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6 Keys to Shoulder Instability Rehabilitation

Shoulder instability is a common injury encountered in physical therapy. But there are many different types of shoulder instability.

Would you treat a high school baseball player that feels like their shoulder is loose when throwing the same as a 35 year old that fell on ice onto an outstretched arm and dislocated their shoulder?  They both have “shoulder instability,” right?

There exists a wide range of symptomatic shoulder instabilities from subtle recurrent subluxations to traumatic dislocations. Nonoperative rehabilitation is commonly utilized for shoulder instability to regain previous functional activities through specific strengthening exercises, dynamic stabilization drills, neuromuscular training, proprioception drills, scapular muscle strengthening program and a gradual return to their desired activities.

But to truly understand how to successfully treat shoulder instability, there are several key factors that you must consider.

Key Factors When Designing Shoulder Instability Rehabilitation Programs

Because there are so many different variations of shoulder instability, it is extremely important to understand several factors that will impact the rehabilitation program.  This will allow us to individualize shoulder instability rehabilitation programs and enhance recovery.

There are 6 main factors that I consider when designing my rehabilitation programs for nonoperative shoulder instability rehabilitation.  I’m going to cover each in detail.

Factor #1 – Mechanism and Chronicity of Shoulder Instability

The first factor to consider in the rehabilitation of a patient with shoulder instability is the mechanism and chronicity of the injury. There are two different types of instability that can be classified as:

  1. Acute, traumatic instability
  2. Chronic, atraumatic instability

Pathological shoulder instability may result from an acute, traumatic event or chronic, recurrent instability. The goal of the rehabilitation program may vary greatly based on the onset and mechanism of injury.

Following a traumatic subluxation or dislocation, the patient typically presents with significant tissue trauma, pain and apprehension. The patient who has sustained a dislocation often exhibits more pain due to muscle spasm than a patient who has subluxed their shoulder. Furthermore, a first time episode of dislocation is generally more painful than the repeat event.

Here’s a great example of a traumatic dislocation. Note the amount of pain the athlete is in as they walk off the field with the shoulder still dislocated.

Rehabilitation will be progressed based on the patient’s symptoms with emphasis on early controlled range of motion, reduction of muscle spasms and guarding and relief of pain. But the main goal is to allow the shoulder capsule to heal.

The primary traumatic dislocation is most often treated conservatively with immobilization in a sling and early controlled passive range of motion (ROM) exercises especially with first time dislocations.

The incidence of recurrent dislocation ranges from 17-96% with a mean of 67% in patient populations between the ages of 21-30 years old. Therefore, the rehabilitation program should progress cautiously in young athletic individuals. It should be noted that Hovelius has demonstrated that the rate of recurrent dislocations is based on the patient’s age and not affected by the length of post-injury immobilization. Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability. Hovelius also noted patients in their 20’s exhibited a recurrence rate of 60% whereas patients in their 30’s to 40’s had less than a 20% recurrence rate. In adolescents, the recurrence rate is as high as 92% and 100% with an open physes.

Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks.

They often times also have the ability to move their shoulder into excessive motion.

multidirectional instability excessive capsular laxity

Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.

Chronic subluxations, as seen in the atraumatic, unstable shoulder may be treated more aggressively due to the lack of acute tissue damage and less muscular guarding and inflammation. Rotator cuff and periscapular strengthening activities should be initiated while ROM exercises are progressed. Caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.

Remember, in these patients, the primary need is stability, not mobility.

The goal is to enhance strength, proprioception, dynamic stability and neuromuscular control especially in the specific points of motion or direction which results in instability complaints.

Factor #2 – Degree of Shoulder Instability

The second factor is the degree of instability present in the patient and its effect on their function.

Varying degrees of shoulder instability exist such as a subtle subluxation or gross instability. The term shoulder subluxation refers to the complete separation of the articular surfaces with spontaneous reduction.

Conversely, a dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint. This will result in underlying capsular tissue trauma. Thus, with shoulder dislocations the degree of trauma to the glenohumeral joint’s soft tissue is much more extensive.

