Posterior Shoulder Instability

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Original Editors

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Search Strategy

Sarch Datebases: CINAHL, Cochrane Library,EBSCO, Elseivier, Health Source Medline with full text, Pubmed, Google Scholar 

Search dates: 11/1/10-11/21/10. 

Search terms: Posterior Shoulder Instability, Rehabilitation, Physical Therapy, Surgical Techniques, Protocols 

Definition/Description

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Epidemiology /Etiology

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Characteristics/Clinical Presentation

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Differential Diagnosis

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Examination

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Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

Although there are articles describing the following physical therapy treatment and this treatment is commonly accepted as best practice, a systematic review by Gibson et al found little “definitive, empiric evidence to substantiate their effectiveness,” (p 230) but concludes that conservative physical therapy treatment should be the first line treatment especially for those patients with isolated dislocations. (Gibson, Engle) The treatment parameters described are mostly based on biological evidence rather than clinical trials.

Immobilization

Immobilization for three weeks may be indicated for patients with primary dislocation to help prevent recurrence of dislocation and instability in the joint. (Kiviluoto) This “low quality RCT” (Gibson) reported 17% recurrence at one year with immobilization at three weeks compared to 26% recurrence with immobilization at one week for patients less than 50 years of age. A limitation of the study was that it was not differentiate what kind of dislocation had occurred.

Strengthening

Rehabilitative treatment of posterior shoulder instability includes strengthening of external rotators and the rotator cuff (supraspinatus, infraspinatus, teres minor, subscapularis) (Hurley, Engle, Provencher), most importantly the infraspinatus muscle. (Van Tongle, Vidal, Engle, Fritsch) Scapular stabilizers (Williams, Vidal, Engle, Fritsch, Provencher), and posterior deltoid (Vidal, Young) strengthening is also important. Strengthening exercises engage the muscular stabilizers of the shoulder joint to compensate for the stretched capsule that often occurs with shoulder instability and to promote proprioception of the joint. (Fritsch) Isometric, concentric and eccentric strengthening is indicated with focus on correct muscle firing and position before moving to more advanced strengthening of glenohumeral muscles. (Engle) Resistance can be given through manual techniques, resistive tubing, free weights, or machines (Provencher). An upper body ergometer may be used to improve dynamic stabilization by demanding coordinated and consistent muscle activity across both arms without moving the arm through painful or unstable motions (Hundza)

Biofeedback and EMG

Simply strengthening the rotator cuff muscles may not be enough because of the underlying lack of muscle firing synergy and abnormal recruitment pattern of muscles commonly seen in posterior instability patients. (Fritsch, Provencher) These deficits have been documented through EMG studies. (Young, Williams, Vidal) To help focus muscular activity on dynamic stabilizers biofeedback can be useful. (Vidal, willimas, Gibson) A case study using EMG biofeedback on the posterior deltoid for neuromuscular reeducation was shown to help the patient activate the posterior deltoid to prevent voluntary dislocations. (Young)

Neuromuscular reeducation

Neuromuscular reeducation is an important part of activating scapular and glenohumeral muscles during functional movements. Strengthening should progress to include full range and diagonal and spiral patterns including PNF patterns. (Engle) Further study is needed to determine if UBE training will normalize muscle activation patterns (Hundza).

Activity modification

Avoiding activities that encourage instability or symptoms such as the forward flexed, adducted, internally rotated position is recommended. (Vidal) Often the instability is only present during sport and activity modification is not realistic unless the person is willing to retire from sport. (Vidal, Hurley)

Effectiveness

Physical therapy usually cannot eliminate the instability but reports of 70%(vidal) to 80% (Williams, burkhead) of patients note improvement and an ability to return to sport after a physical therapy program. (Vidal, Burkhead) A majority of patients in a retrospective study were satisfied with their results from rehabilitative strengthening (Hurley). The effectiveness of physical therapy depends on the type of instability and the demands the patient places on their shoulder. After an extended period of 12 weeks (Gibson, Engle) of rehabilitation without improvement and persistent disability surgery should be considered as long as the instability can be attributed to an anatomical problem. (Vidal, Hurley)

Post-surgical Physical Therapy

Post-surgical rehabilitation does not differ significantly from conservative treatment without surgery. The goals of treatment are the same and treatment includes ROM, neuromuscular reeducation/function, and strengthening.

Strengthening

Again, the rotator cuff and periscapular muscles are important dynamic stabilizers of the joint and much of the rehabilitation is focused on these muscles (Perez, Vidal) Gentle isometric contraction is suggested as the first active muscle contraction progressing to AROM and resisted exercises. (Perez)

Range of Motion

The need to restore normal ROM is an important outcome for the success of posterior shoulder instability post-surgical rehabilitation. The anatomy of the repair, tissue involved, patient motivation, and complications are factors that play a large role in the success and progression of a rehabilitation program. (Perez)

Neuromuscular Function

Supporting musculature of the scapula need to function properly to decrease the stress on the static stabilizers of the joint such as ligamentous and capsular structures that may have been compromised with surgery. (Perez) This includes strength, muscle firing timing, endurance, and coordination. (Perez) Rhythmic stabilization can be used to promote proper muscle firing and enhance stability (Perez) EMG biofeedback has also been used successfully post surgically to reeducate muscle patterns, specifically the posterior deltoid. (Beall)

Treatment Timeline for post-surgical rehabilitation                                    

Vidal, Perez, Provencher, Robinson

Timeline	Treatment
Weeks 1-4	Abduction sling Limited PROM:     -Forward flexion to 90° in scapular plane     -ER to 0°-30° Limited IR and adduction Control swelling and pain Patient education Pendulums Soft tissue mobilization
Weeks 4-6	Abduction sling Control swelling and pain Patient education AAROM:      -With periscapular strengthening Limited IR and adduction Pulleys UBE
Weeks 6-8	AROM with resistance:     -ER and limited forward flexion Joint mobilizations if not achieving ROM
Months 2-3	Full PROM and AROM Isotonic strengthening Proprioception training in end ranges Increased speed and volume of strength training
Month 4	Pain free shoulder Resisted strengthening with free weights General conditioning Avoid resisted activities with posterior force placed on shoulder such as push-ups
Month 6	Isokinetic testing If strength and endurance at least 80% of uninvolved side progress to throwing program or sport specific rehab Push-ups and pull-ups can be attempted
Months 6-9	Recreational athletes return to sport once acheive full ROM, strength and report no pain
Months 8-12	Non-contact athletes (golfers, swimmers) usually return to play
Months 9-12	Contact athletes and power athletes usually return to play

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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