) and those with multidirectional
instability.
• Detected with a positive sulcus sign.
MULTIDIRECTIONAL INSTABILITY
 CO MMO N STRUCTURA L AND
FUNCTIONAL IMPAIRMENTS
• Symptoms are often chronic, intermittent, and activity dependent.
• Weakness of the rotator cuff muscles🡪Repetitive trauma of the joint.
 Traumatic Hypermobility

Traumatic anterior Traumatic posterior

shoulder dislocation. shoulder
dislocation
 TRAUMATIC ANTERIOR
SHOULDER
DISLOCATION
• Stability is provided by the subscapularis, GH ligaments (particularly
the anterior band of the inferior ligament), and long head of the biceps.
 TRAUMATIC POSTERIO R
SHOULDER
DISLOCATION
• Less common
• A force applied to the arm when the
humerus is positioned in flexion,
adduction, and internal rotation,
Bankart lesion
• Fracture of the anterior rim of the glenoid with the attached labrum. The labrum is pulled away
from the anterior glenoid along with a small piece of glenoid.
• this injury results in the labrum being detached anywhere from the 3 o’clock to the 7 o’clock
position resulting in both anterior and posterior structural injury
 SLAP L E S I O N S

• Type I: Superior labrum markedly frayed but attachments intact

• Type II: Superior labrum has small tear; instability of the labral-biceps
complex (most common)
• Type III: Bucket-handle tear of labrum that may displace into joint; labral biceps
attachment intact
• Type IV: Bucket-handle tear of labrum that extends to biceps tendon, allowing tendon
to sublux into joint
 WHAT IS “ P E E L BAC K ” MECHANISM

• Resulted in a posterior Type II SLAP lesion in overhead athletes who demonstrate

increased lateral rotation, decreased medial rotation, and a tight posterior capsule
that results in posterosuperior migration of the head during maximum lateral
rotation, causing a tear of the posterosuperior labrum.three possible mechanisms of
SLAP injuries
S U RG E R Y AND
POSTOPERATIVE
MANAGEMENT
 C LO S E D REDUCTION OF
ANTERIOR
DISLOCATION
Reduction manipulations should be undertaken only by someone specially trained in the
maneuverer because of the vulnerability of the brachial plexus and axillary blood vessels.
M A NAG E M E N T :
PRO TECTION PHASE
PROTECT THE HEALING TISSUE
• Activity restriction🡪 for 6 to 8 weeks in
a young patient.
• If a sling is used, the arm is removed
from the sling only for controlled
exercise.
• During the first week, the patient’s arm may be continuously immobilized because of pain
and muscle guarding.
• An older, less active patient (> 40 years of age) may require immobilization for only 2
weeks.
PRO M O TE TISSUE HEALTH
• Protected ROM
• intermittent muscle setting of the rotator cuff ,deltoid, and biceps brachii muscles,
and grade II joint mobilization techniques (with the humerus at the side or in the
resting position) are initiated as soon as the patient tolerates them.
CO N T RO L L E D M OT I O N PHASE
PROVIDE PROTECTION
• The patient continues to protect the joint and delay full return to unrestricted activity.
• If a sling is being used, the patient increases the time the sling is off.
• The sling is used when the shoulder is tired or if protection is needed.

INCREASE SHOULDER MOBILITY

• Mobilization techniques
• Passively stretching of posterior joint structure
INCREASE STABILITY AND STRENGTH O F ROTATOR CU FF AND SCAPULAR
MUSCLES
• The internal rotators and adductors must be strong to support the anterior
capsule.
• The external rotators must be strong to stabilize the humeral head against anterior
translating forces

• Isometric resistance exercises.

• Partial weight-bearing and stabilization exercises.
• Dynamic resistance.
RETURN TO FUNCTION PHASE
• Restore Functional Control
• Return to Full Activity
 C LO S E D REDUCTION OF
POSTERIOR
DISLOCATION
• The management approach is the same as for anterior dislocation with the
exception of avoiding the position of humeral flexion with adduction and internal
rotation during the acute and healing phases.
• Posterior glide is contraindicated
 GLENOHUMERAL J O I N T STABILIZATION
INDICATIONS FO R SURGERY
• Recurrent episodes of G H joint dislocation or subluxation that impair functional
activities.
• Unidirectional or multidirectional instability during active shoulder movements that
causes apprehension about placing the arm in positions of potential dislocation,
leading to compromised use of the arm for functional activities.
 PROCEDURES
1. Bankart repair
2. Capsulorrhaphy (capsular shift)
3. Electrothermally assisted capsulorrhaphy
4. Posterior capsulorrhaphy (posterior or posteroinferior capsular shift).
5. Repair of a SLAP lesion
 BANKART REPAIR

• Detachment of the capsulolabral complex from the anterior rim of the glenoid🡪
accompanies a traumatic anterior dislocation.
• the humeral insertion of the subscapularis is detached🡪 split longitudinally for
access to the lesion
 CAPSULORRHAPHY (CAPSULAR SHIFT)