In the situation of an acute traumatic dislocation, the anterior capsule may be avulsed off the glenoid. This is called a Bankart lesion, and the posterior capsule may be stretched, allowing the humeral head to dislocate. This has been referred to as the “circle stability concept.”

Bankart lesion shoulder instability

Speer has reported that in order for a shoulder dislocation to occur, a Bankart lesion must be present and also soft tissue trauma must be present on both sides of the glenohumeral joint capsule.

The rate of progression will vary based upon the degree of instability and persistence of symptoms. For example, a patient with mild subluxations and muscle guarding may initially tolerate strengthening exercises and neuromuscular control drills more than a patient with a significant amount of muscular guarding.

Factor #3 – Concomitant Pathology

The third factor involves considering other tissues that may have been affected and the premorbid status of the tissue.

As we previously discussed, disruption of the capsulolabral complex from the glenoid commonly occurs during a traumatic injury resulting in an anterior Bankart lesion. But other tissues may also be involved.

Often osseous lesions may be present such as a concomitant Hill Sach’s lesion caused by an impaction of the posterolateral aspect of the humeral head as it compresses against the anterior glenoid rim during relocation.

This has been reported in up to 80% of dislocations. Conversely, a reverse Hill Sach’s lesion may be present on the anterior aspect of the humeral head due to a posterior dislocation. Similarly, the glenoid can also sustain a boney lesion.

The more boney involvement, the greater amount of instability that is often present.

Occasionally, a bone bruise may be present in individuals who have sustained a shoulder dislocation as well as pathology to the rotator cuff. In rare cases of extreme trauma, the brachial plexus may become involved as well. Other common injuries in the unstable shoulder may involve the superior labrum (SLAP lesion) such as a type V SLAP lesion characterized by a Bankart lesion of the anterior capsule extending into the anterior superior labrum. These concomitant lesions will affect the rehabilitation significantly in order to protect the healing tissue.

Factor # 4 – Direction of Shoulder Instability

The next factor to consider is the direction of shoulder instability present. The three most common forms include anterior, posterior and multidirectional.

Anterior shoulder instability is the most common traumatic type of instability seen in the general orthopedic population. It has been reported that this type of instability represents approximately 95% of all traumatic shoulder instabilities. However, the incidence of posterior instabilities appears to be dependent on the patient population. For example, in professional or collegiate football, the incidence of posterior shoulder instability appears higher than the general population. This is especially true in linemen. Often, these posterior instability patients require surgery as Mair reported 75% required surgical stabilization.

Following a traumatic event in which the humeral head is forced into extremes of abduction and external rotation, or horizontal abduction, the glenolabral complex and capsule may become detached from the glenoid rim resulting in anterior instability, or a Bankart lesion as discussed above.

Conversely, rarely will a patient with atraumatic instability due to capsular redundancy dislocate their shoulder. These individuals are more likely to repeatedly sublux the joint without complete separation of the humerus from the glenoid rim.

Posterior shoulder instability occurs less frequently, only accounting for less than 5% of traumatic shoulder dislocations.

This type of instability is often seen following a traumatic event such as falling onto an outstretched hand or from a pushing mechanism. However, patients with significant atraumatic laxity may complain of posterior instability especially with shoulder elevation, horizontal adduction and excessive internal rotation due to the strain placed on the posterior capsule in these positions.

Multidirectional instability (MDI) can be identified as shoulder instability in more than one plane of motion. Patients with MDI have a congenital predisposition and exhibit ligamentous laxity due to excessive collagen elasticity of the capsule.

One of the most simple tests you can perform to assess MDI is the sulcus sign.

sulcus sign multidirectional shoulder instability

I would consider an inferior displacement of greater than 8-10mm during the sulcus maneuver with the arm adducted to the side as significant hypermobility, thus suggesting significant congenital laxity.  You can see this pretty good in this photo, the sulcus is clearly larger than my finger width.

Due to the atraumatic mechanism and lack of acute tissue damage with MDI, range of motion is often normal to excessive.

