Jospt.2002.32.10.497 2

CLINICAL COMMENTARY
Shoulder Instability: Management and

Rehabilitation
Kimberley Hayes, PT 1
Mary Callanan, MD 2
Judie Walton, PhD 3
Anastasios Paxinos, MD 4
George A. C. Murrell, MD, PhD 5
Shoulder dislocation and subluxation occurs frequently in athletes with peaks in the second and motion.66 Instability is usually de-
sixth decades. The majority (98%) of traumatic dislocations are in the anterior direction. The most fined as a clinical syndrome that
frequent complication of shoulder dislocation is recurrence, a complication that occurs much occurs when shoulder laxity pro-
more frequently in the adolescent population. The static (predominantly capsuloligamentous and
duces symptoms. Dislocation and
labral) and dynamic (neuromuscular) restraints to shoulder instability are now well defined.
Rehabilitation aims to enhance the dynamic muscular and proprioceptive restraints to shoulder
subluxation of the glenohumeral
joint occurs relatively frequently in
Downloaded from www.jospt.org at on April 26, 2023. For personal use only. No other uses without permission.
instability. This paper reviews the nonoperative treatment and the postoperative management of
patients with various classifications of shoulder instability. J Orthop Sports Phys Ther athletes. Rowe82 identified a bimo-
2002;32:497–509. dal distribution of primary shoul-
Key Words: dislocation, muscle control, pathogenesis, recurrence, surgery der dislocation with peaks in the
second and sixth decade (Figure
Copyright © 2002 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
1A). In up to 98% of cases, the

shoulder displaces in an anterior
S
houlder stability is the result of a complex interaction between direction17,59,82 and in about 2%
static and dynamic shoulder restraints. Disruption to these of cases it displaces in the poste-
restraints manifests itself in a spectrum of clinical pathologies rior direction.82
ranging from subtle subluxation to shoulder dislocation. This The major cause of primary
article describes the anatomical variants associated with both shoulder dislocation is traumatic
traumatic and atraumatic shoulder instability and evaluates existing lit- injury. Almost 95% of first-time
erature pertaining to nonoperative and surgical management with the shoulder dislocations result from
Journal of Orthopaedic & Sports Physical Therapy®
ultimate aim of providing guidelines for the rehabilitation of various

either a forceful collision, falling
classifications of shoulder instability.
on an outstretched arm, or a sud-
den wrenching movement. In
Epidemiology these individuals the stabilizing
Primary Dislocations The shoulder is a joint evolved for mobility, and structures are forcefully stretched
to some extent, stability has been sacrificed to achieve a wide range of in a sudden manner. About 5% of
dislocations have an atraumatic
origin (eg, minor incidents such
as raising the arm or moving dur-
1
Physiotherapist, Sports Medicine and Shoulder Service and Orthopaedic Research Institute, St George ing sleep).6,17,66,82 These individu-
Hospital Campus, University of New South Wales, Sydney, Australia. als may have capsular laxity or al-
2
Sports medicine registrar, Sports Medicine and Shoulder Service and Orthopaedic Research Institute, St
George Hospital Campus, University of New South Wales, Sydney, Australia. tered muscle control of the
3
Director of Outcomes Research, Sports Medicine and Shoulder Service and Orthopaedic Research shoulder complex or both.55
Institute, St George Hospital Campus, University of New South Wales, Sydney, Australia. Recurrent Dislocations An impor-
4
Surgical fellow, Sports Medicine and Shoulder Service and Orthopaedic Research Institute, St George
Hospital Campus, University of New South Wales, Sydney, Australia. tant complication of primary dislo-
5
Chief, Sports Medicine and Shoulder Service, Director, Orthopaedic Research Institute, St George cation is subsequent recurrent dis-
Hospital Campus, University of New South Wales, Sydney, Australia.
Send correspondence to George Murrell, Department of Orthopaedic Surgery, St. George Hospital,
locations. Based on a study by
Kogarah NSW 2217, Sydney Australia. E-mail: murrell.g@ori.org.au Rowe,82 about 70% of those who
Journal of Orthopaedic & Sports Physical Therapy 497

100
Number of Patients With a Primary
90
80
Shoulder Dislocation
70
60
50
40
30
20
10
0
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90
Patient Age Range
FIGURE 1A. Age distribution (in years) of subjects presenting with

primary shoulder dislocation (n = 500). Data from Rowe.84
Incidence of Recurrence
100
90
80
70
60
(%)
50
40
30
20
10
0
<20 yrs 20-40 yrs >40 yrs
Patient Age Range
FIGURE 1B. Recurrence rate for the nonoperative management of

primary shoulder dislocation. Dislocation recurs in 66% to 100% of

people aged 20 years or under, 13% to 63% of people aged
between 20 and 40 years, and 0% to 16% of people aged 40 years
or older. Data from Hovelius et al,42 Marans et al,61 McLaughlin et
al,65 Rowe,84 and Simonet and Cofield.87
have already dislocated can expect to dislocate again

