Surgery for Anterior Shoulder Instability

with Phase III Rehab

ExitCare ImageThe purpose of this operation is to restore stability to the shoulder (glenohumeral) joint. In general, more stable joints allow less movement; therefore this procedure may reduce your range of motion. Multiple techniques exist for completing this surgery.

Serious cases of anterior shoulder instability that involve recurrent shoulder dislocations or symptoms that persist for greater than 6 months despite non-surgical (conservative) treatment, may result in an inability to perform activities of daily living. Occasionally surgery will be recommended for individuals after their first dislocation; however, these cases typically have a lower recovery rate.

REASONS NOT TO HAVE SURGERY

  • Infection of the shoulder joint.

  • Inability to complete a post-operative rehabilitation program.

  • Other conditions (emotional or psychological) that may affect the outcome of the surgery.

  • Shoulder instability in any other direction besides forward (anteriorly).

  • Purposely dislocating the shoulder.

  • Arthritis of the joint (not an absolute reason to not have surgery).

RISKS AND COMPLICATIONS

  • Risks inherent to surgery: infection, bleeding, nerve damage, or damage to surrounding tissues.

  • Recurrent symptoms that result in a chronic problem.

  • Shoulder pain.

  • Detachment of one of the shoulder muscles (subscapularis).

  • Loss of motion.

  • Inability to compete in athletics.

  • Moving or breaking of surgical anchors.

  • Arthritis.

TECHNIQUE

Multiple techniques exist for surgically repairing anterior shoulder instability: arthroscopic techniques and open-incision techniques. Both techniques have the same goal of restoring stability to your shoulder and preventing future dislocations or partial dislocation (subluxations). Both techniques involve reattaching the rim of cartilage around the shoulder (labrum) that lines the glenoid fossa if it has been torn away and then tightening the loose shoulder ligaments or tendons.

The most common open-incision technique involves a larger incision to access the shoulder joint. The surgeon will enter the shoulder joint from between the pectoralis and deltoid muscles. In order to reach the joint capsule, the subscapularis muscle is either cut or removed. The labrum is then reattached to the glenoid fossa. After the labrum has been repair, the surgeon tightens the joint capsule by folding it upon itself and then he or she will sew (suture) the fold together.

Arthroscopic techniques for repairing anterior shoulder instability require multiple smaller incisions compared to open-incision surgery. The surgeon uses a video camera and small tools placed in the joint to repair the torn labrum by suturing it to the glenoid fossa. The joint capsule is then tightened by folding it upon itself and having it sutured together or by using heat, which shrinks the capsule.

There are other techniques that are less common that do not focus on trying to replicate the original structure of the joint.

POST-OPERATIVE COURSE

  • The post-operative management depends on the surgical procedure and the preferences of your surgeon and therapist.

  • Keep the wound clean and dry for the first 10 to 14 days after surgery.

  • Immobilize the shoulder joint with the sling provided to you for the period of time that is specified by your surgeon.

  • You will be given pain medications by your caregiver.

  • Passive (without using muscles) shoulder movements may be begun immediately after surgery.

  • It is important to follow through with you rehabilitation program in order to have the best possible recovery.

RETURN TO SPORTS

  • The rehabilitation period will depend on the sport and position you play as well as the success of the operation.

  • The minimum recovery period is 3 months.

  • You must have regained complete shoulder motion and strength before returning to sports.

  • Full shoulder motion and strength are necessary before returning to sports.

SEEK MEDICAL CARE IF:

  • 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 - Surgery for Anterior Shoulder Instability, Phase III Rehab

After you have gained significant flexibility and strength through Phase II and your shoulder is showing consistent signs of healing, your physician will introduce you to Phase III of your rehabilitation. These exercises are more aggressive and are intended to restore your shoulder mobility to levels which will allow you to return to your previous activities. Your clinician may also ask you to continue with Phase II exercises which are still of benefit to you. 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 STRETCH - External Rotation and Abduction

  • Stagger your stance through a doorframe. It does not matter which foot is forward.

  • Choose one of the following positions as instructed by your physician, physical therapist or athletic trainer: place your hands

  • and forearms above your head and on the door frame.

  • and forearms at head-height and on the door frame.

  • at elbow-height and on the door frame.

  • Keeping your head and chest upright and your stomach muscles tight to prevent over-extending your low-back, slowly shift your weight onto your front foot until you feel a stretch across your chest and/or in the front of your shoulders.

  • Hold __________ seconds. Shift your weight to your back foot to release the stretch.

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

ExitCare Image ROM - Internal Rotation

  • Using underhand grips, grasp a stick behind your back with both hands.

  • While standing upright with good posture, slide the stick up your back until you feel a mild stretch in the front of your shoulder.

  • Hold right / left. Slowly return to your starting position.

  • Grasp a stick behind your back with both hands.

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

STRENGTHENING EXERCISES - Shoulder Instability, Anterior, Surgery For Phase III

After you have gained significant flexibility and strength through Phase II and your shoulder is showing consistent signs of healing, your physician will introduce you to Phase III of your rehabilitation. These exercises are more aggressive and are intended to prepare you to gradually return to your previous activities. Your clinician may also ask you to continue with Phase II exercises which are still of benefit to you. 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.

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, 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 - 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 - Horizontal Adductors

  • 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.

  • Turn away from the secured band/tube so it is directly behind you. Grasp an end of the band/tubing in each hand and have your palms face each other. Step forward until the end of band/tubing until it becomes tense.

  • Keeping your arms at your sides, lift your elbows so they are 90 degrees from your body. Your arms should be slightly bent.

  • Keeping your arms elevated 90 degrees, draw your palms together.

  • Hold __________. 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 - Horizontal Abductors

Choose one of the two oppositions to complete this exercise.

Prone: lying on stomach:

  • 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 palm facing the floor 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 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.

Standing:

  • 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.

  • Grasp an end of the band/tubing in each hand and have your palms face each other. 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.

  • Squeeze your shoulder blades together. Keeping your elbows locked and your hands at shoulder-height, bring your hands out to your side.

  • 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 – Scapular Depressors

  • Find a sturdy chair without wheels, such as a from a dining room table.

  • Keeping your feet on the floor, lift your bottom from the seat and lock your elbows.

  • Keeping your elbows straight, allow gravity to pull your body weight down. Your shoulders will rise toward your ears.

  • Raise your body against gravity by drawing your shoulder blades down your back, shortening the distance between your shoulders and ears. Although your feet should always maintain contact with the floor, your feet should progressively support less body weight as you get stronger.

  • Hold __________ seconds. In a controlled and slow manner, lower your body weight to begin the next repetition.

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

ExitCare Image STRENGTH - Scapular Retractors and External Rotators

  • 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. Bend your elbows 90 degrees and lift your elbows to shoulder height at your sides. Step back away from the secured end of band/tubing until it becomes tense.

  • Squeezing your shoulder blades together, rotate your shoulder so that your upper arm and elbow remain stationary, but your fists travel upward to head-height.

  • Hold __________ for 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 - Scapular Retractors and Elevators

  • 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 thumbs-up grip, grasp an end of the band/tubing in each hand. Step back away from the secured end of band/tubing until it becomes tense.

  • Squeezing your shoulder blades together, straighten your elbows and lift your hands straight over your head.

  • Hold for __________ 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.