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Shoulder Instability-Therapy Role In Non-Op and Operative Treatment PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Shoulder Instability: Therapy Role in Non-Op and Operative Treatment” by Trevor R. Born, MD.

This medical PowerPoint presentation is about shoulder instability, a condition in which the ball of the upper arm bone (humeral head) partially or completely dislocates from the shoulder socket (glenoid). It can result from a traumatic injury or can be caused by underlying structural abnormalities in the shoulder joint.

The management of shoulder instability depends on several factors, including the severity of the instability, the underlying cause, and the patients overall health and lifestyle. Treatment options include non-operative and operative management, and physical therapy plays a critical role in both approaches.

Non-operative treatment typically involves a period of rest and immobilization of the shoulder joint, followed by a gradual return to activities of daily living and sports. Physical therapy is an essential component of non-operative management and can help to restore strength, flexibility, and range of motion in the shoulder joint. The physical therapist will typically develop an individualized treatment plan that includes exercises to improve strength and stability in the shoulder joint, as well as techniques to improve posture and body mechanics.

Operative treatment is typically reserved for more severe cases of shoulder instability or when non-operative management fails to alleviate symptoms. Surgical options may include arthroscopic stabilization or open stabilization, depending on the underlying cause and the surgeons preference. Following surgery, physical therapy is an essential component of the recovery process and can help to restore normal shoulder function and prevent recurrent instability.

Tags : shoulder instability, humeral head, Orthopaedic Surgery, Orthopaedic Surgery PowerPoint presentation

Published on : Jun 20, 2023 | Views : 745 | Downloads : 3

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Slide 1-

Shoulder Instability:Therapy Role in Non-Op and Operative Treatment Trevor R. Born, M.D. Sarasota Orthopedic Associates
Slide 2-

Disclosure Statement No financial interest or contractual relationships with any commercial interest to disclose.
Slide 3-

Case Report: IV Drug Abuser with 10 trigger fingers and how it cured their addiction Correlation of a Physician’s Beard with Patient Respect Lie Detectors: A Worker’s Compensation Adjuster’s Best Friend? Hoverboard injuries in the Villages: An Epidemic? Shoulder Instability and the Therapist’s Role Potential Subjects to Discuss
Slide 4-

Trevor R. Born, M.D. Born and raised in Bradenton, FL Graduated from Bayshore High School Parents and 2 siblings still live here Continued education University of Florida- Undergraduate University of South Florida College of Medicine Mayo Clinic- Orthopedic Surgery Residency Brown University- Sports Medicine Fellowship
Slide 5-

The Basics If it popped out the front, don’t abduct/externally rotate the arm If it popped out the back, don’t adduct/internally rotate the arm
Slide 6-

Thank You
Slide 7-

Not All Instability is the Same Traumatic Anterior Dislocation Posterior Shoulder Dislocation Multidirection Instability Luxatio Erecta Proximal Humerus Fracture-Dislocation
Slide 8-

Anatomical Considerations Pathophysiology Dynamic Restraints Rotator cuff muscles (SITS) Scapular stabilizing muscles Static Restraints Labrum, Capsule, IGHL/MGHL/SGHL Anterior band of the IGHL is most important restraint in abduction, external rotation
Slide 9-

Anatomical Considerations Capsule/Ligaments Inferior Glenohumeral Ligament Complex Heavily involved in maintaining shoulder stability Forms a hammock with anterior and posterior bands Primary stabilizer limiting anterior, posterior & inferior humeral translation at 90° abduction Bankart lesion= detachment of anterior band off glenoid Middle Glenohumeral Ligament Primarily effective at 45° abduction Helps limit external rotation, inferior and anterior humeral translation Superior Glenohumeral Ligament Minor role in preventing anterior instability Mainly effective at limiting inferior translation and ER with arm at side/adducted
Slide 10-

Anatomical Considerations Rotator Cuff EMG Studies show that all (with deltoid) are active throughout full ROM of flexion, abduction and elevation Co-contraction helps hold humeral head in center of glenoid throughout arc of motion Create GH compressive force that helps stabilize joint
Slide 11-

Anatomical Considerations Scapulothoracic stability has been emphasized as an important component of GH stability. Dysfunction can lead to failure of scapular rotation beneath the humeral head, permitting abnormal translation Trapezius, serratus anterior and rhomboids all influence scapular movements
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Slide 13-