within 2 years of the initial injury.
Younger and older subjects have a comparable in-
cidence of primary shoulder dislocation (Figure 1A). FIGURE 2. Anatomical section of the shoulder joint with the
However, the incidence of recurrent dislocation is humeral head removed. Abbreviations: B, biceps tendon; SGHL,
highly age dependent and occurs much more fre- superior glenohumeral ligament; MGHL, middle glenohumeral liga-
ment; IGHLC, inferior glenohumeral ligament complex, comprising
quently in the adolescent population than in the the anterior band (AB), posterior band (PB), and the axillary pouch
older population (Figure 1B). Dislocation has been (AP); PC, posterior capsule; A, anterior; P, posterior. Adapted with
reported to recur in 66% to 100% of people aged 20 permission from O’Brien et al.72
years or under, 13% to 63% of people aged between
20 and 40 years, and in 0% to 16% of people aged tainment of the humeral head in the glenoid cavity.
40 years or older.42,61,65,82,87 At most, only 25% of the humeral head is in contact
with the glenoid fossa in any given shoulder posi-
tion.13 Under normal circumstances the shoulder
Functional Anatomy and Biomechanics capsule is relatively large and loose.19 The discrete
thickenings or capsular ligaments of the capsule have
Static shoulder restraints refer to the bony ball and been named the superior glenohumeral ligament
socket configuration of the shoulder and the major (SGHL), the middle glenohumeral ligament
soft tissues holding these bones together. The soft (MGHL), and the inferior glenohumeral ligament
tissues include the capsule, the glenohumeral liga- complex (IGHLC) (Figure 2).72 The relative contri-
ments and the glenoid labrum. Dynamic shoulder butions of the capsuloligamentous restraints to stabil-
restraints refer to the neuromuscular system, includ- ity of the glenohumeral joint are variable. The SGHL
ing proprioceptive mechanisms and the scapular and primarily limits anterior and inferior translation of
humeral muscles. the adducted humerus.15,72 The MGHL primarily
Static Stabilizers While the shoulder joint surfaces limits anterior translation in the lower and middle
are highly congruent,89 there is minimal bony con- ranges of abduction.15,72 The IGHLC is the longest
498 J Orthop Sports Phys Ther • Volume 32 • Number 10 • October 2002

and strongest of the glenohumeral ligaments85 and scapula on the thorax. Stability of the scapula in rela-
has been identified as the primary static restraint tion to the moving upper extremity provides a secure
CLINICAL COMMENTARY
against anterior, posterior, and inferior translations platform for the glenohumeral articulation and the
when the humerus is abducted beyond 45°.72 action of attaching humeral muscles.
The labrum constitutes the fibrocartilagenous rim It has been suggested that proprioceptive mecha-
of the glenoid. Inferiorly it is firmly attached to the nisms involving reflexive muscular action may protect
glenoid, although it may be loose and mobile against excessive translations and rotations of the
anterosuperiorly. Although variable in size, the glenohumeral joint.100 A recent histological investiga-
labrum contributes to shoulder stability by increasing tion97 has demonstrated the presence of mechano-
the depth of the glenoid cavity from an average of receptors (ruffinian corpuscles and pacinian cor-
puscles) within the capsuloligamentous restraints of
4.5 to 9.0 mm in the superior-inferior direction and
the shoulder. These specialized nerve endings relay
from an average of 2.5 to 5.0 mm in the anterior-
afferent information relating to joint position and
posterior direction.43 The labrum may also act as a
chock block, having been shown to increase resis- joint motion awareness (proprioception) to the cen-
tance to glenohumeral translation by up to 20%.58,63 tral nervous system. The perceived sensation of
The labrum provides attachment of the shoulder joint position and movement is likely to
glenohumeral ligaments anteriorly, and the biceps play an important role in coordinating muscular
tendon superiorly. tone and control. It has been suggested that joint
Dynamic Stabilizers A number of dynamic EMG stud- instability secondary to trauma may be associated
ies have shown that the rotator cuff works in a com- with a decrease in proprioceptive reflexes and thus a
bined synergistic action to create a compressive force predisposition to subsequent reinjury.97
at the glenohumeral joint during shoulder move-
ment.16,45,55 Radiographic evaluation of
Traumatic Anterior Dislocation
glenohumeral kinematics in the normal shoulder has Mechanism of Injury The most common mechanism
shown that the center of the humeral head deviates of anterior shoulder dislocation has been described
from the center of the glenoid fossa by no more as forced external rotation and abduction of the hu-
than an average of 0.3 mm throughout abduction in merus as seen in a basketball player who attempts to
the plane of the scapula.22,79 With fatigue of the ro- block an overhead pass.5,59 Other mechanisms of in-
tator cuff and deltoid muscles, there was an average jury have included a fall onto an elevated out-
2.5-mm superior migration of the humeral head.22 stretched arm and direct force application to the
The biceps assist the rotator cuff in creating posterior aspect of the humeral head.5,59
glenohumeral joint compression. In an abducted and Sequelae of Anterior Dislocation There are several
externally rotated cadaveric shoulder model,46 static morphological changes associated with anterior dislo-
loading of the rotator cuff and biceps brachii muscle cation of the glenohumeral joint. The most signifi-
(long and short heads) significantly reduced the cant in terms of recurrent instability are those associ-
magnitude of simulated anterior humeral head trans- ated with the inferior glenohumeral ligament
lation. For conditions of increasing shoulder instabil- complex and its attachments to the labrum and hu-
ity (vented capsule, simulated Bankart lesion) the merus. In 1923 Bankart8 described anterior labral
biceps brachii made a greater contribution to shoul- detachment as the essential lesion in traumatic ante-
der stability than the individual muscles of the rota- rior instability (Figure 3). Rowe and Zarins84 noted
tor cuff.46 the lesion in 85% of traumatic instability cases re-
The individual tendons of the rotator cuff splay quiring surgery. An osseous Bankart defect on the
and interdigitate to form a wide, continuous inser- anteroinferior glenoid rim is best appreciated radio-
tion on the humeral tuberosities.23 Near their inser- graphically with a West Point view.73 Detachment of
tions, the deep surface of these tendons are tightly the anterior labrum and plastic deformation of the
adherent to the underlying joint capsule.23,24 It has capsule and inferior glenohumeral ligament com-
been hypothesized that contraction of the rotator plex10 contribute to increased anterior humeral
cuff muscles may tighten the underlying capsule, cre- translation.44,90
ating a soft tissue barrier to excessive humeral head The most common bony lesion associated with
translation.104,105 traumatic glenohumeral instability is a compression
EMG studies of shoulder kinematics have shown fracture at the posterolateral margin of the humeral
that the scapulothoracic muscles operate as func- head. This occurs as the humeral head impacts into
tional units to create upward scapular rotation.9,45 the glenoid edge during dislocation and has been
Synchronous scapular rotation and humeral elevation termed the Hill Sach’s lesion.39 This lesion has been
is prerequisite for maintaining optimal alignment of reported to occur in over 80% of traumatic instabil-
the glenoid fossa and humeral head.45 Because there ity cases21,73,99 and is best appreciated radiographi-
are no scapulothoracic ligamentous restraints, the cally with a Stryker Notch view and an
scapulothoracic muscles also serve to stabilize the anteroposterior view with the shoulder in internal
J Orthop Sports Phys Ther • Volume 32 • Number 10 • October 2002 499

