SHOULDER INSTABILITY / Management and Treatment

                                             

      SHOULDER INSTABILITY

 GH  JOINT→ INHERENTLY LAX OR LOOSE

                                                                                  
                                     ↓

              OSSEOUS CONFIGURATION

                                                                             
                                     ↓
  GREATEST AMOUNT OF MOBILITY  (SHOULDER SACRIFICE STABILITY                      FOR MOBILITY)
                                      ↓

          MOST COMMON JT. DISLOCATED

§  INSTABILITY DEFINED AS UNWANTED TRANSLATIONS OF GH JT. EXPERIENCED BY THE PATIENT.

§A SHOULDER DISLOCATION
IS DEFINED AS THE COMPLETE LOSS OF THE ARTICULATION B/W THE HUMERAL HEAD AND THE GLENOID SOCKET.

§  SUBLUXATION
 REFERS TO A PARTIAL LOSS OF GH JT. ARTICULATION TO THE EXTENT THAT SYMPTOMS ARE PRODUCED.

STABILITY     →   STATIC    ⏩ GLENOID LABRUM & ARTICULAR CONGRUITY

                      →   DYNAMIC   ⏩ ROTATOR CUFF+ COORDINATION  B/W SCAPULAR MOVT.+ HUMERAL MOVT.



CLASSIFICATION OF SHOULDER INSTABILITY:-



FREQUENCY:-   ⏩  ACUTE

                            ⏩  RECURRENT

                             ⏩ FIXED (CHRONIC)


CAUSE:-             ➦● TRAUMATIC

                            ➦● ATRAUMATIC

                           ➦● MICROTRAUMA

                           ➦●CONGENITAL

                           ➦●  NEUROMUSCULAR CONDITION ( ERBS PALSY, CEREBRAL PALSY, SEIZURES)



DIRECTION:-    ➠●ANTERIOR

                          ➠● POSTERIOR

                          ➠● INFERIOR

                          ➠● MULTIDIRECTIONAL



DEGREE:-        ●➯DISLOCATION

                         ●➯  SUBLUXATION

                         ●➯ MICROTRAUMA                    (TRANSIENT)



ANTERIOR SHOULDER INSTABILITY:

·        MOST COMMON TYPE⏬⏬⏬⏬⏬

·        90% OF SH. DISLOCATION OCCURS ANTERIORLY

·        ARM IN ABDUCTION. & EXTERNAL. ROTATION. ( CLASSIC POSITION FOR ANT. INSTABILITY)

CLASSIFICATION:

·   ➨ TRAUMATIC, ACUTE DISLOCATION 
        (SUBCORACOID, SUBGLENOID, SUBCLAVICULAR, INTRATHORACIC)

·    ➨TRAUMATIC, ACUTE SUBLUXATION

·    ➨ RECURRENT ANTERIOR INSTABILITY

        ●CHRONIC RECURRENT ANT. DISLOCATION

        ●CHRONIC RECURRENT ANT. SUBLUXATION

·        FIXED (LOCKED) ANT. DISLOCATION

PHYSICAL EXAMINATION:➧

   DETAILED HISTORY, POSITION OF ARM AT THE TIME OF INJURY, MECHANISM OF INJURY.

·        INDIRECT LEVELING OF HUMERAL HEAD ANTERIORLY W/ THE SHOULDER POSITIONED IN A COMBINATION OF ABD. & EXT. ROT.

·        LESS COMMONLY BY DIRECT BLOW TO POST. SHOULDER.

·     

OBSERVATION:

·        AFFECTED SHOULDER. USUALLY HELD IN SLIGHT ABD. & EXT. ROT. W/ THE FOREARM  CRADLED BY THE UNAFFECTED ARM.

·        PALPABLE FULLNESS IN THE ANT. SHOULDER.

·        INT. ROT.& ADD. MAY BE LIMITED.

·        AXILLARY NERVE IS COMMONLY INJURED.

 RADIOGRAPH: TO RULE OUT CONCOMITANT #

RECURRENT ANT. INSTABILITY:-

MOST CONSISTENT & SIGNIFICANT FACTOR INFLUENCING RECURRENCE IS AGE AT PRIMARY DISLOCATION

                                                                                         ↓

  ACTIVITIES ( MORE COMMON IN YOUNGER POPULATION )

                                                 ↓

                  PT. YOUNGER<30 YEARS HAVE AN AVG. RISK OF APPROX. 70% OF                                                                      

 RECURRENT DISLOCATIONS
 WHEN TREATED W/ NON-SURGICAL REHAB.                        
                                                  ↓
  OVERALL AVG. RECURRENCE RATE IS 50% ( NON-OPERATIVEE)


DIAGNOSED BY

·        HISTORY (>3)

·        ANT. APPREHENSION TEST ( CRANK TEST)      ⏬⏬⏬⏬⏬

Apprehension (Crank) Test for Anterior Shoulder Dislocation. 

This test is primarily designed to check for traumatic instability problems causing gross or anatomical instability of the shoulder, although the relocation portion of the test is sometimes used to differentiate between instability and impingement. 

The examiner abducts the arm to 90° and laterally rotates the patient's shoulder slowly  By placing a hand under the gleno- humeral joint to act as a fulcrum 



 the apprehension test becomes the fulcrum test. Kvitne and Job recommended applying a mild anteriorly-directed force to the posterior humeral head when in the test position to see if apprehension or pain increases 

·        POSITIVE RELOCATION TEST

NON-OPERATIVE TREATMENT .:-

·        MOST SUCCESSFUL OUTCOME IN PATIENTS >50YRS

·        YOUNGER PATIENTS TREATED CONSERVATIVELY REQUIRE A LONGER COURSE OF IMMOBILIZATION.

