Surgery for Posterior Shoulder Instability

with Phase I Rehab

ExitCare ImageSurgery is only recommended for serious cases of posterior shoulder instability that involve recurrent shoulder dislocations, that result in an inability to perform activities of daily living, or if symptoms persist for greater than 6 months despite non-surgical (conservative) treatment. Surgery for the correction of posterior shoulder instability and the completion of a rehabilitation program has a high probability of success. The purpose of this operation is to restore stability to the shoulder joint (glenohumeral) by tightening the joint capsule. In general, more stable joints allow less movement; therefore this procedure may reduce your range of motion. Multiple techniques exist for completing this surgery, and the timing of surgery is not related to the success of the operation. Posterior shoulder instability is more difficult to correct than other types of shoulder instability. It is likely that the surgery will increase the stability of your shoulder; however, you may still be unable to return to a high level of athletic competition.

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 backward (posteriorly).

  • Purposely dislocating the shoulder.

  • Arthritis of the joint may be a reason not to operate.

  • Damage to the nerves of the rotator cuff may be a reason not to operate.

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.

  • Loss of motion.

  • Inability to compete in athletics.

  • Moving or breaking of surgical anchors.

  • Arthritis.

PROCEDURE

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

The most common open-incision technique involves a larger incision to access the shoulder joint. The surgeon will enter the shoulder joint by detaching the deltoid muscle and either splitting or removing the infraspinatus. The labrum is then reattached to the glenoid fossa if it is torn. After the labrum has been repaired, 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 posterior shoulder instability require multiple smaller incisions than 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 a heat.

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

AFTER THE PROCEDURE

  • 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 6 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 - Shoulder Instability, Posterior, Surgery For Phase I: Immediately After Immobilization

These exercises may help you restore your shoulder mobility once your physician has permitted you to begin moving your shoulder. Most people will begin these exercises between 2 and 6 weeks after their injury. Your starting time will depend on the severity of your injury and the stabilization of your healing tissues. 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 bring your right / left elbow across your body (including sleeping on your opposite side). 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 right / left arm 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.

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 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 right / left seconds. Slowly return to your 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 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 right / left shoulder, but before you have increased shoulder pain.

  • 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.

  • Slowly 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 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.

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 __________. 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, Posterior, Surgery For Phase I: Immediately After Immobilization

These exercises may help you restore your shoulder strength once your physician has discontinued your 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 with 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 bring your right / left elbow across your body (including sleeping on your opposite side). These positions stress the tissues which are trying to heal.

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 do 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 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.

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 do 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 do the next repetition.

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