Physical Therapy Management Of Shoulder Dislocation

Summary of the Condition

The major impairments that a patient with shoulder dislocation may encounter could possibly include: pain, loss of range, decreased strength, decreased functional mobility, inflammation, muscle spasms, and decreased proprioception.^1,2

Guide to PT Practice

Practice Pattern 4D: Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction.²

Intervention Goals From The Guide²:
• Improvement in ability to perform activities, tasks, and actions
• Patient knowledge of personal and environmental factors associated with the condition is increased
• Improvement in physical function
• Risk of recurrence of condition and secondary impairment is reduced

Suggested Interventions From The Guide²:
• ADL training
• PROM & AROM
• Muscular strength, power, and endurance training

You can find information about this practice pattern at www.guidetoptpractice.apta.org (You must be a member to view all information).

Management of Shoulder Dislocation

Operative and non-operative protocols for rehabilitation of shoulder dislocation (whether traumatic or atraumatic) are similar. Therefore, provided below is the non-operative rehabilitation protocol for traumatic shoulder dislocation. This protocol does not have a timeline for each phase. Instead, certain criteria must be met before moving on to the next stage.

Phase I. Acute Phase

During this phase, the main goals of rehabilitation are to decrease pain, provide optimum conditions for healing, reduce the effects of immobilization, restore baseline stability, and prevent further damage to the joint capsule.^1,3

To decrease pain and inflammation^1,4,5:
• A sling or brace may be given to the patient for immobilization. Studies vary on how long the immobilization device should
be worn from a few days to 6 weeks
• Ice and TENS
• Grade I-II joint mobilizations for pain relief

ROM exercises (In the acute phase, it is necessary to be cautious of extreme ranges of motion until baseline stability is restored.)^1,3:
• Pendulums
• AAROM with an L-Bar (flexion, internal/external rotation w/ 30 degrees abduction)
• Rope and Pulley – scapular elevation
*avoid excessive external rotation and horizontal abduction for anterior instability, and avoid excessive internal rotation and horizontal adduction with posterior instability¹
*all ROM exercises performed within pain free arc¹

image taken from: http://www.centraliowaortho.com/Dynamic.aspx?Id=46

Strengthening Exercises^1,3,4:
• Isometric strengthening - flexion, abduction, extension, internal rotation, external rotation, biceps, scapular pro/retraction, scapular elevation/depression

Stabilization^1,3:
• Weight shifts (closed chain)

Phase II. Immediate Phase

During this phase, the main goals of rehabilitation are to increase strength and proprioception, normalize arthrokinematics, and enhance neuromuscular control.¹ In order to advance to this phase, the patient must have near to full ROM, minimal pain, adequate stability and proprioception, and a good MMT for flexion, abduction, internal rotation and external rotation.¹

ROM exercises^1,3,5:
• Same as Phase I but progress to exercises in 90 degrees abduction (pain free)

Strengthening Exercises^1,6:
• Abduction to 90 degrees
• Sidelying external rotation to 45 degrees
• Eccentric internal and external rotation strengthening (theraband)
• Prone extension to neutral
• Prone horizontal adduction
• Prone rowing
• Pushups using table
• Bicep curls
• Tricep push-downs
• Manual rhythmic stabilization

image taken from: http://www.joint-pain-solutions.com/torn-rotator-cuff-exercises.html

Neuromuscular Control Exercises^1,3,6:
• Stabilization with ball against the wall
• PNF techniques
• Core, trunk, gluteal strengthening
• Static holds in push up position on ball
• Push ups on tilt board
• Wall circles with hand on wall

Phase III. Advanced Strengthening Phase

During this phase, the main goals of rehabilitation are to enhance strength, power, and endurance, improve neuromuscular control, increase dynamic stability, and prepare the patient for activity.¹ In order to progress to this phase, the patient must have full ROM without pain, progression of strengthening exercises, and normal muscle strength, stability, and neuromuscular control.¹

