Rehabilitation program of the shoulder

Non-operative rehabilitation 

When designing a rehabilitation program for patients with an unstable shoulder (glenohumeral joint instability), it's important that the follow key factors should be considered:

• Onset of pathology
• Degree of instability and the effect of their functions
• Frequency of dislocation (chronic versus acute)
• Direction of instability (posterior, anterior or multidirectional)
• Concomitant pathologies (Bankart lesion, Hill sachs lesion, a reverse Hill sachs lesion...)
• End range neuromuscular control
• Activity level

When considering all of this seven key factors, each patient will have a different structure of the non-operative rehabilitation program.

This rehabilitation program will be divided into two categories: traumatic and atraumatic. It's important to discuss about this traumatic and atraumatic dislocation protocol, to make it better.

Traumatic

This traumatic dislocation protocol will vary in length for each individual depending on the seven key factors and the arm dominance, desired goals and activities.

Phase 1 - The acute motion phase

The glenohumeral joint will be immobilized in an internally rotated and adducted position (2-4 weeks to allow scarring of the injured capsule and younger people 7-14 days). There is some discuss about the position of immobilisation. Several studies concluded that immobilization in external rotation significantly reduced the the recurrence rate of instability in first-time-dislocaters and chronic dislocation.

The goals of this phase are: decrease pain, inflammation and muscular spasms; re-establish dynamic stability and non-painful range of motion; retard muscular atrophy; improve proprioception and protect the healing capsular structures. To achieve this goals, following aspects will be implement:

• decrease pain and inflammation
• Range of motion (ROM) exercise: activo-passive, passive and active whit some help
  
• Strengthening/proprioception exercises: isometrics performed with the arm at side
• Rhythmic stabilization

Before the patient may enters the following phase, he must meet certain criteria which include:

1) Full functional ROM, 2) minimal pain and diminished inflammation, 3) sufficient static stability and 4) adequate neuromuscular control.

Phase 2 - Intermediate phase

Goals of this phase are: enhance the proprioception, kinesthesia and dynamic stabilization; regain and improve muscular strength and the neuromuscular control; and normalize arthrokinematics. To achieve this goals, following aspects will be implement:

• Progress ROM at 90 degrees abduction (painfree)
• Initiate isotonic strengthening: emphasis on external rotation and scapular strengthening
• Neuromuscular control of the shoulder complex: initiating proprioceptive exercise, rhythmic stabilization drills
• As needed: continue use of ice, eletrotherapy modalities
  

Before the patient may enters phase 3, he must meet certain criteria which include:

1) minimal pain and tenderness, 2) symmetrical capsular mobility, 3) full non-painfull ROM and 4) good strength, endurance and dynamic stability of the upper extremity and scapulothoracic musculature.

Phase 3 - Advances strengthening phase

Goals of this phase are: improve the neuromuscular control, strength, power and endurance; enhance the dynamic stabilizations; and prepare the patient or athlete for his activities. To achieve this goals, following aspects will be implement:

• As needed: continue use of ice or electrotherapy modalities
• Continue isotonic strengthening, but now progressing resistance
• Emphasize PNF (45,90 and 145 degrees)
• When working whit athletes: advanced neuromuscular control drills
• Endurance training: increase the length of an exercise, more repetitions, more exercise periods throughout a day
• Initiate plyometric training

Before the patient may enters phase 4, he must meet certain criteria which include:

1) Full functional ROM, 2) static and dynamic stability and  3) sufficient strength and endurance.

Phase 4 - Return to activity phase

Goals of this phase are: increase the activity level (progressively) to prepare the patient or the athlete for functional return to his activity or sport. To achieve this goals, following aspects will be implement:

• Exercise as in phase 3
• Progress the isotonic strengthening exercises
• An interval sport program
• consider a brace for contact sports (stabilizing the glenohumeral joint)

Follow up:

• Isokinetic test (external and internal rotation; ab- and adduction)
• a progress interval training
• Maintain the exercise program

References

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)