Shoulder Instability

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12 Apr

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What is Shoulder Instability?

Shoulder instability means that the shoulder can dislocate (move out of joint) or sublux (move more than it would normally). This usually occurs when the lining of the shoulder joint ligaments or cartilage become stretched or injured.

There are three main causes of shoulder instability which can be broadly divided into two categories; Traumatic and Non-traumatic dislocation.

Traumatic dislocation

This type of instability is usually caused by an injury which creates enough force to pull the shoulder out of joint, such as a fall or a sporting tackle.

An injury of this nature will usually result in a trip to the Accident and Emergency department to help put the shoulder back in position, known as a reduction. When the shoulder is dislocated in this way, a rim of cartilage around the socket can become damaged. This damage can sometimes cause further future dislocations.

Non-traumatic dislocation

This type of instability is caused by a gradual lengthening of the soft tissues that normally help to support the shoulder joint. This can happen through repetitive movements, particularly those overhead, and can be common amongst people who regularly throw or swim.

If these soft tissues become lengthened, the muscles that help to support your shoulder (the rotator cuff) can also become weak, leading to further symptoms of instability and dysfunction of the shoulder.

3. Genetic factors

Sometimes instability can happen without any form of trauma. Some people are born with a genetic condition that causes increases laxity in the ligaments that support their joints, this is sometimes called being ‘double jointed’ or “hypermobile”.

If the ligaments are lax, this can result in a greater degree of movement within the shoulder joint than would normally be expected. This type of non-traumatic dislocation can often affect both shoulders. Patients who have this type of shoulder instability will often have weak rotator cuff muscles also and will need help to strengthen these muscles to do their job properly.

The Shoulder Joint

The shoulder has two main joints. The acromioclavicular joint (between the acromion of the scapula and the clavicle) and the glenohumeral joint (between the glenoid of the scapula and the humerus).

The glenohumeral joint is a ball and socket joint. Due to its shallow socket and large humeral head this joint can be more unstable. This allows for a greater range of movement than other ball and socket joints found within the human body but makes it more vulnerable to dislocation.

The Rotator Cuff

The rotator cuff is a group of four muscles that are positioned around the shoulder joint. The muscles are named:1.Supraspinatus2.Infraspinatus3.Subscapularis4.Teres Minor

The rotator cuff muscles work as a unit. They help to stabilise the shoulder joint and also help with shoulder joint movement. If these muscles become weak, it can make symptoms of shoulder instability worse because the joint will not be as supported as it needs to be during daily activities and movements of the shoulder.

What are the symptoms of Shoulder Instability?

Symptoms vary from person to person but may include;- Pain and/or weakness around the affected shoulder- Reduced range of movement- Repeated shoulder dislocations- Feelings of anxiety that the shoulder may dislocate in certain positions

Rarely people with shoulder instability following dislocation may complain of pins and needles or numbness affecting their arm, it is important to highlight these symptoms to your GP or Physiotherapist if you think you are experiencing this.

How is Shoulder Instability Diagnosed?

Shoulder instability can be diagnosed after taking a history and a physical examination with your Physiotherapist.

If your shoulder dislocation is due to direct trauma, you will normally be seen in an Accident and Emergency Department who will ask about your mechanism of injury, examine your shoulder and potentially organise for some investigations to confirm your diagnosis.

For those patients whose shoulder instability has not been caused by a recent injury; finding out a little more about your symptoms and when they tend to occur, along with using some special tests during your examination can help to confirm this condition.

Do I need any other investigations?

Imaging can be helpful following trauma resulting in dislocation of the shoulder. Further investigations are rarely needed for non-traumatic/ recurring shoulder dislocations unless your problem is not improving as expected with Physiotherapy and exercise. Your Physiotherapist will be able to advise you when or if this is appropriate for you.

How is Shoulder Instability treated?

For both traumatic and non-traumatic dislocations the first line of treatment is most commonly Physiotherapy, to build strength in the rotator cuff muscles and provide more stability to the shoulder joint.

If the dislocation has caused damage to the cartilage, surgery may be an option to repair this and re-stabilise the shoulder. This type of repair is called a Bankart repair or Latarjet procedure. Speak to your GP or Physiotherapist about these management options.

Physiotherapy plays a significant role in the management of shoulder instability surgery and can help to rehabilitate the shoulder and improve the success of your surgery both before and after the procedure.

What can I do to help myself?

Be positive and keep moving! There are many things you can do yourself to help manage your symptoms. There are no quick fixes and it requires active participation from you throughout to achieve your desired goals.

How long will it take to get better?

