Shoulder Instability: A Systematic Program for Conservative Care and Physical Therapy

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant delves into the various phases of rehabilitation for shoulder instability, providing valuable insights and recommendations. One key phase highlighted is centered around core stability, with Mark emphasizing the significance of incorporating core-related exercises into the rehabilitation program. Specifically, exercises like plank and plank rotations are mentioned as effective ways to engage the core muscles.

Furthermore, Mark discusses the importance of tailoring functional exercises to the individual's capabilities. He explains that if certain exercises, such as overhead press or full bench press, are too challenging, alternative exercises can be introduced. Examples provided include the landmine press, bottoms-up press, and push-up variations. The goal is to find a level of functional activity that the person can comfortably perform and then scale it accordingly. This approach not only helps to keep the individual motivated, but also allows them to track their progress towards their goals.

In addition to core stability, Mark discusses the significance of incorporating speed work into the rehabilitation program. As the patient progresses through the program, Mark suggests gradually introducing speed training. This involves training the tissues to tolerate different velocities of force through a full range of motion. Specific speed work exercises, such as concentric-eccentrics at different beats per minute (30, 50, 70, 90, 120), are mentioned. Additionally, activities like Turkish Get-Ups are highlighted for their ability to improve core resilience while working on shoulder stability.

Overall, Mark underscores the importance of integrating core stability exercises and speed work into the rehabilitation program for shoulder instability. These phases of rehabilitation play a crucial role in enhancing overall function and resilience of the shoulder joint.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

