Treatment of Instability of the Shoulder with an Exercise Program*

Copyright
Treatment
In vestigation
W.
had
luxation
were
hundred
treated
luxation.
For this
ity of the
shoulder
had
reason,
result
from
Every
effort
set
or
patient
anterior
excellent
be thoroughly
initiating
of eleven
humeral
of the
factor
made
subluxation,
others.
Of
operated
on,
noid
labrum,
humeral
the
evaluated
the
on the
The
In 1956,
Rowe
groups:
traumatic
patients
who
the
cent
tions
dislocations
were the
resulted
*No
authors
benefits
divided
and
had
500
had
result
from
in any
did
not
shoulders
on. Trauma
shoulder
dislocated
an
of trauma.
a minor
form
have
890
tDepartment
7703 Floyd
ofOrthopaedics.
Curl Drive.
San
Hypemmo-
had voluntary
dislocation
of the
patients
responded
to musclebut patients
who
had appmedid poorly
treatment’7.
of the
treatment
with
difference
of patients
in patients
have
who
have
the
of
diag-
traumatic
or
been
previously
stressed
reports,
a classification
by
for
was
subluxation
an atnaumatic,
do not have
a!! types
between
who
of the g!enohumeraljoint
I is a traumatic
an
on
without
after
voluntary
psychological
voluntary
psychological
descnibed79’.
previous
disloprevious
sublux-
problems;
subluxation
problems:
Type
in patients
and Type
IV.
subluxation.
Transient
traumatic
reported
by Rowe
and
subluxation
of the shoulder
was
Zarins’
in 1981 and by Rowe’
in
shoulders
in elevation
authors
that
authors
were
reported
the
a
operative
into
reported
shoulders;
4 per
etiology,
received
two
on 488
and
The atraumatic
incident,
such
University
Antonio.
sleep.
a sharp
or pamalyzexternal
rotation
as
or will
from
a commercial
party
related
directly
or indirectly
this article.
No funds
were
received
in support
of this
t2909
Lemmon
Avenue.
Dallas.
Texas 752(14.
Center,
Aittonio
1987. The patients
in these
series
felt
ing pain in the shoulder
after maximum
He
been
during
San
abnormalities
of the
seen on madiogmaphs
dislocations
atmaumatic
importance
and
involuntary
that
was
Radiogmaphs
describe
atmaumatic’4.
or positioning
Center.
cation;
Type
II, a traumatic
subluxation
dislocation;
Type lilA.
an atraumatic,
close
relationship
between
recurrent
subluxation
and
recurrent
dislocation,
and there
was an unsatisfactory
result
in three
of the twenty-four
shoulders
that were
operated
on. The
procedure.
Science
atmaumatic
instability
has
one of us7; in subsequent
IIIB,
who
capsule.
Health
TEXAS
patients
who
Most
of their
exercises,
Type
66 per cent
had an avulsion
of the gleand in the rest, theme was a defect
of the
head
ANTONIO.
twenty-six
shoulder.
strengthening
ation
twenty-four
of Texas
arm.
subluxations
history-taking,
evaluation.
injuries.
the
SAN
were a frequent
finding
in patients
who had
dislocation.
In 1973, Rowe
et al. reported
to dislo-
of the
M.D4.
bile joints
atmaumatic
The
if a
identify
JR..
University
nosis
is to be
to
ROCKWOOD.
ciable
psychiatric
problems
operative
and non-operative
instabil-
as opposed
were
normal:
glenoid
were
the
has
Program*
was described
by Blazina
and
reported
on thirty-seven
shoul-
of most
shoulders
head and
result
treatment
be
dens in thirty-four
patients:
twenty-four
had recurrent
subluxation
were operated
the
muscle-
Incorporated
of the Shoulder
raising
subof
who
conservative
of the shoulder,
in 1969. They
in 115
with fifty-three
(80 per
that had atraumatic
sub-
must
Surgery.
of Orthopaedics,
or atraumatic
ofthe
instability
through
careful
examination,
and radiographic
Traumatic
cation
Satzman
Department
A.
