Shoulder Instability, Multidirectional

with Rehab

Anterior shoulder instability is a condition that is characterized by recurrent dislocation or partial dislocation (subluxation) 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. With multidirectional shoulder instability, dislocations and subluxations of the shoulder joint (glenohumeral) involve the upper arm bone (humerus) displacing forward (anteriorly), downward (inferiorly), or backward (posteriorly). 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 labrum (cartilaginous rim) that lines the joint and helps keep the humerus head in place.

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.

  • Often occurs in both shoulders.

CAUSES

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

  • Microtraumatic or atraumatic (most common).

  • 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.

  • A shallow or malformed joint surface you are born with (congenital).

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.

  • Congenital abnormality (shallow or malformed joint surface).

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 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. Reoccurrence of symptoms is likely for individuals with multidirectional shoulder instability.

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 reduced (the bones realigned) 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 who 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 for 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 massage the area with a piece of ice (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, Multidirectional

These exercises may help you restore your shoulder mobility once your physician has discontinued your 3-8 week immobilization period. The length of your immobilization depends on the intensity of your injury and the quality of the tissues before they were repaired. 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 stretched tissue. 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.

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 / leftarm and shoulder as much as possible.

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

  • Progress your movements so that your right / left 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.

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 right / left arm to its starting position.

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

ROM - Internal Rotation, Supine

  • Lie on your back on a firm surface. Place your right / left elbow about 60 degrees away from your side. Elevate your elbow with a folded towel so that the elbow and shoulder are the same height.

  • Using a broomstick or cane and your strong arm, pull your right / left hand toward your body until you feel a gentle stretch, but no increase in your shoulder pain. Keep your shoulder and elbow in place throughout the exercise.

  • Hold __________. Slowly return to the starting position.

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

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 firm 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.

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 right / left 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 right / left 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.

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 right / left 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.

STRENGTHENING EXERCISES - Shoulder Instability, Multidirectional

These exercises will help you begin to restore your shoulder strength once your physician has discontinued your 3-8 week immobilization period. The length of your immobilization depends on the intensity of your injury and the quality of the tissues before they were repaired. 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 with the resistance and repetition exercises only as your caregiver advises.

  • 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.

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 do the next repetition.

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

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 right / left 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 do the next repetition.

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

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 do the next repetition.

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

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 do the next repetition.

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

STRENGTH - Shoulder Extensors

  • 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. 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, pull your hands down to the sides of your thighs. Do not allow your hands to go behind you.

  • 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.

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.

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.

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.

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 right / left 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.

STRENGTH - Supraspinatus

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

  • Slowly lift your right / left hand from your thigh into the air, traveling about 30 degrees from straight out at your side. Lift your hand to shoulder height or as far as you can without increasing any shoulder pain. Initially, many people do not lift their hands above shoulder height.

  • Avoid shrugging your right / left 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.

STRENGTH - Shoulder Abductors

  • Stand or sit with good posture. Place your right / left arm at your side.

  • With a thumbs-up grasp, hold a __________ weight or a secured rubber exercise band/tubing in your right / left hand. Slowly lift your arm from your side as far as you can without reproducing any of your shoulder pain. Do not lift your hand above shoulder-height unless you have been instructed to do so by your physician, physical therapist or athletic trainer. If this motion causes pain or increased discomfort, discuss this with your physician, physical therapist, or athletic trainer.

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

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

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

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 __________ 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.

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.