shoulder instability

Anterior instability is a common condition I tend to come across which can be hard to diagnose especially if there seems to be multiple problems occurring concurrently.

Anterior shoulder instability can be traumatic or atraumatic origin and emergency case that we cant miss in the clinic is TUBS which stands for Traumatic, Unidirectional, Bankart, Sugery (indication for surgical intervention).

at time, conservative treatment can be tricky and is difficult to determine where to start and how fast you progress. Here is a general consensus as to how it should be approached, but keep in mind that treatment will vary slightly among individual presentations.

As clinicians, we can attempt to alter dysfunction of the active and control subsystems to improve motor control. This may prevent or alleviate problems with dynamic stability. Firstly, It must be remembered that scapulothoracic joint stability is an essential component of dynamic control of the shoulder complex. Exercise protocols to improve scapula stability have been a good start of rehabilitation if your assessment findings indicate of any abnormalities at scapulothoracic joint (Magarey & Jones 1992; Moseley et al 1992; Mottram 1997). Below is a management strategy aimed at improving the dynamic control of the glenohumeral joint.

principles are:

• Aiming for local control of the rotator cuff especially of inner range contractions
• Integrating and development of automatic control
•  Gradually progressing into more unstable positions
• Control with additional load and speed requirement for functional retraining.

TECHNIQUES FOR GAINING LOCAL CONTROL OF THE ROTATOR CUFF

• Conscious setting actions (centring humeral head) in supine or sitting
• aim is to increase proprioception and joint position sense
• ? maybe you can copy positions of contralateral shoulder position in which you put it with patient having their eyes closed or trace a line on a paper with tip of elbow to retrain detexterity of shoulder movements
• Inner range holds of internal rotation and external rotation
• Internal rotation and external rotation will activate all of the rotator cuff musculature including supraspinatus. The arm can be taken actively or passively into the inner ranges of internal or external rotation and held in this position until fatigue occurs or substitution strategies are used.
• Taping
• Joint compression through closed kinetic chain exercise
• Integration and development of automatic control
• Once local control of the glenohumeral joint has been achieved with a stable scapula, controlled movement of the glenohumeral joint should be encouraged.
• Clinically, it is often the case that once movement is initiated, the scapula is not stable and the rotator cuff musculature will reverse its origin and insertion roles, creating scapular movement and not glenohumeral joint motion.
• Active IR and ER through range
• Isometric contractions
• resistance training
• closed kinetic chain exercise with unstable surfaces
• 'flicks and wobbles' as a transition between strengthening exercises to sport-specific exercises
• Global strengthening

also Manual therapy can be integrated as a multimodal approach if necessary. manual therapy has been shown to alleviate pain for shoulder pathology and would reduce any capusuloligamentous structural tightening.

NT: Rotator cuff muscles in shoulder joint are like equivalent of TA or multifidus in Low back. it needs to be targeted initially via local activation, proprioceptive training, and correcting movement pattern.

Most of this information was obtained via S. A. Hess's articles.