Anterior Shoulder Dislocation Sarah Popernack, SPT Picture source: http://www.newhealthadvisor.com/Anterior-Shoulder-Dislocation.html

Condition Identification & Context1 Atraumatic hypermobility (chronic) or traumatic instability (acute) Laxity of ligaments or repetitive overhead activities/ loading of joint Anterior: most common, motions of abduction and external rotation stress anterior structures of glenohumeral (GH) joint Less common: posterior instability (forces against flexed humerus) and inferior instability (typically rotator cuff weakness), multidirectional Traumatic dislocation: separation of articular surfaces, acute incident

Condition Identification & Context1 Impairments in structure and function Pain and muscle guarding Posterior structures of GH joint tight High risk of recurrent dislocation, especially in younger patients Activity limitations and participation restrictions Inability to reach or lift to the horizon Restricted ability to participate in sports Restricted movements to complete ADLs- dressing, grooming

Patient Record and Relevant Findings History2,3 Tests and Measures1 20-year-old male, pitcher on college baseball team- atraumatic hypermobility predisposed to traumatic instability Immobilized in sling for 4 weeks Pain 3/10 at rest, 8/10 with activity Pain and dependent on others with ADLs (dressing, bathing) Primary concern: returning to baseball in the following season Ibuprofen and icing to temporarily relieve pain Deficits in PROM of shoulder abduction, extension, external rotation; empty-end feels due to pain Deficits in MMT of shoulder internal and external rotation, adduction Positive apprehension test on R shoulder

Most Important Problem to Address Expected Outcomes1 1. By session 24, patient will increase PROM of right shoulder abduction to a “normative” value of 180 degrees in order to gain the range needed to pitch for baseball. 2. By session 24, patient will increase strength to 5/5 for the rotator cuff muscles (shoulder internal and external rotators, shoulder adductors) in order to increase stability of the right shoulder complex so that the patient can safely return to sport with lower risk of recurrent dislocation of the anterior shoulder. Along with increased stability, the patient will have increased endurance to be able to tolerate repetitive motions inherent in pitching for baseball. 3. By session 24, patient will be able to complete dressing and bathing with a pain score of 0/10 to enhance quality of life when completing activities of daily living. 4. By session 24, patient will report a changed score of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire from 35/100 at the initial evaluation to 1/100 before discharge so that participation restrictions are minimal and the patient is able to return to a high-functioning quality of life. Ultimate goal: returning to pitch for baseball Precautions: initial healing/ protection phase- external rotation should be completed with elbows at sides, staying less than 10-15 deg. beyond neutral, abduction to 90 should be avoided1 Contraindications: extension beyond 0 deg.1

Prioritized Intervention: Weeks 1-31 Literature Case Condition Interventions Increase shoulder mobility: grade 3 mobilization, posterior joint structures passively stretched with self-stretching (horz. Add) Increase stability and strength of rotator cuff and scapular muscles Internal rotators and adductors protect anterior joint External rotators strong to resist anterior glide in external rotation/ abduction motions Scapular stability for shoulder function and scapular alignment Exercises: Isometric resistance in pain-free range Partial weight-bearing and stabilization exercises Wand, Gear shift exercises Protective weight bearing Seated-> standing Isometric, manual resistance HEP: horizontal adduction self- stretching, self-applied isometrics against a wall, wall washing

Isometric manual resistance Wall Washing Picture sources: https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=zp4391 https://www.youtube.com/watch?v=PgUy-jL0n4U http://slaptearsurgeryandrecovery.blogspot.com/2011/01/home-therapy-exercises-part-ii.html http://www.sparkpeople.com/mypage_public_journal_individual.asp?blog_id=6032723 Self-applied isometrics Wand exercises

Prioritized Intervention: Weeks 3-91 Literature Case Condition Interventions Dynamic resistance limited to 50 degrees ext. rotation 3 weeks- supervised isokinetic resistance for internal rotation and adduction 180 deg. Per second or higher Progression to 90 degrees of shoulder flexion, not abduction 5 weeks- all shoulder motions incorporated into exercises on isokinetic or mechanical equipment except 90 deg. Abduction with external rotation Isokinetic system BodyBlade Dynavision HEP: Extension, abduction, internal rotation self-stretching, Theraband exercises, weighted ball

Shoulder extension BodyBlade Weighted ball Theraband Picture Sources: http://wavesport.ning.com/profiles/blogs/how-to-recovery-from-a-rotator http://www.dcrmt.com/2015/03/shoulder-abduction-theraband/ https://www.youtube.com/watch?v=853o4gqDsys http://accidentalamazon.com/ther-scap-ex.pdf http://www.coreperformance.com/daily/movement/q--a-no-wall-for-medicine-ball-throws.html https://www.amazon.com/OPTP-BOING-Oscillation-Integrates-Neuromuscular/dp/B001EL2RUK Weighted ball Theraband

As seen at APTA’s 2016 NEXT Conference Dynavision Increase shoulder ROM Increased reaction time Quick changes of direction Explosive movements for return to sport Used for many populations and patient conditions http://www.dynavisioninternati onal.com/athletic

Prioritized Intervention: Weeks 9-121 Literature Case Condition Interventions Return to function: Restore control- balance in strength of shoulder/ scapular muscles Coordination of scapulothoracic and arm muscles Endurance for shoulder instability exercises Stability improves, progress to: eccentric to maximum load, increasing speed and control of combined motions, simulating desired functional patterns Upper body ergometer Theraband Chest passes and overhead throws Dynavision HEP: Theraband, weighted ball, Aquacise at Michael J. Zone recreation center

Overhead throws Chest passes Theraband Picture Sources: http://www.stack.com/video/2226311188001/steve-cishek-med-ball-split-stance-overhead-throw http://utahshoulderknee.com/words/physical-therapy/shoulder/shoulder-instability-stabilization-exercises/ http://cathrynsveryfirstblog.blogspot.com/2015/04/showing-basics-of-basketball.html Chest passes

Results1 Test and Measures Expected Outcomes PROM in shoulder abduction, extension and external rotation within 5 degrees of “normative” values MMT of shoulder internal and external rotation, adduction 5/5 (3/5 at initial visit) Negative apprehension test 1/100 DASH questionnaire 0/10 pain at rest, throughout the day and after independently completing ADLs Ability to return to baseball as determined by: no muscle strength imbalance, coordination with skilled movements is present, apprehension test is negative

Findings Compared with Literature Case Condition Findings Full rehabilitation takes 2.5 to 4 months1 Patients younger than 20 typically require surgery, patients older than 30 typically get treated conservatively (PT) 2 Ability to safely return to sport is determined upon three criteria1 Patient was seen for 24 sessions for a total of 12 weeks1 Patient is 20, treated conservatively because of the large amount of rehabilitation time post-season2 Patient progression throughout the plan of care to meet the three criteria1

References Kisner Colby L. Therapeutic Exercise: Foundations And Techniques. 6th ed. Philadelphia, PA: F. A. Davis Company; 2012:577-580. Wang RY, Arciero RA, Mazzocca AA. The Recognition and Treatment of First-Time Shoulder Dislocation in Active Individuals. Journal of Orthopaedic and Sports Physical Therapy. 2009;39(2):118-123. Matthew S, Fahrner J, Stevenson H, Lowe R, Burns SA. Shoulder Dislocation. Physiopedia, universal access to physiotherapy knowledge. http://www.physio-pedia.com/shoulder_dislocation. Accessed June 18, 2016.