Many Things to Consider with Shoulder RehabPatients are often sent to physical therapy for strengthening when the shoulder joint is unstable. But physical therapists don't prescribe the same exercise program for everyone. That's because there are so many variables to consider.
For example, does the patient have anterior instability (shoulder moves forward in and even out of the socket). Or is there posterior (backward) instability. Sometimes patients have multidirectional instability (unstable in more than one direction). Each one of these situations calls for an individual rehab program.
Then there is the scapula (shoulder blade) to consider. How well does it move? Is it moving in a coordinated rhythm with the shoulder? Scapular control is an important part of glenohumeral (shoulder joint) stability. Muscles must be evaluated for weakness, shortening, length-tension, and ability to generate as well as withstand forces needed for arm movement.
And the therapist mustn't forget addressing proprioception (joint sense of position) with a physical therapy program. Restoring these aspects of scapular and glenohumeral motion is vital. This concept is especially important for the athlete who depends on his or her arm for accuracy and strength in motion and function (e.g., think about the need for a baseball pitcher to deliver the ball exactly in the strike zone across the home plate).
Another aspect of rehab planning is whether or not the patient has had surgery or is trying to avoid surgery. When surgery is done, the therapist plans treatment that protects the healing tissues. This varies depending on whether the surgeon used an open incision technique or completed the procedure arthroscopically. More muscles are cut into with open surgery so rehab must progress differently than without surgery or with minimally invasive arthroscopic techniques.
Finally, the plan of care is designed by the physical therapist for each specific patient. The therapist uses clinical skill, expertise, experience, and evidence-based information to decide which mode (type) of exercise to use. The same decision-making process is involved in determining a starting point for frequency, duration, and intensity of the exercises. Progressively moving the athlete back toward full function for his or her sport is often the direction therapy goes. This type of conditioning is called a sports specific functional progression.
Physical therapists interested in guidance when planning a rehabilitation program will find this article helpful. The authors provide details for each of the topics presented along with photos of patients performing many of the exercises recommended. Surgeons and physical therapists must work together and maintain close communication. Ongoing changes in surgical technique make it necessary to tweak the postoperative rehab program to get the best results.
More research is needed to verify optimal treatment for shoulder instability whether it's an anterior, posterior, or multidirectional instability. With all the factors, variables, and considerations the therapist must consider, it's no wonder one exercise program does not "fit all."
Gregory N. Lervick, MD. Shoulder Rehabilitation in Glenohumeral Instability. In Current Orthopaedic Practice. January/February 2013. Vol. 24. No. 1. Pp. 79-83.
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