Treatment of Recurrent Instability.
Last updated Thursday, February 10, 2005
Post-operative recovery and rehabilitationRecovery After surgery, most patients are started on a self-conducted '90-0"
rehabilitation program with instructions from a physical therapist or a
physician. We move the shoulder soon after surgical repair because 1)
it has proven safe for the reliable patient, and 2) there is evidence
that early motion can increase the ultimate strength of a ligament
repair. (Frank, 1996)Patient post-op limitations On the day after surgery, five times daily exercises are started,
including assisted flexion to 90° and external rotation to 0°.
The contralateral arm is used as the assistant until the
operated arm can conduct the exercises alone. The patient is allowed to
perform many activities of daily living as comfort permits within the
90°/0° range without lifting anything heavier than a glass of
water.
Allowed activities include eating and personal hygiene, as well as
certain vocational activities, such as writing and keyboarding.
Gripping, isometric external rotation, and isometric abduction
exercises are started immediately after surgery to minimize effects of
disuse. If a patient does not appear able to comply with this
restricted use program, the arm is kept in a sling for three weeks,
otherwise a sling is used only for comfort between exercise sessions
and to protect the arm when the patient is out in public and at night
while sleeping. Driving is allowed as early as two weeks after surgery,
if the arm can be used actively and comfortably, particularly if the
patient's car has automatic transmission and if the operated arm is not
used to set the emergency brake.
This rapid return to functional activities is made possible because
of the strength of the repair and is encouraged to maintain the
shoulder's strength and neuromuscular control. It minimizes the
immediate postoperative disability and discomfort without jeopardizing
the healing process. Re-evaluation and rehabilitation At three weeks the patient should return for an examination and
should have at least 90 degrees of elevation and external rotation to
zero degrees. From three weeks to six weeks postoperatively, the
patient is instructed to increase the range of motion to 140 degrees of
elevation and 40 degrees of external rotation. At six weeks after
surgery, if there is good evidence of active control of the shoulder,
controlled repetitive activities such as swimming and using a rowing
machine are instituted to help rebuild coordination, strength, and
endurance of the shoulder. More vigorous activities such as basketball,
volleyball, throwing, and serving in tennis should not be started until
three months and only then if there is excellent strength, endurance,
range of motion, and coordination of the shoulder.
Vigilance must be exercised for patients over 35 years of age to be
sure that they do not develop unwanted postoperative stiffness. Thus,
particularly for these patients, the three week and six week checks are
very important to make sure that the ranges of elevation and external
rotation are respectively 90 and 0 degrees at three weeks, and 140 and
40 degrees at six weeks. Efficacy of this program In a 5.5-year follow-up of the first group of these repairs, we found
97 per cent good to excellent results based on Rowe's(Rowe, 1978)
grading system. One of 39 shoulders had a single redislocation four
years after repair while the patient was practicing karate. He became
asymptomatic after completing a strengthening program and is back to
full activities including karate. The average range of motion at
follow-up was 171 degrees of elevation, 68 degrees of external rotation
with the arm at the side, and 85 degrees of external rotation at 90
degrees of abduction. Ninety-five per cent of these patients reported
that their shoulder felt stable with all activities; 80 per cent had no
shoulder pain while 20 per cent had occasional pain with activity. None
had complications of posterior subluxation due to excessive anterior
tightness. None had complications related to hardware!Disclaimer
This resource has been provided by the University of Washington Department of Orthopaedics and Sports Medicine as general information only. This information may not apply to a specific patient. Additional information may be found at http://www.orthop.washington.edu or by contacting the UW Department of Orthopaedics and Sports Medicine.
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