Shoulder Instability, Anterior

with Rehab

ExitCare ImageAnterior shoulder instability is a condition that is characterized by recurrent dislocation of the shoulder joint. Dislocation is an injury in which two adjacent bones are no longer in proper alignment, and the joint surfaces are no longer touching. Subluxation is a similar injury to dislocation; however, the joint surfaces are still touching. Dislocations and subluxations of the shoulder joint (glenohumeral) most commonly involve the upper arm bone (humerus) displacing forward (anteriorly). The shoulder joint allows more motion than any other joint in the body, and because of this it is highly susceptible to injury. When the glenohumeral joint is dislocated or subluxed, the muscles that control the shoulder joint (rotator cuff) tendons become stretched. Repetitive injury results in the shoulder joint becoming loose and results in instability of the shoulder joint. These injuries may also cause a tear in the cartilage that lines the joint and helps keep the humerus head in place (labrum).

SYMPTOMS

  • Severe shoulder pain when the joint is dislocated or subluxed.

  • Shoulder weakness, pain, and/or inflammation.

  • Loss of shoulder function.

  • Pain that worsens with shoulder function, especially motions that involve arm movements above shoulder height.

  • Feeling of shoulder weakness or instability.

  • Signs of nerve damage: numbness or paralysis.

  • Crackling (crepitation) feeling and sound when the injured area is touched or with shoulder motion.

CAUSES

Anterior shoulder instability is caused by injury to the glenohumeral joint that causes it to become dislocated or subluxed. Common mechanisms of injury include:

  • Direct trauma to the shoulder joint.

  • Repetitive and/or strenuous movements of the shoulder joint, especially those with the arm above shoulder height.

  • Sprain of on the ligaments of the shoulder joint.

  • An abnormality you are born with (congenital). This includes a shallow or malformed joint surface.

RISK INCREASES WITH:

  • Contact sports (football, wrestling, and basketball).

  • Activities that involve repetitive and/or strenuous movements of the shoulder joint, especially those with the arm above shoulder height (baseball, volleyball, or swimming).

  • Previous shoulder injury.

  • Poor strength and flexibility.

PREVENTION

  • Warm up and stretch properly before activity.

  • Allow for adequate recovery between workouts.

  • Maintain physical fitness:

  • Strength, flexibility, and endurance.

  • Cardiovascular fitness.

  • Learn and use proper technique. When possible, have a coach correct improper technique.

  • Wear properly fitted and padded protective equipment.

PROGNOSIS

The extent of recovery and likelihood of future dislocations and subluxations depends on the extent of damage done to the shoulder.

RELATED COMPLICATIONS

  • Damage to the nervous system or blood vessels that may cause weakness, paralysis, numbness, coldness, and paleness.

  • Damage to the bones or cartilage of the shoulder joint.

  • Permanent shoulder instability.

  • Tear of one or more of the rotator cuff tendons

  • Arthritis of the shoulder.

TREATMENT

When the shoulder joint is dislocated it must be realigned (reduced) by someone who is trained in the procedure. Occasionally reduction cannot be performed manually, and requires surgery. After reduction, the use of ice and medication may help reduce pain and inflammation. The shoulder should be immobilized with a sling for 3 to 8 weeks to allow the joint to heal. After immobilization it is important to perform strengthening and stretching exercises to help regain strength and a full range of motion. These exercises may be completed at home or with a therapist. Surgery is reserved for individuals have sustained multiple shoulder dislocations due to shoulder instability.

MEDICATION

  • General anesthesia or muscle relaxants may be necessary for reduction of the shoulder joint.

  • If pain medication is necessary, then nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen, or other minor pain relievers, such as acetaminophen, are often recommended.

  • Do not take pain medication within 7 days before surgery.

  • Prescription pain relievers may be given if deemed necessary by your caregiver. Use only as directed and only as much as you need.

COLD THERAPY

Cold treatment (icing) relieves pain and reduces inflammation. Cold treatment should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or an ice massage.