Patients with recurrent shoulder instability due to MDI generally have weakness in the rotator cuff, deltoid and scapular stabilizers with poor dynamic stabilization and inadequate static stabilizers. Initially, the focus is on maximizing dynamic stability, scapula positioning, proprioception and improving neuromuscular control in mid range of motion.

Also, rehabilitation should focus on improving the efficiency and effectiveness of glenohumeral joint force couples through co-contraction exercises, rhythmic stabilization and neuromuscular control drills. Isotonic strengthening exercises for the rotator cuff, deltoid and scapular muscles are also emphasized to enhance dynamic stability.

Factor #5 – Neuromuscular Control

The fifth factor to consider is the patient’s level of neuromuscular control, particularly at end range.

Injury with resultant insufficient neuromuscular control could result in deleterious effects to the patient. As a result, the humeral head may not center itself within the glenoid, thereby compromising the surrounding static stabilizers. The patient with poor neuromuscular control may exhibit excessive humeral head migration with the potential for injury, an inflammatory response, and reflexive inhibition of the dynamic stabilizers.

Several authors have reported that neuromuscular control of the glenohumeral joint may be negatively affected by joint instability.

Lephart compared the ability to detect passive motion and the ability to reproduce joint positions in normal, unstable and surgically repaired shoulders. The authors reported a significant decrease in proprioception and kinesthesia in the shoulders with instability when compared to both normal shoulders and shoulders undergoing surgical stabilization procedures.

Smith and Brunoli reported a significant decrease in proprioception following a shoulder dislocation.

Blasier reported that individuals with significant capsular laxity exhibited a decrease in proprioception compared to patients with normal laxity.

Zuckerman noted that proprioception is affected by the patient’s age with older subjects exhibiting diminished proprioception than a comparably younger population.

Thus, the patient presenting with traumatic or acquired instability may present with poor neuromuscular control that must be addressed.

Factor # 6 – Pre-injury Activity Level

The final factor to consider in the nonoperative rehabilitation of the unstable shoulder is the arm dominance and the desired activity level of the patient.

If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free motion and adequate strength has been achieved.

Patients whose functional demands involve below shoulder level activities will follow a progressive exercise program to return full ROM and strength. The success rates of patients returning to overhead sports after a traumatic dislocation of their dominant arm are often low, but possible.

Arm dominance can also significantly influence the successful outcome. The recurrence rates of instabilities vary based on age, activity level and arm dominance. In athletes involved in collision sports, the recurrence rates have been reported between 86-94%.

Keys to Shoulder Instability Rehabilitation

To summarize, nonoperative rehabilitation of shoulder instability has many subtle variations.  To simplify my thought process, I always think of these 6 key factors before I decide what I want to focus on for each person.  

Learn How I Evaluate and Treat the Shoulder

mike reinold shoulder seminar

Want to learn exactly how I rehabilitate shoulder instability?

I have a whole lesson on this as part of my comprehensive online program on the Evidence Based Evaluation and Treatment of the Shoulder.  If you want to learn exactly how I evaluate and treat the shoulder, including shoulder instability, this course is for you.  You’ll be an expert on shoulders!

5 Common Core Exercise Mistakes and Fixes

We’ve come along way over the last decade when it comes to training the core.  Not too long ago, training the core consisted of mainly exercises like sit ups, with no specific attention to how the core functions.

One of the key areas of core training that I focus on to enhance movement quality and performance is stabilizing the core while the arms and legs move.  Essentially proximal stability, with underlying distal mobility of the extremities.

However, don’t forget that the body is amazing at compensating to get the job done.

Any lack of mobility or motor control will often result in compensatory movements.  Many people want to fly through their core program, but often times don’t focus on the quality of the movement.

Here are 5 common core exercise mistakes that I see, along with some suggestions on how to fix them.  I posted these as a series on Instagram, if you want to see more posts like this, be sure to follow me there.

 

Front Plank

A common error I see when people perform a front plank is over relying on the hip flexors to hold the position. You sometimes see them tighten their core but also come up into a bit of hip flexion.

If you hold planks for too long, you may also notice that you slowly creep up into this position as your core fatigues and your hip flexors take over.

