Case Study: Chronic Case Study: Chronic Anterior Shoulder Anterior Shoulder

DislocationDislocation

Nicole Boyko, PT/sNicole Boyko, PT/s

Carolyn Michalski, Carolyn Michalski, PT/sPT/s

Bridget Promaulayko, Bridget Promaulayko, PT/sPT/s

Introducing Joe ShoulderIntroducing Joe Shoulder

History of Present History of Present ConditionCondition

28 y/o English-speaking single white 28 y/o English-speaking single white malemale

2 wks s/p (L) ant shld dislocation 2 wks s/p (L) ant shld dislocation incurred while reaching for stationary incurred while reaching for stationary object from moving vehicleobject from moving vehicle

Manual relocation performed under Manual relocation performed under anesthesia in ERanesthesia in ER

Pt D/C’d with sling and pain medicationsPt D/C’d with sling and pain medications Presents to PT for conservative trial of Presents to PT for conservative trial of

therapy in hopes of avoiding surgerytherapy in hopes of avoiding surgery

History ContinuedHistory Continued Long hx of prior (L) ant shld dislocations Long hx of prior (L) ant shld dislocations

x 4x 4 PMH significant for multiple sports-PMH significant for multiple sports-

related fx/sprainsrelated fx/sprains FH significant for father with chronic (R) FH significant for father with chronic (R)

ant shld instability, s/p capsulorraphyant shld instability, s/p capsulorraphy Triathlete, actively training prior to injuryTriathlete, actively training prior to injury Currently unemployed finance investorCurrently unemployed finance investor SH noncontributorySH noncontributory

PT Tests and MeasuresPT Tests and Measures Upper Qtr Screen: (-) for cervical Upper Qtr Screen: (-) for cervical

involvementinvolvement Motor Control: Motor Control:

Delayed scapular mvmt with GH elevationDelayed scapular mvmt with GH elevation Posture: Posture:

Prominent ant humeral heads (B)Prominent ant humeral heads (B) Mild-mod winging scapulae (L)>(R)Mild-mod winging scapulae (L)>(R) Mild FHPMild FHP

PT Tests and Measures PT Tests and Measures cont’cont’

Pain:Pain: Dull ache of (L) shld 4/10, intermittently at Dull ache of (L) shld 4/10, intermittently at

rest and after activityrest and after activity sharp pain with ER, abd, 6/10sharp pain with ER, abd, 6/10

Jt Mobility:Jt Mobility: (R)(R) (L)(L) Posterior GlidePosterior Glide 2/62/6 1/61/6 Anterior GlideAnterior Glide 4/64/6 5/65/6 Superior GlideSuperior Glide 2/62/6 2/62/6 Inferior GlideInferior Glide 3/63/6 4/64/6

PT Tests and Measures PT Tests and Measures cont’cont’

FunctionFunction Drives short distancesDrives short distances Difficulty with overhead tasksDifficulty with overhead tasks

SensationSensation Intact lt touch C2-T1Intact lt touch C2-T1 Numbness/tingling (L) UENumbness/tingling (L) UE

Special TestsSpecial Tests + apprehension (L)+ apprehension (L) + ant load & shift, ant drawer & mild impingement+ ant load & shift, ant drawer & mild impingement + relocation test+ relocation test (-) drop arm, empty can(-) drop arm, empty can

PT Tests and Measures PT Tests and Measures cont’cont’

Right Shoulder

Left Shouder

Muscle Group/

Motion Strength ROM Strength ROM

Elbow Flexion 5/5 5/5 WNL

Extension 5/5 5/5 WNL

Supraspinatus 5/5 5/5 WNL

Shld Flexion 5/5 4/5* 170*

Extension 4/5 4-/5 WNL

Hor Abd 4+/5 4-/5* WNL

Hor Add 5/5 4/5 WNL

Abduction 5/5 5/5* 170*

Adduction 5/5 5/5 WNL

Int Rotation 4/5 3+/5* 15*

Ext Rotation 4-/5

WNL

3/5*# 20*

* = pain/empty end feel # = apprehension

Muscle Muscle Performance/ROMPerformance/ROM

Mahaffey et al (1999)

Relocation TestRelocation Test Pt in supinePt in supine Shld is abducted/ERShld is abducted/ER Use edge of table Use edge of table

as fulcrumas fulcrum Test (+) for Test (+) for

anterior instability anterior instability if apprehension if apprehension demonstrated & demonstrated & relieved by relieved by posterior stress on posterior stress on shldshld

