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Arthroscopic inferior glenohumeral ligament reconstruction (IGHL reconstruction)

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This is an uncommon operation done for severe or recalcitrant multidirectional shoulder instability with predominant inferior instability. The goal is to recreate the inferior "sling" of the IGHL that supports the shoulder against gravity and inferiro subluxation. This is achieved by using tendon allograft which is then weaved from the glenoid to the inferior part of the humeral head and then brought out laterally over the greater tuberosity. There is an anterior and posterior limb of the reconstruction which aims to replicate the respective limbs of the native ligament. 

anterior IGHL.png
posterior IGHL.png

​Physiotherapy Prescription: (developed in conjunction with Daniel Abrams, Physiotherapist)

 

  • Support elbow till week 6

  • Sling support till week 6 except for exercises

  • Isometrics 3 X 3 to 5 reps X 3 sec hold, twice daily:

  • Isometrics = tension without any movement

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  • ER at 0 deg /outward rotation:

  • Seated with elbow supported, arm by side

  • Arm 30 deg rotated inwards

  • Set shoulder blade up 1 cm, back 1 cm

  • Place R hand over L fist

  • Outwardly rotate, pushing L fist into R hand without any movement

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  • IR @ 0 deg / internal rotation:

  • Seated with elbow supported, arm by side

  • Arm 30 deg rotated inwards

  • Set shoulder blade up 1 cm, back 1 cm

  • Place L hand into R fist

  • Inwardly rotate, pushing L hand into R fist without any movement

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  • EXTENSION / BACKWARDS:

  • L elbow bent at right angles, supported underneath by R hand under elbow

  • Stand back in the doorway, L upper arm slightly forwards of the body

  • Set shoulder up 1 cm, back 1 cm

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  • ISOMETRIC ABDUCTION in SCAPTION:

  • L elbow bent at right angles, supported underneath by R hand under elbow

  • Rotate trunk/hips/shoulders 30 deg towards wall

  • Set shoulder up 1 cm, back 1 cm

  • Push entire forearm into wall

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  • SHRUGS IN SIDELYING

  • R sidelying,

  • L arm by side ,folded towel under upper arm

  • Single red theraband loop around L foot

  • Set shoulder blade up 1 cm, back 1 cm then shrug up again 1 cm and hold for a count of 5

  • 3 x 3 – 5 reps

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  • WRIST FLEXION/EXTENSION WITH ELBOW SUPPORTED:

  • Seated

  • Support L forearm on a table

  • Set shoulder blade up 1 cm, back 1 cm

  • Holding ½ kg weight in L hand, palm down

  • extend wrist up and down in mid range

  • Slow and steady

  • 3 x 10

  • Turn palm upwards and repeat

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  • WEEK 6:

  • Out of sling

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  • ISOMETRIC ER AND IR IN NEUTRAL

  • Forearm facing forwards

  • Single red theraband loop around shoulder

  • Set shoulder blade up 1 cm, back 1 cm

  • Outwardly rotate, pushing L fist into wall

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  • ISOMETRIC IR

  • Forearm facing forwards

  • Single red theraband loop around shoulder and attached to opposite foot

  • Set shoulder blade up 1 cm, back 1 cm

  • Inwardly rotate, pushing L hand into R fist without any movement

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  • SHRUGS WITH ARM BY SIDE, NO WEIGHT

  • Standing upright

  • Single red theraband loop around L shoulder – held down and forward to the right

  • Set shoulder blade up 1 cm, back 1 cm then shrug up 1 cm and hold

  • 1 – 2 x 20 reps x 5 sec hold, once daily

  • Progress to ½ to 1 kg

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  • ER IN SIDELYING, 0 – ½ g

  • 3 x 3 to 3 x 5 reps

  • Later, progress to 3 x 10

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  • ELBOW FLEXION – BICEPS:

  • 1/2 to 1 kg weight

  • Single red theraband loop around shoulder

  • Set shoulder up 1 cm, back 1 cm

  • Bend elbow up and down middle range

  • 3 x 5

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  • ELBOW EXTENSION – TRICEP PULL DOWNS, ARM BY SIDE:

  • Single red theraband for resistance

  • 3 x 5

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  • WEEK 8:

  • SHRUGS WITH ARM BY SIDE WITH WEIGHTS:

  • ½ to 2 kg

  • THERABAND ROWS, ARM BY SIDE:

  • Single red theraband around L shoulder

  • Set shoulder blade up 1 cm, back 1 cm

  • Elbow bent at right angles, forearm horizontal

  • Pull on single red theraband till upper arm by side and back again

  • 3 x 3 to 3 x 5

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  • THERABAND INTERNAL ROTATION, ARM BY SIDE, TO NEUTRAL

  • 3 x 3 to 3 x 5

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  • THERABAND EXTERNAL ROTATION, ARM BY SIDE, TO NEUTRAL

  • 3 x 3 to 3 x 5

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  • WEIGHTED EXTERNAL ROTATION IN SIDELYING, ARM BY SIDE:

  • 0 – 2 KG, in ½ kg increments

  • 3 x 3 to 3 x 5

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  • SUPINE ASSISTED FLEXION TO 90 DEG, BENT ELBOW

  • Rolled towel under upper arm

  • 5 – 10 x

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  • ELBOW FLEXION – BICEPS:

  • Increase weight in ½ kg increments

  • 3 x 5 – 10

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  • WEEK 10:

  • THERABAND INTERNAL ROTATION, ARM BY SIDE, FROM ½ WAY OUT

  • THERABAND EXTERNAL ROTATION, ARM BY SIDE, TO ½ WAY OUT

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  • WEEK 12:

  • SHRUGS @ 20 DEG DEG ABDUCTION:

  • 0 – 2 KG

  • SUPINE FLEXION TO 120 DEG

  • 0 – 2 kg

  • THERABAND RESISTED EXTERNAL ROTATION @ 30 - 45 DEG AWAY FROM BODY,

  • THERABAND RESISTED INTERNAL ROTATION @ 30 – 45 DEG AWAY FROM BODY

  • ​THERABAND ROWS @ 30 – 45 DEG AWAY FROM BODY

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  • BENT OVER ROWS, @ 0 DEG, ARM BY SIDE

  • 1 – 2 KG, opposite leg forward

  • Lean on R forearm or hand, holding single red theraband in R hand and around L upper arm

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  • ISOMETRIC FLEXION, ARM BY SIDE, ELBOW BENT

  • Set shoulder blade up and back – single red theraband loop around shoulder

  • 3 x 10 x 3 sec hold

  • BENT ELBOW ABDUCTION TO 45 DEG IN SCAPTION

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  • Then:

  • WEEK 14

  • DUMBBELL ABDUCTION TO 60 DEG IN SCAPTION

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  • CKC – TABLE PUSH, BOTH HANDS – SCAPULAR SETTING:

  • Hands on table, back straight

  • Leaning 30 degrees forward

  • Push table away – protract shoulder blades

  • Move forwards to mid position and back again

  • 3 x 10 daily

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  • Then:

  • SUPINE PUNCHES WITH DUMBBELL

  • SUPINE CIRCLES CW/CCW

  • BENT ELBOW DUMBBELL CIRCLES @ 60 DEG ABD

  • BENT ELBOW RESISTED FLEXION WITH DUMBBELLS – ½ kg

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  • WEEK 16:

  • DUMBBELL ABDUCTION TO 90 DEG IN SCAPTION

  • BENT ELBOW DUMBBELL CIRCLES @ 90 DEG IN SCAPTION

  • 4 POINT KNEEL CKC - PROTRACTION

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