Rehabilitation program of the shoulder

Non-operative rehabilitation [edit | edit source]

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: [1]

  • 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[edit | edit source]

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. [1]

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. [1][2]

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: [1]

  • 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: [1]

  • 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: [1]

  • 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



Atraumatic[edit | edit source]

Post-operative rehabilitation[edit | edit source]

References[edit | edit source]

  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)
  1. 1.0 1.1 1.2 1.3 1.4 1.5 E. Wilk, K., C. Macrina, L., M. Reinold, M., 'Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability', North american 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)