• Tightening the capsule to reduce capsular redundancy 🡪overall capsule volume by

incising🡪overlapping in a pants-and-vest manner (imbrication)🡪then securing the
lax or overstretched portion of the capsule (plication)
 E L EC T ROT H E R MA L L Y ASSISTED
CAPSULORRHAPHY
• Arthroscopic approach that uses thermal energy (radiofrequency thermal delivery or
nonablative laser) to shrink and tighten loose capsuloligamentous structures
 POSTERIOR CAPSULORRHAPHY

• Posterior or posteroinferior capsular shift

• open or arthroscopic capsular shift to remove posterior and inferior redundancy of
the capsule.
• Additional soft tissue procedures, such as repair of a posterior labral tear
(reverse Bankart lesion)
 REPAIR O F A SLAP LESION

• Tear of the superior labrum is classified as a SLAP lesion.

POSTOPERATIVE MANAGEMENT
 FAC TO R S THAT INFLUENCE THE
REHABILITATION PROGRAM A F TE R
SURGERY FO R R EC U R R E N T INSTABILITY
O F THE G H J O I N T
• IMMOB ILIZ ATION
POSITION
ANTERIOR O R ANTEROINFERIOR INSTABILITY🡪immobilized in a sling or splint
in adduction (arm at the side) or varying degrees of abduction and in internal rotation
(forearm across the abdomen) with the arm slightly anterior to the frontal plane of the
body

POSTERIOR O R POSTEROINFERIOR INSTABILITY🡪shoulder is immobilized in

the “handshake” position (neutral rotation to 10° to 20° of external rotation, 20° to 30° of
abduction, elbow flexed, and arm at the side or sometimes with the shoulder in slight
extension).
• DURATION
□ 1 to 3 weeks to as long as 6 to 8 weeks.
□ The duration of immobilization is usually shorter for an elderly patient than for a
young patient

•EXERCISE PROGRESSION
Maximum Protection Phase
□ Initial phase of rehabilitation
extends for about 6 weeks
after surgery.
□ Exercises may be initiated
the day after surgery
□ ROM is delayed for a longer
period of time after a
thermally assisted
Goals and interventions
□ Control pain and inflammation
□ Prevent or correct posture impairments.
□ Maintain mobility and control of adjacent regions
□ ■ Restore shoulder mobility while protecting tightened or repaired
tissues
□ Prevent reflex inhibition and atrophy of G H musculature

CRITERIA TO PROGRESS
□ A well healed incision.
□ Reasonable improvement in ROM.
□ Minimal pain.
□ No sense of apprehension about instability with active motions
MODERATE PROTECTION PHASE
□ begins around 6 weeks postoperatively
□ continues until approximately 12 to 16 weeks
□ To maintaining joint stability
□ Achiving full active (unassisted) ROM.
□ Developing neuromuscular control,
□ Strength, and endurance of scapulothoracic and G H musculature.

GOALS AND INTERVENTIONS

□ Regain nearly full, pain-free, active ROM of the shoulder
□ Continue to increase strength and endurance of shoulder musculature
CRITERIA TO PROGRESS

M I N I M U M PROTECTION/RETURN TO FU NC T ION PHASE

□ Begins around 12 weeks postoperatively or as late as 16 weeks.
□ Stretching should continue until ROM consistent with functional needs has been
attained
□ Gains in ROM are possible for up to 12 months
ACRO MIOCLAVICULA R AND STERNOCLAVICULAR
J O I N T STABILIZATION
P RO C E D U R E S AND
POSTOPERATIVE MANAGEMENT
AC RO MIO C LAV IC U L A R JOINT STABILIZATION
• A grade III separation in which the acromioclavicular
(AC) and coracoclavicular ligaments are completely
ruptured may be surgically reduced and stabilized
with a variety of techniques.
• Kirschner wires, Steinman pins, screws, or most
recently bioabsorbable tacks, sutures, or fiber wires
are used for surgically reduction.
STERNOCLAVICULAR JOINT STABILIZATION
• Sternoclavicular (SC) dislocations are managed nonoperatively.
• acute posterior dislocation of the S C joint that cannot be successfully reduced with a
closed maneuver.
• S C joint that dislocates recurrently are managed surgically .
• Surgical options for posterior S C dislocations include open reduction with repair of
the stabilizing ligaments or resection of a portion of the medial clavicle and fixation
of the remaining clavicle to the first rib or sternum with a soft tissue graft.
 POSTOPERATIVE MANAGEMENT

• Shoulder is immobilized for up to 6 weeks after the surgical stabilization.

• Active ROM of the wrist and hand during the first few weeks of immobilization
• Active ROM of the elbow and forearm if the elbow is supported on the table
• Shoulder ROM are completely prohibited during the first 6 weeks
• Shoulder ROM (passive, progressing to assisted ROM), active scapular motions, and
light isometrics of the shoulder musculature are initiated after the immobilization can
be removed.
• Stabilization exercises, dynamic strengthening of the shoulder and scapula
musculature, and stretching to restore full ROM are gradually introduced and
progressed, as graduated functional activities are integrated into the rehabilitation
program.
THANK YOU