Target Review Group: Senior Orthopedic Surgeons and Sports Rehabilitation Specialists

Abstract:

This presentation details the surgical and early phase rehabilitation management of a 20-year-old elite wrestler (Aman) presenting with recurrent post-traumatic shoulder instability. The patient sustained two dislocations within one year, necessitating timely intervention given his professional status. The surgical management involved an arthroscopic repair via standard portals (anterior, superior, posterior) to preserve musculature integrity, which is paramount for high-performance athletes. The subsequent phased rehabilitation protocol is outlined: the initial six weeks focused exclusively on joint protection using isometric exercises and scapular mobilization to ensure labral healing while maintaining muscle activation. The transition at six weeks introduced passive range of motion (ROM) movements (abduction, rotation, circumduction) to prevent post-operative stiffness, strictly avoiding the high-risk position of 90-degree abduction combined with 90-degree external rotation, which is associated with recurrent dislocation. Emphasis is placed on meticulous adherence to the structured rehabilitation plan to ensure a successful six-month return to elite-level competitive wrestling.

Surgical Management and Phased Rehabilitation Protocol

• 0:11 Patient Demographics and Pathology: The subject is Aman, a 20-year-old state/national level wrestler, who suffered recurrent shoulder dislocation (two episodes over one year of play).
• 0:40 Importance of Early Intervention: The surgeon notes that early surgical intervention is crucial, as delayed treatment often results in increased soft tissue damage from multiple dislocations (compared to patients who present after 10–15 episodes).
• 1:00 Recurrence Risk: Patients between the ages of 18 and 25 have a high probability of recurrent dislocation due to tissue structure; this risk diminishes after age 25–30.
• 1:36 Surgical Procedure: The shoulder instability was managed via arthroscopic surgery (keyhole technique), utilizing standard portals (anterior, superior, and posterior). This minimally invasive approach minimizes damage to superficial muscles, such as the deltoid, thereby maintaining post-operative strength required for high-level sport.
• 1:57 Overall Rehabilitation Goal: The recovery process leading to full return to competitive wrestling is estimated to take approximately six months.
• 2:25 Phase 1: Initial Post-Operative Rehabilitation (First 6 Weeks): The focus is on protecting the labral repair while initiating muscle activation.
  • Scapular Glides: Exercises demonstrated include upward/downward and circular movements of the scapula to strengthen crucial stabilizing muscles. Scapular muscle strength is highlighted as the core source of power for the shoulder complex.
  • 3:59 Isometric Strengthening: The core of Phase 1 involves isometric exercises (holding resistance without joint movement) for the deltoid and rotator cuff. Movements demonstrated include pushing the elbow backward, pushing the hand forward, pushing outward, and pushing inward against a stable surface (wall) for 5-second holds, repeated 20 times.
  • 5:41 Principle: Isometrics are used to activate muscles while ensuring the shoulder joint and the surgically repaired labrum remain stable and unstressed.
  • 5:54 Assisted ROM: Limited supported flexion and extension are performed using the non-operated arm for support, again minimizing stress on the repair site.
• 6:39 Phase 2: Post-Six-Week Transition: Passive range of motion (ROM) is introduced, as soft tissue healing is estimated to exceed 50%. This prevents stiffness that would otherwise develop from six weeks of immobilization.
  • Passive Movements: Passive abduction and external/internal rotation are initiated, with the therapist providing the force while the patient keeps the arm relaxed. Initial range is limited (30, 40, 50 degrees).
  • 7:51 Dislocation Mechanism: Critical caution is maintained regarding the combination of 90 degrees abduction and 90 degrees rotation, as this position is the mechanism that causes instability and must be avoided until later rehabilitation stages.
  • 9:53 Supported Circumduction: Rotational movements (clockwise and counter-clockwise) are started with support to regain full motion without actively stressing the stabilizing muscles. All movements are prescribed for 20 repetitions, 2–3 sets daily.
• 11:47 Clinical Concern (Scapular Weakness): Observationally, the patient already exhibits signs of scapular muscle weakness (scapula appearing more prominent on the operated side), underscoring the necessity of strict adherence to the scapular strengthening regimen to prevent future instability.
• 10:41 Prognosis and Responsibility: The successful restoration of the athlete's career depends equally on the high quality of the arthroscopic repair and the precise, time-bound physiotherapy protocol, requiring patience and dedication from the athlete.