How Do We Manage Glenohumeral Instability?

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How Do We Manage Glenohumeral Instability?

Individuals with shoulder stability may have mobility or motor control issues that can put themselves at risk during functional tasks and potentially lead to progressive pathologies. It’s important to decipher the difference at a particular joint or body part to ensure that the influencing factors are apparent and understood.

Shoulder instability can be divided into traumatic (TUBS) and atraumatic (AMBRI):

T – Trauma                                          A– Atraumatic

U – Unidirectional                            M – Multidirectional

B – Bankart                                         B – Bilateral

S – Surgery                                          R – Rehabilitation

                                                                I – Inferior

Primarily instability of the shoulder is caused from a traumatic episode that accounts for 95% of first-time dislocations; and 70% have a likelihood of a recurrence within the first 2 years of the initial injury.1 Management for traumatic instability may have a different focus versus atraumatic instability. Hayes et al1 indicates how age is a predictor of recurrent dislocations; adolescents seem to have a higher recurrence versus the elderly population. Perhaps age-related changes can influence instability of the shoulder. Hayes et al1 also indicates how there are collagen changes from over stretched tissues during development; this can be from repetitive movements including overhead sport athletes or continuous capsular stress on the static restraints of the joint.

Traumatic instability management may include immobilization for protection and allow proper healing of various structures. The use of immobilization has been demonstrated by the literature to be not effective with individuals encountering recurrences despite immobilization period.1 Immobilization may also lead to proprioceptive deficits.3 Typically, those who sustain traumatic unidirectional injuries will undergo surgical intervention. Strengthening of the periscapular musculature and scapular stabilization may help improve results; further research is still needed.1 

Management for atraumatic instability may not have the same focus as traumatic instability.  Joint instability can create a disconnection of afferent information where the joint is unable to determine its relative position.3 There is an importance to incorporate an exercise prescription that provides stability to the glenohumeral joint including scapular thoracic, rotator cuff and periscapular structures.  Focusing on specific tasks including press-downs for the lower trapezius, push up plus, rows for middle trapezius and rhomboids were found through EMG studies were determined to be ideal exercises for nonoperative rehabilitation.4 Strengthening of the infraspinatus and teres minor also help to decrease shoulder impingement.2 A combination of joint proprioception and scapular stabilization are important during the recovery process with an individual with shoulder instability. 

Individuals with neurological deficits may acquire glenohumeral instability issues. We may need to address the impairments and functional limitations with perhaps a variation to a typical approach for an individual with an orthopedic glenohumeral instability. Koyuncu et al5 found that the implementation of using functional electric stimulation to the supraspinatus and posterior deltoid in conjunction with conventional therapy was more beneficial than using conventional therapy alone. However, it appears that they did not look at the long-term outcomes. The use of electrical stimulation can help to recruit muscle fibers during early strengthening programs in individuals with glenohumeral instability of an orthopedic population.3 Reinold et al6 determined that the use of neuromuscular electric stimulation improved peak shoulder external rotation of individuals who underwent rotator cuff surgery with repair to the supraspinatus tendon. The use of electric stimulation seems to play a role in recovery for those presents with glenohumeral instability.

Understanding the etiology of glenohumeral instability will be helpful to guide clinicians to determine appropriate interventions and to deliver the highest quality care for their respective patients.

Article Written By Eric Trauber, PT, DPT, OCS, CSCS, FAAOMPT

References:

  1. Hayes K, Callanan M, Walton J, Paxinos A, and Murrell CAC. (2002). Shoulder instability: management and rehabilitation. Journal of Orthopaedic and Sports Physical Therapy, 32(10): 497-509.
  2. Reinold MM, Escamilla R, and Wilk KE. (2009). Clinical concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature. Journal of Orthopaedic and Sports Physical therapy, 39(2): 105-117.
  3. Wilk KE, Macrina LC, and Reinold MM. (2006). Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. North American Journal of Sports Physical Therapy, I1(1): 16-31.
  4. Guerrro P, Busconi B, Deangelis N, and Powers G. (2009). Congenital instability of the shoulder joint: assessment and treatment options. Journal of Orthoapedic and Sports Physical Therapy, 39(2): 124-134.
  5. Koyuncu E, Funda G, Yuzer N, Dogam A, and Ozgirgin N. (2010). The effectiveness of functional electrical stimulation for the treatment of shoulder subluxation and shoulder pain in hemiplegic patients: a randomized controlled trial. Disability and Rehabilitation, I32(7): 560-566.
  6. Reinold MM, Macrina LC, Wilk KE, Dugas JR, Cain EL, and Andrews JR. (2008). The effect of neuromuscular electrical stimulation of the infraspinatus on shoulder external rotation force production after rotator cuff surgery. American Journal of Sports Medicine, 1-5.