The goal of treatment for shoulder instability is to reconstruct its normal anatomy and restore stable function. Conservative treatment is used early in the injury and a longer-term rehabilitation program is established. For athletes with ineffective conservative treatment, repeated shoulder dislocations, or those participating in competitive events, early implementation of surgical anatomical repair is advocated. The principles of postoperative rehabilitation are to protect the joint capsule, glenoid labrum and related ligaments, to strengthen the dynamic stabilizing structures with early and reasonable training, to improve the tension of the deltoid and rotator cuff, and to promote blood circulation in the anterior shoulder capsule, ligaments and anterior glenoid labrum to relieve pain and promote healing of the injured tissue. Strengthen the neuromuscular control of the glenohumeral joint. Establish the coordination relationship between the movement of the periapical muscles – rotator cuff – capsular ligaments to reduce postoperative complications.
Basic steps of rehabilitation treatment.
Postoperative rehabilitation is divided into 4 phases, each phase is about 2-3 weeks
Phase I: Brake rehabilitation training phase, 0-2 or 3 weeks after surgery.
①Objective: to relieve pain, edema and inflammatory response, promote tissue healing and prevent muscle atrophy.
②Support: Immediately postoperative fixation in functional position with a shoulder support or shoulder forearm sling.
③Joint mobility: Start active flexion and extension training of the elbow, wrist and finger joints on the same day. 1 week after surgery, perform pendulum and paddle exercises of the affected shoulder in a relaxed and tension-free state. At 2 weeks postoperatively, pain-free activities of daily living (ADL) training was started. 15-20 strokes per exercise, 2-3 times per day.
④ Muscle strength training: Active hand grip training can be performed after surgery. L-3 days after surgery, start isometric contraction of the periapical muscles, upper limb muscles, and early movement of the scapula. After treatment, ice packs were applied for 15min-20min.
Phase II: Protective rehabilitation training phase, 2-4 weeks after surgery.
①Objective: to improve joint mobility and enhance scapular muscle strength training.
②support: if there is rotator cuff injury the upper limb should be placed in an abducted 30 degree neutral position.
③Joint mobility: 2 weeks postoperatively, perform active shoulder joint motion training and gradually increase the range while maintaining pain-free status. In case of anterior glenoid labrum injury, avoid shoulder external rotation, abduction and posterior extension movements; do active shoulder exercises below the scapular plane. In the early stage, distal resistance exercises should be avoided. after 4 weeks, start to strengthen external rotation and posterior extension training, and gradually increase extension training. Patients with more severe injury or insufficient training will have different degrees of external rotation and posterior extension limitation. Use pulleys, sticks, pulleys and other apparatus to assist training. Horizontal position exercise: patient prone position, in the state of non-resistance to gravity, the affected upper limb straight for the inversion, abduction, flexion and descent movement. The affected upper limb was straightened and slowly drawn upward and sustained in the maximum drawn position for 5 seconds, while shoulder ladder climbing training was performed within the pain-free range.
④ Muscle strength training: 3-4 weeks after surgery, active power-assisted activity training of the shoulder joint, deltoid and rotator cuff muscles in the scapular plane to increase the tension of the deltoid and rotator cuff. At 4 weeks postoperatively, resistance training of the scapular muscles, latissimus dorsi, biceps and triceps was gradually started. Shrugging, moving the shoulder forward and backward, and slow scapular band movements are performed. In addition, multi-angle resistance exercises can be performed using elastic bands. And gradually increase the range and amount of motion of the above activities, which should not be completed forcibly.
Phase III: Muscle strength rehabilitation training phase, 4-8 weeks after surgery.
①Objective: To increase the active and passive mobility of the shoulder joint and to strengthen the muscular strength and proprioceptive training of the periapical muscles.
②Support: removal of the support or forearm sling fixation.
③Joint mobility: Gradually complete the maximum range of motion of the shoulder joint in all planes. Patients obtain the maximum range of joint motion while making pendulum, paddle, shoulder pulley and shoulder ladder active training to avoid causing shoulder joint pain.
④ Muscle strength training: scapular muscles, periacetabular muscles training, active training of fingers, wrists and elbows and resistance training. The elastic band was used and the resistance against it was gradually increased. (b) 8 weeks postoperatively, complete the muscle strength training of shoulder anterior flexion, posterior extension, abduction, adduction, internal rotation, external rotation and scapular lift muscle groups respectively.
⑤ proprioceptive training: Shoulder proprioception is located in the proprioceptors on the joint capsule, ligaments, muscles and skin, which can sense the position and movement of the shoulder joint and regulate muscle movement through feedback, thus maintaining shoulder joint stability. At the same time, instability of the shoulder joint also leads to decreased proprioception. Pay attention to the neuromuscular control and muscle endurance training to maintain good coordination and reduce re-injury of the shoulder joint during the movement.
Phase IV: Motor function rehabilitation training phase, 8-12 weeks after surgery.
①Objective: To increase the flexibility and coordination of shoulder joint movement, restore joint mobility and normal motor function, and gradually resume training in professional sports; training that cannot be completed will depend on the situation. Some of them need 6-7 months to complete the basic training of professional programs.
②Joint mobility: strive to obtain normal range of motion of the shoulder joint in all directions.
③ Muscle strength training: continue to strengthen the progressive resistance training of the scapular muscles and other muscles around the shoulder joint, skill training, posture correction training, etc.
④ Motor function recovery training: start professional program training. Increase elastic band training, other equipment strength training. Gradually start weight lifting training, such as grip barbell supination: supine position, with a barbell supination, to the arms and torso vertical 90 degrees, gradually increase the number of supination and barbell weight. For throwing athletes, professional throwing training can be started. Repeated throwing exercises can be performed to increase the flexibility and coordination of structural movements around the shoulder joint. Motor function recovery training should be done in stages, depending on the individual, usually 2 – 3 times per week.
Rehabilitation therapy for shoulder function recovery after shoulder arthroscopy avoids postoperative complications such as shoulder adhesions, stiffness, and muscle atrophy. Early postoperative activities and longer supervised medical treatment play an important role in reducing permanent stiffness. A hasty approach to training can cause new injuries.