Physical Therapy for Climbers after Anterior Shoulder Instability Surgery

I first subluxed my shoulder almost thirty years ago during my freshman year of high school soccer. A subluxation is where the head of humerus, the ball of the upper arm bone, partially moves out of the shoulder socket and then back in. I used my shoulder carelessly to body check an opponent to win the ball. Instinctively, I threw it back in place with a backward motion of my trunk and the resulting momentum caused the humeral head to slide back into place. Years later, I subluxed again. It happened a few times bouldering overhung problems and once golfing with a bad follow-through after a tee-off drive. Eventually, I noticed my shoulder felt vulnerable with certain overhead movements in climbing, yoga, and working out. I tried physical therapy twice which helped build some confidence and trust, but the apprehension was still there. The fear of “popping out” prevented me from climbing to my fullest potential. I dreaded what seemed inevitable: surgery. MRI findings reported a “probable tearing of the anteroinferior labrum with small chronic appearing Hill-Sachs deformity.” What does this mean? My orthopedic surgeon performed a quick history and exam and to no surprise, recommended surgery.

More than likely, after recurrent subluxations or dislocations, you will need surgery. Recovery, rehab, and return to climbing after surgery takes months and is highly dependent on compliance and participation in physical therapy. This article will guide the rock climber though a rehabilitation program after Arthroscopic Anterior Stabilization with or without Bankart repair and get them back to crushing their projects.

Figure 1

How does the shoulder, or glenohumeral joint, become unstable? The glenohumeral joint becomes unstable when the ball or head of the humerus is outside of its normal position in the socket. (See Figure 1.) This instability can happen after it is subluxed repeatedly, dislocated, or congenital. You get to a point where the net force on or across the glenohumeral joint is so great that it cannot be compensated for by the anatomical structural stability of the shoulder, which include the bones, labrum, ligaments, joint capsule, and the rotator cuff muscles.

The shoulder’s bony structures provide little to no structural stability by themselves. There is a very small and shallow socket or glenoid cavity that articulates with a large ball (head of humerus) like a golf ball on a tee. (See Figure 2.) This makes the shoulder prone to being unstable. The “static” stabilizers of the shoulder joint consist of the joint capsule, ligaments, and labrum. The labrum is a thick ring of cartilage that surrounds the edge of the glenoid, essentially deepening the socket 50%-75% which helps keep the ball in place. The joint capsule is a sac made up of ligaments and connective tissue that encapsulates the joint. (See Figure 3.) The intricate arrangement of ligaments connects the humerus to the glenoid, providing a main source of stability for the shoulder.

Figure 2

Figure 3

The rotator cuff muscles are the “dynamic” stabilizers of the shoulder. (See Figure 4.) They center the humeral head on the glenoid by pulling the head of the humerus into the glenoid fossa. (See Figure 5.) The tendons of the rotator cuff muscles are intimate with the joint capsule.

Figure 5

Figure 4

The most common symptom that people get with shoulder instability is that they feel like their shoulder is popping out of their socket, the same symptom I felt after multiple subluxations. This is due to trauma, microinstability, or congenital. Shoulder subluxation or dislocation can happen with a traumatic event such as a Fall Onto an Outstretched Hand (FOOSH). This usually results in damage to the supporting structures of the shoulder (i.e. labrum, ligaments, joint capsule, bones) which requires surgery for the joint to become stable again.  Microinstability can happen from repetitive microtrauma where over time, repetitive movements such as throwing weaken the structures of the shoulder. If the joint capsule gets stretched out and the shoulder muscles become weak, the ball of the humerus begins to slip around too much within the shoulder. This is common among baseball pitchers, volleyball players, and swimmers. Finally, individuals can be genetically predisposed to having unstable shoulders due to lax ligaments. This is often known as Multidirectional Instability (MDI) that becomes symptomatic over a course of time without specific mechanism of injury other than repetitive use.

Figure 6

The humeral head that fits into your shoulder socket can sublux or dislocate in several directions depending on how it is loaded. Most subluxations or dislocations (~90% incidence) occur through the front of the shoulder. For the purposes of this article, we will be focusing on anterior or frontal instability. In many cases (90% or greater) of anterior subluxation or dislocation individuals have a Bankart lesion which requires surgery. (See Figure 6.)

Figure 7

Figure 8

A Bankart lesion is when the labrum, a connective tissue ring around the socket, pulls off the front of the socket. It can also bring damage to the connection between the labrum and joint capsule. You need an MRI to shed light on what soft-tissue damage you have suffered. This usually happens when the arm is outstretched, abducted, and externally rotated. Imagine if you’re biking and need to make a right hand signal with your arm. (See Figure 7.) A “bony” Bankart is where a portion of the glenoid surface breaks off with the labrum. Additionally, during dislocation the back humeral head can impact the front the glenoid rim, or edge of the socket, causing a compression fracture or depression defect on the humerus called a Hills Sacks lesion. (See Figure 8.) Other associated pathology can occur with anterior dislocation including a traction injury of the brachial plexus and axillary blood vessels. If you are a patient being seen by a physical therapist, the therapist should follow up with a neurological screen to see if there are lingering nerve palsies or damage for a better idea of prognosis or additional medical work up.