There are two easy ways to improve this:

1. Focus on tightening your core AND your glutes.  This should help hold the neutral pelvic position.
2. Perform sets of planks with each rep being ~8-10 seconds, with no break, just a quick reset, instead of sustained holds.⠀This will keep the focus on the core before the hip flexors take over.

 

 

Side Plank

Similar to the front plank, the side plank is easy to use larger muscle groups to compensate.  One easy way to ruin a good side plank is simply to lift the body too high off the table. You’ll see too much side bend and will make this a lateral bend motion instead of a core stability exercise.

To fix this, try performing with a mirror so you can see your form. Your body should be in a straight line with a nice neutral spine.

 

 

Dead Bug

One of the common faults we see with the dead bug core exercises is a loss of neutral spine when the arms or the legs are full extended. ⠀The person tends to focus on getting there hands and feet extended, rather than keeping their core stable.

Remember the goal of the exercise is to brace and stabilize the core while moving the extremities.

Be sure to keep that brace, but also realize that it’s often better to reduce your arm and leg motion a bit if you are struggling and arching your back.⠀I’d rather you make the exercise less challenging, but performed well, then slowly progress over time.

 

 

Bird Dog

I’m a big fan of the bird dog exercise for two main reasons:

1) It’s great exercise to work on driving hip extension with proper core stability. A lot of people hyperextend their back instead of extending their hip.
2) Because you use alternate arm and leg for advanced variations, it also provides some rotational stability through the core.

But people LOVE to perform this exercise poorly by compensating and arching their back.  Many people struggle to extend their hip while keeping their spine stable.  Be sure to keep your core stable and just work on reaching with arms and legs.⠀Similar to the dead bug, I’d rather you reduce the quantity of your motion, and focus on the quality of the motion.

 

 

Glute Bridge

A common flaw with the glute bridge exercise (and hip thrusts) is thinking that you need to go as far as possible, as far as your body will go.

But keep in mind, the goal here is the glutes, not the low back. So the exercise should really be performed to extend you hips and NOT your back.

To help with this, really tighten your anterior core during the exercise and focus on squeezing your glutes. Then, simply stop the motion when the glutes are done squeezing. Many people want to keep going.  They tighten their glutes, but then keep pushing the body higher over the ground.  Resist the urge to continue by hyperextending at your back.

 

 

Want to Learn More About How I Train the Core?

Check out Eric Cressey and I’s Functional Stability Training of the Core program.  We discuss the core in detail and how we rehabilitate and train the core.

 

 

 

 

How to Perform and Advance Rhythmic Stabilization Drills

The latest Inner Circle webinar recording on How to Perform and Advance Rhythmic Stabilization Drills is now available.

 

How to Perform and Advance Rhythmic Stabilization Drills

How to Perform and Advance Rhythmic Stabilization Drills Mike ReinoldThis month’s Inner Circle webinar is on How to Perform and Advance Rhythmic Stabilization Drills.  Rhythmic stabilization drills have become very popular since I discussed in my DVD Optimal Shoulder Performance several years ago.  These are easy and excellent drills to start working on dynamic stabilization.  However, I must say over the years I feel like people are getting pretty sloppy with these drills, which essentially makes them much less effective.  Just because an exercise is simple, doesn’t mean that we should be sloppy with how we perform.  In this inservice presentation, I discuss how to perform rhythmic stabilization drills and all the ways we advance them from simple to advanced.

In this webinar, we discuss:

  • Why rhythmic stabilization drills are a great way to start enhancing dynamic stability
  • How to perform basic rhythmic stabilizations
  • How to advance rhythmic stabilization drills by changing technique variables
  • How to know when to advance someone or scale back to get the most out of the drills

To access this webinar:

 

 

4 Keys to Staying Healthy During the Baseball Season

The latest Inner Circle webinar recording on my 4 Keys to Staying Healthy During the Baseball Season is now available.