(16 per cent) of the
patients)
that had
a good
each
should
CHARLES
shoulders
a specific
compared
shoulders
expected.
AND
mu!tidirectional
Only twelve
(sixty-eight
successful
etiology
physical
forty
or
with
subluxation
the exercises,
of the sixty-six
M.D.t,
Service,
and
and Jeitit
an Exercise
of traumatic
posterior,
exercises.
shoulders
traumatic
JR.,
Shoulder
a diagnosis
anterior,
strengthening
seventy-four
from
cent)
at the
One
that
recurrent
BURKHEAD.
performed
ABSTRACT:
patients
Z.
of Bopu’
of Instability
with
BY
by The Journal
I 992
cent
of
96 per
dislocasimply
ofTexas
Health
Texas
78284.
subject
coined
subluxation.
treated
with
the muscles
rotator
earlier
treatment
cuff.
operative;
vorably
In
the
tients
series,
the fifty shoulders
that did
to the exercise
regimen
were
modified
Bankant
In 1980, Neer
who
had
repair’5.
and Foster
involuntary
and
to respond
shoulder.
by psychiatric
the shoulder
shift
Science
blow.The
the
to describe
the symptoms
asSome
patients
noted
the sensathe arm was externally
rotated.
aware
of the
were initially
to strengthen
failed
of the
of
a direct
and some
were
not
semies’’,
the patients
resistance
exercises
subluxation
be received
to the
study.
on after
term
dead-arm
syndrome
sociated
with this injury.
tion of subluxation
when
reported
inferior
dislocation
of
on
non-
thirty-six
pa-
multidirectional
shoulder
to a previous
standard
Al! of the patients
were
evaluation
and finally
was
not respond
fatreated
with
a
and
the
In both
specific
of the
that
had
reconstruction
treated
initially
and strengthening
exercises
for
by a specific
inferior
capsular-
procedure.
The purpose
of this
a specific
rehabilitation
THE
paper
is to report
on the effect
of
program
for the shoulder
on a
JOURNAL
OF
BONE
AND
JOINT
SURGERY
TREATMENT
OF
INSTABILITY
OF
THE
SHOULDER
TABLE
DATA
WITH
AN
EXERCISE
891
PROGRAM
I
ON THE
PATIENTS
Generalized
No.
Type
of
Subluxation
Shoulders
of:
Male/Female
Patients
Patients
Average
Age
Dominant
Shoulder
Bilateral
Instability
Ligamentous
Laxity
(Yrs)
Traumatic
Type I
Type
II
40
37
33/4
20
19 (48%)
3 (8%)
0
34
31
28/3
31
18 (53%)
3 (10%)
0
Atraumatic
Type
lIlA
S
5
2/3
21
2
3
5
Type
IIIB
16
10
5/5
24
13
3
16
Type
IV
45
32
14/18
27
32 (70%)
group
of patients
who
mu!tidirectiona!
had
traumatic
instability
of the
Materials
and
The cases of 115 patients
able
for review.
In addition
preoperative
and
able. Eighty-seven
by the
patients
senior
either
a detailed
on atmaumatic
Methods
were availcharts,
the
madiographs
evaluated
were
one of us (C. A. R.. Jr.), and
were contacted
by telephone
questionnaire
rehabilitation
concerning
program;
thirteen
The
diagnosis
the
and
uation
of radiographs.
asked
concerned
trauma
occurred,
the
c!assification
The
the
and
after
the
injury.
The
out
of the
responded
into
based
and
lateral’3,
and
notch
that
the
amount
nadiographs
osseous
humemal
inferior
head.
Stress
madiographs
instability
was suspected.
Traumatic
I
without
-
(forty
previous
Thirty-three
and
the
74-A,
previous
shoulders)
dislocation
patients
average
thirty-eight
inant
side,
VOL.
in the
glenoid
also
were
age
were
was
dislocation:
male
twenty
and
years
years).