Relocation TestRelocation Test

Speer et al (1994)Speer et al (1994) All subjects had singular dxAll subjects had singular dx Subjects undergoing surgery; able Subjects undergoing surgery; able

to visually confirm dxto visually confirm dx Overall accuracyOverall accuracy

<50% pain alone<50% pain alone >80% apprehension alone>80% apprehension alone

EvaluationEvaluationImpairmentsImpairments Functional Functional

LimitationsLimitationsDisabilityDisability

Faulty scapulothoracic, GH Faulty scapulothoracic, GH rhythm and cervical-thoracic rhythm and cervical-thoracic spine alignmentspine alignment

Decreased (L) shld motionDecreased (L) shld motion

Hypermobility ant and inf Hypermobility ant and inf glides; hypomobility sup and glides; hypomobility sup and post glidespost glides

Pain with end range shld Pain with end range shld girdle motion, esp in open girdle motion, esp in open packed positionpacked position

Impaired muscle Impaired muscle performanceperformance

Unable to reach or Unable to reach or pull overheadpull overhead

Unable to drive > Unable to drive > 30 min without 30 min without significant significant discomfortdiscomfort

Unable to Unable to continue training continue training for triathlonfor triathlon

Unable to Unable to participate in participate in regular gym regular gym programprogram

DiagnosisDiagnosis

Pattern 4D: Impaired Joint Mobility, Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, Motor Function, Muscle Performance, and Range of Motion Associated with and Range of Motion Associated with Connection Tissue DysfunctionConnection Tissue Dysfunction

ICD-9 Code 831- Shoulder DislocationICD-9 Code 831- Shoulder Dislocation

PrognosisPrognosis Predicted Optimal Level of Predicted Optimal Level of

ImprovementImprovement

Training for triathlon with modificationsTraining for triathlon with modifications

Home activities/ADLS with min-no painHome activities/ADLS with min-no pain

Sufficient shld stability to avoid surgerySufficient shld stability to avoid surgery

PrognosisPrognosis Predicted Interval Levels of ImprovementPredicted Interval Levels of Improvement

Pt will perform 3x10 reps shld ER in scaption Pt will perform 3x10 reps shld ER in scaption with green (intermediate) t-band to fatigue x 4 with green (intermediate) t-band to fatigue x 4 wkswks

Pt will perform 3 x 10 reps shld IR in scaption Pt will perform 3 x 10 reps shld IR in scaption with blue (mod) t-band to fatigue in 4 wkswith blue (mod) t-band to fatigue in 4 wks

Pt will show decreased signs of apprehension Pt will show decreased signs of apprehension as seen with performance of D2 PNF pattern as seen with performance of D2 PNF pattern with 2 lb pulley weightwith 2 lb pulley weight

PT will be able to flex and abduct (L) shld to PT will be able to flex and abduct (L) shld to 170 with min-no pain allowing for (I) ADLs such 170 with min-no pain allowing for (I) ADLs such as overhead reaching and dressing.as overhead reaching and dressing.

Plan of CarePlan of Care

Frequency/Duration: 2 x/wk x 8 wksFrequency/Duration: 2 x/wk x 8 wks Criteria for DischargeCriteria for Discharge

Return to 90% premorbid function with Return to 90% premorbid function with necessary modificationsnecessary modifications

90% ROM of unaffected side90% ROM of unaffected side 4+/5 mm strength or greater4+/5 mm strength or greater Proper mm length-tension relationshipsProper mm length-tension relationships Pain less than or equal to 2/10Pain less than or equal to 2/10 (I) home exercise program(I) home exercise program

InterventionsInterventions

Patient-related instructionPatient-related instruction Periodic reassessment of HEP- written Periodic reassessment of HEP- written

instructionsinstructions Injury prevention and sports modificationInjury prevention and sports modification

Direct InterventionsDirect Interventions Therapeutic ExerciseTherapeutic Exercise Functional TrainingFunctional Training Manual Therapy TechniquesManual Therapy Techniques Electrotherapeutic ModalitiesElectrotherapeutic Modalities Physical Agents and Mechanical ModalitiesPhysical Agents and Mechanical Modalities

Phases of RehabilitationPhases of Rehabilitation Phase IPhase I: :