loading of surrounding capsuloligamentous re-
straints.
Proprioceptive deficits have been shown for pa-
tients with traumatic anterior shoulder instabil-
ity.88,100 Warner et al100 reported a significantly
greater threshold to detection of passive shoulder
motion for patients with shoulder instability com-
pared to subjects with normal shoulders (2.8° angu-
lar displacement versus 1.9° angular displacement
before detection of passive shoulder motion). Repro-
duction of a joint reference position was also signifi-
cantly less accurate for subjects with shoulder insta-
bility.100 Interestingly, in this same study, a third
group of test subjects who had undergone
arthroscopic or open Bankart repair demonstrated
normal proprioceptive function for both of the vari-
ables examined. Capsulolabral integrity may thus be
important for normal proprioceptive function.
FIGURE 3. Detachment of the labrum and capsule from the anterior Age-Related Changes
glenoid (Bankart lesion), left shoulder.
The high incidence of recurrent shoulder disloca-
% Collagen Type III % Collagen Type I tion in the adolescent population as opposed to re-
currence in those over 40 years of age may be ex-
120
plained, in part, by the collagen profile of
Collagen Composition of
100 encapsulating shoulder tissues. Collagen is the major

Shoulder Tissue
80 protein of ligaments and tendons. In newborns,

60
soluble collagen (type III) is synthesized and the fi-
bers formed from collagen type III are supple and
40
elastic. With each passing decade, collagen-producing
20
cells make less soluble collagen and progressively

0 convert to synthesizing an insoluble, more stable type
Birth Adolescence Young Adult Older Adult I collagen (Figure 4). This form of collagen has sul-
Age Category fur groups that have a high tendency to cross-link
and form bridges between the collagen filaments,
FIGURE 4. Schematic illustration of the changing ratios of collagen causing the fibers they comprise to be relatively
types III:I in soft tissues over time. Data from Bakerman.7 tough and nonelastic. This changing ratio of col-
lagen types I and III throughout the body is so reli-
rotation.73 The lesion must involve more than 30% able that chronological age of an individual can be
of the proximal humeral articular surface to play a
determined by analyzing the collagen type III con-

significant role in recurrent instability.90 The lesion is tent of a skin sample according to the following
smaller than this in the majority of cases of traumatic equation:7 collagen type III (mg)/wet dermis
shoulder instability.83,99 (g) = 1.3e-Age/23.5. Thus, the higher content of
Scapulothoracic motion asymmetry, as determined stretchy collagen in tendons and ligaments can help
by Moire topographic evaluation, has been found in to account for the observation that younger people
64% of patients with anteroinferior shoulder instabil- who have already had a dislocated shoulder are
ity compared to 18% of subjects with normal shoul- much more prone to recurrent dislocation than
ders.101 In 36% of patients with anteroinferior insta- older people. Once excessively stretched, their cap-
bility, this asymmetry presented as scapular winging, sule and ligaments may be too loose to provide the
hence an increased anterior orientation of the secure and stable shoulder support required for
glenoid with repeated shoulder elevation. Simulated maximum athletic performance.
glenoid anteversion in the abducted and externally
rotated shoulder has been shown to significantly in- Atraumatic Dislocation
crease in situ strain of the anterior band of the infe-
rior glenohumeral ligament.102 Regardless of whether A small group of patients dislocate or sublux their
scapulothoracic motion asymmetry represents a cause shoulders with minimal force application or by put-
or an effect of shoulder instability, suboptimal ting their arms into certain positions. Neer and Fos-
glenohumeral joint alignment implies an increased ter70 thought the pathological entity was a loose re-

