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Your Guide to Shoulder Instability

This information has been prepared to help you fully understand your condition so you will be in the best position possible to work with your physio and follow the steps to your full recovery. Understanding the goals of your treatment and having complete confidence in your physio are vital elements of your recovery plan, so if you have any questions then please feel free to ask your physio.

Introduction

The shoulder joint is a ball-and-socket joint. Shoulder instability means that the ball at the top of the arm bone (humerus) is able to slide around too much in the socket of the shoulder blade (scapula). In some cases the ball partially slips out of the socket (subluxation), and if the ball slips completely out of the socket it is called a dislocated shoulder.

Anatomy

The shoulder is made up of 3 bones: the scapula (shoulder blade), the humerus (upper arm bone) and the clavicle (collar bone). The bony socket is very shallow so a rim of cartilage called the glenoid labrum increases the depth of the socket to provide more stability, however  it is still very shallow compared to other joints such as the hip. To make up for this we rely on a group of muscles called the rotator cuff to hold the joint in the right position. This group of 4 muscles have to contract in a very co-ordinated way to keep the ball of the humerus tightly in the socket of the scapula during arm movements, especially with quick movements at shoulder height or above, or when lifting and carrying weights.

Surrounding the shoulder joint is the joint capsule and this is reinforced in certain areas by various ligaments. The capsule and its ligaments normally help control how far the joint moves, and if the shoulder is forced past its normal movement limit then the capsule, its ligaments, the rotator cuff muscles and part of the socket may be torn or damaged. This subluxation or dislocation normally occurs when the arm is forced out and up away from the side of your body and usually occurs in contact sports such as rugby or AFL.

Another type of shoulder instability is due to general laxity of all the ligaments in the body and this is referred to as congenital multi-directional instability. Some people are just born more flexible and with more ligament laxity than others so they may have shoulder instability with repeated shoulder subluxations and/or dislocations without a specific accident or trauma. Other people, eg. throwers and baseball pitchers, may create localised shoulder ligament laxity by doing very repeated movements, and they may also have dislocations/subluxations without any specific incident.

What Happens If I Don`t Fix My Shoulder?

Left untreated an unstable shoulder often becomes gradually looser and it will sublux or dislocate more frequently and more easily. You may start to get constant pain in the shoulder and reduced movement. It is unlikely you will be able to continue with your normal activities, and more damage is often done each time the shoulder dislocates. Ongoing instability can lead to arthritis, rotator cuff tears and impingement, glenoid labrum tears, SLAP tears and other complications.

How Long Does It Take To Get Fully Better?

Depending on the degree of instability and associated symptoms it can take from 8 weeks to 6 months to fully recover. If it becomes evident that physio is not able to give you the best recovery then surgery may be required, especially if you have had traumatic dislocations. You would then need physio afterwards to restore your movement, strength and correct movement patterns to get you back doing the things you enjoy with minimal risk of further injury.

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Your journey to peak performance with Central Physio

Your physio has been extensively trained to thoroughly assess and diagnose your injury. They will give you a step-by-step recovery plan to make your treatment easier for you to understand. The most common phases, or steps, that you will go through during your recovery plan are outlined below. The order and timing of the phases are tailored individually for you and so may vary form this list. Please feel free to ask your physio if you have any questions about your recovery plan.

Phase 1: Optimise and Control Inflammation

Inflammation is the redness and swelling that occurs whenever you injure yourself. Our bodies need inflammation to start the normal healing process but we also need to control it. Initial physio treatment to control pain and inflammation after a dislocation usually includes rest and restricting initial shoulder movement, taping for support, gentle pain-free movements, and hands-on treatments including massage and soft-tissue releases to reduce muscle bracing.  Anti-inflammatory medication may also be recommended.

An important early treatment goal is to prevent further subluxations or dislocations, which will prolong your inflammatory response. You will be shown ways to avoid the positions and activities that put your shoulder at risk of further dislocations, and your physio may also strap your shoulder to support it.

Phase 2: Muscle Re-Activation

Stability of the shoulder joint relies heavily on the strength and co-ordination of the rotator cuff muscles to hold the ball in the centre of the socket, as well as the scapula (shoulder blade) stabilisers to control your shoulder girdle alignment. With instability or dislocations these muscles may be damaged, become weak, and get inhibited due to pain. It is vital that they are activated again as early as possible to restabilise your shoulder and allow normal shoulder movement to return. Your physio will use specific muscle re-activation exercises to help you switch your rotator cuff and scapula stabiliser muscles back on. They may also use feedback devices such as EMG or video feedback to help you make sure the right muscles work at the right time to control correct shoulder alignment.

Phase 3: Restore Range Of Motion

Shoulder instability usually leads to reduced shoulder movement, either because of pain or due to protective muscle tightening and changed movement patterns. Restoring full movement with the correct pattern is essential to allow a full progression back to your normal activities.

Your physio may use hands-on techniques such as joint mobilisations and releases to the muscles and surrounding soft tissues to increase range. These will be integrated with specific exercises for you to do at home to regain your full movement. If your thoracic spine (mid-back) has stiffened up due to your altered shoulder mechanics then hands-on treatment and home exercises may be used to restore full mobility here as well.

Phase 4: Re-Educate Movement Patterns

Shoulder instability often changes the way we use the muscles around the shoulder when doing tasks such as reaching, lifting, throwing and pushing. This is usually seen as “hitching”, where the shoulder blade is lifted too far up towards the ear when the arm is taken away from the side. This movement adaptation may be helpful initially but if continued leads to reduced movement, muscle weakness/tightness and poor shoulder function.

Your physio will use a combination of hands-on techniques and specific exercises to get your correct shoulder movement patterns restored. Taping can also be very useful to hold you in the right position and re-train your muscles in the right way to move.

Phase 5: Specific Muscle Strengthening

Once your joint stability and correct movement range has been restored you need to get the strength back into your muscles to let you return to your normal activities. Your physio will guide you through a graded exercise program to boost the strength of your shoulder muscles whilst ensuring that the joint will not re-dislocate and that correct movement patterns are maintained. Often clients find that integrating an exercise physiology program is extremely beneficial at this stage to fully restore your mobility and strength not just in your shoulder but also throughout your whole upper body. This can be especially effective at restoring your confidence in your shoulder to remain stable during more varied and stressful activities.

Phase 6: Sports/Ballistics and Advanced Strengthening

This is the last phase of your journey to full recovery. When you are returning to your activity you must be able to do it at full speed and resistance before being back in the game. You need to have confidence that your shoulder will stay stable under stressful and fatiguing sporting situations, so your need to train with correct technique first to prevent another injury. In this phase we tailor exercises specifically to your activity by doing advanced sports-specific strengthening and high speed movements combined with rapidly changing directions. This phase is essential both for getting your back to your full level of performance, and also for preventing re-injury due to persisting background weakness or reduced co-ordination of muscle contractions.

Many clients find that seeing one of our Exercise PhysiologistsStrength and Conditioning coaches or Personal Trainers is a great way to build strength, ability and confidence for a smooth return to full sporting activity. If Pilates is more your style then our great Sports Pilates program is an ideal way for you to continue to build your stability and strength. As well as being an important part of your rehab program these services can help you lift your sports performance whilst staying safer and reducing your risk of future injury.

For more information or to speak with one of our physio’s to discuss your symptoms please call us on 9280 2322 or contact the clinic.

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