00:00 - MARK GALLANT Alright, what is up PT on ICE crew? Dr. Mark Gallant here, lead faculty for the Ice Extremity Management Division. alongside Eric Chaconas and Lindsey Hughey. Coming at you, sorry, Lindsey, messing up that last name. Happened to me for years, now it's happening to you. Lindsey Huey, the other extremity management lead faculty. Coming at you here on Clinical Tuesday, wanna talk about atraumatic shoulder instability and traumatic shoulder instability, and what a good plan is if we're gonna treat these folks non-operatively. Before we get into that, I want to update on a few courses coming up. So I'll be in Woodstock, Georgia, November 11th. Cody Gingrich will be in Newark, California, December 2nd. And Lindsey Huey will be in Windsor, Colorado on December 9th. So a lot of opportunities, different regions of the country to check out ice extremity management. over the next couple months if you need to get in those CEUs for the year. So again, that's November 11th, Woodstock, Georgia. December 2nd will be in Newark, California, and December 9th will be in Windsor, Colorado. So definitely come meet us out on the road. 02:58 - CONSERVATIVE CARE FOR SHOULDER INSTABILITY So when we're looking at shoulder instability, it used to be that if someone had a traumatic shoulder instability, it was an automatic do not pass go, you're required to have surgery. And then the folks that had atraumatic shoulder instability, the people who were either born loose or worn loose, those folks, it was a maybe depending on how many dislocations, what was going on. But oftentimes a lot of these folks were getting filtered into surgical procedures. What we've now seen over the last couple of years, now that we're getting better with our rehab programs, is that conservative care and physical therapy can do quite well with both the traumatic shoulder instability and the atraumatic shoulder instability. So Anju Jaggi, who's been researching shoulder instability for years, came out with a trial this past year that recently released that showed in folks who had atraumatic shoulder instability, if they had conservative care versus if they had an inferior capsular shift, if they had an inferior capsular shift or an inferior capsular shift placebo procedure where they actually did nothing, that the folks who had the placebo treatment did just as well with physical therapy. So placebo surgery versus actual surgery, the placebo surgery with physical therapy did wonderful. We also have Ellen Shanley in 2019 who looked at what happens if people do have a traumatic shoulder instability event and they go through a full course of physical therapy and found that a majority of those folks were able to return to their sport the next year. So 85% of the individuals who had an instability event had good physical therapy and they were able to return to their sport. We do want to have some humility as physical therapists and allied health professionals that These folks were all individuals who did not have bony damage, so no bony bank hearts and no Hill Sachs lesions in these studies. If those things are not present, we can do quite well. So what is this actually going to look like? Margie Olds, who's another researcher who does a lot with shoulder instability, recently came out with a clinical commentary of how do we best do how do we best work with these folks? And we've been using it in clinic and seeing some really nice results. What the overall theme is, is we really want to get some of the local rotator cuff muscles really functioning well so that the lats, the pecs, the big movers don't have to take over. 04:13 - MUSCLE FIRING PATTERNS & PRIME MOVERS What we used to see is everyone would try to disinhibit the prime movers, the pecs, the lats. We saw this a lot in FAI treatment where we would try to disinhibit the TFL. What we realize now is this is very challenging, and what we actually wanna do is get the muscles that aren't firing as well to be more robust, more resilient, and fire well, and that will calm down the prime movers. So what we see is if we get the posterior cuff functioning well, if we get the subscapularis functioning well, that we will see the tone of the pecs and the lats calm down. The issue traditionally in physical therapy has been once we get to that stage, we don't move them on to more functional fitness, to more global resilience, to more general preparedness of the system. So what is this gonna look like in clinic? It's actually gonna look quite a bit like our tendinopathy progressions for rehabbing folks. So we're gonna start folks out with more isometric contractions, really getting the cortex and those muscles firing, progressing them more into a rehab dose with concentric eccentrics, then we're gonna focus on speed training, getting those tissues to tolerate speed and different velocities of force through a full range of motion, and then getting them back to their overall functional fitness. So what we specifically like to do in clinic is early on, first phase, they're first coming in to see you, they may or may not have been in a sling for a few weeks, Recommendation for slings and these folks now, if it's first time instability event, or if they've had that atraumatic shoulder instability and they had an instability event, is you can put them in a sling short term. There's no research that says it benefits them. There's no research that says it harms them. Put them in the sling. We don't want them in a sling for more than three weeks. If they feel like they need that to calm down, it is okay for a short period of time. We're going to get them in clinic and we're going to start with our isometrics. Two things that we specifically want to hit with our isometrics, if they can get into a 90-90 external rotation position, we want to hold that three sets, 30 seconds. If that person's willing to perform more, five sets of 45 seconds is even better. Whatever range of that external rotation they can get in, without pain going over a mild and whatever range they have access to, that's where we're going to perform that exercise. The other exercise we're going to perform to go after that subscapularis is a prone liftoff. So they're going to be on their stomach, they're going to put their hand behind their back as far as they can, and they're going to rotate into internal rotation to lift the wrist and hand off the back. If they can only get to the glute day one or just barely to their side, that's totally fine. When you're looking at this one, we want to be really careful that that person is actually internally rotating the shoulder. So this is not the time to turn around and type your notes. We want to be focused that they're getting true shoulder internal rotation. what a lot of people are going to do is they're going to wind up trying to extend their shoulder more or really dump through that scapula. So making sure that when they're doing that isometric, they're getting a pure shoulder internal rotation. We also want to start working on co-contraction of the shoulder. So where the delts, all the muscles are going. Oftentimes these people, although weight-bearing, closed-chain exercise is beneficial, early on it may be too much for the system. We're gonna start them out with a side-lying arm bar. So our big three exercises that we've found to be very beneficial are 90-90 ER, three sets to 30 seconds, if they can tolerate five for 45, that's even better, that prone lift-off isometric, and then a side-lying arm bar for that same period of time. Once they're able to demonstrate that they can do these exercises well, then we're going to, that they can do