Shoulder instability is a condition that can significantly impact both athletic performance and everyday life. It occurs when the humerus (upper arm bone) is forced out of the glenoid fossa. The anatomy of the shoulder plays a crucial role in maintaining its stability. Injuries sustained to the ligaments or rotator cuff can contribute to shoulder instability. The most common shoulder dislocation is an anterior dislocation. We will be focusing on the anterior shoulder dislocation for the purpose of this post, which reviews the types of shoulder instability and physical therapy exercises for shoulder instability.
**This is not medical advice. Please consult your medical provider for more information.
Understanding Shoulder Anatomy
The shoulder joint is a complex joint. There are many structures hard at work to keep your shoulder mobile, stronger, and stable. To understand shoulder instability, we should first look at how the shoulder joint gets it’s stability.
Your shoulder joint has many ligaments that keep the bones in place. A ligament is a thick fibrous tissue that connects one bone to another bone. The ligaments that help protect against an anterior shoulder dislocation are the glenohumeral ligaments. More specifically, the glenohumeral ligaments can be broken down into the superior glenohumeral ligament, the middle glenohumeral ligament, and the inferior glenohumeral ligament. These all sit at the front of the shoulder joint, acting like a sling to hold the humeral head within the glenoid fossa.
Muscles of the shoulder also work alongside the ligaments to keep the shoulder stable. The rotator cuff is a crucial part of the shoulder and is comprised of four different muscles, including the supraspinatus, infraspinatus, teres minor, and subscapularis. This complex structure’s significance is to provide movement of the shoulder and prevent shoulder instability. Every time you reach out to grab something, wash your hair, or throw a ball, the rotator cuff is hard at work.
If either a ligament or muscle is compromised, this could impact the stability of the shoulder joint.
Types of Shoulder Instability
Shoulder dislocations can be either traumatic or atraumatic. A traumatic dislocation occurs from a single event where an injury occurs. An example of this could be someone falling on their shoulder and it dislocating. An atraumatic dislocation can be from structural abnormality, ligament laxity from genetic predispositions or repetitive movements, and poor neuromuscular control.
Along with traumatic and atraumatic shoulder instability, there are also different directions that dislocations can occur.
An anterior dislocation occurs anteriorly, meaning the humeral head moves forward out of the glenoid fossa. This is the most common and occurs in 90-95% of all dislocations. There may be apprehension with the shoulder in external rotation and/or abduction after anterior dislocations. Anterior shoulder instability and dislocations can come from both traumatic and atraumatic causes.
A posterior dislocation is rare, occurring in only 5-10% of cases. This occurs when the humeral head moves backward out of the glenoid fossa. This type of dislocation is almost always attributed to a direct injury. There may be apprehension with the shoulder in internal rotation and/or adduction after a posterior dislocation.
It is possible to have multidirectional instability. This is when an individual lacks stability in multiple directions. This type of instability is often seen in athletes, but can affect anyone with repeated stress on their shoulders or who may have a genetic predisposition.
What Can Be Done About Shoulder Instability?
Shoulder instability can be successfully treated both surgically or conservatively, depending on the extent of injury and prior history with conservative treatment.
For individuals who require surgical intervention due to anterior shoulder instability and also have bone loss, the Laterjet procedure is often performed. This procedure provides osseous stabilization by creating a muscle sling at the front of the shoulder. Physical therapy should follow the surgery to ensure proper healing and functional restoration. There will be a period of immobilization as everything heals, followed by guided therapeutic intervention to restore range of motion and strength back. Even though the Laterjet procedure fixes the instability, you want to ensure that you strengthen all of the muscles around the shoulder to reduce the chances of future injury and to ensure there are no recurring dislocations.
For individuals dealing with either chronic shoulder instability or an acute dislocation that was reduced, physical therapy can be very helpful. In these cases, conservative treatment is usually very helpful. The emphasis in these cases is on improving motor control and stability. For chronic shoulder instability, range of motion is not the issue. Instead, this individual has too much range of motion so stabilizing and strengthening is the biggest concern. Someone who suffers an acute shoulder dislocation that is reduced can sometimes have range of motions restrictions because of the trauma that just occurred at the shoulder. The body goes into “protect” mode and everything becomes stiff. Range usually comes back, but same as with the chronic shoulder instability, ensuring stabilization is important after that.
Surgical intervention may be needed for someone who fails conservative treatment. Consult with your PCP to establish what treatment options may be best for you.
Rehabilitation and Exercises for Shoulder Instability
The goal of rehabilitation and exercises is to give the shoulder the stability it has lost. To do this, we work on strengthening the muscles around the shoulder to provide the stability that either the ligaments are lacking or to provide the muscle strength and coordination the current individual is lacking.
For more acute injuries or for those who have had surgical intervention, submax shoulder isometrics are a great way to start getting the muscles to activate. This is for gentle strengthening and can even help reduce pain levels. As you start to tolerate this more, a combination of open chain and closed chain exercises are used to help stabilize the shoulder complex.
Here are a variety of exercises that you can try if you are suffering from shoulder instability. Remember to consult with your healthcare provider before beginning. If you are interested in taking your recovery a step further and would like to have a consult with a licensed physical therapist, you can schedule a consult here. You can also reach me with an email here.
4-Way Shoulder Isometrics
For this exercise, we will do the same thing in 4 different directions (flexion, extension, external rotation, and internal rotation).
Have 1-2 small towels handy. You can place one between your elbow and your side for comfort. This is mainly there only if you want it. The other will be used for you hand against the wall.
Stand facing a wall and keep your elbow bent at 90 degrees. Place one of the towels between your hand and the wall. Make a fist and keep your wrist neutral.