Signs and symptoms for anterior shoulder instability

Some of the common associated findings with anterior shoulder instability typically involve a traumatic event, for example a FOOSH, direct hit to the shoulder, or full dislocation. During the physical examination, there may be several signs that help form the basis for a diagnosis. With anterior shoulder instability you may feel diffuse pain over the anterior and posterior (back) of the shoulder with palpation. Palpation is when a health care professional uses their fingers and hands to feel and assess the anatomical structures of your body. You might also feel diffuse pain after a dislocation that reduces significantly after you have had your shoulder reduced or put back into its place by a health care professional. During the exam, active and passive range of motion can be highly variable depending on acuity. You may have full or near full range of motion with “guarding” later in recovery. Guarding is a physical or emotional protective response aimed at preventing pain or injury. This often presents as being unable or unwilling to move into end ranges of shoulder abduction and external rotation. The climber may feel pain or apprehension with certain overhead movements, where the shoulder is in 90 degrees of abduction and 90 degrees of external rotation with the elbow flexed. (See Figure 7.) This is the most vulnerable position for the shoulder. Personally, I felt vulnerable and apprehensive before a committing to a gaston (See Figure 9) or dyno. After an acute injury, you may have minimal motion and be unwilling to move. While testing your shoulder strength, it may be limited by pain, especially rotator cuff weakness particularly in external rotation and abduction. The most common sequela of anterior shoulder instability is recurrent dislocations or subluxations. Other complications include Bankart lesions, injury to the inferior glenohumeral ligament, Hill Sachs lesion, and “dead arm.” Dead arm occurs when the arm is in an abducted and externally rotated position, and you feel a sharp, anterior shoulder pain and numbness and/or tingling down the affected arm.

Figure 9

Assessment

Diagnosis of anterior shoulder instability is through a thorough interview, imaging, and a cluster of special tests. First, a health care professional will obtain relevant information about you, your current condition or chief complaint, associated symptoms, and history. Next, you will perform a physical examination which might include visual inspection, motion, strength, palpation, neurological screening, pain assessment, passive mobility testing, functional testing, special tests for the shoulder, and clearing procedures for neighboring joints. A health care professional will interpret these signs and symptoms from the subjective interview and objective examination that may warrant further diagnostic testing such as imaging and/or referral to another health care professional.

The most common scenario is that you’ve had your shoulder reduced after a dislocation. A few weeks after the injury, you’re in a physical therapy clinic. Your shoulder is feeling better with more movement and reduced symptoms and inflammation. At this point, we want to find out if the glenohumeral, or shoulder joint, is stable. The best cluster of tests for anterior instability are the Anterior Apprehension/Relocation test, Load and Shift, and the Sulcus Sign. The single best test is the Anterior Apprehension Test but it’s also the most aggravating. Save this test for last. This test is highly specific, which means that a positive test result is strongly predictive of anterior shoulder instability. If you see excessive anterior translation, you start to speculate what the anterior apprehension test might look like. If you find excessive anterior translation with the Load and Shift Test, you start to speculate what the Anterior Apprehension test might look like.

The Rock Rehab Pyramid

The Rock Rehab Pyramid is a framework developed by Dr. Jared Vagy to help climbers self-manage climbing injuries. The pyramid consists of four phases: 1) Pain, inflammation, and tissue overload, 2) Mobility, 3) Strength, and 4) Movement. This rehabilitation and injury prevention program begins at the bottom of the pyramid and progressively advances up until you fully recover. For more science-based, injury prevention and rehabilitation information designed specifically for climbers check out the book Climb Injury-Free.

Once a shoulder is subluxed or dislocated, it can become unstable and prone to future dislocations or subluxations. When an individual has a subluxation with no major nerve or tissue damage, the shoulder should improve quickly. Strengthening exercises may help to increase the stability of the shoulder joint. If you are going to manage conservatively, the four Ps of conservative rehabilitation described by Jobe1 can be utilized for nearly every post-operative recovery or progression relative to instability of any kind for the shoulder complex. The four Ps are the glenohumeral Protectors (rotator cuff), the scapular Pivoters (trapezius, serratus anterior, levator scapulae, and rhomboids), the humeral Positioners (deltoid), and the Propeller muscles (latissimus dorsi and pectoralis). If you had a dislocation or subluxation, you’re going to lose proprioception. It’s very important to do a lot of dynamic rhythmic stabilization techniques or perturbations as well as exercises that require the eyes to be closed as early as possible. A physical therapist can prescribe a home exercise program tailored to each person’s needs. In this article, we will focus on post-operative guidelines for Arthroscopic Anterior Stabilization (anterior capsule-labral repair).

