The Management of Shoulder Instability. By Debbie Prince Clinical Shoulder Specialist
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1 The Management of Shoulder Instability By Debbie Prince Clinical Shoulder Specialist
2 Shoulder Dislocation The most common joint dislocation Traumatic Instability, highest incidence in males aged 21 to 30 years 98% of shoulder dislocations are anterior
3 Classification of Shoulder Instability
4 Acute Traumatic Shoulder Dislocation Significant trauma causes dislocation Normal Beighton s score Previous TUBS classification
5 X-ray of Anterior Dislocation
6 Shoulder Dislocation
7 Structures at Risk of Damage on Traumatic Dislocation Bankart lesion Bony Bankart lesion Hill Sachs lesion
8 Bankart Lesion Bankart lesion Anterior glenoid labral detachment Universal in young patients, occurs in 86% to 100% of patients (Larrain 2001)
9 Bankart Lesion
10 Bony Bankart Lesions Bony Bankart Lesion Bone loss of inferior glenoid diameter Pear shaped glenoid becomes inverted
11 CT Scan of Bony Bankart Lesion
12 Hill Sach s Lesion Hill Sach s lesion or humeral head defect(38% to 100% Buttoni 2003) Posterior humeral head impacts on the anterior glenoid in the dislocated position Small Hill Sach s lesion is common with no increased risk of recurrent instability Engaging Hill Sach s is significant. The humeral head defect engages with the anterior glenoid in a functional position
13 Hill Sach s Lesion
14 What are the Chances of it Dislocating Again? Overall risk of redislocation is 58% 87% of recurrent problems noted within 2 years.(robinson J Bone joint Surg 2006) Recurrent dislocation under 20 is 83% to 90% (Rowe) Higher rate with contact sports and overhead activities
15 Surgical Management INDICATONS History of 2 or 3 true/convincing dislocations supported with a X-ray Dislocation in bed at night Feelings of apprehension limiting sport/function Instability episodes are becoming more recurrent with reducing force/effort to dislocate shoulder. Aged over 18
16 Investigations MR Arthrography Involves injection of contrast material into the joint space Distends joint capsule to reveal capacious/baggy joint capsule Identifies labroligamentous injuries ie) Bankart lesions
17 Surgical Procedure Arthroscopic and open technique Anterior capsular shift restricts end range Abduction and ER Restores ligamentous and capsular tension Anatomically restore the anterior glenoid labral restraint Bankart Repair?Repair bone defects laterjay procedure
18 Surgical Repair BANKART REPAIR CAPSULAR SHIFT
19 Should all Traumatic Shoulder Dislocations be Surgically Managed? Overall reduction of instability risk of 82% of patients having arthroscopic Bankart repair. Significant improvement in functional outcome scores(robinson 2008) However, immediate surgical stabilisation for patients under 25 could unnecessarily treat 30%
20 Summary Highest risk of recurrent instability following shoulder trauma if: Under 25 years Significant bony pathology is identified ie)hill Sachs lesion >250mm Needs to return to contact sports or overhead activities 90% trauma clinicians treat first time dislocations with immobilisation and physiotherapy. 3
21 Atraumatic (Polar Type 3) Instability Previous AMBRI classification Muscle patterning Instability Often posterior and or inferior component Neuromuscular control/sequencing problem?congenitally acquired abnormal collagen fibres
22 Proprioception Shoulder very dependant on feedback systems due to unstable nature of joint Mechanoreceptors++ in capsuloligamentous structure provides afferent input and via feedback loops = tremendous impact on the dynamic stability Direct relationship between reflex arc capsule to shoulder rotator cuff Disruption in proprioception effects cuff recruitment = reduced stability of joint
23 Proprioception
24 Physiotherapy Aims of Treatment Observe rotational control of GHJ, scapula dyskinesia, core control and use of substitution strategies Restore static and dynamic control of trunk, GHJ and scapula thoracic joint Enhance Afferent information to facilitate normal movement in Core, Scapula and Rotator Cuff Control.
25 Where to Start?
26 Physiotherapy for Core Control Training Consider the kinetic chain, sequencing and movement integration Use of gym ball for wall slides with rotator cuff activation Free weight Rotator Cuff Exercises with step ups, standing on one leg, squats in lunge standing Achieve biomechanical efficiency with movement force flowing in diagonal patterns consider myofascial slings(elphinson 2013)
27 Core Control Training
28 Physiotherapy for Scapula Facilitation Techniques Closed Chain Exercises, use of gym ball Biofeedback to activate somatosensory awareness, use of taping, double mirrors, standing against wall, manual facilitation or pressure garments(omotrain) Commands to pre-activate muscle tone and recruitment(professor Anne Cooles, Belgium) FES Feed forward- 2 electrodes on motor points Serratus anterior and lower fibres of trapezius (Andre Le Leu, Stanmore)
29 Physiotherapy for Rotator Cuff exercises Rotator Cuff facilitation and Activation test Supine One kilo free weight, humeral head centring thro rotational arc of motion. Side lying Rotator Cuff training Prone Lying Towel under Scapula Arc of rotation
30 Atraumatic Instability Summary No structural damage found on MR arthrogram Surgery is usually not recommended for this patient group Physiotherapy treatment to include core control, dynamic scapula and rotator cuff control exercises May take up to six months to alter neuromuscular control or change a centralised neurological component
31 THANK YOU
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