dundant inferior capsule and introduced the term the horizontal plane. A current hypothesis is that
multidirectional instability. Multidirectional instability repetitive glenohumeral capsular overload in this po-
CLINICAL COMMENTARY
is less often associated with a labral detachment or sition of extreme range of motion leads to gradual
Bankart lesion. The condition is associated with gen- attenuation of the anteroinferior static restraints,38,57
eralized ligamentous laxity.3,70 increased glenohumeral translation and a continuum
The definitive etiology of atraumatic instability is of shoulder pathology.57 On the basis of arthroscopic
still not clear and it may be multifactorial. Current observations, Kvitne and Jobe57 described a pattern
etiological theories include suboptimal muscle con- of injury in this athletic population that involved pri-
trol for shoulder function, a deficiency in the rotator mary instability and secondary subacromial impinge-
cuff interval, and connective tissue abnormalities. ment or posterosuperior glenoid impingement of the
EMG analyses of shoulder motion have demon- undersurface of the rotator cuff with the postero-
strated altered patterns of shoulder muscle activity superior glenoid rim. In a separate retrospective re-
for patients with atraumatic anterior instability when view of arthroscopic findings for 61 throwing ath-
compared to normal subjects.56 Radiographic analy- letes, Nakagawa et al69 reported anterior joint laxity
ses of glenohumeral kinematics in patients with in 33% of patients, detachment of the superior
atraumatic multidirectional instability have demon- glenoid labrum in 51% of patients, posterior labral
strated an increase in humeral translation and a de- injury in 80% of patients, and rotator cuff tears in
crease in upward rotation of the glenoid fossa for 66% of patients. While this study confirmed the pres-
scapular plane abduction when compared to normal ence of several different shoulder pathologies in this
subjects.75 While these studies have shown a correla- athletic population, there was no correlation among
tion between abnormal shoulder muscle activity, anterior joint laxity, superior or posterior labral in-
glenohumeral incongruence and scapulohumeral jury, and a rotator cuff tear.
motion asymmetry, it remains to be determined
whether these findings represent a cause or an effect Nonoperative Management of Dislocation
of atraumatic shoulder instability. Traumatic Instability Various treatments, including
Clinical studies have documented an association
shoulder immobilization, activity restriction, and ex-

between the size of the rotator cuff interval (a defect ercise rehabilitation have been advocated in the
in the anterosuperior capsule between the superior management of primary traumatic anterior shoulder
border of the subscapularis tendon and the anterior dislocation. While low recurrence rates have been
margin of the supraspinatus tendon) and the reported for this condition for conservatively man-
amount of anterior84 and inferior glenohumeral
aged older patients, the prognosis for patients aged

translation.71 A biomechanical study using a
20 years and younger is generally considered to be
cadaveric shoulder model has confirmed the impor-
poor.
tance of the anterosuperior capsule in preventing
In a prospective study of 257 patients (age range
inferior subluxation of the adducted shoulder.36 A
12 to 40 years) with a primary traumatic anterior
large rotator cuff interval has been viewed by some
shoulder dislocation, Hovelius et al42 found no dif-
authors as a possible causal mechanism in some cases ference in redislocation rates between treatment with
of atraumatic shoulder instability. early mobilization and treatment with 3 to 4 weeks of
Rodeo et al81 analyzed the collagen and elastic fi- immobilization. Regardless of the immobilization pe-
bers in the shoulder capsule in patients with unidi-
riod, redislocation occurred in 47% of patients aged

rectional anterior instability, multidirectional instabil-
from 12 to 22 years, 34% of patients from 23 to 29
ity at primary surgery, multidirectional instability at
years, and 13% of patients aged from 30 to 40 years
revision surgery, as compared to patients with no his-
for the 2-year duration of the study.
tory of instability. Skin analysis between these groups
Other studies of primary traumatic anterior shoul-
demonstrated a significantly smaller mean collagen
der dislocation performed retrospectively have found
fibril diameter in skin samples in the primary
no beneficial effect of immobilization of up to 6
multidirectional instability group compared with the
weeks duration.61,87 In one study of 21 patients (age
unidirectional anterior instability group. This sug- range 4 to 16 years), 100% recurrence rates were
gests the possibility of an underlying connective tis- reported for immobilization periods that included 0,
sue abnormality. 4, and 6 weeks in duration.61 Another study of 116
patients (age range 14 to 96 years) reported an over-
Acquired Shoulder Instability all redislocation rate of 33% with no difference in
Chronic stress associated with repetitive overhead recurrence for periods of immobilization between 0
sports has been cited as a predisposing factor to an- and 6 weeks duration.87 In the same study, 82% of
terior shoulder instability.1,2,31,57 These athletes usu- athletes aged 30 years or younger sustained a
ally perform activities such as throwing, volleyball, redislocation (all due to athletic injury) compared to
and tennis, all of which require extreme external 30% of nonathletes of similar ages. While the type or
rotation with the humerus abducted and extended in length of shoulder immobilization had no influence