Patient Evaluation Physical Exam Strength Muscle atrophy and scapular winging Motor and sensory exam ROM assessment Soft-tissue laxity Beighton Score Special tests Sulcus Sign Load and Shift Apprehension Test Relocation Jerk Test
Slide 14-

Shoulder Instability Imaging Radiographs CT Best to assess bone stock 3D reconstructions MRI With or without arthrogram Evaluate the soft-tissues
Slide 15-

Shoulder Instability Traumatic vs. Atraumatic Direction of Instability Age Single episode vs. Recurrent Arm dominance Activities/Sports Contact vs. Non-contact, overhead Co-Morbidities
Slide 16-

Anterior Instability Anterior Instability >90% of Dislocations Abducted and externally rotated arm Recurrent Dislocation Under 20 years old: Wide variation between studies (<25% to >90%) Less likely as age increases Males higher risk than females at all ages Higher risks in contact sports Rotator Cuff Tears After 40 yrs old – 40% Initial Management Reduction, immobilization
Slide 17-

Anterior Instability Bankart Lesion and avulsion of IGHL from glenoid >90% Includes bony component at times Humeral Avulsion of Glenohumeral Ligament (HAGL) <10%
Slide 18-

Treatment Immobilization in internal vs. external rotation No consensus, no apparent benefit in ER In season dislocations: AJSM 2004 study (Buss et al) showed 87% return to sport that season Averaged 1.4 incidents of recurrent dislocation >50% had surgery the following off-season
Slide 19-

Treatment Risks with non-operative management in a first time dislocator, especially young male in contact sports Recurrent instability Damage to joint, glenoid over time necessitating open procedure Reported correlation with number of dislocations and risk of failing surgical management Arthropathy
Slide 20-

Surgical Treatment Open vs. Arthroscopic procedures Level 1 study showed no difference (AJSM 2006) Systematic review (Sports Health 2011) No significant difference in redislocation rate, return to activity, or functional outcomes Better ROM in arthroscopic group High level contact athletes, some argue open is preferred method Bony deficiencies Glenoid- restore bone stock Latarjet Procedure Humerus (Hill-Sachs deformity)- fill in space Remplissage
Slide 21-

Arthroscopic Management (Bankart Lesion)
Slide 22-

Arthroscopic Management (Bony Bankart)
Slide 23-

Open Management Latarjet Procedure
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Posterior Instability 4% of all glenohumeral dislocations High energy, seizure, electric shock Can see from repetitive use/stress e.g. Football linemen 50-80% missed at initial presentation Often present with internally rotated, adducted upper extremity Radiographs – Axillary view essential Posterior Subluxation Apprehension sign: posteriorly directed force with the adducted arm flexed 90° and internally rotated 90°
Slide 25-

Treatment Reduction if needed Traction, external rotation, abduction Immobilization 4-6 weeks in neutral rotation Surgical stabilization for Chronic instability/dislocations Articular fractures >20% Large glenoid rim fractures Displaced lesser tuberosity fracture Humeral head replacement Chronic dislocations > 3-6 months Fracture of humeral head >50%
Slide 26-

Arthroscopic Management
Slide 27-

Open Management McLaughlin Procedure
Slide 28-

Multidirectional Instability (MDI) Can be from overuse (microtrauma) Swimmers, gymnasts, volleyball, throwers Associated with connective-tissue disorders Marfan’s, Ehler-Danlos Will possess patulous inferior capsule and deficient rotator interval Primary treatment is always non-operative Dynamic strengthening Surgical treatment reserved for patients who failed prolonged conservative management Focus on the capsule
Slide 29-

Non-operative and post-operative rehab will essentially follow similar principles
Slide 30-

Rehabilitation No scientific studies available to support one specific rehab regimen in preference to another Key to pain-free shoulder function for sporting activities is functional stability or a balance between stabilizers of the shoulder and forces applied to the shoulder Rehab should aim to optimize the performance of the dynamic stabilizers Post-operatively, key is initial protection of repaired structures, followed by introduction of sequential strengthening/stabilization exercises
Slide 31-