Nineteen
shoulders
and both
extremities
were
NO.
(.
JULY
1992
four
were
the
The dominant
extremity
was involved
(53 per cent)
and both
shoulders,
(10 per
and
five
A traumatic
cent).
were
Twenty-nine
average
to forty-two
in eighteen
in three
pa-
dislocations
were
ante-
posterior.
Subluxation
appreciable
for
and
the
when
subluxation
(Table
(range,
women;
eighteen
female
and two
years (range,
The
dominant
and
both
anterior
alized
psychological
extremity
shoulders,
and two
!igamentous
problems.
was
in three.
involved
in two
Three
were posterior.
laxity.
All
patients
-
shoulders.
Five
the subluxation
the instability
patients
were
patients
dislocations
Type IJIB
voluntary
subluxation
logical
problems:
Ten patients
(sixteen
voluntary
subluxation
and no psychological
six shoulders,
it was anterior;
Three
were male; the average
age
twelve
to thirty-six
years).
were
had
gener-
and no psychoshoulders)
had
problems.
In
was posterior
and
was multidirectional
in four,
in six
male
female,
and
five
were
and the average
age was twenty-four
years
(range,
thinteen to thirty-four
years).
The dominant
extremity
was
involved
in thirteen
patients
and both shoulders.
in three.
All of the patients
had generalized
ligamentous
laxity.
Type IV involuntary
subluxation:
Thirty-two
patients (forty-five
shoulders)
had involuntary
subluxation.
Thirty-seven
had
traumatic
of the shoulder
three
(mange,
patients
were
was twenty-one
made
made
nor
and
years
thirty-one
dislocation
of the shoulof subluxation.
There
found to have
of
oblique
radiobeen
made
to
labmum
years).
patients
thirty-one
In
dislocation:
the
remainit was
were
Subluxation
Type
patients
with no
changes
was
shoulders),
and in the
shoulders),
Type
lilA
voluntary
subluxation
and psychological problems:
In the course
of the evaluation
and rehabilitation
program,
five patients
(five shou!ders)
were
examination
were
an apical
et a!., has
identify
(six
on a
eva!-
the range of motion
of the shoulder.
the stability
of the shoulder,
and whether
or not apprehension
was
present
during
testing
for anterior-posterior
or inferior
instability.
Anterior
and posterior
(with the arm in internal and exterior
rotation),
axillary
lateral,
West
Point
all patients”.
In recent
years,
graph,
as described
by Garth
previous
shoulders),
twenty-eight
tients
included
axillary
with
-
(thirty-four
men
shoulders
physical
II
patients
age
involved,
the position
of the arm when the injury
and the amount
of pain involved
at the time of
injury
anterior.
Type
twenty-eight
or filled
questions
episode,
patients
the symptoms
who
of the
pertinent
In four
were
groups
was
examination,
initial
cent).
der had preceded
results
patients
and atraumatic
history,
a physical
(8 per
were availat follow-up
to the questionnaire
were also persona!ly
evaluated.
The
patients
were followed
for an average
offorty-six
months
(range,
two to six years).
the traumatic
carefully
taken
patients
45 (100%)
traumatic
subluxation
was posterior,
ing thirty-three
patients
(thirty-four
(140 shoulders)
to the hospital
postoperative
patients
and
shoulder.
18 (40%)
I).
multidirectional
female,
fifteen
were on the dominvolved
in three
Eight
shoulders
had posterior
had anterior
instability,
and
to
instability.
instability.
thirty-three
Fourteen
four shoulders
shoulders
had
patients
were
male
and eighteen
were female;
the average
age was twentyseven
years (range.
twelve
to fifty-four
years).
The dominant
extremity
was
involved
in thirty-two
patients
892
W.
Shoulder
Exercises
Shoulder
The
at
Z.
BURKHEAD.
JR..
AND
Strengthening
Service-Department
University
of Texas
C.
A.
ROCKWOOD.
EXERCISE
JR.
3
of Orthopaedics
Health
Science
Center
San Antonio
Do
each
time
for
exercise
times.
