Shoulder dislocation in young athletes have a high rate of recurrence, leading to chronic shoulder instability. After a shoulder dislocation, the shoulder joint becomes unstable which increases the chance of developing chronic subluxation problem. The term subluxation refers to the complete separation of the articular surfaces with spontaneous reduction. In the other hand, dislocation is a complete separation of the articular surfaces and requires a specific movement or manual reduction to relocate the joint. Most anterior dislocations damage the attachment of the labrum to the anterior glenoid margin (Bankart lesion). There may also be an associated fracture of the anterior glenoid rim (bony Bankart lesion) or disruption of the glenohumeral ligaments. These lesions are the main reason of recurrence. After the first dislocation, most of the time you loose the static stability of the joint (labrum, ligaments, the capsule itself) that maintains the humeral head into the socket. At this point, your only option is to stabilize the joint with your dynamic stabilizers which are in this case the rotator cuff muscles.
Unfortunately, the incidence of recurrent dislocation ranges from 17-96% with a mean of 67% in patient populations between the ages of 21-30 years old. Individuals between the ages of 19 and 29 years are the most likely to experience multiple episodes of instability.
There are different types of instability: traumatic onset, congenital hyperlaxity and, aquired laxity (congenital laxity superimposed repetitive stresses).
- Traumatic onset: In a case of a football player, most of the time, a traumatic shoulder dislocation occurs when the player tries to tackle an opponent and the shoulder is in abduction and external rotation.
- Congenital Hyperlaxity: Some athlete always had joint laxity which we call congenital hyperlaxity and makes them more vulnerable for shoulder subluxation/dislocation.
- Aquired Laxity: combination of congenital laxity and repetitive stresses on the shoulder. QBs (anterior shoulder laxity) and Linemans (posterior capsule laxity) are the most likely to acquire laxity overtime.
Rehabilitation for Recurrent Shoulder Subluxation/Dislocation
The rehabilitation program should include position-specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises once full, pain free ROM and adequate strength have been achieved. For instance, dynamic stabilization exercises for Quarterbacks should be done from 90° to 120° of shoulder flexion. For Linemans, it should be from 45° to 90° of shoulder flexion etc. Also, it is important to enhance strength, proprioception, dynamic stability and neuromuscular control in the specific points of motion or direction which results in instability complaints. When starting rehabilitation, caution is placed on avoiding excessive stretching of the joint capsule through aggressive ROM activities.
Therapeutic Exercises to Enhance Dynamic Stability of the Shoulder
- Supine dynamic stabilization drills in flexion/extension with the shoulder at specific degrees depending on player position.
- The progression would be from supine to weight-bearing on wall on unstable surface such as a physio ball. This progression is mostly important to perform with Linemans due to the position of the shoulder when they initiate the contact.
- Lastly, the last progression is in 4 points on treatment table with hand on unstable surface such as a tennis ball which put more weight on the shoulder and increase the difficulty.
- Supine dynamic stabilization drills in ER/IR with shoulder at 45° and 90° of shoulder abduction.
- ER/IR exercises with tubing and a towel roll. These exercises can be progressed with manual perturbation at the end range of ER.
- For QBs, I like to give the dribbling exercise on wall with a tennis ball which replicate the QB’s motion and at the same time it works the dynamic stability of the shoulder.
- Push-up on unstable surface such as a BOSU or wobble board. Manual perturbation can be added as a progression to this exercise.
- Sports specific drills and a gradual return to play.
Braces to Prevent Shoulder Subluxation/Dislocation
Some braces can be used to decrease the risk of shoulder subluxation and/or dislocation. The two main characteristics of this type of braces are the limitation of shoulder abduction and external rotation which are the 2 movements responsible for most of anterior dislocation. I personally like the Donjoy Sully Shoulder Brace.
Surgical Procedures
Lastly, when conservative treatments failed, surgical stabilization is often prescribed. Depending on the direction of instability, the surgeon will use the most appropriate procedure including: Bankart repair, capsular shift, thermal shrinkage and capsular plication.
Shoulder subluxation and dislocation are very common with young football player and it is very important to diagnose the most vulnerable player at the beginning of the season.
References
- Hovelius L, Saeboe M. Neer Award 2008: Arthropathy after primary anterior shoulder dislocation – 223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg. 2009; 18: 339-347.
- Hovelius L et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five year follow up. J Bone Joint Surg Am. 2008; 90: 945-952
American Football Staff 