on the rate of recurrence, significantly better results ment group that received immediate arthroscopic
were reported for patients aged 30 years or younger surgery followed by an identical immobilization and
with 6 to 8 weeks of activity restriction compared to rehabilitation regime (mean follow-up of 32
activity restriction of less than 6 weeks in duration months). Another prospective study17 involving 29
(resolution of symptomatic shoulder instability in shoulders with recurrent anterior shoulder instability
56% and 15% of patients, respectively). secondary to a previous dislocation demonstrated
Therefore, the literature does not support shoul- good or excellent results (as determined by the
der immobilization with a traditional sling in the Rowe and Zarins grading system84) in only 7% of
nonoperative management of primary traumatic an- cases with a rehabilitation program that emphasized
terior shoulder dislocation. In a recent study47 of 18 progressive strengthening of the rotator cuff, deltoid,
patients who underwent magnetic resonance imaging and scapular stabilizer muscles (mean follow-up of 46
between 1 and 60 days after traumatic anterior dislo- months). Further research is warranted to clarify the
cation (6 patients with a primary dislocation, 12 pa- efficacy of exercise rehabilitation in the nonoperative
tients with recurrent dislocation), better approxima- management of primary traumatic anterior shoulder
tion between the Bankart lesion and the glenoid dislocation.
neck occurred with the humerus positioned in ad- Atraumatic Instability As for traumatic instability,
duction and external rotation as compared to that there have been few investigations pertaining to exer-
which occurred with conventional immobilization in cise rehabilitation in the nonoperative management
a position of humeral adduction and internal rota- of atraumatic shoulder instability. In a prospective
tion. In support of this finding, a cadaveric shoulder study17 of 47 patients (age range 12 to 54 years) with
experiment37 involving similar humeral positions (ad- anterior, posterior, and multidirectional instability of
duction and external rotation versus adduction and atraumatic origin, good or excellent results as deter-
internal rotation) and a simulated Bankart lesion, mined by the Rowe and Zarins grading system84 were
demonstrated significantly greater contact force be- reported in 80% of cases with a rehabilitation pro-
tween the detached glenoid labrum and the glenoid gram that emphasized progressive strengthening of
neck with the arm in the externally rotated position. the rotator cuff, deltoid, and scapular stabilizer
Lack of capsulolabral and glenoid contact after muscles (mean follow-up of 46 months). Shoulder
glenohumeral joint dislocation helps to explain the strengthening and coordination exercises combined
observation in previous studies that the rate of recur- with lifestyle modification is the most commonly rec-
rence is not influenced by the method or duration ommended treatment for atraumatic instabil-
of shoulder immobilization.47 ity.17,60,70,103

There have been few studies investigating out- There is much to learn about the best methods to
comes for exercise rehabilitation in the nonoperative enhance compression of the humeral head on the
management of primary traumatic anterior shoulder glenoid and to restore scapulothoracic motion sym-
dislocation. In one prospective study6 of 20 male pa- metry and proprioception to the unstable shoulder.
tients (age range 18 to 22 years), Aronen and Regan Most authors have acknowledged the importance of
reported a return to unrestricted duty and sports strengthening exercises for all components of the
participation without redislocation for 75% of cases rotator cuff and deltoid as a means of controlling
with a rehabilitation program that emphasized glenohumeral translation. Infraspinatus and teres
strengthening for the muscles of shoulder internal minor strengthening exercises performed in higher
rotation and adduction (mean follow-up of 35.8 degrees of abduction have been advocated as a
months). Another study107 of 104 patients (mean age means for reducing anterior glenohumeral ligamen-
± SD = 21.5 ± 8.5 years) reported a success rate of tous strain during the throwing motion.18 Strength-
83% with a 6-week graduated exercise regime of lim- ening exercises have also been advocated for the bi-
ited abduction (mean follow-up of 156 months). ceps brachii as well as the latissimus dorsi, pectoralis
These studies support a role for activity restriction major, and teres major to enhance the stabilizing
and exercise rehabilitation in the nonoperative man- action of the rotator cuff muscles at the
agement of primary traumatic anterior shoulder dis- glenohumeral joint.27,46,78,104
location. Functional exercises that require coordination
In a prospective randomized study54 involving 40 among multiple muscle groups (eg, hitting a tennis
patients, aged 30 years or younger, with a primary ball backhanded) have been recommended for re-
traumatic anterior shoulder dislocation, Kirkley et training normal patterns of muscle activity in the
al54 reported a 47% redislocation rate for a treat- patient with shoulder instability.27 In a pilot project80
ment group that received 3 weeks of immobilization involving nonoperative treatment of atraumatic ante-
followed by a supervised shoulder range of motion rior shoulder instability, significant improvements in
and muscle strengthening regime (activity restriction work and sport function and pain intensity were re-
enforced for 4 months). In the same study, a ported for a functional retraining program designed
redislocation rate of 16% was reported for a treat- to improve rotator cuff muscle control through the

use of electromyographic biofeedback. Changes in attach the labrum without an open incision and with-
work and sport function and pain intensity were not out subscapularis detachment. The reported
CLINICAL COMMENTARY
significant for a second rehabilitation program that redislocation rates for arthroscopic anterior shoulder
consisted of isokinetic resistance exercises designed stabilization are higher than those reported for open
to improve shoulder muscle strength and endurance. procedures (2–18% versus 11%) (Table). However,
Various forms of scapular muscle retraining have arthroscopic procedures are associated with less loss
been advocated in the rehabilitation of shoulder in- in external rotation than open procedures.
stability.27,53,105 These have included exercises de- Arthroscopic techniques for reattaching the labrum
signed to stabilize the scapulothoracic articulation can be divided into three categories: (1) a
(isometric exercises, manual stabilization tech- transglenoid suture technique,14,26,35,51,62,74,76 (2)
niques), to restore normal patterns of scapular arthroscopically delivered and tied suture an-
muscle activity (upper extremity weight-bearing activi- chors,33,40,93 and (3) arthroscopically delivered biode-
ties), and to maximize scapulothoracic muscle gradable tacs.4,12,25,26,28,51,52,86,92 A comparison of the
strength and endurance in preparation for a return reported rates of recurrent dislocation for each tech-
to normal functional use (resistance exercises, nique is made in the Table.
plyometric exercises, sport-specific drills). It remains Multidirectional Instability The most commonly per-
to be determined whether scapular motion asymme- formed and most successfully reported surgical pro-
try can be corrected with exercise rehabilitation in cedure for multidirectional instability of the shoulder
the patient with shoulder instability. is an anterior capsular shift, an open procedure that
The interplay between neural and muscular involves the overlaying and thus shortening of the
mechanisms for dynamic glenohumeral joint stability anterior and inferior capsule.3,60,77 Closure of the
is incompletely understood. Inman45 theorized that capsular interval between the subscapularis and
proprioceptive mechanisms were elicited as a result supraspinatus has been reported to be successful in a
of specific movement patterns rather than isolated small series of patients with subluxation.30,36
muscle actions. This theory would imply a role for More recently, capsular shrinkage has been advo-
functional exercises that include positions of instabil- cated as a treatment for more subtle cases of shoul-
ity to evoke reflexive muscular activity that may pro- der instability. Thermal denaturation of collagen re-
tect against potential joint instability. Other forms of sults in uncoupling of the triple helices and
neuromuscular re-education,27,104,105,106 including shortening of the collagen. A recent study noted a
joint repositioning tasks, proprioceptive 15% to 40% reduction in length of a cadaveric
neuromuscular facilitation techniques, upper extrem-
shoulder capsule subjected to 65°C to 72°C heat

