Surgery for Multidirectional Shoulder Instability

with Phase II Rehab

ExitCare ImageMultidirectional shoulder instability is often not associated with trauma, as other types of shoulder instability are, but instead by repetitive and/or strenuous use of the shoulder joint. Thus, the onset of instability is a slower process. Occasionally surgery will be recommended for individuals after their first dislocation. However, these cases typically have a lower recovery rate. The 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.

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).

  • Damage to nerves that connect the rotator cuff (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.

  • Unequal balance of tightening of the joint capsule, that results in dislocation or subluxation of the shoulder in the other direction.

  • 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 multidirectional 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 dislocations (subluxations). Your shoulder is loose in many directions, but usually one direction is the most common, and the surgery is dependent on the predominate direction of looseness. Surgeons may access the shoulder joint from the front (anterior) or back (posterior) or both.

The most common open-incision technique involves a larger incision to access the shoulder joint either posteriorly or anteriorly. The rim of cartilage around the shoulder (labrum) is then reattached to the shoulder joint socket (glenoid fossa). 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 anterior 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 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.

POSTOPERATIVE 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 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 - Surgery for Multidirectional Shoulder Instability, Phase II Rehab

After you have gained your initial flexibility and strength through Phase I, and your shoulder is showing signs of beginning to heal, your physician will introduce you to Phase II of your rehabilitation. These exercises will help you progress your shoulder mobility. Your clinician may also instruct you to begin advancing some of your exercises by raising your arms above your head. 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 – 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 right / left 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 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 – 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 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, 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 for __________ seconds. Slowly return to the 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 right / left shoulder as your arm rises by keeping your shoulder blade tucked down and toward your mid-back spine.

  • Hold for __________ 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, Surgery For Phase II

After you have gained your initial flexibility and strength through Phase I and your shoulder is showing signs of beginning to heal, your physician will introduce you to Phase II of your rehabilitation. These exercises will help you progress your shoulder strength. Despite progressing to Phase II, you may be asked to continue with some of the Phase I exercises. Your clinician may also instruct you to begin advancing some of your exercises by raising your arms above your head. Only advance or alter your exercises with permission from your clinician. 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, 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 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 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 Depressors

  • Find a sturdy chair without wheels, such as a chair 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 for __________ 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 - 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.

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 for __________ 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 - 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.

ExitCare Image STRENGTH - Supraspinatus

  • 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 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.

ExitCare Image 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 for __________ 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 - 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 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 - Horizontal Abductors

Choose one of the two positions 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 direction 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 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 - Shoulder, External Rotation/Rowing

  • Anchor/secure rubber band/tubing around a stable object such as a stair post or around the knob of a closed door.

  • Stand holding the rubber band/tubing in front of you with your arms extended.

  • Squeeze/pinch your shoulder blades together and pull your arms back bending your elbows. Your fists should end at shoulder height and close to your body.

  • Hold this position for __________ seconds and then slowly 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 for__________ seconds. Slowly ease the tension on the band/tubing as you reverse the direction and return to the starting position.

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

ExitCare Image STRENGTH - Scapular Retractors and External Rotators, Rowing

  • 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.

  • Step 1: Squeeze your shoulder blades together. Bending your elbows, draw your hands to your chest as if you are rowing a boat. At the end of this motion, your hands and elbow should be at shoulder-height and your elbows should be out to your sides.

  • Step 2: Rotate your shoulder to raise your hands above your head. Your forearms should be vertical and your upper-arms should be horizontal.

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

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