This will depend on the severity of your symptoms and it may take up to a few months to improve. It is vital to make sure the muscles around the shoulder are working well and this is usually achieved through an individual exercise programme. Your shoulder should start to feel better within 6 to 12 weeks if you follow our guided exercise program. By following these exercises we will guide you through each step on your return to normal activity.

The Exercises

Participating in an exercise program carries a certain element of risk for some people. You should consult with your physiotherapist before initiating this program to ensure your safety.

If you have any issues please do not hesitate to contact the physiotherapy department. If you feel light headed, dizzy or have issues with your breathing please contact your general practitioner (GP) immediately.

If you are in a sling following a first time dislocation, your Consultant or Physiotherapist will be able to advise when you are allowed to remove it to complete your exercises.

When carrying out this exercise program you may feel some discomfort at your Shoulder. It is important that this pain does not exceed 3/10, where 10/10 is the maximal and 0/10 is no pain.

Section 1.

Aim to work on speed of muscle activation, plyometrics and deceleration of fast movement. Complete maximum repetitions until fatigue of specified target reached. Repeat 2 x per day.

Exercise	Target Reps
Drop & Catch 1 kg weight at 90 scaption	100
Drop & Catch 1 kg weight at 90 scaption on one leg (opposite side)	100
Drop & Catch 1 kg weight at 90 scaption with eyes closed	100
Drop & Catch 1 kg weight in AER/AIR	100
Falling press up in standing on wall	50
Falling press up in standing to waist level	50
Plyometric press up with clap	20
Doorway Fall	20

Drop & catch a 1kg weight at 90° scaption. Aim 100 repetitions. Progress to doing the exercise

https://www.youtube.com/watch?v=UhUpQhOsRMk

With eyes closed.

Standing on one leg (opposite leg).

Drop & catch 1kg weight in Anterior external rotation (anterior instability) or 4b: internal rotation (posterior instability). Aim 100 repetitions

https://www.youtube.com/watch?v=nK8rIEbhw30https://www.youtube.com/watch?v=w6ApUibvPo8

Falling press up in standing. Aim 50 repetitions. Fallagainst the wall and uses 2 hands to absorb the impact. Push away fast from the wall to the original standing position.

https://www.youtube.com/watch?v=sIQK18neGD0

Falling press up to waist level. Aim 50 repetitions. Fall against kitchen worktop and uses 2 hands to absorb the impact. Push away fast from the wall to the original standing position.

https://www.youtube.com/watch?v=vtFwF4bwuvY

Plyometric push up with hand clap. Aim 20 repetitions.

https://www.youtube.com/watch?v=usJoPmlykCc

Doorway fall. Aim 20 repetitions. Stand one step away from a doorway. Fall through the doorway and catch bodyweight with two hands on the frame of the door. Then explosively push back up to the original standing position.

https://www.youtube.com/watch?v=wIx27QTraAs Section 2. Working on muscle balance, trunk stability and proprioception.

Exercise	Target time
Single handed bar roll on wall	60s
Single handed kneeling crosses	60s
Kneeling single handed ball roll	60s
Single handed crosses in push up position	60s
Double handed ball roll in push up position	60s
Double ball roll in push up position	60s

Single handed ball roll on wall. Aim 60 seconds. Lean on a ball in a standing position. Roll the ball up and down slowly and as smoothly as possible. Once you can do this easily for 60 seconds progress to the next exercise.

https://www.youtube.com/watch?v=opt8L8Xk0lk

Single handed kneeling crosses. Aim 60 seconds. Kneel and weight-bear on your affected arm. Then shift your bodyweight through the affected arm by pointing with the other hand in the shape of a cross.

https://www.youtube.com/watch?v=As_ChGhpVHI

Kneeling single handed ball roll. Aim 60 seconds. Kneels with your weight on a ball. Roll it up and down slowly and as smoothly as possible. Once you can do this easily for 60 seconds progress to the next exercise.

https://www.youtube.com/watch?v=TrT26tmqbyI

Single handed crosses in push up position. Aim 60 seconds. Start in a one-handed press up position weight-bearing on the affected arm. Shift your bodyweight through the affected arm by pointing with the other hand in the shape of a cross.

https://www.youtube.com/watch?v=Gl9MOZSjLHU

Double handed ball roll in push up position. Aim 60 seconds. Start in a press up position with your hands on a ball. Try to do a smooth slow rolling action up and down for 60 seconds.

https://www.youtube.com/watch?v=CqeCQmyxltc

Double ball roll in push up positions. Aim 60 seconds. Start in a press up position with each hand on a ball. One ball is rolled upwards whilst simultaneously rolling the other downwards and vice versa.

https://www.youtube.com/watch?v=HRVNu16SfHA