SEEK MEDICAL CARE IF:

  • Treatment seems to offer no benefit, or the condition worsens.

  • Any medications produce adverse side effects.

  • Any complications from surgery occur:

  • Pain, numbness, or coldness in the extremity operated upon.

  • Discoloration of the nail beds (they become blue or gray) of the extremity operated upon.

  • Signs of infections (fever, pain, inflammation, redness, or persistent bleeding).

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Shoulder Instability, Anterior

These exercises may help you restore your shoulder mobility once your physician has discontinued your 2-6 weeks of immobilization. Beginning these before your provider's approval may result in delayed healing. Your symptoms may resolve with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds. A stretch should never be painful. You should only feel a gentle lengthening or release in the stretch.

  • During your recovery, avoid activity or exercises which involve actions that place your right / left hand or elbow above your head or behind your back or head. These positions stress the tissues which are trying to heal.

ExitCare Image ROM - Pendulum

  • Bend at the waist so that your right / left arm falls away from your body. Support yourself with your opposite hand on a solid surface, such as a table or a countertop.

  • Your right / left arm should be perpendicular to the ground. If it is not perpendicular, you need to lean over farther. Relax the muscles in your right / left arm and shoulder as much as possible.

  • Gently sway your hips and trunk so they move your arm without any use of your right / left shoulder muscles.

  • Progress your movements so that your arm moves side to side, then forward and backward, and finally, both clockwise and counterclockwise.

  • Complete __________ repetitions in each direction. Many people use this exercise to relieve discomfort in their shoulder as well as to gain range of motion.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH – Flexion, Seated

  • Sit in a firm chair so that your right / left forearm can rest on a table or on a table or countertop. Your elbow should rest below the height of your shoulder so that your shoulder feels supported and not tense or uncomfortable.

  • Keeping your right / left shoulder relaxed, lean forward at your waist, allowing your hand to slide forward. Bend forward until you feel a moderate stretch in your shoulder, but before you feel an increase in your pain.

  • Hold __________ seconds. Slowly return to your starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH – Flexion, Standing

  • Stand with good posture. With an underhand grip on your right / left hand and an overhand grip on the opposite hand, grasp a broomstick or cane so that your hands are a little more than shoulder-width apart.

  • Keeping your right / left elbow straight and shoulder muscles relaxed, push the stick with your opposite hand to raise your arm in front of your body and then overhead. Raise your arm until you feel a stretch in your right / left shoulder, but before you have increased shoulder pain.

  • Try to avoid shrugging your shoulder as your arm rises by keeping your shoulder blade tucked down and toward your mid-back spine. Hold __________ seconds.

  • Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH – Abduction, Supine

  • Stand with good posture. With an underhand grip on your right / left hand and an overhand grip on the opposite hand, grasp a broomstick or cane so that your hands are a little more than shoulder-width apart.

  • Keeping your right / left elbow straight and shoulder muscles relaxed, push the stick with your opposite hand to raise your right / left arm out to the side of your body and then overhead. Raise your arm until you feel a stretch in your shoulder, but before you have increased shoulder pain.

  • Try to avoid shrugging your shoulder as your arm rises by keeping your shoulder blade tucked down and toward your mid-back spine. Hold __________ seconds.

  • Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image ROM – Flexion, Active-Assisted

  • Lie on your back. You may bend your knees for comfort.

  • Grasp a broomstick or cane so your hands are about shoulder-width apart. Your right / left hand should grip the end of the stick/cane so that your hand is positioned "thumbs-up," as if you were about to shake hands.

  • Using your healthy arm to lead, raise your right / left arm overhead until you feel a gentle stretch in your shoulder. Hold __________ seconds.

  • Use the stick/cane to assist in returning your arm to its starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH – Flexion, Standing

  • Stand facing a wall. Walk your right / left fingers up the wall until you feel a moderate stretch in your shoulder. As your hand gets higher, you may need to step closer to the wall or use a door frame to walk through.

