REHABILITATION IN SHOULDER INSTABILITY:
The glenohumeral joint is an unstable joint because the depth and size of the glenoid fossa are not proportional to the humerus, and the range of motion is greater than all other joints in the body for the same reason.
Static factors such as joint surface compatibility, articular version, glenoid labrum, capsule and ligaments in providing stability; Dynamic factors such as the rotator cuff, biceps tendon, negative intra-articular pressure and the muscles forming the scapulothoracic movement (trapezius, serratus anterior, rhomboid muscles, latissimus dorsi) play a role. Failure of one or more of these formations causes instability.
GLENOHUMERAL IS SEPARATED INTO 2 ACCORDING TO THE DEGREE OF INSTABILITY;
SUBLUXATION: The joint surfaces are not completely separated from each other.
DISLOCATION: The joint surfaces are completely separated. Many different types of dislocations are seen. These are;
Anterior dislocation (90%): It occurs with direct trauma to the arm with external rotation and abduction.
Posterior dislocation: Caused by a large direct posterior force to the internally rotated arm.
Multidirectional instability: Occurs due to loose shoulder capsule.
Inferior dislocation: It occurs with inferior force towards the arm when the arm is in abduction. It is usually seen in neurological diseases.
CAUSES OF GLENOHUMERAL INSTABILITY:
TRAUMATIC INJURY ; It is usually a unilateral shoulder injury. Bankart lesion and Hill–Sach lesion formation are very common. It is usually treated with surgery.
ATRAMUATIC INJURY ; Multidirectional instability is seen and they are bilateral injuries. Rehabilitation is the first choice in such injuries. If conservative treatment fails, surgical treatment is considered. (inferior capsular shift surgery)
SYMPTOMS OF GLENOHUMERAL INSTABILITY:
- The acromion is more prominent.
- The image of the humeral head under the deltoid disappears and a visible cavity is formed.
- It is severely painful with all ROM movements.
- The patient grabs his arm and sticks it to his body.
GLENOHUMERAL INSTABILITY TESTS:
GLENOHUMERAL INSTABILITY TREATMENT:
A. CONSERVATIVE TREATMENT:
At this stage, our aim is to reduce pain and inflammation, to support the repair of the capsule, and to prevent the muscles from atrophy.
Shoulder straps are used and simple ROM exercises and isometric exercises are practiced in the sling. Also, since the shoulder strap may cause postural disorders, posture exercises, scapular muscle exercises and proprioception exercises will be used.
We try to increase ROM. We do exercises to gain scapular muscle balance and scapular muscle strength. We also continue with proprioception exercises.
BACK TO SPORTS:
Gaining full ROM and full strength is important at this stage. We continue with rotator cuff and scapula thoracic exercises. We start light sports activities and perturbation and plyometric exercises, which are important for athletes, are passed at this stage.
B. SURGICAL TREATMENT:
SURGICAL TREATMENT OPTIONS:
Bankart repair: If open surgery is performed, the subscapularis muscle is cut and rehabilitation begins on the 2nd post-op day. If arthroscopic surgery is performed, rehabilitation begins after the 3rd week after the post-op surgery.
Anterior plication: The capsule is contracted.
Thermal Capsulography: It is a technique of shrinking the capsule by giving heat, but it is not used much.
C. PHYSIOTHERAPY AFTER SURGERY:
0-3 weeks of immobilization and early movement reduce pain and re-dislocation and increase functionality.
If soft tissue technique was used (Bankart repair):
0-3 WEEKS: Shoulder 90° flexion is practiced.
90° abduction in the scapular plane is practiced.
20-30° External and internal rotation is practiced.
3-6 WEEKS: 130-140° flexion is practiced on the shoulder.
40-50° external rotation is practiced.
45° internal rotation is practiced.
Stretching of the posterior capsule is started.
6-12 WEEKS: Wand exercises are started in 6 weeks. (active assistive exercise)
Full ROM is intended but stretching is prohibited.
It is aimed to achieve full passive ROM by week 12.
If there is a lack of external rotation, external rotation stretching is not performed at 90° abduction before the 12th week.
Scapulothoracic retraction is exercised.
Scapular exercises are started without putting a load on the repair area.
AFTER 12 WEEKS: If full external rotation is not achieved at 12 weeks, prolonged external rotation stretching should not be performed.
It is not recommended to return to sports before 6 months.
IF BONE BLOCK TECHNIQUES ARE USED:
0-3 WEEKS: We should prevent shoulder extension to protect the subscapularis and chorocoid.
According to pain tolerance, forward flexion and abduction in the scapular plane should be used.
30°-40° external rotation is practiced in the scapular plane.
Internal rotation at 45° scapular is practiced.
3-6 WEEKS: We continue to increase flexion and extension.
We can practice internal and external rotation at different angles.
6-12 WEEK: Active assistive ROM is started in the 6th week.
Careful stretching is done to increase passive ROM.
The rotator cuff and scapulothoracic are strengthened.
After week 8 it should be full passive ROM.
After 4 months; return to sports.