Physical Therapy for Repeated Shoulder Dislocation and Weakness

Tim in Sapparo, Japan asks:

"I play football and am a goalkeeper. When I was 14 I dislocated my shoulder. Ever since then it has been extremely weak and regularly comes out of joint during minor activities. I can't have an operation as I am currently living abroad in Japan but I would like to start playing football again and start Karate. Is there any way that I can regain full usage of my shoulder with physical therapy?"

Marc Bernier at the Alabama Sports Medicine and Orthopaedic Center (ASMOC), replies:

"Before responding to your current situation, a brief lesson in anatomy is in order. The shoulder joint (otherwise known as the glenohumeral joint) consists of the junction between the humerus (upper arm bone) and the 'glenoid fossa' of the scapula (shoulder blade). As with all joints of the body, the stability of the glenohumeral joint is dictated by 3 anatomical components: the shape of the joint itself (how the bones fit together); the integrity of the ligaments and capsule which surround the joint; and the dynamic stabilization provided by the muscles that surround the joint.

"The shape of the shoulder is such that you essentially have a 'ball' (humeral head) coming in contact with a slightly concave 'socket' (glenoid fossa). Unfortunately, this structural make-up does not provide much stability to the joint. Consequently, the other 2 components (ligaments/capsule and muscles) must therefore compensate for this deficiency in structural integrity.

"In a situation where there are multiple episodes of dislocations and/or subluxations (partial dislocations), the ligaments become either stretched or torn. The ligaments are then unable to provide sufficient passive support to prevent a reoccurrence of shoulder dislocation, leaving the muscles as the prime stabilizing component of the shoulder.

"Physical therapy after a single episode of shoulder dislocation or recurrent subluxations can be effective at minimizing the risk of future injuries. Rehabilitation focuses on strengthening the rotator cuff muscles (which stabilize and rotate the humeral head), scapular stabilizers (which fix the shoulder blade during movements) and prime movers of the shoulder (which as their name suggests provide the muscular force for large shoulder movements - Deltoids, Pecs, Lats, etc.). Particular attention is paid to the rotator cuff musculature, as their primary role is that of stabilizing the joint, whereas the larger muscles such as the Deltoid are responsible for large upper extremity movements.

"Rotator cuff strengthening involves very specific movement, with an emphasis on perfect form, to ensure maximum involvement of the proper muscles. Many of the exercises are performed with surgical tubing type material (Theraband), which makes this type of program very easy to perform at home. Rehabilitation is very effective in allowing a return to previous levels of athletic activity (depending upon the sport and position involved) in the single dislocation episode or 2-3 episodes of subluxation.

"Unfortunately, your situation appears to be a good bit more severe than the scenario described above. A shoulder that truly dislocates with minor activities would indicate that the ligamentous structures are significantly damaged, and unable to provide adequate contribution to stability of the shoulder. Additionally, in shoulders that chronically dislocate, a defect can form on the head of the humerus called a 'Hill-Sachs Lesion'. This lesion presents as an indentation in the humeral head which is believed to be caused by repetitive impaction of the glenoid during chronic dislocations. It is believed that this indentation may actually make it easier to dislocate the shoulder, to the point that dislocations can occur with minor activities.

"My recommendations for you would be to consult with an orthopedist to evaluate the extent of damage in your shoulder. Once that has been determined, I would request a few visits with a Physical Therapist to establish a proper home exercise program to focus on strengthening the musculature described previously. Perform the strengthening program for a minimum of 6-8 weeks before attempting higher level athletic activities such as karate, as it takes approximately that long to see an increase in true strength once a program has been initiated.

"Based on the brief description you provided, the severity of the injury to your shoulder seems fairly significant. This severity may make it difficult for you to return to higher level activities without surgical intervention. However, performing a properly prescribed rehabilitation program may allow a return to lower level activities until you are able to consider surgical correction of your injury."

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Article published: 20th December 2003

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