______counts.
______
times
Begin with
per
Do
Hold
exercise
day.
____weeks.
____weeks.
____
_____
Then
use
Yellow
Theraband
for
Red Theraband
for
Then
use
Green
Then
use
Blue
Then
use
Black
Theraband
Then
use
Gray
Theraband
EXERCISE
each
program
Theraband
for
Theraband
for
for
for
weeks.
____
____
weeks.
weeks.
weeks.
1
ji:
_1
-4
EXERCISE
2
EXERCISE
FIG.
Figs. 1-A and I -B: A specific
rehabilitation
program
to strengthen
permission.
from Young.
D. C.. and Rockwood.
C. A.. Jr.: Complications
Surg..73-A:972.973.Aug.
1991.)
Fig. 1-A: Initially.the
patient
is given
rubberTherabands
(Hygenics,
parts
of the deltoid.
(71 per cent)
and both
cent).
All of the patients
Findings
Radiographic
noid
were
noted
shoulders
strengthen
the
that
had
Type-I
humeral
(55 per
(traumatic)
head
cent)
instability
and
off of the
chip fracture
on calcification
inferior
aspect
of the g!enoid
on anterosub!uxa-
the same
as we!!
presence
fracture
the anterior
rim. In Type-Il
or calcification
as evidence
of a posterolatemal
of the
old
of the glenoid
dislocation,
compression
to the
cent) of the patients
who
luxation
had radiographic
in
such
fracture
as
of
anterior
Rehabilitation
After
and
was
muscles
ofthe
rotator
and
the
three
or the presence
of
in a previous
oper-
glenohumeral
joint.
had
cvi-
Four
(9 per
had Type-IV
(atraumatic)
subevidence
of a subtle
rounding-
portion
of the
glenoid
rim.
Program
the
classified,
cause
the
of the
patients
set of exercises
designed
the muscles
of the rotator
previously
progressive
cuff
with
Joint
ofthe
twenty-one
shouldemsthat
instability
had radiographic
or gleof the
that
had
changes
included
a
on
of injury
( Reprinted.
J. Bone
and
stabilizer
muscles.
their
management.
the humemal
head
(Hill-Sachs
lesion)
a screw
on staple
that had been used
dence
changes
in the
in twenty-two
twenty-seven
(79 per cent)
of the shoulders
Type-Il
(traumatic)
instability.
The radiographic
in the shoulders
that had Type-I
subluxation
the
deltoid.
rotator
cuff. and scapular
of a failed
Bristow
procedure
and
ation,orboth.None
Type-Ill
(atraumatic)
Radiographic
noted,
5
Akron.Ohio)to
shoulders,
in eighteen
(40 per
had generalized
ligamentous
45
I-A
the
laxity.
tions,
-H-
described’
resistance.
THE
and
The
JOURNAt.
instabi!ity
had
began
performing
to strengthen
cufL This
been
evaluated
a specific
the
program
deltoid
has
and
been
is based
on the principle
first phase
of the resistance
OF
BONE
AND
JOINT
SURGERY
of
TREATMENT
OF
Pulley
weight
INSTABILITY
OF
THE
SHOULDER
WITH
kit and
exercise
EXERCISE
Shoulder
PROGRAM
893
Shrug
I(/_J(c
4511:
0
____
____
Do each exercise
times.
Hold each time for
counts.
Do exercise program
times a day.
Begin with 10 lbs. of weight and add
3 lbs. every three weeks until _____ tbs.
of weight
AN
Do
each
-_
exercise
times.
counts.
Use
pounds of weight.
Do exercise program
- times
Hold
each
time
for
a day.
are obtained.
Wall
Push-Up
Knee
Push-Up
30’
Regular
Do each
exercise
____
____
Push-Up
times.
Do exercise
Hold
each time
program
for
counts.
times
a day.
FIG.
1-B
When
the patient
is proficient
with exercises
1 through
5. exercises
are begun
with a kit that consists
of a pulley.
hook,
rope.
and handle.
