The glenohumeral joint (shoulder joint) is the most commonly dislocated joint in the body, with over 90% of dislocations occurring anteriorly. It’s higher rate of dislocation relates directly to the anatomy of the glenohumeral joint. The humeral head sits on a shallow glenoid fossa (socket), with only 30% in contact with glenoid in various shoulder positions. The glenohumeral joint has the highest range of motion of any joint in the human body and relies mainly on soft-tissue stability in the absence of adequate bony coverage.
The Latarjet procedure is used to treat anterior glenohumeral instability by transferring the coracoid to the anterior glenoid. Stabilization is thus achieved through restoration of the glenoid bone, the conjoint tendon acting as sling on the subscapularis, and anterior capsulolabral repair. For more information on the procedure ask your Physiotherapist.
The Latarjet procedure has a lower recurrence rate than the arthroscopic and open Bankart repairs. Rates of recurrence of re-dislocations after a Latarjet procedure have been reported between 7.5 and 11.6%. The Latarjet procedure is becoming the primary surgical choice for individuals who have experienced repetitive shoulder dislocations. The Latarjet procedure has been extensively researched and shown to have excellent functional outcomes long-term and a high rate of return to sport among athletes.
Progression through the Latarjet protocol is influenced by multiple factors. Progression is usually function/goal driven and not time based. This protocol is designed to give you a guide around what functional goals are needed to help achieve a successful return to activity. Factors such as age, gender, previous level of function and your goals all influence the structure of the rehabilitation program. Even though progression through the protocol is function based, consideration must also be given to the healing of the graft to ensure this is adequately healed and is up to taking the demands of the physical tasks.
Below is a guideline of the multiple steps involved in navigating successful Latarjet rehabilitation with the goals of each outlined below:
Pre-Surgery Phase: Injury recovery and readiness for surgery
Phase 1: Post-Op recovery
Phase 2: Control and capacity
Phase 3: Strength and accumulation
Phase 4: Sport preparation
Phase 5: Return to play and maintain performance
Pre- Surgery Phase: The purpose of the stage is to get individuals ready both physically and mentally for surgery. Your physio will take you through a rehabilitation program to help build up strength of the shoulder girdle.
This stage also allows us to pick up on any compensatory strategies or weakness that may have contributed to your injury or that might help in navigating a successful rehab. If you are part of a team environment working with a strength and conditioning coach or other coaches, they might be involved in helping to work on other aspect of your training to help keep you sport fit.
Post-Op Recovery - Phase 1: The goals of this phase of rehabilitation are to protect the surgical reconstruction, optimize the environment for tissue healing, control oedema and swelling, and achieve protected range of motion. This phase of rehabilitation is time-based to allow adequate healing of the subscapularis, and bony union of the coracoid process. 6 weeks is required minimum in this phase, however the below goals are also a requirement before progressing.
To protect the reconstruction, the arm is immobilized for four to six weeks in a sling. Two weeks following surgery your Physiotherapist will commence passive range of motion exercises, which are beneficial in preventing post-operative stiffness.
Your Physiotherapist will start soft-tissue techniques for the shoulder musculature, specifically the pectorals, as well as scar mobilization.
Control and Capacity – Phase 2: The goals of this phase of rehabilitation are to advance active shoulder motion and improve muscular endurance and neuromuscular control of the shoulder complex. This initially starts with active-assisted range of motion exercises then progresses to active range of motion exercises. External rotation will often be slow to progress, due to a combination of immobilization and surgical constraints. It is important to attain full external rotation, as any deficit in range can have long term implications on joint health.
Scapular control should be advanced in this phase as it will help athletes optimize functional performance via improved kinetic chain integration. Exercises focusing on activation of the upper traps and serratus anterior should be encouraged – dynamic hugs and wall slides.
Strength Accumulation - Phase 3: This phase of rehabilitation is aimed towards increasing muscular strength and challenge neuromuscular control. Before starting on this phase, your surgeon will confirm bony union, either by an x-ray or CT scan. Your Physiotherapist will undergo a thorough review of your sport requirements. If you are an overhead athlete, it is important to progress strength into the necessary range, as well as starting to replicate functional activities involved in your sport.
Before you can progress into Phase 4, external and internal rotation strength at 90 degrees abduction must be tested, to formulate your ER/IR ratio. The balance between external and internal rotation strength is important to normal shoulder function. An adequate ratio at 90 degrees abduction has been emphasized in the literature with an optimal ratio between 65 and 75%.
Sport Preparation Phase – Phase 4: The main goal of this phase of rehabilitation is to maximize power development. Plyometrics are also incorporated, which recruit fast twitch muscle fibres and enhance neuromuscular control.
Progression of upper limb plyometrics begins with two-handed drills such as chest pass, side-to-side throws, and overhead soccer throws. Once they are performed successfully, the athlete can progress to one-handed drills such as standing one-hand throws, 90/90 wall dribbles, and prone ball drops. Your Physiotherapist will also include closed-chain plyometric exercises, including depth-drop push-ups, and clap push-ups.
Return to Play and Maintain Performance – Phase 5: This phase is about incorporating sport specific movement back into rehab and integrating the athlete back into a sport/team environment. This phase will be dependent on the sport or activity that you are returning to. If you are an overhead athlete, an interval throwing program (ITP) will be introduced during this phase. The ITP gradually introduces quantity, distance, intensity, and types of throws needed to facilitate the restoration of normal throwing motions for the specific throwing sport.
Once you have been given the all clear from the medical team to return to sport it is important to keep fit and maintain your strength.
For more information on the Foundation Clinic Latarjet Rehabilitation Guideline, ring 07 579 5601 to make an appointment with a Physiotherapist, or email [email protected]
