Shoulder pain and instability normally presents with pain or irritation around the shoulder joint with activites above head or to the side of the body. For example reaching to the top shelf, putting on a jersey or reaching behind your back. Instability is caused by different factors such as traumatic injuries, overuse conditions, muscle weakness or poor movement patterns.

Did you know?

The shoulder is the most mobile joint of the body.

Therefore, it has the highest risk for joint dislocations.

After a shoulder dislocation there is a 95% recurrence rate for another shoulder injury.

Young male athletes are at the highest risk of developing recurrent shoulder instability.

Patients with recurrent shoulder instability are more likely to develop a degenerative shoulder condition.

 

 

Shoulder instability treatment

The type of treatment dependends on how the shoulder instability was obtained & how severe the instability is. The main goal of exercise therapy is to move your shoulder freely, without having to worry about pain. While at the same time doing what you love with a strong and stable shoulder.

In this article, we explain the different treatment options we provide as Biokineticists. And why it is important to receive rehabilitation in the form of exercise therapy. We also discuss the symptoms (scroll down) and types of shoulder instabilities.

A. Atraumatic instability

Atraumatic means you might have shoulder pain and dislocations but it has not been due to a direct blow or injury. This category can be seen as a more long-term reason for shoulder instability. Things like poor posture, weak muscle control, poor balance and coordination, as well as abnormal movement patterns, can all lead to an unstable shoulder. For example, many office workers struggle with pain in front of the shoulder due to long hours in front of their desk.

Treatment: For this type of instability the best place to start is with assessing you posture and the way you move your shoulder. This type of exercise therapy includes:

     1. Practising correct posture and implementing it in daily routines & activities

Poor shoulder and upper body posture presents with muscle groups that are unbalanced. A typical example is forwardly slouched shoulders and weak back/shoulder muscles with tight front shoulder muscles. With unbalanced muscles comes abnormal movement patterns, leading to instability over time. Posture correction can assist the shoulder muscles to perform movements with the correct mechanics.

     2. Correcting abnormal movement patterns & obtaining muscle movement control

When a muscle is not activating correctly during movements it means that other near by muscles are compensating to produce the movement. If this compensation movement keeps occurring, the muscle primarily responsible for the movement becomes inactive and weaker. While the compensatory muscles become overactive or overworked. By including muscle activation training into the rehabilitation process, we can target and activate the specific muscle to improve their strength and function. This minimizes instability and assists us in the goal of preventing future dislocations.

     3. Strengthening the shoulder and surrounding muscles

We evaluate your shoulder & surrounding muscles’ mobility, strength, endurance and function. Based on your test results, we prescribe an individualised exercise therapy program for you. This addresses your specific problem areas which was identified during the evaluation. During this process it is crucial that we also work on strengthening the muscles surrounding & influencing the shoulder joint. Focus is placed on gradual progressions to prevent setbacks and premature return to work or sport which may lead to injuries.

     4. Focussing on proper functional movement biomechanics & proprioception

During this phase of shoulder pain and instability rehab we start to include functional & balance training. Improved reaction & control with functional upper body movements is one of the main goals. All of the previously mentioned factors included into the rehab process will collectively build up.  This is so that your shoulder muscles are able to activate & control the movements apprpriately. The aim is to be strong enough to handle loads placed on your shoulder during activities of daily living, work and sports.

B. Micro-traumatic/repetitive conditions

Overuse injury is the more common term for shoulder injuries where there is a repetitive force placed on them. It normally occurs in sport and work activities where the shoulder is working above head or in a specific posture for a prologed period. Additionally the shoulder joint has to endure this stress for prolonged periods of time and at high velocity work for athletes. For example, people who work in construction or athletes that hit, throw, bowl or catch above the head. If the shoulder cannot endure these prolonged stressors placed on the shoulder joint, it will start to pain, develop instability and lose its optimal functioning capacity.  Pain might be indicative of muscle and ligament injury, which has to undego exercise therapy to heal and return to work or sport.

Treatment: The best form of treatment for overuse injury is with exercise therapy (Biokinetics). There are 3 goals in the rehab process.

    1. Load management

After an overuse injury, adequate rest is needed for the injured joint to recover. Rest does not necessarily mean stopping all activites, but it does mean we have to determine which activites/loads are allowed and which ones aren’t. During this stage, focus is on managing inflammation & pain if present. Early stages of exercise therapy includes strengthening work in a pain free range of motion.

    2. Progressive strengthening

The next step is to gradually strengthen the shoulder and surrounding muscles with progressive and appropriate exercise loads. During this stage we focus on correct shoulder muscle activation and movement techniques. Exercise therapy not only includes the assurance of correct muscles activation for each shoulder movement but it places the focus on learning adequate shoulder muscle control & balance.

    3. Return to work or sport

The final stage includes endurance/strength, balance, and power/plyometric training (if needed) exercise therapy. Including shoulder endurance/strength training in the final phase is vital to ensure the joint and surrounding muscles are able to produce the required movements for the period needed in their work or sport. It also ensures that the shoulder can perform the correct activation and technique, even during a fatigued state. Balance training improves the joints spatial awareness, muscle activation in relation to different positions, and overall coordination and control.

By incorporating power/plyometric training into the final phases of rehabilitation, we prepare the muscle for optimal performance especially during explosive movements required in sports participation. With return to sport rehabilitation, sport specific training drills and exercises is incorporated to mimic the loads that are placed on the joint during real life movements and sport participation. This type of training and rehabilitation allows for supervised and controlled return to sport/activities.