The
pulley
is attached
to the hook.
which
is fixed to the wall, and the five exercises
are performed.
Initially.
the patient
is instructed
to use five or
ten pounds
(two or five kilograms)
of weight:
this is gradually
increased
over
a period
of several
months
to as much
as twenty-five
pounds
(eleven
kilograms).
The purpose
of the five exercises
is to strengthen
the three
parts of the deltoid
muscles,
the internal
rotators,
and the external
rotators.
Recently.
we have
added
exercises
to strengthen
the scapular
stabilizer
muscles.
To strengthen
the serratus
anterior
and rhomboids.
the
patient
is instructed
first to do wall push-ups.
and to gradually
begin
knee
push-ups
and then regular
push-ups.
The shoulder-shrug
exercise
is
used to strengthen
the trapezius
and levator
scapulae
muscles.
exercise
rubber
program
Themabands
is three
inches
is accomplished
with use
(Hygenics,
Akron,
Ohio).
(7.6
centimeters)
long
centimeters)
and
is tied
wide
into
and
of a set of
Each band
five
a 1oop
feet
so it can
(152
be
fastened
to a fixed object
such as a doorknob.
Six bands
are available;
each band provides
incmeasing resistance,
from
one to six pounds
(0.5 to 2.7 kilograms),
at increments
of one pound
(0.5 kilogram).
The
bands
one
are
color-coded
to show
the
resistance
that
each
provides.
The
patients
are
instructed
in the
number
of times
the exercises
are to be performed
each day, the number
of repetitions
to be done, and the length
of time that each
exercise
should
be done before
they progress
to the next
VOL.
74-A,
NO.
6, JULY
1992
exercise
(Fig.
to three
times
1 -A).
exercise
before
is held
progression
for
although
patients
next band
if theme
with
the
Each
a day,
current
of the five exercises
five
repetitions
each
is done
two
and
each
time,
a count
of five. The usual
interval
to the next band is two to three weeks,
are instructed
is any discomfort
not
to progress
when
they
to the
exercise
band.
The
patient
second
phase
has progressed
patient
is then
against
eight
of strengthening
through
all
of
to do
instructed
to ten
pounds
the
(four
begins
after
the bands.
the
The
same
exercises
but
to five
kilograms)
of
weight,
using a pulley
kit (Fig. 1-B) consisting
of nylon
rope. one-eighth
of an inch (three
of a piece
millimeters)
in diameter;
The
a handle;
a pulley;
and
a hook.
patient
894
W.
TABLE
Z.
BURKHEAD.
JR..
AND
C.
A.
II
GRADING
ROCKWOOD,
JR.
A grading
________was
SYsTENI’S*
used
(Table
Points
system
to rate
results
Results
No
limitation
in sports
baseball
and football:
No
limitation
baseball,
swimming
normally
Marked
Traumatic
in work:
slight
limitation
in throwing
serving
forcefully
in tennis.
or
crawl-stroke:
can throw
football
limitation
to work
with
arm
35
in all sports:
0
unable
None
Moderate
10
Severe
no subluxation
30
Negative
apprehension
with arm in position
rotation
test. hut discomfort
of abduction
and
15
Positive
test
apprehension
and
sense
range
As
had
posterior
instability,
a good
Type
II
result.
with previous
More
than
*Excellent
69 points.
25 per
loss
cent
loss
of motion
in any
good
= 30 or fewer
poor
in any plane
of motion
90 to lOC) points.
=
and
cent
= 70 to 89 points.
fair
that
shoulders
against
cises
three
as had
times
five,
and
weight
gradually
the
weight
good
on excellent
doing
been
done with the
a day, holding
each
doing
five
repetitions.
the
same
five
bands,
exercising
two
exercise
for a count
When
this
For men,
the weights
as twenty
to twenty-five
grams)
and for women,
(seven
kilograms).
the patient
can
are
to
of
amount
becomes
easy
for the patient.
the weights
increased
by increments
of two pounds
kilogram).
exem-
increased
of
to as much
suitable
weights
can
the weights
from
instruct
the
hence,
program.