Strengthening Exercises^1,3,4,6:
• Progress to end range stabilization drills
• Progress to full ROM strengthening
• Bench press (in restricted horizontal abduction)
• Seated rowing
• Lat pull downs

PNF Techniques^1,3:
• D2 pattern with rhythmic stabilization at 45, 90, and 145 degrees

Neuromuscular Control Exercises^1,6:
• Push ups on ball or rocker board with rhythmic stabilizations
• External rotation at 90 degrees abduction with manual resistance and rhythmic stabilization at end range

image taken from: http://www.shapefit.com/best-body-weight-exercises.html

Endurance Exercises^1,3:
• Timed exercises instead of reps (30-60 sec)
• Increase number of reps (15-20)
• Multiple times throughout the day (3X)

Plyometric Exercises^1,3:
• 2 hand drills – chest pass throw, side to side throw, overhead throw
• Progress to 1 hand drills – 90/90 basketball throws, 90/90 baseball throws against wall, wall dribbles

Wall dribbles in the 90/90 position.¹

Phase IV. Return to Activity

During this phase, the main goals of rehabilitation are to maintain the highest level of strength, power, and endurance, and progressively enhance activity level to prepare the patient for full functional activities.¹ In order to advance to this phase, the patient must have full ROM, no pain or tenderness, and adequate clinical exam and isokinetic tests.¹

Continue all exercises in Phase III
Progress strengthening exercises
Initiate sport program if appropriate
Resume normal lifting program

Modalities

Kinesio tape: Different kinesio taping techniques can be used on the shoulder to help decrease pain.⁷ It is placed on the shoulder to increase support, especially during movement.⁷ It is also thought to help increase proprioception.⁷ However, there is no supporting evidence that these taping techniques are actually effective.⁷

Transcutaneous electrical nerve stimulation (TENS): TENS can be used to help relieve both acute and chronic shoulder pain by way of the gate theory.⁸ Evidence has shown that TENS can be effective for immediate pain relief.⁸

Ice: Ice can help decrease pain and swelling in an inflamed shoulder.

Electrical Stimulation: E-stim may be used to help in the recruitment of
muscle fibers when performing different exercises such as sidelying external
rotation.¹ However, more studies need to be conducted on the
effectiveness of E-stim for this purpose.¹

image taken from: http://www.istockphoto.com/stock-photo-4746216-electrical-stimulation-machine-on-shoulder.php

References

1. Wilk KE, Macrina LC, Reinold MM. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J Sports Phys Ther, 2006;1(1):16–31.
2. American Physical Therapy Association. Guide to physical therapist practice. second edition. american physical therapy association. Phys Ther, 2001;81(1):9-746.
3. Lervick GM. Nonsurgical rehabilitation protocol for posterior shoulder instability. Minnesota Orthopedic Sports Medicine Institute, 1-4. http://www.tcomn.com/images/wmimages/OnlineForms/Lervick_Nonsurg_Post_GH_Instability_MOSMI.pdf
4. Hayes K, Callanan M, Walton J, Paxinos A, Murrell G. Shoulder instability: management and rehabilitation. Journal of Orthopaedic & Sports Physical Therapy, 2002;32(10):1-13.
5. Burgess B, Sennett BJ. Traumatic shoulder instability: nonsurgical management versus surgical intervention. Orthopaedic Nursing, 2003;22(5): 345-352.
6. Pabian PS, Kolber MJ, McCarthy JP. Postrehabilitation strength and conditioning of the shoulder: an interdisciplinary approach. Strength & Conditioning Journal, 2011;33(3): 42-55.
7. Thelen MD, Dauber JA, Stoneman PD. The clinical efficacy of kinesio tape for shoulder pain: a randomized, double blinded, clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 2008;38(7): 389-395.
8. Philadelphia Panel. Philedelphia panel evidence based clinical practice guidelines on selected rehabilitation interventions for shoulder pain. Physical Therapy, 2001;81(10): 1719-1730.