ity weight-bearing exercises, and plyometric exercises (Figure 5).98 Also noted was an associated 15% loss
have been used to retrain proprioceptive mecha- in load to failure properties. Arthroscopic devices
nisms. Further research is needed to determine the have been designed to deliver heat to the shoulder
efficacy of these exercises in the rehabilitation of capsule with the potential to ‘‘shrink’’ redundant
shoulder instability. capsule arthroscopically. A short-term study has re-
ported excellent results using this technique.86 Fur-
Surgical Management ther long-term evaluations are necessary to identify
the technique, indications, and results of this novel
Traumatic Unidirectional Instability The most recent
method of reducing capsular volume.

and most successful surgical procedures for unidirec-
tional shoulder instability reattach the detached
labrum and associated glenohumeral ligaments with Postoperative Rehabilitation
little disruption to the length or attachment of other
structures around the shoulder (Bankart repair). An The basic principles of nonoperative rehabilitation
open Bankart repair consists of detachment and later for shoulder instability (restoration of glenohumeral
reattachment of the humeral insertion of subscap- compression stability, scapulohumeral motion
ularis (or a split of the subscapularis) and a reattach- synchrony, and proprioceptive mechanisms) apply
ment of the labrum to the anterior glenoid with su- equally to postoperative patients. The specific con-
tures through bone or with suture anchors. Most tent of postoperative rehabilitation varies according
surgeons also reduce any capsular redundancy by to the stabilization procedure performed, individual
tightening the anterior capsule with sutures. Open pathology, and the activity level of the individual.
anterior stabilization is associated with a 12° loss of
external rotation of the shoulder, probably secondary
to shortening of the subscapularis tendon after Anterior Stabilization
detachment-reattachment.34
Arthroscopic techniques for unidirectional Cryotherapy Cryotherapy in the postoperative shoul-
glenohumeral instability have been developed to re- der (applied for 15-minute durations every 1 to 2

TABLE. Comparison of dislocation recurrence rates for treatment methods for anterior shoulder instability.
Number of Follow Up
Technique Year* Patients (Years) Recurrence Reference
No surgery
Rehabilitation 1996 245 10.0 48% 41
Rehabilitation 1996 55 8.0 85% 26
Mean: 55%
Open surgery
Open Bankart 1996 12 2.5 8% 35
Open Bankart 1997 60 12.0 5% 34
Open Bankart 1998 26 3.0 4% 12
Open Bankart 2000 22 4.5 9% 25
Open Bankart 2000 66 4.0 23% 96
Open Bankart 2001 48 3.0 10% 52
Open Bankart 2001 26 1.1 12% 92
Mean: 11%
Arthroscopic surgery
Transglenoid suture 1996 37 5.6 19% 76
Transglenoid suture modified 1996 42 3.2 5% 62
Transglenoid suture 2000 72 N/A 7% 14
Mean: 18%
Suture anchor 1995 30 2.0 7% 40
Suture anchor + shrink 2000 53 2.8 8% 33
Suture anchor + shift 2000 29 2.0 7% 93
Mean: 7%
Bankart tack 1995 19 1.6 0% 4

Suretac 1998 20 3.0 20% 12
Suretac 2000 20 3.4 30% 28
Suretac 2000 37 4.5 11% 25
Fastak 2000 55 3.2 16% 51
Suretac 2001 48 3.1 13% 26

Suretac 2001 60 2.3 15% 52
Suretac 2001 30 1.1 23% 92
Mean: 17%
Suretac + shrink 1999 43 3.0 2% 86
Mean: 2%
*Year of publication.
as compared to no-cryotherapy conditions.91 We rec-

ommend 15 minutes of cryotherapy every second
hour for the first week after a stabilization procedure

and after every exercise session for the duration of
rehabilitation.
Activity Restriction The postoperative management
of anterior instability has typically involved a mini-
mum of 6 weeks of activity restriction to minimize
stress to healing structures. During this period of
limited upper extremity use, we recommend active
exercise of noninvolved joints (elbow, wrist, and
hand). In the case of the injured athlete, rehabilita-
tion also aims to maintain cardiovascular fitness and
lower limb and trunk muscle condition.
FIGURE 5. The effects of heat on glenohumeral capsular length. Isometric Exercise Isometric shoulder muscle exer-
Data from Vangsness et al.97 cises, initially performed with the arm adducted by
the side of the body, provide a means for preventing
waking hours for the first 24 hours, and 4 to 6 times muscular inhibition during the period of activity re-
daily for the ensuing 9 days) has been shown to sig- striction. Isometric exercises for the scapulothoracic
nificantly decrease the frequency and intensity of muscles are commenced during the first postopera-
shoulder pain both at rest and during rehabilitation tive week. Isometric exercises for the humeral

