have you ever had a shoulder dislocation?
Do you have a unstable shoulder?
Did you know –
Recurrent shoulder instability is associated with the development of glenohumeral arthritis. Franceschi et al. noted a 2.3 times increased risk of glenohumeral arthritis with increasing number of preoperative dislocations. At 25 years follow-up Hovelius and Saeboe noted that patients with just 1 recurrent subluxation or dislocation had moderate or severe glenohumeral arthritis in 35% of cases compared to 17% in patients who did not have recurrent instability. (1)
The shoulder joint is the most mobile joint in the body think of it like a golf ball on a golf tee. It allow movement at many different angles but this also places it at a high risk of being dislocated.
This blog is going to briefly cover the different types of dislocations, the tissues that can be affected and the rehab process that we recommend with some of our top exercises.
Types of dislocations:
Anterior dislocation — The top of the humerus is displaced forward, toward the front of the body. This is the most common type of shoulder dislocation, accounting for more than 95% of cases. In young people, the cause is typically sports-related. In older people, it usually is caused by a fall on an outstretched arm.
Posterior dislocation — The top of the humerus is displaced toward the back of the body. Posterior dislocations account for 2% to 4% of all shoulder dislocations and are the type most likely to be related to seizures and electric shock. Posterior dislocations also can happen because of a fall on an outstretched arm or a blow to the front of the shoulder.
Inferior dislocation — The top of the humerus is displaced downward. This type of shoulder dislocation is the rarest, occurring in only one out of every 200 cases. It can be caused by various types of trauma in which the arm is pushed violently downward (2).
Tissues the may be affected:
The rotator cuff muscles – The rotator cuff consist of 4 small muscles, their main role is to help create stability of the humeral head and keep it in the socket. When the humerus is dislocated these muscles may be damaged.
It is recommended to investigate for rotator cuff damaged when:
• Shoulder dislocations occur in patients over 40 years of age
• There has been substantial initial displacement of the humeral head (such as in a subglenoid dislocation) and
• There is persistent pain or loss of rotator cuff strength three weeks after a glenohumeral dislocation (3).
Stabilising ligaments and structures – The most common form of ligament injury is the Bankart lesion, in which the ligaments are torn from the front of the socket. If the labrum and the ligaments do not heal, the shoulder may continue to be unstable, allowing the ball to slip from the center of the glenoid even with minimal force (4).
Bony damage –
When a trauma takes place, an anterior shoulder dislocation can cause a head impression fracture what we call a Hill sachs lesion. The posterolateral aspect of the humeral head impacts on the anterior glenoid in the dislocated position, which makes the glenohumeral joint unstable (5).
What to do after a dislocation:
Phase 1 (up to 6 weeks):
Goal is to maintain anterior-inferior stability, Immobilization
It has traditionally been thought to be immobilized with internal rotation, but according to Miller, immobilization has been beneficial in external rotation because there is more contact force between the glenoid labrum and the glenoid. Research by Itoi suggests immoboilization at 10 degrees of external rotation has a lower recurrence rate than internal immoboilization at 10 degrees of external rotation has a lower recurrence rate than internal rotation. There is currently no consensus on the duration of immobilization in a sling. But, typical time periods in a sling range for 3-6 weeks if under the age of 40 and 1-2 weeks if older than the age of 40. During the immobilization period, the focus is on AROM of the elbow, wrist and hand and reduction of pain. Isometrics can be incorporated for the rotator cuff and biceps musculature (6).
Phase 2 (6-12 weeks):
Goal is to restore adequate motion, specifically in external rotation, AAROM to achieve full range of motion
When stretching is permitted, passively stretch the posterior joint capsule through the use of joint mobilizations or self-stretching.
No strengthening or repetitive exercises should start until achievement of full range of motion (6).
Phase 3 (12-24 weeks):
Successful return to sports or physical activities of daily living
Begin strengthening exercise
Strengthening exercises should be impairment-based. Typically begin strengthening exercise in a pain-free motion with exercises for stability. A possible progression could begin by focusing on the rotator cuff musculature and scapular stabilizers, which include trapezius, serratus, levator scapulae, and rhomboids. Then, progress to the larger musculature such as the deltoids, latissimus dorsi, and pectorals (6)
Start focusing on functional exercises
Include proprioceptive training
Tailor to promote patient's activities and participation in society (6).
Our recommended exercises:
Check out our video of recommended exercises to assist you with your rehabilitation.
Below we have also provided a brief explanation of our recommended exercises.
1. External and Internal rotations at various ranges as able.
This basic exercise gets a lot of negative press, but it is a good exercise to use as a beginning or warm up exercise for the reasons below:
- It places load through the respective rotator cuff muscles in a safe and controlled manner
- It promotes blood flow and improves healing.
- It will develop low-level strength and endurance
BUT this should not be what you are doing for 9 month of rehab. Increase the challenge as guided by your therapist by working in different ranges of motion and progressing in both reps (10>15 >20) and resistance levels (be it resistance bands or weights).
2. Open Chain proprioception exercises
In order to keep the humeral head safe in the shoulder joint the rotator cuff must react to potentially sudden unexpected forces when the arm is out to the side or overhead (Open chain). We can help train this with proprioception exercises often called reactive stability or rhythmic stability exercises.
Such examples of exercises are throwing a ball against a ball quickly, rhythmically and repetitively training the shoulder to be stable, fatigue resistant and hopefully pain free.
3. Closed chain proprioception exercises
Much the same as able the rotator cuff but be able to also keep the humeral head safe in the shoulder joint and react to potentially sudden unexpected forces when the arm is fixed and the body is effected (closed chain)
Mid range examples are holding yourself in a push up position and having someone try to push you off balance with little quick moderate pressure pushes. Another one is to perform touching challenges so that the arm still fixed must work hard to stabilize, transfer weight and control movement.
Full ROM examples are using a soccer ball and maintaining constant pressure writing the alphabet on the wall. Working from mid range towards overhead ranges.
Check out the video here!
We hope this helped. Remember if you have on going pain or were not managed appropriately following a dislocation or shoulder injury seek advice and guidance by a knowledgeable practitioner as soon as you can to improve the chance of a successful outcome.
Until next time.
The health Depot