  • Try to avoid shrugging your shoulder as your arm rises by keeping your shoulder blade tucked down and toward your mid-back spine.

  • Hold __________ seconds. Use your other hand, if needed, to ease out of the stretch and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRETCH – External Rotation

  • Tuck a folded towel or small ball under your right / left upper arm. Grasp a broomstick or cane with an underhand grasp a little more than shoulder width apart. Bend your elbows to 90 degrees.

  • Stand with good posture or sit in a chair without arms.

  • Use your strong arm to push the stick across your body. Do not allow the towel or ball to fall. This will rotate your right / left arm away from your abdomen. Using the stick turn/rotate your hand and forearm away from your body. Hold __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

STRENGTHENING EXERCISES - Shoulder Instability, Anterior

These exercises may help you restore your shoulder strength once your physician has discontinued your 2-6 weeks of immobilization. When completing these exercises, do not raise your arm above shoulder-height until your physician, physical therapist or athletic trainer has instructed you to do so. Advancing your exercise before your provider's approval may result in delayed healing. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Progress the resistance and repetitions only as guided.

  • You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does worsen, stop and make certain you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your clinician.

  • During your recovery, avoid activity or exercises which involve actions that place your right / left hand or elbow above your head or behind your back or head. These positions stress the tissues which are trying to heal.

STRENGTH - Scapular Depression and Adduction

  • With good posture, sit on a firm chair. Supported your arms in front of you with pillows, arm rests or a table top. Have your elbows in line with the sides of your body.

  • Gently draw your shoulder blades down and toward your mid-back spine. Gradually increase the tension without tensing the muscles along the top of your shoulders and the back of your neck.

  • Hold for __________ seconds. Slowly release the tension and relax your muscles completely before completing the next repetition.

  • After you have practiced this exercise, remove the arm support and complete it in standing as well as sitting.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Shoulder Flexion, Isometric

  • With good posture and facing a wall, stand or sit about 4-6 inches away.

  • Keeping your right / left elbow straight, gently press the top of your fist into the wall. Increase the pressure gradually until you are pressing as hard as you can without shrugging your shoulder or increasing any shoulder discomfort.

  • Hold __________ seconds.

  • Release the tension slowly. Relax your shoulder muscles completely before you the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Shoulder Abductors, Isometric

  • With good posture, stand or sit about 4-6 inches from a wall with your right / left side facing the wall.

  • Bend your right / left elbow. Gently press your elbow into the wall. Increase the pressure gradually until you are pressing as hard as you can without shrugging your shoulder or increasing any shoulder discomfort.

  • Hold __________ seconds.

  • Release the tension slowly. Relax your shoulder muscles completely before you the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Internal Rotators, Isometric

  • Keep your right / left elbow at your side and bend it 90 degrees.

  • Step into a door frame so that the inside of your right / left wrist can press against the door frame without your upper arm leaving your side.

  • Gently press your right / left wrist into the door frame as if you were trying to draw the palm of your hand to your abdomen. Gradually increase the tension until you are pressing as hard as you can without shrugging your shoulder or increasing any shoulder discomfort.

  • Hold __________ seconds.

  • Release the tension slowly. Relax your shoulder muscles completely before you the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - External Rotators, Isometric

  • Keep your right / left elbow at your side and bend it 90 degrees.

  • Step into a door frame so that the outside of your right / left wrist can press against the door frame without your upper arm leaving your side.

  • Gently press your right / left wrist into the door frame as if you were trying to swing the back of your hand away from your abdomen. Gradually increase the tension until you are pressing as hard as you can without shrugging your shoulder or increasing any shoulder discomfort.

  • Hold __________ seconds.

  • Release the tension slowly. Relax your shoulder muscles completely before you the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Protractors, Standing

  • Stand arms-length away from a wall. Place your hands on the wall, keeping your elbows straight.