muscles are commenced during the second postop- that will be imposed upon the shoulder during func-
erative week. Care is taken when performing isomet- tional upper extremity use.
CLINICAL COMMENTARY
ric internal rotation for the first 6 weeks following an Rotator Cuff and Humeral Muscle Strengthening Exer-
open Bankart repair, in which the subscapularis cises Rotator cuff strengthening is commenced with
muscle is detached and reattached, to prevent rup- isometric exercises, as detailed above. Light resis-
ture from its humeral insertion. We recommend tance exercises for the rotator cuff and biceps
pain-free contractions of 3 to 5 seconds duration and brachii muscles are introduced during the fourth
a minimum of 30 daily repetitions20,32,64 for all iso- postoperative week. (For open stabilization proce-
metric exercises. dures involving detachment or reattachment of the
Range of Motion Exercises Assisted shoulder exercises subscapularis, resistance exercises for the
subscapularis muscle are introduced during the sixth
initially performed within a limited range of motion
postoperative week). We advocate exercises that in-
are designed to protect the surgical repair and pre-
volve both concentric and eccentric modes of con-
vent adhesion formation in the early postoperative
traction initially performed at glenohumeral angles
period. These exercises are commenced during the
of less than 45° elevation. We use the same range of
second postoperative week. External rotation range motion to commence strengthening of the latissimus
of motion is limited to 30° (0° abduction) for the dorsi, pectoralis major, and teres major.
first 4 postoperative weeks. Combined external rota- Dynamic control of the scapulothoracic and
tion and abduction range of motion is avoided for glenohumeral joints and an absence of pain and ap-
the first 6 postoperative weeks. Assisted elevation is prehension for movements performed between 0°
initially performed in the plane of the scapula to and 45° elevation are prerequisite for exercise pro-
maximize humeral and glenoid congruency.50 The gression to higher angles of elevation. Rotator cuff
absence of pain, apprehension, and abnormal move- strengthening for higher angles of elevation includes
ment patterns with assisted exercise are prerequisite the use of Theraband27,105 (eg, internal and external
for the progression to active range of motion exer- rotation), free weights11,49,94 (eg, prone horizontal
cise. Rehabilitation aims to restore full active range abduction with arm externally rotated and scapular
of motion by 12 weeks after arthroscopic29 and open plane elevation), and training activities27,106 (eg, un-
anterior stabilization.103 derarm, side-arm, and overhead throwing or catching
Scapulothoracic Muscle Retraining In addition to iso- exercises using balls of various weights and sizes).
metric scapulothoracic muscle exercises, the first Humeral muscle strengthening includes Theraband
exercises27 (eg, extension and adduction initiated
postoperative week involves treatment for any

strength or flexibility deficits within the lumbar or from 90° flexion and abduction, respectively), free
thoracic areas.53 Upper extremity weight-bearing ex- weights94 (scapular plane elevation with arm inter-
ercises that incorporate specific scapular movements nally rotated and horizontal abduction with arm in-
at glenohumeral angles of less than 60° elevation are ternally and externally rotated), press-ups,27,94 push-
ups,48 and various weight machines.27
introduced during the third postoperative week.53
Light resistance exercises are commenced during the Proprioception In the latter stage of rehabilitation,
emphasis is given to functional exercises that prepare
fourth postoperative week. We emphasize retraining
the neuromuscular and cardiovascular systems for
for scapular protraction and retraction and advocate
the return to sports participation. We include activi-
multiple sets of up to 30 repetitions for exercises

ties that require the coordination of multiple
that involve both concentric and eccentric modes of
contraction. muscles (eg, catching and throwing activities, racquet
and other batting activities, and goal defense activi-
Dynamic scapulothoracic stability, scapulohumeral
motion synchrony, and an absence of pain and ap- ties) to achieve the desired magnitude, duration, and
sequence of motor output for a given functional
prehension for movements performed between 0°
task. These exercises initially use glenohumeral posi-
and 90° elevation are prerequisite for further reha-
tions that are least likely to provoke an instability
bilitation progression. Once these goals have been
achieved, upper extremity weight-bearing exercises episode. An absence of symptoms and quality of
movement are fundamental prerequisites for exercise
are advanced to higher angles of elevation and
weight-bearing loads are increased (eg, press-ups, progression to positions that maximally challenge the
push-ups, and quadruped exercises).53 The dynamic shoulder restraints.
scapulothoracic muscles are comprehensively condi-
tioned through the use of free weights,27,67 various Stabilization for Multidirectional Instability: Special
resistance machines27,53 (eg, rowing, upright rows, Considerations
and pull-downs, anterior to the frontal plane) and
training activities27,105,106 (eg, throwing movement Postoperative rehabilitation for multidirectional
exercises, blocking and ball defense exercises, and instability is characterized by activity restriction and
water-based exercises) designed to replicate stresses strict range of motion control. Care is taken to pre-

