Anterior Capsular Shift Rehab
ANTERIOR CAPSULAR SHIFT
Melanie McNeal, PT, CSCS, CFT
for patients of
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.
REGULAR PROGRAM (GENERAL ORTHO PATIENT)
ANTERIOR CAPSULAR SHIFT
PHASE ONE
(Week 1-4)
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.
Patients will be placed in either a sling or an immobilizer based on their degree of instability. If placed in a sling, it will usually be worn for 4-6 weeks, including during sleep. The sling can be taken off to perform the indicated exercises. Make sure to consult with the physician regarding the appropriate length of time the patient needs to wear the sling.
Patients with multi-directional instability are usually immobilized anywhere from 4-6 weeks based on the physician’s determination of the stability of the repair and the likelihood of the patient to stretch out again.
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: 90° until wk 6
- Scaption: 60°
- ER: 0-15° at 30° abduction wk2
- 25-30° at 30° abduction wk 4
- 0° at scapular plane until wk 4
- IR at 30°: as tolerated
- NO ACTIVE SHOULDER MOTION
- Active wrist and elbow full ROM
EXERCISES
ROM
- Pendulums
- Rope and pulley – flexion to 90°, scaption to 60°
- AA cane/wand into flexion, ER at 0° and 30°
- 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 4-6)
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: to 90° until wk 6
- ER/IR at scapular plane wk 5 (25-35° by wk 6)
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 6-12)
The goals in this phase are to restore full active ROM, progress strengthening and scapular stabilization exercises, normalize arthrokinematics, and perform HEP.
ROM goals:
- Flexion/elevation gradual increase
- ER at 90° abduction gradual increase
- IR at 90° abduction as tolerated
*Pt should have 80% of their motion by 10 weeks – let them achieve the rest gradually on their own with continued exercise and ADLs.
Full ROM should be achieved by 12-14 weeks!
*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 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.
- 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 12: Initiate two-handed plyometrics including ball toss –chest pass, OH pass, diagonals
- Week 14: 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
- Continue with ROM exercises
- UBE high resistance, for endurance
- Large muscle exercises including shoulder press, lat pull-downs, bench press – do not allow elbow to extend past plane of thorax
- At week 14-16, do a biodex test at 180°/sec and 300°/sec. – goal is for strength to be at 70% 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 20 (consult with physician first)
*Initiate interval sports program at wk 20-28