Multidirectional Instability (Shoulder) Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for patients diagnosed with Multidirectional Instability (MDI) of the shoulder. It is designed to be a guideline and should be modified based on individual patient presentation, examination findings, and progress.

Pathophysiology

Multidirectional Instability (MDI) is characterized by symptomatic instability in more than one plane (anterior, posterior, and inferior). Unlike traumatic dislocations, MDI is often atraumatic or associated with repetitive microtrauma. Underlying factors often include generalized ligamentous laxity, capsular redundancy, muscle imbalances, and impaired proprioception. The glenohumeral joint relies heavily on dynamic stabilizers (rotator cuff, scapular stabilizers) to compensate for inherent structural instability. Conservative management focuses on strengthening these dynamic stabilizers and improving neuromuscular control.

Assessment

A thorough evaluation is crucial to determine the specific impairments contributing to the patient's instability. This should include a detailed history, observation, palpation, range of motion assessment, strength testing, and special tests to assess for instability in multiple planes.

Common Special Tests:

• Apprehension Test (Anterior): Assesses anterior instability.
• Relocation Test (Anterior): Reduces apprehension caused by the Apprehension Test, suggesting anterior instability.
• Posterior Apprehension Test: Assesses posterior instability.
• Sulcus Sign: Assesses inferior instability by pulling the arm distally and observing a sulcus below the acromion.
• Load and Shift Test: Assesses the amount of translation in the glenohumeral joint in anterior, posterior, and inferior directions.
• Feagin Test: Assesses inferior and posterior instability.

Phase I: Protection (Weeks 0-4)

Goals: Reduce pain and inflammation, protect healing tissues, restore pain-free range of motion, initiate scapular stabilization exercises.

• Activity Modification: Avoid activities that exacerbate symptoms or place the shoulder in positions of vulnerability (e.g., overhead activities, reaching behind the back).
• Pain Management:
  • Ice/heat as needed to control pain and inflammation.
  • Gentle joint mobilizations (Grade I & II) to maintain joint nutrition and reduce pain.
  • Modalities such as electrical stimulation or ultrasound (if appropriate) to manage pain.
• Range of Motion (ROM):
  • Pendulum exercises.
  • Supine forward flexion and external rotation within pain-free limits using a cane or pulley.
  • Table slides (shoulder flexion and abduction).
  • Goal: Achieve pain-free ROM.
• Scapular Stabilization Exercises:
  • Scapular retractions (squeezing shoulder blades together).
  • Scapular protraction (reaching forward).
  • Scapular upward rotation (shrugging).
  • Scapular downward rotation (depressing shoulders).
  • Perform exercises in prone, seated, or standing positions, progressing from isometric to dynamic.
• Isometric Exercises:
  • Isometric rotator cuff exercises (internal rotation, external rotation, abduction, scaption) at 0 degrees abduction.
  • Isometric biceps and triceps exercises.

Phase II: Loading (Weeks 4-12)

Goals: Improve strength and endurance of rotator cuff and scapular muscles, progress ROM, improve proprioception, initiate functional activities.

• ROM Progression: Continue to progress ROM as tolerated, focusing on achieving full ROM. Include cross-body adduction stretching.
• Strengthening Exercises:
  • Isotonic rotator cuff exercises with light resistance (theraband, dumbbells). Focus on proper form and control.
    • External rotation, internal rotation, abduction, scaption.
  • Progress to more challenging exercises:
    • Rows, lat pulldowns (light weight).
    • Prone horizontal abduction.
    • Bicep curls, tricep extensions.
    • Push-ups against a wall, progressing to on knees, then toes.
  • Continue scapular stabilization exercises, progressing to more challenging variations (e.g., scapular clock exercises with resistance).
• Proprioceptive Exercises:
  • Weight shifting exercises on a stable surface, progressing to unstable surfaces (e.g., balance board, foam pad).
  • Rhythmic stabilization exercises using manual resistance.
  • Perturbation training with light weights.
• Functional Activities:
  • Gradually introduce functional activities that mimic the patient's desired activities, focusing on proper technique and controlled movements.
  • Start with light resistance and gradually increase as tolerated.

Phase III: Return to Function (Weeks 12+)

Goals: Return to pre-injury activity level, maintain strength and stability, prevent recurrence.

• Advanced Strengthening:
  • Progress to higher-level strengthening exercises, such as plyometrics and sport-specific drills.
  • Continue to challenge rotator cuff and scapular muscles with progressive overload.
  • Consider isokinetic testing to assess strength and power.
• Sport-Specific Training:
  • Gradually increase the intensity and duration of sport-specific activities.
  • Focus on proper technique and biomechanics.
  • Implement a progressive return-to-sport program, monitoring for any signs of recurrent instability.
• Maintenance Program:
  • Develop a home exercise program to maintain strength, stability, and proprioception.
  • Encourage regular participation in activities that promote shoulder health.
  • Emphasize the importance of proper posture and biomechanics.

Progression Criteria: Progression through each phase is dependent on the patient's ability to meet specific criteria, including pain control, ROM, strength, and functional performance. If symptoms increase, regress back to the previous phase.

Note: This protocol is a general guideline and may need to be modified based on individual patient needs and progress. Regular communication between the physical therapist and the referring physician is essential.