Gently push your hand into the wall. This should not cause more pain. You are not trying to push as hard as you can into the wall. It is supposed to be gentle (imagine you are pushing at 20% of your effort).
You will push and hold for 10 seconds and repeat 10 times.
Repeat this by turning around and placing the towel between your elbow and the wall, pushing your elbow back into extension. Remember not to allow your humeral head to push forward. Repeat again into internal rotation by placing the towel inside your hand and between a wall and “pulling” your arm inwards. Finally, repeat into external rotation by placing the towel between the wall and the backside of your hand and pushing” you arm outwards.
Wall Ball Circles
You will need a small ball for this exercise. This can be performed with swiss ball if this is all you have.
Extend your arm out directly in front of you. Hold the ball between the wall and your hand. Your arm should be roughly at shoulder height.
Keeping your shoulder blade down and back (you’re not allowing your shoulder to shrug up towards your ear), move your arm in small circles clockwise and counterclockwise.
Complete 30 circles clockwise and then 30 circles counterclockwise.
Wall Clock
You will need a resistance band for this exercise. Place the band around your wrists, then place your hands up against the wall.
Move your right arm upwards like you are reaching up on a clock towards 12 o’clock. Then bring your arm back to center. Reach out towards 1 o’clock and come back to center. Complete going around the clock. Once you get to 6 o’clock, complete the remainder of the circle with the left arm.
Complete 3-5 cycles around the clock.
Foam Roll Bruegger Flexion
Place a resistance band around your wrists. You will start with a foam roll horizontally against the wall with your forearms against it holding it up. If you don’t have a foam roll, you can use a pillowcase or towel against the wall so it is easier for your arms to move up and down.
While maintaining pressure into the foam roll, roll your arms upwards and back down. Maintain pressure into the resistance band the entire time, trying to keep your shoulders, elbows, and wrists in alignment. You may feel he back of the shoulder blades and the deltoids working, too.
Common faults for this exercise involve the elbows moving outside of the wrists. Make sure to keep the shoulders, wrists, and elbows in alignment. If your elbows flare out to the side, the exercise is much easier and your external rotators will not be working as much as they could be.
Also, ensure your ribs are not flaring so your lumbar spine is not arching.
Perform 3 sets of 10 reps.
Standing I’s, T’s, and Y’s
You will be using a resistance band for this exercise.
With the band anchored in front of you, hold one end in each hand. The first movement is the “I.” Keep your arms straight and extend your hands directly behind you. Pause briefly at the end of the movement, then bring your arms back in front of you. Next, pull your arms up and back at shoulder height. This is your “T” position. Finally, your “Y” will involve lifting the arms up and back above shoulder height (think about the YMCA song – mirror the “Y” in this song).
You will then repeat the cycle. All 3 movements count as 1 repetition. Perform 3 sets of 10 reps.
Bear Position Shoulder Taps
Start on your hands and knees. Push up onto your toes while hovering your knees above the ground. This is your bear position.
Reach your right hand and touch your left shoulder and place it back down. Then, reach your left hand and touch your right shoulder. Continue to alternate shoulder taps making sure to limit the rotation through your hips and spine. Keep your trunk stable.
Perform 3 sets of 10 reps.
Low to High Plank
Start in a low plank position – holding a plank down on your forearms. Keeping your plank position, push up to a high plank by extending one arm straight and then the other. Then, lower one arm back down onto your forearm and follow with the other side.
Continue alternating from a low to high plank for 3 sets of 10 reps. Try to limit how much your trunks and hips move and twist around. Use your core to hold you steady.
Preventing Shoulder Instability
While there is no way foolproof way to 100% protect the shoulder against dislocations, there are precautionary steps you can take to help reduce your chances of injury.
Strengthening is going to be your best friend. It is extremely important to understand that strengthening exercises are not just beneficial, but are essential. There should be an intricate balance between the muscles of both the glenohumeral joint and the scapulothoracic joint, along with accessory musculature. This helps protect the shoulder joint against the risk of dislocation, labral tears, ligament injuries, and muscle tears.
Along with strengthening, proper technique and form should be of the utmost importance. This is especially important for athletes. Overhead athletes place a significant amount of stress on the shoulder joint. While strength is essential, it cannot outrun poor form.
Empowering Your Journey Beyond Instability
Understanding shoulder anatomy plays a pivotal role in identifying how dislocations and instability can occur. It also makes it easier to understand how to rehab shoulder instability once it has occurred. The shoulder joint offers lots of mobility, and with it, comes a lack of stability. If you have suffered an acute shoulder dislocation or deal with chronic instability, conservative treatment is a great place to start. Physical therapy allows for the shoulder to regain its strength, function, range, and stability. You’ll learn effective techniques to help prevent future injury and return back to your prior level of function.
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Other Articles Related to Shoulder Pain
- 5 Best Shoulder Strengthening Exercises for Healthy Movement and Stability
- How to Fix Your Rhomboid Pain
- 5 Important Shoulder Rehab Exercises for Optimal Function
- How to Fix Rounded Shoulders
- Unlock Your Shoulder’s Full Potential with Serratus Anterior Workouts
- The Shoulder Warm-Up You Need Before Lifting
- Exercises for Shoulder Impingement and Pain Free Movement
References
Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am. 1981;63(8):1208-1217.
TL;DR
The anatomy of the shoulder plays a crucial role in maintaining its stability. Injuries sustained to the ligaments or rotator cuff can contribute to shoulder instability. This post reviews shoulder anatomy and its link to shoulder instability, the different types of shoulder instability, and physical therapy exercises for shoulder instability.