vent overstretching of tightened capsular tissues, par- 6. Aronen JG, Regan K. Decreasing the incidence of
ticularly after thermal shrinkage procedures that in- recurrence of first time anterior shoulder dislocations
duce an initial decrease in collagen tensile with rehabilitation. Am J Sports Med. 1984;12:283–291.
7. Bakerman S. Quantitative extraction of acid-soluble
strength.95,98 We restrict axial loading of the upper human skin collagen with age. Nature.
extremity for 6 weeks. For cases with an anterior 1962;196(4852):375–376.
component of instability, we restrict external rotation 8. Bankart ASB. The pathology and treatment of recurrent
range of motion to 30° (0° abduction) for the first dislocation of the shoulder joint. Br J Surg. 1923;2:23–
4 postoperative weeks and avoid combined external 29.
rotation and abduction range of motion for the first 9. Basmajian JV, DeLuca C. Muscles Alive: Their Functions
6 postoperative weeks. For cases with a posterior Revealed by Electromyography. 5th ed. Baltimore, MD:
Williams and Wilkins; 1985.
component of instability, we avoid combined flexion, 10. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL,
internal rotation, and horizontal adduction for the Pawluk RJ, Mow VC. Tensile properties of the inferior
first 6 postoperative weeks. glenohumeral ligament. J Orthop Res. 1992;10:187–
Glenohumeral and scapulothoracic muscle retrain- 197.
ing guidelines used in the postoperative management 11. Blackburn TA, McLeod WD, White B, Wofford L. EMG
of anterior instability are also appropriate for the analysis of posterior rotator cuff exercises. Athletic
postoperative rehabilitation of multidirectional insta- Training. 1990;25:40–45
12. Boileau P, Clement T, Walch G, Argenson C. Results of
bility. We advocate a more conservative approach to
anterior stabilization of the shoulder using open and
the rate of rehabilitation progression after stabiliza- arthroscopic Bankart suture repair. Proceedings of the
tion procedure for multidirectional instability, as the 8th Congress of the European Society of Sports
success of this condition may be more dependent Traumatology, Knee Surgery and Arthroscopy. Nice,
upon the restoration of normal shoulder muscle France; 1998.
function. 13. Bost FC, Inman VT. The pathological changes in recur-
rent dislocation of the shoulder. A report of Bankart’s
operative procedures. J Bone Joint Surg. 1942;24A:595–
CONCLUSION 613.
14. Boszotta H, Helperstorfer W. Arthroscopic transglenoid

In summary, there have been significant advances
suture repair for initial anterior shoulder dislocation.
in methods to restore function in both unidirectional Arthroscopy. 2000;16:462–470.
and multidirectional shoulder instability.68 15. Bowen MK, Warren RF. Ligamentous control of shoul-
Biomechanical and anatomical studies have en- der stability based on selective cutting and static
hanced our understanding of the mechanics of the translation experiments. Clin Sports Med. 1991;10:757–
shoulder joint with implications for the management 782.

and rehabilitation of shoulder instability. Further in- 16. Bradley JP, Tibone JE. Electromyographic analysis of
muscle action about the shoulder. Clin Sports Med.
vestigation of the mechanisms responsible for dy-
1991;10:789–805.
namic glenohumeral control will help to delineate 17. Burkhead WZ, Jr., Rockwood CA, Jr. Treatment of
the optimal treatment for shoulder instability. instability of the shoulder with an exercise program. J
Bone Joint Surg Am. 1992;74:890–896.
ACKNOWLEDGEMENTS 18. Cain PR, Mutschler TA, Fu FH, Lee SK. Anterior stability
of the glenohumeral joint. A dynamic model. Am J
All authors were employed by or received financial Sports Med. 1987;15:144–148.
support from the St. George Hospital and South East 19. Carmichael SW, Hart DL. Anatomy of the shoulder
Health Service. joint. J Orthop Sports Phys Ther. 1985;6:225–228.
20. Carolan B, Cafarelli E. Adaptations in coactivation after
isometric resistance training. J Appl Physiol.
1992;73:911–917.
21. Caspari RB, Geissler WB. Arthroscopic manifestations of
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CLINICAL COMMENTARY

Shoulder Instability: Management and

1A). In up to 98% of cases, the

ultimate aim of providing guidelines for the rehabilitation of various

Journal of Orthopaedic & Sports Physical Therapy 497

FIGURE 1A. Age distribution (in years) of subjects presenting with

FIGURE 1B. Recurrence rate for the nonoperative management of

primary shoulder dislocation. Dislocation recurs in 66% to 100% of

have already dislocated can expect to dislocate again

498 J Orthop Sports Phys Ther • Volume 32 • Number 10 • October 2002

J Orthop Sports Phys Ther • Volume 32 • Number 10 • October 2002 499

100 encapsulating shoulder tissues. Collagen is the major

80 protein of ligaments and tendons. In newborns,

cells make less soluble collagen and progressively

determined by analyzing the collagen type III con-

500 J Orthop Sports Phys Ther • Volume 32 • Number 10 • October 2002

shoulder immobilization, activity restriction, and ex-

aged older patients, the prognosis for patients aged

riod, redislocation occurred in 47% of patients aged

J Orthop Sports Phys Ther • Volume 32 • Number 10 • October 2002 501

of shoulder immobilization.47 ity.17,60,70,103

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shoulder capsule subjected to 65°C to 72°C heat

method of reducing capsular volume.

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Bankart tack 1995 19 1.6 0% 4

Suretac 2001 48 3.1 13% 26

as compared to no-cryotherapy conditions.91 We rec-

hour for the first week after a stabilization procedure

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postoperative week involves treatment for any

multiple sets of up to 30 repetitions for exercises

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14. Boszotta H, Helperstorfer W. Arthroscopic transglenoid

shoulder joint with implications for the management 782.

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Arthroscopic versus open reconstruction of the shoulder 2001;29:538–542.

2002. Clin Orthop. 1995;143–151.

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97. Vangsness CT, Jr., Ennis M, Taylor JG, Atkinson R.

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