Treatment of Recurrent Instability.

Last updated Thursday, February 10, 2005

Figure 1 - Internal rotation

Figure 2 - External rotation

Figure 3 - Supine press

Figure 4 - Shoulder shrug

Figure 5 - Taping the shoulder

Nonoperative management

Stabilizing with muscle strength

Strengthening exercises

Strengthening of the rotator cuff, deltoid and scapular motors can be accomplished with a simple series of exercises. During the early phases of the program, the patient is taught to use the shoulder only in the most stable positions, that is those in which the humerus is elevated in the plane of the scapula (avoiding, for example, elevation in the sagittal plane with the arm in internal rotation if there is a tendency to posterior instability). As coordination and confidence improve, progressively less intrinsically stable positions are attempted. Taping may provide a useful reminder to avoid unstable positions. The shoulder is then progressed to smooth repetitive activities, such as swimming or rowing, which can play an essential role in retraining the neuromuscular patterns required for stability.

Finally, it is important to avoid all activities and habits that promote glenohumeral subluxation or dislocation; patients are taught that each time their shoulder goes out it gets easier for it to go out the next time.

Rockwood and colleagues (Rockwood et al, 1986) and Burkhead and Rockwood (Burkhead and Rockwood, 1992) found that 16 per cent of patients with traumatic subluxation, 80 per cent of those with anterior atraumatic subluxation, and 90 per cent of those with posterior instability responded to a rehabilitation program. Brostrom et al (Brostrom et al, 1992) found that exercises improved all but five of 33 unstable shoulders, including traumatic and atraumatic types. Anderson et al have demonstrated the effectiveness of an exercise program using rubber bands in improving internal rotator strength. (Anderson et al, 1992) Rockwood et al have demonstrated that nonoperative management can be successful even when there is a congenital factor in instability. They reported 16 patients with hypoplasia of the glenoid. (Wirth, Lyons and Rockwood, 1993) A subset of this group consisted of five patients with bilateral glenoid hypoplasia and multidirectional instability as indicated by symptomatic increased translation of the humeral head during anterior, inferior, and posterior drawer testing. In addition, generalized ligamentous laxity of the metacarpophalangeal joints, elbows, or knees was noted in all five patients. Four of the patients had been involved in occupational or recreational activities, or both, that had placed heavy demands on the shoulders. Four of these patients had considerable improvement in the ratings for pain and the ability to carry out work and sports activities at an average of 3 months after they had begun a strengthening program designed by Rockwood. None of the patients needed vocational rehabilitation, despite the heavy demands on their shoulders associated with their occupational or recreational activities.

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