The patients
weeks
months,
lems
to
lems.
reported
voluntary
These
psychiatrist.
and
we call
this
were
observe
if a patient
operative
was never
had
patient
that
procedure
recommended
direct
instability
was
and
were
had
not
recommended.
or performed
had
referred
disorder;
adjustment
had
reaction
operative
IIIB
and
had
a
-
logical
problems:
a good
or excellent
and
one
one,
who
of the
two
pa-
had
a
program.
The two
and the other
patient
disorder
had had a
and
voluntary
subluxation
Fourteen
of the
All
an adohad an
disorder
did
program.
Operative
of these
patients.
result.
psychologi-
and
patient
reconstruction
and
sixteen
of the
not
respond
treatment
no
was
psycho-
shoulders
shoulders
had
that
had
result.
Type
IV
involuntary
-
(ten
shoulders)
dens),
to
enough
to enable
the patient
ties without
instability.
The
in all of the eight shoulders
four
pmoban
tion
and
only
a
two
anterior
The
forty-five
the
had
of the
THE
became
had
Thirty-nine
a good
(twenty-nine
stable
(88 pen cent)
shoulders
shouland
of the
strong
thirty-three
instability.
that
had
However,
predominantly
had a good or excellent
result.
who
had Type-IV
subluxation
JOURNAL
(87
result
to return
to normal
activiresult
was good or excellent
that had posterior
subluxa-
multidinectional
four
instability
patients
result
shoulder
in twenty-nine
that
shoulders
on an excellent
in that
shoulders
pmob-
of the
subluxation:
to eight
of
seventy-
program.
personality
ofsix
care
a good
had psychiatric
treatment.
as having
a hysterical
pen-
a hysterical
cent)
the
(of the
had
of the
exercise
two, schizophrenia;
reaction.
The
adjustment
who
excellent
An operation
in patients
who
to
one
subluxation
subluxation
pen
psychological
cent)
the
Five patients
were diagnosed
adolescent
pro-
improved.
pen
after
rehabilitation
After
three
psychological
(9
on
posterior
on multidinectional
instability
had a good
on
excellent
result,
whereas
only two (50 per cent)
of the
four shoulders
that had anterior
instability
had a good or
of the muscles.
orthopaedist
rehabilitation
at intervals
their
progress.
who
had no
subluxation
patients
the
an orthothenapy
followed
the
the
three
and
traumatic
voluntary
-
patients
sonality
!escent
Type
stone.
It must be carefully
explained
to patients
that they
must not progress
too rapidly
with either
the Thenabands
or the weights,
as this will cause
discomfort
in the shoul-
Only
subluxation
(16
had
result
to the rehabilitation
not offered
to any
goods
den and will prevent
proper
strengthening
We believe
that
it is important
that
lilA
previous
be used. or
a sporting-
result
had a good
the twenty-nine
subluxation
posterior
twelve
that
problems:
tients
an excellent
shoulders
cent)
of
good
result
from
the rehabilitation
patients
who had schizophrenia
who
had a hysterical
personality
are
(one
pounds
(nine
to eleven
kiloto as much
as fifteen
pounds
Any
purchase
anterior
had
had
Subluxation
lvpe
cal
had
that
only
shoulders
= 40 to
points.
while
thirty-
result.
The two shoulders
that had anterior
and a good
or excellent
result
had only mild
changes
and no Hill-Sachs
lesion.
four
Two
pulls
Of the
dislocation:
shoulders
Atraurnatic
0
plane
-
two
of the thirty-four
result.
Two (9 per
Oven-all,
10
of motion
as 25 per
much
III)
dislocation:
per cent)
excellent
0
Motion
Full
previous
without
-
one,
or excellent
instability
degenerative
external
of subluxation
I
and
five
test,
(Table
that
overhead
apprehension
Zamins’6
program
Subluxation
Type
Pain
Stability
Negative
and
four shoulders
that had an anterior
dislocation,
only six
(18 per cent)
had a good
result
(three
shoulders)
on an
excellent
result
(three
shoulders).
