Case Study: Chronic Anterior Shoulder Dislocation

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Case Study Chronic Anterior Shoulder Dislocation

• Nicole Boyko, PT/s

• Carolyn Michalski, PT/s

• Bridget Promaulayko, PT/s

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Introducing Joe ShoulderHistory of Present
Condition

• 28 y/o English-speaking single white male
• 2 wks s/p (L) ant shld dislocation incurred while
  reaching for stationary object from moving
  vehicle
• Manual relocation performed under anesthesia in
  ER
• Pt D/Cd with sling and pain medications
• Presents to PT for conservative trial of therapy
  in hopes of avoiding surgery

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History Continued

• Long hx of prior (L) ant shld dislocations x 4
• PMH significant for multiple sports-related
  fx/sprains
• FH significant for father with chronic (R) ant
  shld instability, s/p capsulorraphy
• Triathlete, actively training prior to injury
• Currently unemployed finance investor
• SH noncontributory

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PT Tests and Measures

• Upper Qtr Screen (-) for cervical involvement
• Motor Control
• Delayed scapular mvmt with GH elevation
• Posture
• Prominent ant humeral heads (B)
• Mild-mod winging scapulae (L)gt(R)
• Mild FHP

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PT Tests and Measures cont

• Pain
• Dull ache of (L) shld 4/10, intermittently at
  rest and after activity
• sharp pain with ER, abd, 6/10
• Jt Mobility (R) (L)
• Posterior Glide 2/6 1/6
• Anterior Glide 4/6 5/6
• Superior Glide 2/6 2/6
• Inferior Glide 3/6 4/6

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PT Tests and Measures cont

• Function
• Drives short distances
• Difficulty with overhead tasks
• Sensation
• Intact lt touch C2-T1
• Numbness/tingling (L) UE
• Special Tests
• apprehension (L)
• ant load shift, ant drawer mild impingement
• relocation test
• (-) drop arm, empty can

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PT Tests and Measures cont
Muscle Performance/ROM
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Relocation Test

• Pt in supine
• Shld is abducted/ER
• Use edge of table as fulcrum
• Test () for anterior instability if apprehension
  demonstrated relieved by posterior stress on
  shld

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Relocation Test

• Speer et al (1994)
• All subjects had singular dx
• Subjects undergoing surgery able to visually
  confirm dx
• Overall accuracy
• lt50 pain alone
• gt80 apprehension alone

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Evaluation
Impairments Functional Limitations Disability
Faulty scapulothoracic, GH rhythm and cervical-thoracic spine alignment Decreased (L) shld motion Hypermobility ant and inf glides hypomobility sup and post glides Pain with end range shld girdle motion, esp in open packed position Impaired muscle performance Unable to reach or pull overhead Unable to drive gt 30 min without significant discomfort Unable to continue training for triathlon Unable to participate in regular gym program
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Diagnosis

• Pattern 4D Impaired Joint Mobility, Motor
  Function, Muscle Performance, and Range of Motion
  Associated with Connection Tissue Dysfunction
• ICD-9 Code 831- Shoulder Dislocation

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Prognosis

• Predicted Optimal Level of Improvement
• Training for triathlon with modifications
• Home activities/ADLS with min-no pain
• Sufficient shld stability to avoid surgery

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Prognosis

• Predicted Interval Levels of Improvement
• Pt will perform 3x10 reps shld ER in scaption
  with green (intermediate) t-band to fatigue x 4
  wks
• Pt will perform 3 x 10 reps shld IR in scaption
  with blue (mod) t-band to fatigue in 4 wks
• Pt will show decreased signs of apprehension as
  seen with performance of D2 PNF pattern with 2 lb
  pulley weight
• PT will be able to flex and abduct (L) shld to
  170 with min-no pain allowing for (I) ADLs such
  as overhead reaching and dressing.

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Plan of Care

• Frequency/Duration 2 x/wk x 8 wks
• Criteria for Discharge
• Return to 90 premorbid function with necessary
  modifications
• 90 ROM of unaffected side
• 4/5 mm strength or greater
• Proper mm length-tension relationships
• Pain less than or equal to 2/10
• (I) home exercise program

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Interventions

• Patient-related instruction
• Periodic reassessment of HEP- written
  instructions
• Injury prevention and sports modification
• Direct Interventions
• Therapeutic Exercise
• Functional Training
• Manual Therapy Techniques
• Electrotherapeutic Modalities
• Physical Agents and Mechanical Modalities

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Phases of Rehabilitation

• Phase I
• Rest and immobilization
• Pain ctl with NSAIDs
• Ice applied to shld
• Phase II (begin PT)
• Isometrics
• Isotonics
• Body mechanics/ergonomics
• Emphasis on increasing fxnl mvmt
• Stability exercises
• PNF
• Proprioceptive awareness

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Phases of Rehabilitation

• Phase III
• Endurance
• Progressive strengthening
• High-level activity challenging shld in
  open-packed position
• Phase IV
• Sports specific activities

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Selected Intervention

• Scapular stability exercise
• Provide dynamic restraint to anterior translation
• Key muscles include subscapularis, traps and
  serratus anterior
• Exercises to target
• Subscapularis Isometric Exercise
• Push ups with a plus

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Rationale

• Shoulder mobility requires stable base
• Normal scapulohumeral rhythm 21 ratio
• Rehab should emphasize restoring normal
  physiological patterns
• Scapular stability exercises
• Early isometrics and scapular setting
• CKC exercises to re-establish normal motor firing
  patterns
• 4 core exercises target all 8 scapular muscles
  scaption, push-up plus, press-up, rowing

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Selected Interventions

• Sports specific exercise
• Shoulder PNF
• D2 pattern for swimming stroke
• Concentric/Eccentric
• Theraband
• Manual resistance
• Pulleys

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Rationale

• Biomechanics of freestyle swim stroke
• Forceful concentric IR/add through acceleration
  phase
• Eccentric activation of ER in follow-through
  phase
• Unique characteristics of swimmers
• Excessive external rotation ROM
• Limited internal rotation ROM, post capsule or
  cuff tightness
• ER IR ratio typically lower in swimmers than
  normal subjects 2 selective strengthening of IR
• Higher ER IR ratio found in overhead athletes
  with instability

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Rationale

• Sports-specific rehab should include
• Balanced exercises for the rotator cuff and
  scapular muscles (serratus ant, traps)
• Stretching post structures to prevent further
  reduction in IR ROM being cautious not to stretch
  beyond frontal plane to avoid excessive ant
  displacement
• Stroke modifications increasing body roll,
  maintaining high elbow, avoiding excessive elbow
  extension before beginning hand insweep

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Outcome

• Joe was able to avoid surgery and return to
  training
• He went on to win the Ironman in Hawaii
• Look for Joe in Athens in the 2004 Summer
  Olympics!

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Questions?