Dr. David Lintner - Orthopedic Sports Medicine Surgeon

ANTERIOR CAPSULAR SHIFT

Melanie McNeal, PT, CSCS, CFT

DAVID LINTNER, MD

This type of surgery is performed on patients with multi-directional instability that is either acquired or congenital. Multi-directional instability (MDI) refers to subluxation or dislocation of the shoulder in three directions – anterior, posterior, and inferior. In surgery, the stretched-out, redundant, ligamentous capsule is incised, tightened, and then sutured back together. Usually, patients with acquired MDI are young, inactive, and generally ligamentously lax. Through repetitive movements that place stress on the anterior-inferior shoulder joint, the capsule is gradually stretched out to the point of impairment. Typical athletes with acquired laxity include swimmers, baseball players, and gymnasts.

The post-op protocol following surgery is based on various factors. Patients with congenital laxity will progress at a slower rate than those with acquired laxity due to the tendency of their ligaments to eventually stretch back out. The therapist should be aware if any other procedures, such as Bankart repair, were performed during surgery and progress as indicated if so. Progression will also vary based on the patient’s tissue status. This should be determined by observing the post-op report or communicating directly with the physician. Pre-op measures including ROM, strength, and stabilization status is another important indication of how rehab will progress. Patients who lacked full ROM and had poor strength measures prior to surgery will be more likely to have difficulties regaining range and strength post-operatively and will progress at a slower rate.

The patient’s functional status must also be considered. Generally, athletes are treated much more aggressively than non-athletes. Overhead athletes are especially progressed at a quicker rate since it is imperative that they regain their full ROM. Conversely, treatment for the general orthopedic patient with generalized laxity must be more conservative. Their goal is adequate ROM in order to fulfill work and everyday activities. The key is achieving balance between having enough range to accomplish these tasks while simultaneously preserving the antero-inferior capsular complex . Usually, it is adequate to only obtain 80-85% PROM with manual techniques with these patients due to their laxity and tendency to stretch out. Because of the different rates of progression for athletes vs. non-athletes, a different protocol should be followed for each.

ACCELERATED PROGRAM (OVERHEAD ATHLETE)

ANTERIOR CAPSULAR SHIFT

PHASE ONE (Week 1-2)

In phase one, the general goals are to protect the surgical repair, initiate ROM to prevent adhesions and increase circulation, decrease pain and inflammation, and stress emphasis of HEP.

A sling will be worn for 1-2 weeks unless instructed otherwise by MD

The sling is to be removed to perform following exercises 2-3X/Day.

The RC gets a better blood supply when the shoulder is slightly away from the body; therefore, advocate the use of a towel roll under the arm when in a resting position.

ROM limitations:

Flexion/scaption: to tolerance immediately

ER in scapular plane: 20° by wk 2

IR in scapular plane as tolerated

NO ACTIVE SHOULDER MOTION

Active wrist and elbow full ROM

EXERCISES:

ROM: Pendulums

Rope and pulley – flexion, scaption

AA cane/wand into flexion, ER at 0° and 45°

Seated or supine posterior cuff stretch into horiz adduction

Grade I-II g-h and scapular joint mobs and manual stretching

Strength: Hand gripping exercises - putty

Submax pain-free isometrics at 0° abduction

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE TWO (Week 2-4)

General goals in Phase Two are to gradually restore ROM, initiate active muscle contractions with a focus on regaining proper scapulo-humeral rhythm, begin to train joint proprioception, and continue with HEP.

ROM Limitations/goal:

Flexion/elevation: to tolerance

ER at 90° abduction: 45° by wk 4

IR in scapular plane: to tolerance

EXERCISES:

ROM: Continue with AAROM exercises from Phase One – pulley, cane/wand

Initiate towel IR stretch if needed

Posterior capsule stretch

G-H joint mobilizations emphasizing post and inf glides. Should be pain-free and in loose/open packed position.

Passive stretching should be performed following mobilizations.