Once you’ve had surgery to repair the anterior labrum and capsule, the rehabilitation is straight forward. Initially, the goal is to balance protection of the repair while initiating early range of motion to prevent long-term stiffness and pain. This is known as the protective phase. Clinical studies that advocate for initiating early range of motion have shown quicker return to functional range of motion and functional activity, with no increased instability.2 However, avoid being over-aggressive with range of motion and stretching early and creating synovitis. You will respect and protect appropriate tissues for 4-6 weeks by avoiding closed-chained positions and limit shoulder external rotation. Once you are out of the protective phase, then you want to start working on progression of elevation/scaption, usually working to get full motion somewhere around 10-12 weeks ideally. Start with external rotation in neutral (by your side), then work yourself up to 45 and 90 degrees of abduction respectively to avoid anterior capsule stress. You are respecting when you would load those tissues that have been repaired. Begin rotator cuff activation, not strengthening, as early as possible. You also want to start scapular stabilizer muscle activation and rhythmic stabilization as early as possible.

The intent of the protocol below is to provide a guideline for the clinician, therapist, and rock climber following an arthroscopic anterior stabilization procedure. The author takes no responsibility and assumes no liability for improper use of this guideline. Individual patient values, expectations, preferences, and goals should be used in conjunction with this guideline.

In summary, respect and protect the appropriate tissues post-operatively. Progression of strength training and proprioceptive/dynamic stability should be based on performance criteria, not the times listed below. These time frames are just examples and are adjusted based on clinical criteria. It doesn’t matter how long it takes to get the strength back. It could be anywhere from 3 to 8 months, depending on various factors. Additionally, endurance and neuromuscular control are equally important as strength. The end stage of rehabilitation must be individualized to the functional tasks and demands of a rock climber.

Arthroscopic Anterior Stabilization Post-Op Guidelines

Protective or Acute Phase: Immediate Post-surgical (Week 1 – 3)

Goals:

  • Respect and protect healing tissues
  • Diminish pain and inflammation
  • Initiate para-scapular muscle training/activation
  • Initiate early Range of Motion (ROM)

Precautions:

  • Always remain in sling, only removing for showering, physical therapy, and elbow/wrist ROM
  • Avoidance of abduction and external rotation to prevent anterior capsule stress
  • No lifting objects with operative shoulder

Week 1-2

Unload exercises:

  • Wear sling at all times except where indicated above (Includes sleeping)
  • Ice/cryotherapy

Mobility exercises (3 x daily – 7 x weekly – 1 set – 15-20 reps):

Week 3

Unload exercises:

  • Continue use of sling

Mobility exercises (3 x daily – 7 x weekly – 1 set – 15-20 reps):

Protective Phase: PROM/AAROM (Weeks 4 & 5)

Goals:

  • Gradually restore PROM of shoulder
  • Do not overstress healing tissue

Precautions:

  • No shoulder lifting or AROM

Week 4 & 5

Unload exercises:

  • Continue use of sling
    • May come out of sling at home and seated or in very controlled environment

Mobility exercises (3 x daily – 7 x weekly – 1 set – 15-20 reps):

Strength exercises:

Sub-acute / Intermediate Phase (Week 6 & 7)

Goals:

  • Initiate neuromuscular/proprioceptive/dynamic stability training ASAP
  • Gradually increase external rotation ROM
  • Progressive strengthening
    • rotator cuff, scapular muscles, trunk, and legs
  • Emphasis on muscular endurance

Precautions:

  • Wean from sling
  • No lifting with affected arm

Week 6 & 7

Unload exercises:

  • May wean from sling, except in crowds, slippery surfaces, etc

Mobility exercises:

Strength/Activation Exercises:

Strengthening Phase (Week 8 – 12)

Goals:

  • Continue to enhance and normalize muscular strength, endurance, and stability
  • Full AROM at 12 weeks
  • Continue to gradually increase external rotation passively
  • Enhance muscular strength, endurance, and stability

Precautions:

  • No overhead strengthening
  • Avoid extension and abduction until 12 weeks to minimize stress on the anterior capsule

Week 8-11

Mobility exercises:

  • Continue to progress with non-painful AROM/AAROM
  • Continue to increase External Rotation AAROM gradually
    • Up to 65° at 20° abduction (see previous videos and increase range of motion)
    • Up to 75° at 90° abduction (see previous videos and increase range of motion)
  • Continue posterior capsule and pectoralis stretching

Strength Exercises: