Recovery: Posterior stabilisation

The operation

This operation is done infrequently in comparison to anterior stabilisation procedures. The shoulder will be dislocating predominantly postero-inferiorly. Conservative care (physiotherapy) is the first line of treatment. The shoulder problems can be complicated in this group of patients, often involving pain & elements of abnormal muscle patterning.

The operation normally involves tightening the capsule to try and prevent posterior dislocation. This involves a capsular tightening repair. It may be done as an open procedure or arthroscopically.

A bone graft may also be done if necessary to provide a posterior bony buttress. In an open procedure Infraspinatus will be shortened (the equivalent of subscapularis in the anterior stabilisation procedure). Medial rotation, flexion & adduction will ‘stretch’ the repair. Therefore the shoulder may need to be immobilised in abduction and external or 0º rotation immediately after the operation. The exact amount of this will be dependent on the instability of the individual shoulder. A general guide is 15º flex, 0º rotation, 40º abduction, but it may be more or less. ‘Routine’ time for immobilisation is four weeks but it may be longer (although rarely more than six weeks). The splint should only be removed for axilla hygiene and elbow movement.

Four weeks post-operation

Once Mr. Cole has given instructions for mobilisation to start – normally four weeks – wean the patient out of the splint. The patient may use a polysling or collar and cuff until comfortable, or to stop inferior distraction if occurring.
For four weeks following the mobilisation date, the main emphasis is on regaining movement through abduction and lateral rotation, facilitating appropriate muscle activity around the scapula and cuff.

i. Passive to active assisted to active (eg slings, hydrotherapy, sliding boards) not above 90º. Short levers to long levers
ii. Encourage movement through abduction or plane of the scapula
iii. Neutral to lateral rotation with movement
iv. Extension
v. Lateral rotation – passive and active assisted
vi. Do not start with pendular swings etc
vii. Start isometric abduction and lateral rotation
viii. Get scapula movement and stability
ix. Do not emphasize latissimus dorsi work
x. Correct any trunk side-flexion and hyper-lordosis
xi. If your patient regains movement quickly – do not push mobility
xii. Work on movement patterning and muscle re-education – scapula & cuff. Open and closed chain

Eight weeks post-mobilisation

The main emphasis is on regaining flexion and medial rotation range of movement without force/stretch.

i. Start flexion – active assisted to active
ii. Start hand behind back
iii. Progress to isotonic cuff and general strengthening (look for and avoid any over-activity in muscle groups – eg latissimus, pectoralis)
iv. Progress scapula muscle activity

Eight weeks post-mobilisation

The main emphasis is on regaining cross body adduction and maximising muscle control and strength around the shoulder complex.
i. Start horizontal flexion/cross body adduction range
ii. If regaining range quickly do not emphasize end of range stretches
iii. Generalised strengthening but with care (see above – emphasis on abductors and lateral rotators)
iv. Movement patterning without effort may still be more important at this stage

Guidelines for returning to activities

These are dependent on the start of mobilisation programme. The protective phase can be long, depending on the degree of instability and pre-operative muscle activity. For example, driving may not be possible for 8 weeks and there should be no heavy work or contact sports for at least six months. Mr. Cole will advise on each individual case.

With thanks to the Oxford Shoulder & Elbow Clinic, at the Nuffield Orthopaedic Centre for sharing their written physiotherapy guidance with us.