Multidirectional Instability Reconstruction

Phase I: Protect Repair (0 to 6 weeks)

May remove dressing and shower postop day # 3.
Sutures are all underneath the skin and will dissolve on their own
Ice or cold flow systems encouraged for the first week at a minimum: should be used 3-4 times per day.
Sling should be in place when not performing exercises.
May start active scapular mobility exercises at 4 weeks – Must keep the shoulder musculature relaxed.
Strict ROM restrictions
Initiate exercise program 3 times per day:

Immediate elbow, forearm and hand range of motion out of sling Pendulum exercises
Emphasize home program (instruct family member with ROM)
Passive and active assistive ER at the side to 30, flexion and scapular plane elevation to 90 only

May discontinue sling.
Lifting restriction of 5 pounds with the involved extremity.
Initiate gentle rotator cuff strengthening and scapular stabilizer strengthening.
Avoid ROM above stated limits.
Advance active and passive ROM:

Begin combined abduction with ER and IR ROM and advance capsular mobility (gently).
Discontinue lifting restrictions.
Advance rotator cuff and scapular stabilizer strengthening.
Initiate functional progression to sports specific activities at 4 months.

Many patients will have a component of impingement due to improper scapular mechanics and cuff weakness resulting in poor humeral depression
All patients will have some degree of scapular dyskinesia

Assess patients for impingement type symptoms and scapular dyskinesis.
If impingement present then exercises must start in pain free range and progress toward increasing scaption as time progresses
Cannot progress through stages until scapula is stable on chest wall

Restore normal proprioception and movement patterns (especially scapulothoracic)

Should be pain free
Train muscle groups (force couples) rather than individual muscles
Incorporate contralateral therapy Scapula Based Rehabilitation Program
Evaluate and correct postural alignment (lumbopelvic, thoracolumbar, scapulothoracic)
Clear soft tissue restrictions
Establish scapulothoracic stability focusing on scapular position and control

Correct postural abnormalities and scapular position through muscle reeducation including lumbopelvic and scapulothoracic stability
Include anterior chest wall stretching
Isometric scapular retraction and depression
Trunk extension/scapular retraction
Emphasize lower trapezius activation (elbow in back pocket)

Cuff

Begin with closed-chain static and short arc isometrics in pain free range including flexion, abduction, extension, ER and IR
Facilitate muscular co-contraction to improve dynamic joint stabilization
Progress to isotonic cuff strengthening through wider range of motion
Rubber tubing for sidelying internal rotation, sidelying external rotation, prone posterior deltoid, internal rotation and external rotation at 90° abduction, biceps, and triceps
Supraspinatus program: flexion, scaption in IR, prone horizontal abduction and press-ups

Scapula

Isometric and eccentric scapular stabilization
Rubber tubing for shrugs, retraction, depression, D2 flexion, D2 extension, prone and seated rows, chair press-ups, supine serratus anterior, lat pull downs, push-ups with a plus
Scapular clocks with hand stabilized on wall at 90° (elevation, depression, protraction, retraction)
Closed chain axial load (ball rolls on table top) to emphasize scapular positioning
As healing progresses and ROM

Core

Core body strengthening exercises to emphasize lumbopelvic and thoracolumbar stability

Other

Strength

Improve strength, power and dynamic stability
Advance concentric and stress eccentric cuff strengthening per upper extremity strengthening program
- Muscle Ratios
- ER/IR: 65-70%
- ER/Deltoid: 65-70%
- Scapular retractor/protractor: 100%
Advance eccentric and concentric scapular stabilization
Reverse corner pushups, wall angels
Lat pull downs with free weights,
Push-up plus
Scapular punches with various weights and positions
Shoulder dumps and diagonal punches with light hand weights
Dynamic strengthening at 90-90 position for external and internal rotation
Core based muscle synergy
Progress PNF patterns
Start upper extremity plyometric program

Endurance

Begin upper body ergometers at low resistance and height below 90° and slowly progress to height at 140° flexion

Develop sport or work specific ROM
Plyometric, neuromuscular control and dynamic stabilization drills
Initiate isokinetic rotator cuff strengthening at high speeds for muscular endurance; i.e. 240°/second X 30 second bout with 30 second rest, 300°/second X 30 second bout with 30 second rest, etc.
Sport or work specific kinematics and exercises
Sport or work specific drills for quickness and agility, endurance and power
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