The Basics If it popped out the front, don’t abduct/externally rotate the arm If it popped out the back, don’t adduct/internally rotate the arm
Slide 32-

Rehabilitation Dynamic compression—1st mechanism of functional stability Subscapularis co-contracts with infraspinatus and teres minor to center and compress humeral head into glenoid fossa Interior fibers of rotator cuff co-contract with anterior deltoid to help keep head centered on glenoid Dynamic ligament tension—2nd mechanism of functional stability Rotator cuff tendons blend with shoulder capsule at their point of insertion and serve to tighten capsule on contraction Reactive neuromuscular control—3rd mechanism of functional stability Involves exercising the unstable shoulder in positions that maximally challenge dynamic stabilizers Plyometrics helps to retrain neuromuscular control
Slide 33-

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Slide 34-

Exercises Subscapularis Internal rotation activities Isometric against wall, side-lying, prone, standing Infraspinatus External rotation activities Isometric against wall, side-lying, prone, standing Teres Minor External rotation activities Isometric against wall, side-lying, prone, standing
Slide 35-

Exercises Anterior deltoid Forward flexion exercises Supine, prone, standing forward flexion-thumb up Push ups- wall, counter, floor Serratus Anterior Serratus punches, push up plus, rows Latissimus Dorsi Lat pulls, seated press ups Isometric contraction Rhomboids Rows, scapular squeezes, standing horizontal abduction
Slide 36-

It’s not just the ball and socket
Slide 37-

Rehabilitation Scapulothoracic motion Provision of stable platform under humeral head requires the scapula and humerus to move in synchrony and allows orientation of glenoid to adjust in responses to changes in arm position Trapezius and serratus anterior contribute to 2 important force couples that produce scapular elevation Rotator Cuff Positions of protraction limit maximal rotator cuff strength Decreased strength by 23% Supraspinatus strength increased 11-24% when the scapula was in a position of retraction (Kibler, AJSM 2006) Maximal strength at neutral protraction/retraction
Slide 38-

Scapular Dyskinesis Multidirectional Instability Altered biomechanics and muscle activation Increased protraction of scapula often seen. Pectoralis minor and latissimus dorsi increase activation Lower trapezius and serratus anterior less active Results in hyperactive rotator cuff and biceps Humeral head migrates away from center Correction of scapular positioning can successfully treat MDI
Slide 39-

Evaluation of the Scapula Expose the scapula Evaluate resting posture Evaluate dynamic motion Repetitive motions may reveal weakness Scapular Assistance Test Evaluates scapular contributions to impingement and rotator cuff strength Scapular Retraction Test Evaluates contributions to rotator cuff strength and labral symptoms
Slide 40-

Treatment of Scapular Dyskinesis First must optimize surrounding anatomy Treat any nerve dysfunction or structural injury Rehab emphasis should “start proximally and end distally” Core strength and stability 3-dimensional control of the scapula Serratus anterior & lower trapezius strengthening Acute Phase: Low row, inferior glide, Closed-Kinetic chain Recovery Phase: lawnmower, robbery exercises, wall slides Maintenance Phase: medicine ball toss, tubing plyometrics Rotator cuff strengthening after scapula stabilized Coordinate scapular motion with trunk and hip motion
Slide 41-

Treatment of Scapular Dyskinesis – First Exercises Low Row Inferior Glide Push hand maximally against surface Adduct arm maximally against surface
Slide 42-

Treatment of Scapular Dyskinesis – Later in Progression Lawnmower Robbery
Slide 43-

Not all shoulder instability is the same Not all patients are the same Age/activities/co-morbidities Need to know direction(s) of instability/what was repaired Don’t forget the scapulothoracic joint Younger, male, contact athletes- higher risk of failure with non-op management i.e. Recurrent dislocations Rehab focused on dynamic rotator cuff strengthening and scapular stabilization Summary
Slide 44-

Do not need to immobilize in ER after anterior dislocation Patient had seizure, shoulder pain with “negative” x-ray and can’t ER think posterior dislocation Patient older than 40 with dislocation and can’t raise arm a few weeks after surgery rotator cuff tear Protect repaired structures early on during rehab, early isometrics Multidirectional instability ask about family history of connective tissue disorders Shoulder Instability Pearls
Slide 45-

Thank You