·      RECURRENCE IS PRIMARY COMPLAINT

                                      ↓

 GOAL OF REHAB PROGRAM IS TO OPTIMIZE SHOULDER STABILITY

                                       ↓

 AVOIDANCE OF ANY PROVOCATIVE MANEUVERS

                                       ↓

  CAREFUL MUSCLE/ STRENGTHING.

==========================================================================
NON-OPERATIVE MANAGEMENT OF ANTERIOR. SHOULDER INSTABILITY:

PHASE 1: WEEKS 0-2

RESTRICTIONS: EXT. ROT

                             ABDUCTION

                            DISTRACTION

IMMOBILIZATION: SLING IMMOBILIZATION → REMOVE FOR EXERCISE





 ⏩⏩⏩⏩⏩   DURATION OF IMMOBILIZATION IS AGE DEPENDENT (IMPROVED HEALING OF THE   CAPSULOLABRAL COMPLEX)

·         < 20YR = 3-4 WEEKS

·          20-30 YR = 2-3 WEEKS

·         >30 YR = 10 DAYS- 2 WEEKS

·         >40 YR = 3-5DAYS

PAIN CONTROL:

·   RED OF PAIN & DISCOMFORT IS ESSENTIAL FOR RECOVERY

·  MEDICATIONS: 1. NARCOTICS- 5-7 DAYS

                        2. NSAIDS - ↓INFLAMMATION

·        THERAPEUTIC MODALITIES: ICE, US, HVPGS (MOIST HEAT BEFORE THERAPY, ICE AFTER THERAPY)

MOTION SH.:   ONLY FOR THOSE ABOVE 30 YR

MOTION ELBOW: 

·        PASSIVE- PROGRESS TO ACTIVE

·         0-130 FLEXION

·        SUPINATION/ PRONATION AS TOLERATED

MUSCLE STRENGTHENING:

·        SCAPULAR- ONLY FOR >30 YR

·        GRIP STRENGTHENING
=============================================================================

PHASE 2 : WEEK 3-4

CRITERIA FOR PROGRESSION

·        REDUCED PAIN & TENDERNESS

·        ADEQUATE IMMOBILIZATION

RESTRICTIONS:

·        AVOID PROVOCATIVE POSITION OF SH. THAT RISK RECURRENT INSTABILITY

·        SH. MOTION

1.      140° OF FLEXION

2.      40° OF EXT. ROT. W/ THE ARM AT THE SIDE( 0° ABD.)

3.      AVOID EXTENSION

IMMOBILIZATION: SLING-AS PER IMMOBILIZATION

SH. MOTION:-

·        GOALS:   

  1.      140° OF FORWARD FLEXION

  2.      40° OF EXT. ROT. W/ THE ARM AT THE SIDE.

·        EXERCISE:

1.      PENDULAR EX.

2.      PROM

3.      ACTIVE ASSISTED

4.      AROM

MUSCLE STRENGTHENING:

·        ROTATOR CUFF ( CLOSED CHAIN- ISOMETRIC STRENGTHENING)

·        SCAPULAR STABILIZERS

============================================================================

PHASE 3 : WEEK 4-8

CRITERIA:

·    PAIN FREE FORWARD FLEXION 140°; EXT. ROT. 40°( ARM SIDE)

·    MINIMAL PAIN OR TENDERNESS W/ STRENGTHENING EX.

·    IMPROVED STRENGTH.

RESTRICTIONS:

·        ABD. + EXT. ROT.

·        SH. MOTION

1.      160° OF FORWARD FLEXION

2.      40° OF EXT. ROT. W/ THE ARM IN 30°-45° OF ABD.

MOTION: SHOULDER:-

GOALS:

·   160° OF FORWARD FLEXION

·   40° OF EXT ROT W/ THE ARM AT 30°-45° OF ABD.

EXERCISE:

·        PROM

·        ACTIVE ASSISTED ROM EX

·        AROM

MUSCLE STRENGTHENING:

·     ROTATOR CUFF

·    CLOSED CHAIN ISOMETRIC STRENGTHENING W/ THE ARM IN 30°-45° OF ABD.

·    OPEN CHAIN STRENGTHENING

·    THERABAND

·    LIGHT ISOTONIC DUMBELL

·    SCAPULAR STABILISERS

==========================================================================

PHASE 4 : 8-12 WEEK

CRITERIA:

·    PAIN FREE FORWARD FLEXION 160°, EXT. ROT. 40° AT 30-45 ABD.

·     MINIMAL PAIN

·     IMPROVED STRENGTH

·     SATISFACTORY PHYSICAL EXAMINATION

GOALS:

·     IMPROVE SH. STRENGTH & ENDURANCE

·    IMPROVE NEUROMUSCULAR CONTROL & SH. PROPRIOCEPTION

·    RESTORE FULL SH. MOTION

RESTRICTIONS: AVOID POSITIONS THAT EXACERBATE INSTABILITY

MOTION:

·        ALL EX.

·        CAPSULAR STRETCHING

·        MUSCLE STRENGTHENING

·        ENDURANCE TRAINING

==========================================================================

PHASE 5: WEEK 12-16

·    PREPARE FOR FUNCTIONAL & SPORTING ACTIVITIES

·    ESTABLISH HOME EX. PROGRAME.