4 Keys to Staying Healthy During the Baseball Season

4 Keys to Staying Healthy During Baseball SeasonThis month’s Inner Circle webinar is on 4 Keys to Staying Healthy During the Baseball Season.  In this webinar I’ll discuss:

  • How and why injuries happen in baseball
  • What you should watch out for in regard to loss of mobility
  • My criteria you should achieve before picking up a ball everyday
  • The #1 thing I see youth players do wrong that causes injuries
  • How to maximize performance by minimizing overuse

To access this webinar:

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the Lunge

One thing I talk about a lot when it comes to training and rehabilitation is the need to train the body in all three planes.  This often requires moving in one plane of motion and stabilizing in the other two.   We are often very good at moving in the sagittal plane, and poor at stabilizing in the transverse and frontal planes.  This is a big topic of discussion in my program Functional Stability Training of the Lower Body.

To enhance this triplanar stability, we often attempt to facilitate greater contraction of the gluteus medius muscle during sagittal plane exercises.  The lunge in particular is a great exercise for triplanar stability as the narrow stance challenges strength in the sagittal plane and stability in the transverse and frontal planes.

 

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the Lunge

The Effect of Ipsilateral and Contralateral Loading on Muscle Activity During the LungeA recent study was published in the Journal of Strength and Conditioning Research that investigated the effect of holding a dumbbell in either the contralateral or ipsilateral hand during a split squat and forward lunge.  (Note: they called it a “walking lunge” but I am 99% certain it was a forward lunge, so I’m just going to say forward lunger in this article…  probably just semantics.)

The study found that:

  • Holding the dumbbell on the ipsilateral side had no effect on glute med activity.
  • Holding the dumbbell on the contralateral side resulted in a significant increase in glute med activity, but only during the forward lunge, not the split squat.

I was a bit surprised that glute med activity was not impacted during the split squat, but perhaps the static nature of the position inherently requires less transverse and frontal plane stability.

There was one other finding from this study that I thought was interesting.  Kinematic differences during the forward lunge were found between a group of trained individuals in comparison to a group without training experience.

This makes sense as the forward lunge is a complex movement pattern that requires an understanding of how to control the pattern.  It requires both mobility and stability, but also the ability to control the eccentric deceleration phase.

contralateral lungeHowever, there were no kinematic differences between training age during the split squat, meaning that both novice and experienced trainees performed the split squat in a similar fashion.  This make split squats a great exercise to incorporate in the early phases of training for those with limited training experience, eventually progressing to forward lunge as they get better at moving and stabilizing the pattern.

This helps solidify the use of split squats in our lunge regression system.

 

Implications

I like simple studies like this.  Having the rationale to make small tweaks to your program is what sets you apart.  It’s the small things that may not be obvious at first but will produce better results over time.

Based on these results, I would recommend using the split squat with bilateral dumbbells to maximize strength gains since a unilateral load did not alter glute med activity.  The split squat is more of a basic exercise, so why not just use it to work on strength gains in the novice trainee.  As the person progresses, you can add the forward lunge variation with a contralateral load to enhance triplanar stability.

 

 

 

Are We Missing the Boat on Core Training?

A lot of attention has been placed on core training over the last several years, both in the rehab and fitness industry.  I recently watched my friend Nick Tumminello’s latest product Core Training: Facts, Fallacies, and Top Techniques and it made me think.

We’ve made exceptional progress in our understanding of the core and have shifted away from isolated ab training to integrated core training.  My DVD with Eric Cressey on Functional Stability Training for the Core discussed this at length and showed a nice system to effectively train every aspect of the core.

However, the more I read on the internet the more I wonder if we are still missing the boat a little bit.  I’ll chalk this up as a another pendulum swing, but while we have progressed away from isolated abdominal exercises like sit ups, I wonder if we have swung too far to an extreme and started to focus only on isometric anti-movement exercises for the core.

 

Anti-Movement Core Exercises

Realistically the core helps stabilize the body and allow a transfer of energy.

Anti-movement exercises, such as planks for anti-extension, should be the foundation of the basic levels of core training.

Plank - core training

Once your baseline ability to maintain an isometric posture with the core is obtained, the next progression is to control limb movement with a stable core.  This involves combining upper body and lower body movements while maintain a stable core.  An example of this would be an anti-extension drill with TRX Rip Trainer.

However, the core does need to “move” during normal function.  It rotates, bends, flexes, extends, and all of these at once!  Should we train this?

