Recurrent Joint Subluxations: Developing joint-specific stability programs for the shoulder and patella.

Recurrent joint subluxations and dislocations are a hallmark of symptomatic joint hypermobility (HSD and hEDS). In the absence of strong, restrictive ligaments, the musculoskeletal system relies entirely on dynamic muscular control to maintain joint congruence. The shoulder and patella are notoriously vulnerable due to their reliance on soft tissue and the broad range of motion they possess.

For the physical therapist, the challenge is not just strengthening, but training the muscles to fire preemptively and rapidly to stabilize the joint within its safe, functional mid-range, avoiding the catastrophic end ranges.

Foundational Principle: Proximal Control First

Before initiating joint-specific exercises, the proximal stability (the core and girdle stabilizers) must be activated, as discussed previously. An unstable scapula cannot anchor the shoulder, and an unstable pelvis cannot control the femur’s alignment relative to the patella.

1. The Shoulder (Glenohumeral Joint) Stabilization Program

The shoulder is a ball-and-socket joint that relies heavily on the rotator cuff and scapular stabilizers for dynamic centration. Subluxations often occur in abduction and external rotation.

Phase 1: Deep Cuff and Scapular Endurance

The focus is on training the deep rotator cuff muscles (especially the supraspinatus and subscapularis) to keep the humeral head centered in the glenoid fossa, and the scapular stabilizers to anchor the socket.

• Exercise: Isometrics and Co-Contraction: Perform low-load internal and external rotation isometrics in the scapular plane (approximately $30^\circ$ abduction). Use minimal resistance (theraband or fingertip pressure) and emphasize endurance holds (30-60 seconds) rather than maximal strength lifts.
• Exercise: Serratus Activation: Focus on controlled scapular protraction and upward rotation (e.g., modified push-up plus against a wall or prone serratus punches). The scapula must be stable to prevent anterior shoulder gliding.

Phase 2: Rhythmic Stabilization (Reactive Control)

This phase trains the joint to react to unexpected forces, crucial for preventing accidental subluxation.

• Exercise: Closed-Chain Stability (Quadruped/Plank): Begin in a modified position (e.g., quadruped or kneeling plank on a stable surface). Once stable, the therapist applies gentle, rhythmic, and unpredictable perturbations (pushes and pulls) to the humeral head. The patient’s goal is to maintain stillness and stability.
• Progression: Move from a stable surface to an unstable one (e.g., standing with the hand on a stability ball against the wall) and repeat the rhythmic stabilization.

2. The Patella (Kneecap) Stabilization Program

Patellar subluxation often occurs laterally due to poor dynamic control of the femur and hip, often exacerbated by foot pronation. The key is controlling the angle of pull on the kneecap.

Phase 1: Hip Control and VMO Isolation

The program must establish control of the femur via the hip muscles, and improve the timing and strength of the VMO (Vastus Medialis Obliquus), which helps pull the patella medially.

• Exercise: Gluteus Medius Endurance: Side-lying hip abduction or clam shells using a resistance band. Focus on minimizing pelvis roll and maximizing the sustained isometric hold of the glute medius. This prevents the femur from internally rotating, which is a major subluxation trigger.
• Exercise: Terminal Knee Extension (TKE) Focus: Perform TKE using a resistance band anchored behind the knee. The patient focuses on achieving the last few degrees of extension with maximal VMO engagement, ensuring the movement remains controlled and non-hyperextended.

Phase 2: Controlled Functional Loading (Dynamic Stability)

Once the stabilizers are active, they must be integrated into functional weight-bearing movements.

• Exercise: Single-Leg Squat/Step-Down with Alignment Cues: The patient performs squats or step-downs, placing mirrors or markers to ensure the knee tracks precisely over the middle of the foot. The therapist provides tactile or verbal cues to engage the glutes to prevent dynamic valgus (the knee collapsing inward).
• Exercise: Controlled Descent: Focus on the eccentric phase of the squat (lowering slowly), as this is where the VMO and gluteal muscles must work hardest to decelerate the joint and prevent unwanted movement.

Program Management and Pacing

Given the systemic fatigue and pain common in hypermobility, these programs must be managed carefully:

• Avoid Overload: Start with very low resistance and high-frequency, low-repetition sets. Stop before fatigue compromises form.
• No Hyperextension: Every single movement must be performed with a conscious effort to stop just short of the joint’s maximal hyperextension range, training the muscles to act as a biological brake. Use visual or tactile cues (e.g., place a towel under the knee during supine TKE) to enforce this.
• The “Feel” vs. The “Strength”: Constantly cue the patient to focus on feeling the deep stabilizers engage and controlling the movement, rather than just lifting the weight.

By developing joint-specific stabilization programs built upon a foundation of core stability and proprioception, Joint hypermobility physiotherapist Gold Coast can significantly reduce the frequency of subluxations, restoring confidence and improving the functional independence of hypermobile clients.