Rest and immobilizationRest and immobilization Pain ctl with NSAIDsPain ctl with NSAIDs Ice applied to shldIce applied to shld

Phase IIPhase II (begin PT): (begin PT): IsometricsIsometrics IsotonicsIsotonics Body mechanics/ergonomicsBody mechanics/ergonomics Emphasis on increasing fxnl mvmtEmphasis on increasing fxnl mvmt Stability exercisesStability exercises PNFPNF Proprioceptive awarenessProprioceptive awareness

Phases of RehabilitationPhases of Rehabilitation

Phase IIIPhase III: : EnduranceEndurance Progressive strengtheningProgressive strengthening High-level activity challenging shld in open-High-level activity challenging shld in open-

packed positionpacked position Phase IVPhase IV: :

Sports specific activitiesSports specific activities

Hall and Brody (1999) p. 612

Selected InterventionSelected Intervention

Scapular stability exerciseScapular stability exercise Provide dynamic restraint to anterior Provide dynamic restraint to anterior

translationtranslation Key muscles include subscapularis, Key muscles include subscapularis,

traps and serratus anteriortraps and serratus anterior Exercises to targetExercises to target

Subscapularis Isometric ExerciseSubscapularis Isometric Exercise Push ups with a plusPush ups with a plus

Townsend et al (1991) Mosley et al (1992) Kibler (1998) Decker et al (1999)

RationaleRationale Shoulder mobility requires stable baseShoulder mobility requires stable base Normal scapulohumeral rhythm 2:1 ratioNormal scapulohumeral rhythm 2:1 ratio Rehab should emphasize restoring normal Rehab should emphasize restoring normal

physiological patterns physiological patterns Scapular stability exercises Scapular stability exercises

Early isometrics and scapular settingEarly isometrics and scapular setting CKC exercises to re-establish normal motor firing CKC exercises to re-establish normal motor firing

patternspatterns 4 core exercises target all 8 scapular muscles: 4 core exercises target all 8 scapular muscles:

scaption, push-up plus, press-up, rowingscaption, push-up plus, press-up, rowing

Selected InterventionsSelected Interventions

Sports specific exerciseSports specific exercise Shoulder PNFShoulder PNF

D2 pattern for swimming strokeD2 pattern for swimming stroke– Concentric/EccentricConcentric/Eccentric

TherabandTheraband Manual resistanceManual resistance PulleysPulleys

RationaleRationale Biomechanics of freestyle swim strokeBiomechanics of freestyle swim stroke

Forceful concentric IR/add through acceleration Forceful concentric IR/add through acceleration phasephase

Eccentric activation of ER in follow-through Eccentric activation of ER in follow-through phasephase

Unique characteristics of swimmersUnique characteristics of swimmers Excessive external rotation ROMExcessive external rotation ROM Limited internal rotation ROM, post capsule or Limited internal rotation ROM, post capsule or

cuff tightnesscuff tightness ER: IR ratio typically lower in swimmers than ER: IR ratio typically lower in swimmers than

normal subjects 2normal subjects 2° selective strengthening of IR° selective strengthening of IR Higher ER: IR ratio found in overhead athletes Higher ER: IR ratio found in overhead athletes

with instabilitywith instability

Black et al (1997); McMaster et al (1998); Rupp et al (1995)

RationaleRationale Sports-specific rehab should includeSports-specific rehab should include::

Balanced exercises for the rotator cuff and Balanced exercises for the rotator cuff and scapular muscles (serratus ant, traps)scapular muscles (serratus ant, traps)

Stretching post structures to prevent further Stretching post structures to prevent further reduction in IR ROM being cautious not to reduction in IR ROM being cautious not to stretch beyond frontal plane to avoid stretch beyond frontal plane to avoid excessive ant displacementexcessive ant displacement

Stroke modifications: increasing body roll, Stroke modifications: increasing body roll, maintaining high elbow, avoiding excessive maintaining high elbow, avoiding excessive elbow extension before beginning hand elbow extension before beginning hand insweepinsweep

OutcomeOutcome

Joe was able to avoid surgery and Joe was able to avoid surgery and return to trainingreturn to training

He went on to win the Ironman in He went on to win the Ironman in HawaiiHawaii

Look for Joe in Athens in the 2004 Look for Joe in Athens in the 2004 Summer Olympics!Summer Olympics!

Questions?Questions?