them well with pain less than a, than a three out of 10 or keeping it in that mild symptoms, they can tolerate the entire timeline. Then we're going to move them into a more of our rehab dose program where we're going to start getting some, some resistance through the system and getting, getting into some actual concentric eccentric repetitions. we really like to do the same motions. So we're going to stand them up, have a, have either a meter band, or if you have a cable pulley system, their hand is going to be behind their back. The cable will be to the opposite side, and they're going to have to do that lift off with resistance. We want them to hit somewhere in the 15 to 20 rep, keeping those symptoms mild for three sets. that will get their subscap, their internal rotation, again, making sure they're not solely substituting extension in that motion. Then we're gonna get them back, either on the table or in quadruped, hitting their 90-90 ER. This time we're gonna hit a light weight, two and a half to five pounds, and then we're gonna do, again, 15 to 20 reps. Can they tolerate that high volume, 15 to 20 reps? keeping their symptoms mild, that would be good for that motion. Then we're going to progress them now instead of doing their open chain arm bar, we're going to see how they can tolerate planks. So getting them into that plank position and having them do plank taps. We can modify this depending on the person by either widening their feet to get a better base of support or putting them onto a box. So for phase two, again, we want to hit that lift off, this time with either a band or a cable resistance, 15 to 20 reps, three sets. We're going to hit our 90-90 ER, two and a half to five pounds, if they can tolerate that, keeping symptoms mild. Again, higher on those repetitions. And then we're going to start working towards our plank taps. As they progress through this phase, then we're gonna start working on speed. 10:30 - SPEED & METRONOME TRAINING What we wanna look at with the speed is how much can that person tolerate velocity? The metronome is one of the best tools we can use to get this going. We've seen this a lot in the tendinopathy research. Margie Old is the first person that we're aware of that really laid out in a peer-edited journal article, clinical commentary, how exactly they're doing this with shoulder instability patients in clinic and what they're doing is they're starting them out 30 beats per minute on the metronome and they're going to do neutral internal rotation with a band or a cable column at that 30 beats per minute then as they can tolerate that well they're going to progress to 50 beats per minute then to 70 beats per minute, 90 into 120, which is moving pretty fast. If they're doing internal rotation at 120 beats per minute, it's pretty rapid. As they can tolerate that better, they're going to go out, put a towel under their arm, 45 degree angle of abduction, hitting those same 30, 50, 70, 90, 120 beats per minute, and then progressing to a 90-90 position, hitting that 30, 50, 70, 90, 120 beats per minute. Same with external rotation for that posterior cuff, 30 beats per minute in the neutral, progressing to 50, to 70, to 90, to 120. Then looking at can they do it at 90 degrees of external rotation or 90 degrees of front plane external rotation, 30, 50, 70, 90, 120. and then progressing up to 135 similar to that face pull type of motion. Again, 30, 50, 70, 90, 120. So really systematically progressing the speed training the same way you would with your loaded resistance exercise. Now, the other thing that we're gonna do during that phase three, we're gonna start progressing the plank taps. Can they now do a plank with a rotation going on to their side. So they've got to get a little bit movement through that closed chain exercise. And we love to add Turkish get up variations. So one thing that we see with a lot of, especially atraumatic shoulder instability folks, is that they're going to have a, their core is not going to be as resilient as it could be. So we often see a lot of that anterior and posterior trunk dysfunction leading to maybe the lats and the pecs having more myofascial tone and if we can work on that while we're getting the shoulder more resilient that can be a nice beneficial step. So what we'd like to do is do the first part of the Turkish get up or doing a whole Turkish get up so that we're getting some shoulder stability and we're getting a big massive core engagement. And then the final phase, phase four, where historically A lot of PTs have stopped. Oftentimes these folks are out of pain now, so compliance becomes more challenging. Really encouraging these folks that we want to get them fully back to everything that we're doing and build as much resilience to their shoulder. This is where you're going to really work on your vertical pulls, your horizontal pulls, so your pull-ups, your rows, your vertical presses, your overhead press, your horizontal press, your bench press, and then really getting into dynamic speed work or sports training. So snatches, push jerks, push press, burpees, things that are going to be more functional and have some velocity to them are really good here. Your kipping pull-ups. What we want to encourage is we're not going to only start the functional phase after they've gone through phase one, phase two, phase three. So phase one, again, being more of your isometrics, phase two being your slow concentric eccentrics, oftentimes starting at a higher volume, those 15 to 20 reps and progressing to more load. Phase three, working on your speed work, 30 beats per minute, 50 beats per minute, 70, 90, 120 beats per minute. Working on your core related exercises, with shoulder stability. We're not going to only do functional exercise after that's all done. We're going to find what is the level of that functional exercise that they can do. So if they can't overhead press, can they landmine press? If they can't do a full bench press with the barbell, can they do a bottoms-up press? Can they do a push-up variation? What is the level of functional activity that they can do? We're gonna scale it down to that level so that the person is, they've got that goal in mind. They are always aware of what they're getting back to. They're doing something that's getting all of the tissues moving. Oftentimes it's a little more fun for them. So we're keeping that as part of the program. as early as irritability allows us. So again, overall for shoulder instability, what we now know is for both traumatic and atraumatic, as long as there's not a Hill Sachs or a bony bank heart or severe trauma related changes that we do quite well in conservative care and physical therapy, we want to have a systematic program starting out with your isometric exercises that give both the posterior cuff and the anterior cuff really going. 16:01 - PROGRESSING TO CONCENTRIC-ECCENTRICS Progressing those to our concentric eccentrics, typically starting out with a higher volume. When they can do that, then we're going to progress to our speed work with our concentric eccentrics, 30 beats per minute, 50 beats per minute, 70, 90, 120, making sure we've got some activities that also engage the core, like our Turkish get ups, our closed chain exercises with those plank and plank rotations, and then getting into our more functional fitness or whatever their sport related activity is. Hope this helped overall. Love to hear anything in the comments. We would love to chat and engage about this. Hope you all have a great Tuesday in clinic and hope to see you on the road soon.

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