Strength: Scapular stabilizer strengthening – rows, shrugs, punches

IR/ER with theraband using towel roll between upper arm and thorax

Side-step holding t-band at neutral IR/ER for isometric resistance

Biceps, Triceps strengthening

Rhythmic stab progressing from supine to sidelying to partial sitting to standing as tolerated

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE THREE (Week 4-6)

Goals in this phase are to continue to protect the healing connective tissue, stress importance of adherence to ROM guidelines, perform HEP, and gradually increase strength and ROM.

ROM goals:

Flexion/elevation 160° by week 6

ER at 90° abduction 75° by week 6

IR at 90° abduction 70° by week 6

The RC muscles are very small; therefore, we use lower intensities to isolate each muscle without recruitment from surrounding larger muscles. Focus on hypertrophy initially by high volume (V= Reps X intensity/weight). Following the hypertrophy phase, strength is the focus with lower reps and higher intensities/weight.

EXERCISES

ROM: Continue with cane/wand, pulley as before

Towel for IR

Progress post cuff stretch and IR stretch to sidelying position

Continue with Grade II and III g-h jt and scapular mobilizations if needed to gain ROM

Strength: UBE

Progress theraband exercises by color, sets, and repetitions

Initiate standing dumbbell routine – flexion, scaption, empty can, deceleration

Push-up progression – wall, counter, table, knees, regular – emphasize push-up with plus

Dynamic hug with sports cord or theraband

Cable column or T-band biceps, triceps, seated rows, scapular

punches

T-band or manual PNF patterns

Modalities: Ice following exercise

PHASE FOUR (Week 6-12)

The goals in this phase are to restore full active ROM, progress strengthening and scapular stabilization exercises, and initiate more functional drills into rehab program.

ROM goals:

Flexion/Elevation: full range by 10 wks

ER: 90-100° by wk 8

115° by wk 12

IR: full range

Continue stretching for 6 months!!!!

EXERCISES:

ROM: Continue with previous exercises to gain full ROM

May need to add chicken wing stretch for ER

Mobilizations may be more aggressive if needed

Strength: Continue with previous T-band and C. column exercises

Continue with db therex increasing sets, reps, and intensity (up to 7 lbs)

Initiate T-band ER at 90/90 position – slow and fast reps

Initiate prone db therex including scaption at 130° with thumb up, horiz abduction with thumb up, extension with palm down, ER

Week 8:

Initiate two-handed plyometrics including ball toss –chest pass, OH pass, diagonals

Week 10:

Progress to one-handed plyos including ball toss, ball on wall

Eccentric RC strengthening using plyoball, deceleration tosses, T-band

Biodex – isokinetics for IR/ER beginning in modified neutral position, progress to 90/90 position in scapular plane

Large muscle exercises including shoulder press, lat pull-downs, bench press – do not allow elbow to extend past plane of thorax

Modalities: Ice as needed

PHASE FIVE (Week 12-24)

Goals include regaining full functional strength, implementing functional or sports specific training, and establishing a progressive gym program for continued strengthening and endurance training.

*Continue as needed with ROM exercises

*UBE high resistance, for endurance

* Progress to one-handed plyos including ball toss, ball on wall

*Eccentric RC strengthening using plyoball, deceleration tosses, T-band

*Large muscle exercises including shoulder press, lat pull-downs, bench press – do not allow elbow to extend past plane of thorax

*For high school athletes: at 12 weeks, passive ER should be 100-105°; allow the athlete to gain the rest on his own.

*For college/pro athletes: at 12 weeks, active ER should be 100-105° and passive ER should be 110-115° - allow the rest to come on its own

*At week 12, do a biodex test at 180°/sec and 300°/sec. – goal is for strength to be at 80% of unaffected side

*Expected Biodex results: ER/IR ratio at 180°/sec: male–66; female- 71

Peak T/BW range for ER at 180°/sec: male11-15; female 8-12

Peak T/BW range for IR at 180°/sec: male 17-23; female 13-17

*Initiate interval throwing program at wk 16 – consult with physician first

*Throwing from mound at wk 20

*Initiate sports specific/functional training at wk 16

*Competitive sports at wk 26-30

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