Of the six shoulders
20
work.
throwing
crawl-stroke.
in throwing
Rowe
50
or work:
able to throw
can swim crawl-stroke
Moderate
limitation
in overhead
baseball
and football.
swimming
or serving
in tennis
by
of the rehabilitation
II).
Function
gram;
suggested
the
OF
BONE
AND
JOINT
and
SURGERY
a
TREATMENT
OF
INSTABILITY
OF
THE
SHOULDER
TABLE
RESULTS
PROGRAM
EXERCISE
AFTER
WITH
AN
EXERCISE
III
ACCORDING
TO THE
CLASSIFICATION
Sum.t
OF
Traumatic
Type
895
PROGRAM
JXATION7’
Atraumatic
I
(N=40)
Type
(N=34)
II
Type
lilA
(N=5)
34
29
3
4
6
2
1
2
4
2
28
27
2
2
2
6
5
2
6
8
3
1
1
6
8
3
4
1
0
0
6
33
6
29
I)
4
Type
IIIB
(N=16)
Type
IV
(N=45)
Anterior
No. of shoulders
Good
or excellent
Fair
or poor
result
result
Posterior
No. of shoulders
Good
or excellent
Fair
or poor
result
result
Multidirectional
No. of shoulders
Good
or excellent
Fair
good
or poor
result
or excellent
noted
five
result
result
after
that the shoulder
weeks
(range,
two
the
rehabilitation
became
stable
to twelve
weeks).
program
at an average
Maximum
a good
of
sta-
bility of the shoulder
was reached
at an average
of fourteen weeks
(range,
six to thirty-six
weeks).
There
was no
identifiable
difference
between
the shoulders
that mesponded
and those
that did not with respect
to the age or
sex
of
the
patient,
radiographic
It is very
the
oped
through
the
cises
are
done
still
the
sumed.
once
a stable
at least
had
exercises.
when
the
This
of
rehabilitation
Some of the patients
stopped
eliminated
duration
findings.
important.
was
exercise
to three
times
two
symptoms
The symptoms
strengthening
true
or
the
the
a week.
when
they
were
once
again
program
was mefor
teen-agers.
The
accurately,
recall
Thenabands
indicated
strongest
or
which
exercise
was the most difficult
which
co!or
of the
fact
that
shoulder
exercises
and
improve
often
can
ative
intervention
is not
recommended
conservative
location
of the shoulder
weakest,
and
to perform.
patients
responded
decreased
the
nor traumatic
with
well
prevalence
dislocation
a combination
the dynamic
obviate
the
state
need
Aronen
of recurrence
of the shoulder
of isometric,
isotonic,
for open-
Regan
of a single
anteto 25 per cent
and
for the shoulder.
found
a substantial
satisfactory
responses
matic
and atraumatic
had traumatic
instability
VOL.
74-A,
NO.
6. JULY
1992
difference
in the
isokinetic
who
number
between
patients
instability.
(Type
Of the shoulders
I or II), 15 per cent
had
shoulders
or
of
trauthat
had
IV),
In this
atmaumatic
subluxation
have.
initial
injury,
the assumption
series.
by definition,
being
that
capsule
is stretched
out either
from
from repetitive
microtmauma
resulting
subgroup,
instability
instability.
responded
Because
instability
have
that
for
the
patients
better
many
a component
ligamentous
of this
have
study,
and
capsular
stabilizer
rhomboids)
who
laxity
have
a clean-cut
have the
history
tell-tale
humeral
head
program
has
patients
then
but most
rehabilitation
are
(the
1-B).
told
the described
physical
proposed
chance
is not
imminent
that
that
Some
procedure,
to try the specific
orthotherapy
Most
patients
who have
tmauwho have not responded
to
accept
our data and begin
Patients
are
indicative
have no radiographic
are thrilled
to learn
and
rehabilitation
of success.
a reconstructive
rehabilitation.
problem
and who
the shoulder
joint
anterior
injury
and also
on the glenoid
rim or
the
findings
scap-
anterior,
from this study
has
Patients
who have
cent
matic
instability,
even those
a previous
exercise
program,
and
to
in shou!the
serratus
that
of them prefer
program.