 

Don’t Forget the Trunk is Designed to Move

I would say we should.  I think the difference here is to train these movements within a stable range of motion.  We should be training the body to work within it’s normal mobility, but to stabilize at end range of motion.

We get into problems with core movements, like rotation, when we depend on our static stabilizers, like the joints and ligaments, to control end range instead of our muscular dynamic stabilizers.

Perhaps the goals should be to train to control the core at end range of motion.

 

End Range Core Stability

These types of drills would include chops, lifts, push-pull movements on a cable or Keiser system, and medicine ball drills.  You are probably doing these already, right?

They all involve a transfer of energy from the limbs through the core.  The core needs to move during these exercises, but you are working in the mid ranges of motion and controlling end range.  These should also progress to include functional movements patterns like swings, throws, and kicks.

In the video above, I combine the act of throwing and decelerating in the half kneel position.  This takes the lower half out of it and requires the core to stabilize.

I guess the point is that we shouldn’t be afraid to move the core.  That is not beneficial to teach our patients, clients, and athletes.  Rather, train the core to move and stabilize at end range of motion to take stress off the structures of the spine.

 

 

Great Exercise to Enhance Posterior Shoulder Strength, Endurance, and Overhead Stability

I wanted to share an exercise I have been incorporating into my programs lately to develop posterior shoulder strength, endurance, and overhead stability.  I call it the ER Press as it combines shoulder external rotation in an abducted position with an overhead press.  When performed with exercise tubing, it provides an anterior force that the posterior musculature must resist during the movement.  The key is to resist the pull of the band while you press overhead.

I use this drill a lot with my baseball players and overhead athletes.  I think it’s a great drill that hits many of the areas that I focus on when training a strong posterior chain of the trunk and arm.

It’s also becoming a favorite of my Crossfit and olympic lifting athletes, who are reporting that they feel more comfortable overhead and have more stability with their snatches and overhead squats.

There are numerous progressions that can be performed by simply changing the position the athlete is in, including tall kneeling, half kneel, and split squat stances.  You can also perform some rhythmic stabilizations at the top range of motion once to increase the challenge.

 

Laxity Does Not Mean Instability

Several years ago, when Eric Cressey and I released Optimal Shoulder Performance, I discussed the Beighton Laxity Scale and how I use it to determine the amount of laxity that individuals may possess.  This is just one of the many factors that go into how I design my rehabilitation and performance programs, as an individual’s amount of laxity influences program design.

Since then, I have started to hear comments from people that their clients may have Ehlers-Danlos syndromeLoeys-Dietz syndrome or Marfan syndrome because of their Beighton score.

 

Laxity is Normal

Beighton Scale Laxity InstabilityIf you Google “Beighton Score,” you see that this is a scale often used to diagnose the above hypermobility syndromes, however each has their own specific features.  A Beighton score is not the only factor involved, and actually is probably not the most important finding in any of these syndromes.

Laxity is not a syndrome, in fact, laxity is normal.

We all have a certain degree of laxity, you’ve probably seen many people along this spectrum from the really tight to the really loose.  A high Beighton score does not indicate that they have a syndrome or problem, it just helps determine where they sit in the laxity spectrum.

 

Laxity Does Not Mean Instability

While joint laxity is normal, a high amount of laxity does not necessarily mean you have instability.  Stability is a combination of the function of your static and dynamic stabilizing systems.  Instability is when you have an issue with either (or both) of the static and dynamic stabilizers.  Functional stability is the ability to dynamically stabilize a joint during functional activities to allow proper control and movement.  This is the basis behind our entire Functional Stability Training programs.

Check out this video of my friend Sam’s Beighton score.

As you can see, Sam has a high Beighton score and a lot of joint laxity.  But Sam can deadlift over 2x her body weight.  That is laxity combined with functional stability.  She doesn’t have any problems because she can control her laxity.

Don’t automatically assume a lot of laxity is a bad thing, in fact many professional athletes possess a high amount of laxity.  Remember laxity is normal, does not mean instability, does not mean you have a clinical syndrome, and something you can control with the right program.