  • Begin by dropping your shoulder blades down and toward your mid-back spine.

  • To strengthen your protractors, keep your shoulder blades down, but slide them forward on your rib cage. It will feel as if you are lifting the back of your rib cage away from the wall. This is a subtle motion and can be challenging to complete. Ask your clinician for further instruction if you are not sure you are doing the exercise correctly.

  • Hold for __________ seconds. Slowly return to the starting position, resting the muscles completely before completing the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Protractors, Supine

  • Lie on your back on a firm surface. Extend your right / left arm straight into the air while holding a __________ weight in your hand.

  • Keeping your head and back in place, lift your shoulder off the floor.

  • Hold __________ seconds. Slowly return to the starting position and allow your muscles to relax completely before completing the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Protractors, Quadruped

  • Get onto your hands and knees with your shoulders directly over your hands (or as close as you comfortably can be).

  • Keeping your elbows locked, lift the back of your rib cage up into your shoulder blades so your mid-back rounds-out. Keep your neck muscles relaxed.

  • Hold this position for __________ seconds. Slowly return to the starting position and allow your muscles to relax completely before completing the next repetition.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Shoulder Extensors, Prone

  • Lie on your stomach on a firm surface so that your right / left arm overhangs the edge. Rest your forehead on your opposite forearm. With your thumb facing away from your body and your elbow straight, hold a __________ weight in your hand.

  • Squeeze your right / left shoulder blade to your mid-back spine and then slowly raise your arm behind you to the height of the bed.

  • Hold for __________ seconds. Slowly reverse the directions and return to the starting position, controlling the weight as you lower your arm.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Shoulder Flexion

  • Stand or sit with good posture. Grasp a __________ weight or an exercise band/tubing so that your hand is "thumbs-up," like when you shake hands.

  • Slowly lift your right / left arm as far as you can without increasing any shoulder pain. Initially, many people can only raise their hand to shoulder height.

  • Avoid shrugging your shoulder as your arm rises by keeping your shoulder blade tucked down and toward your mid-back spine.

  • Hold for __________ seconds. Control the descent of your hand as you slowly return to your starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Scapular Retractors

  • Secure a rubber exercise band/tubing so that it is at the height of your shoulders when you are either standing or sitting on a firm arm-less chair.

  • With a palm-down grip, grasp an end of the band/tubing in each hand. Straighten your elbows and lift your hands straight in front of you at shoulder height. Step back away from the secured end of band/tubing until it becomes tense.

  • Squeezing your shoulder blades together, draw your elbows back as you bend them. Keep your upper arm lifted away from your body throughout the exercise.

  • Hold __________ seconds. Slowly ease the tension on the band/tubing as you reverse the directions and return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Internal Rotators

  • Secure a rubber exercise band/tubing to a fixed object so that it is at the same height as your right / left elbow when you are standing or sitting on a firm surface.

  • Stand or sit so that the secured exercise band/tubing is at your right / left side.

  • Bend your elbow 90 degrees. Place a folded towel or small pillow under your right / left arm so that your elbow is a few inches away from your side.

  • Keeping the tension on the exercise band/tubing, pull it across your body toward your abdomen. Be sure to keep your body steady so that the movement is only coming from your shoulder rotating.

  • Hold __________ seconds. Release the tension in a controlled manner as you return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - External Rotators

  • Secure a rubber exercise band/tubing to a fixed object so that it is at the same height as your right / left elbow when you are standing or sitting on a firm surface.

  • Stand or sit so that the secured exercise band/tubing is at your side that is not injured.

  • Bend your elbow 90 degrees. Place a folded towel or small pillow under your right / left arm so that your elbow is a few inches away from your side.

  • Keeping the tension on the exercise band/tubing, pull it away from your body, as if pivoting on your elbow. Be sure to keep your body steady so that the movement is only coming from your shoulder rotating.

  • Hold __________ seconds. Release the tension in a controlled manner as you return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.