In
stability
instructed
trapezius,
to have
shoulder.
osseous
architectural
since the completion
an 18 per
elect
or
posterior
to stmengthen
of a traumatic
osseous
changes
only
serious
shoulder
it appears
restore
been
exercises
muscles
(Fig.
of
have
accommodate
of the
consistently
also
push-up
cent
trauma
overuse.
had
can
when
fixed
In the years
patients
no
the
of hyperlaxity.
cannot
joint
occurred.
had
per
traumatic
trivia!
from
exercises
and
exercises
that
than those who had anterior
patients
who have
posterior
muscle-strengthening
contrast,
83
by a high prevalence
joint.
Patients
who
The information
that was gained
helped
us in the care of our patients.
stability
and
the
III
was accompanied
changes
in the
radiographic
u!ar
and
exercises.
Yoneda
et a!. reported
that, in 104 patients
who
had traumatic
anterior
dislocation,
a satisfactory
result
was achieved
in 82.7 pen cent after
use of a program
of
exercises
We
result.
den shrug
a new concept.
In 1936, Davis
treatment
for recurrent
disand reported
that six of eight
to exercises.
on excellent
changes
of
Discussion
The
had a good
subluxation
the glenohumemal
rehabilitation
program
patient
to demonstrate
of
(Type
In each
exem-
result;
sub!uxation
has develthat
recurrent
particu!arly
routine
shoulder
program,
degree
of compliance
with the
was measured
by the ability
ofthe
the
symptoms,
on excellent
atraumatic
the
rehabilitation
a success
mate of 83 pen cent.
Unsatisfactory
and occasionally
who
have
a history
of an atmaumatic
abnormalities
that an operation
program
disastrous
in
has
results
w. z.
896
have
been
for
on
traumatic
patients
reported
when
instability
who have
operations
reconstructions
are
BURKHEAD.
operations
of the
atraumatic
that
JR..
are
the most
common
of the shoulder
atraumatic
cause
and
of the
causes
in patients
multidirectiona!
high
rate
C.
of success
and
best
cent
of the
responded
atraumatic
subluxations
exer-
to exercises
is helpful
in our
in the
the exercise
program.
if the patient
program.
In addition,
the physician
has
has any additional
factors.
such
as psychological
that could
compromise
the
reconstructive
procedure
The value of any classification
or
results
ample
corn-
psychiatric
even if the
is performed.
system
lies in its ability
to predict
a response
to a specific
form of treatment
or
to guide
in operative
decision-making,
or both. The classification
that we used enables
the physician
to predict.
be-
with
who
cises for these problems.we
recommend
a trial of specific
resistance
strengthening
exercises
before
reconstruction
of the shoulder
is considered.
The fact that more
than 80
pen
JR.
to continue
plicating
disorders,
Jr.)”.
with
that
of rehabilitation
ROCKWOOD.
during
the exercise
time to determine
of failure
of
who
have
subluxation,
A.
of patients
designed
shoulder
are performed
subluxation’4’5:
these
been
referred
to the senior
one of us (C. A. R..
Because
of the high rate of complications
associated
a routine
reconstructive
procedure
on a shoulder
has
AND
some
have
accuracy.
traumatic
the response
to exercises
by patients
and atraumatic
subluxation
of the
shoulder.
patients
N
encouragement
1 he authors
)Fi
thank
John
Urna.
Nt.I)..
help in res
br
ewing
the cases
ot
cral
ses
of
he l)iiicfliS.
References
1.
2.
J. 6.,
Med..
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M. E., and
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Academy
3.
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Garth,
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K.: Decreasing
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JOURNAL
OF
BONE
AND
JOINT
SURGERY