 

 

C. Traumatic incident / injuries

When the shoulder joint is dislocated due to poor movement control, weakness or a direct impact to the joint, the surrounding muscles, ligaments, and joint capsule is at risk for injury. Not only can there be damage to the soft tissues, but the bone structures can also be damaged.

Dislocations of the shoulder joint can occur more frequently and much easier if the shoulder already presents with instability. Instability that is due to weak ligaments and muscles. It is worth noting that with every dislocation there is a stretch to some of the tissues that results in laxity in these structures. Laxity in the ligaments or muscles means more movement in the shoulder but less strength and protection in the shoulder joint.

Treatment:

In this instance, the first healthcare provider to see would be a doctor in an emergency setting at a hospital so that x-rays can be taken if deemed necessary. And the shoulder can be properly put in the correct placement if needed.

If the injury presents in an emergency setting, the first aid responders should make sure the shoulder is splinted properly and the patient is on their way to see a doctor.  The doctor assesses the degree of damage to the soft tissues and bony structures after the dislocation. If the damage is severe, corrective surgery is needed. If the injuries are not severe, the doctor prescribes medication to help with the pain and inflammation in combination with: recommending movement limitations, rest, and wearing a supportive sling for a few weeks before starting with rehabilitation therapy. A referral to a physiotherapist or biokineticist is normal and should be taken seriously. The doctor can also refer the patient  for x-rays or an MRI to further assess the shoulder joint.

You are welcome to contact us once you have been cleared by the doctor, physio or orthopaedic surgeon to start rehabilitation in the form of exercise therapy. You are also welcome to contact us if you are not sure how to start the process or if you have not seen any other specialist. Specific rehabilitation protocols are followed to ensure a gradual return to full range of motion and shoulder strength. The total time it takes to return to work or sport can range anything between a few weeks to a few months depending on the severity, if surgery is completed, patient adherence and any other complications.

Take home message for shoulder instability treatment

Many people do not know or realise how effective exercise therapy is and that it can prevent future dislocation and surgeries. It is vital to take part in a rehabilitation program after any dislocation or surgery to the shoulder – even after physiotherapy. WHY? Because you need to make sure your shoulder is strong enough and we can help you.

It is vital to take part in a regular exercise therapy program to maintain the gained strength and control. Especially once your back to work or sport activities. If you go back to your original way of not strengthening the shoulder – you will end up with the same results = shoulder instability and dislocations. Spescific shoulder strength training should still be incorporated into your regular training routine. This reduces the risk for future injuries, instabilities and dislocations. Make sure you decrease the risk of developing chronic shoulder instability and degenerative shoulder conditions.

Shoulder instability rehab is a long term process (2-3 months or longer) and when patients do not adhere to the full process, their risk increases for:

• Re-injury due to the surrounding shoulder muscles and structures not being fully healed or strong enough to produce required movements or activities.
• Not returning to work or sport in full capacity.
• Stagnation and regression of progress already made.
• Restarting the exercise therapy process.
• Surgery to stabilize the shoulder.
• Development of chronic shoulder instability = recurrent dislocations.
• Developing abnormal movement and compensatory patterns due to ineffective shoulder control & proprioception.
• Compensation injuries to the neck, arms, upper back muscles & other areas.

 

Signs & symptoms of shoulder instability

Most people not participating in sport, experiences shoulder pain, irritation or numbness in the shoulder and arm area. Mostly with daily activities or during work activities. Athletes might also feel the same symptoms but often they start to see a change in their sport performance due to the painful shoulder. When you experience pain or any of the following symptoms or signs, you might have shoulder instability:

• Shoulder dislocations during activities of daily living or sport movements
• Pinching or numbness in the shoulder or arm/hand
• Shoulder joint feeling loose and unstable
• Shoulder muscle weakness
• Decrease in sports/activity performance
• Apprehension to perform specific shoulder movements
• Pain with movements above head or to the side of the body
• Pain in the front or back of the shoulder

 

Sports and activities that create high risks for shoulder instability

• All activities and sports that require repeated loads especially overhead shoulder movements. Shoulder movements that require great force to resist or power when doing the movement. Any activity that is repetitive and prolonged.
• Tennis
• Volleyball
• Rugby
• Swimming
• Cricket
• Dancing
• Gymnastics
• Netball
• Taikwando
• Boxing
• Crossfit

 

Clinical categories of shoulder instabilities

Anterior instability – The ligaments and soft tissue in the front of the shoulder joint are not strong enough to keep the head of the humerus in the shoulder socket during movements. Lifting your arm next to your side or outward rotation of the arm is painful and can be experienced as weak movements when you have anterior shoulder instability.

Posterior instability – The ligaments and soft tissue in the back of the shoulder joint are not strong enough to keep the head of the humerus in the shoulder socket during movements. When you have posterior shoulder instability you can experience pain or weakness when crossing arms over chest or if you push open a heavy door.

Inferior instability – The ligaments and soft tissue underneath the shoulder joint are not strong enough to keep the head of the humerus in the shoulder socket during movements. Pain when carrying a heavy bag on your shoulder might indicate inferior shoulder instability.

Multidirectional instability – This refers to when the shoulder is unstable in various directions. It can be a combination of anterior, posterior, and inferior shoulder instability.

 

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