Body Planes. (A) Transverse Superior Inferior (B) Sagittal Medial Lateral (C) Coronal Anterior Posterior Extremity Proximal Distal
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2 Body Planes (A) Transverse Superior Inferior (B) Sagittal Medial Lateral (C) Coronal Anterior Posterior Extremity Proximal Distal C B A
3 Range of Motion Flexion Extension ADDUCTION ABDUCTION
4 Range of Motion External rotation (away from body) Internal rotation (towards body)
5 Range of Motion Horizontal abduction Horizontal adduction Circumduction circular movement of the limb, which is a complex movement and a combination of flexion, extension, abduction, adduction, and rotation
6 0 Shoulder Home Position for Internal & External Rotation
7 Anterior Subluxations Dislocation most common traumatic dislocation in the human body High recurrence rate: 47%- 100% Traditional treatment: adduction & internal rotation Recent studies: Adduction: Not ideal Bankart lesion remains detached EXOROTATION!
8 Shoulder Dislocation/ Subluxation It is common with shoulder dislocations, or subluxations, for damage to occur to the Labrum, Capsule, and/ or Rotator Cuff. These conditions may or may not require surgery (Ito 2003, 2007, 2011) Optimal Product: Ultrasling ER
9 Superior Labrum Anterior to Posterior Labral Repair SLAP Lesion Repair Tear 9:00-12:00-3:00 May be due to a weak Rotator Cuff creating malpositioning of Bicep Tendon and tearing of the tendons from the Superior Labrum from the Glenoid Optimal Product: Ultrasling IV Ultrasling ER (Itoi s study)
10 Banckart Lesion Complication of Anterior luxation Avulsion of the Labrum Needs refixation or proper immobilisation
11 Rotator Cuff Injuries
12 Postoperative Care (traditional) Since Hypocrates: Imobilisation in neutral position or internal rotation BUT!! - Treatment of luxations with or without Glenoid avulsion since 2001!
13 Ultrasling Series Traditional treatment for shoulder dislocation: a sling in internal rotation Problem: Shoulder dislocation recurrence rate 20% - 48% (age under 20 66% - 94%) New study: ER - externally rotated position (Ito 2001,2004,2007, 2010) 1. UltraSling IV abd 2. UltraSling IV AB 45 or 60 abd sling Ultrasling III Ultrasling III ER UltraSling III AB
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16 UltraSling ER Ultrasling III ER Ultrasling IV ER Better patient compliance, better immobilization
17 Itoi et al. (JBJS, 2001) Schematic of the capsulo-labral detachment -Bankart lesion following anterior shoulder dislocation with the arm positioned in (a) Internal rotation: capsular structures are lax and allow hematoma to form (b) External rotation: Better approximates the labrum to the glenoid rim better position for healing
18 Itoi (JSES, 2003) Goal: Decreased rate of recurrent shoulder luxations in ER immobilisation?? N=40, 2 treatments, Follow-up: 15.5 m IR group: 45% Recurrency rate ER group: 0% IR group: 70% recurrences within 1 year ER group: 18.7 % within 2.5 years
19 198 patients with initial anterior dislocation of the shoulder IR group: 42% Recurrence rate ER group: 26% Recommend 3 weeks Immobilisation ER position
20 Conclusions: Bracing in external rotation may provide a clinically important benefit over traditional sling immobilization
21 Arthroscopic stabilization is being increasingly recommended after a first-time dislocation; however, surgical stabilization after a first-time dislocation still remains controversial. In this paper, we introduce a basic study that provides evidence for the development of immobilization in external rotation, recent clinical outcomes, and future perspective. Furthermore, how to choose the treatment options for first-time dislocations is discussed.
22 ER Brace Comparison DJO Ultra-sling ER EBI Sports medicine shoulder system Lerman Shoulder Brace In a recent comparative study of 4 commercially available external rotation braces, Sullivan et al. (2007, Arthroscopy) found the DonJoy Ultra-sling ER 15 rated the most comfortable brace by the patients. USMC Gunslinger II
23 The Journal of Arthroscopic and Related Surgery, Vol 23, No 2 (February), 2007: pp Conclusions: We have shown that the commercially available shoulder external rotation braces evaluated in this study vary in (1) ability to achieve and maintain a desired position of external rotation of the shoulder, and (2) comfort ratings. -
24 Incorrect Application! No off-loading on shoulder
25 Ultrasling is the better soft brace in achieving ER and best in patient compliance The Journal of Arthroscopic and Related Surgery, Vol 23, No 2 (February), 2007: pp
26 The Journal of Arthroscopic and Related Surgery, Vol 23, No 2 (February), 2007: pp Amount of External Rotation Required The ideal amount of external rotation required to achieve the beneficial effects of glenohumeral joint external rotation for Bankart lesion coaptation is unknown In the only published clinical trial reported 10 of external rotation A cadaveric study of the bone soft tissue interface at a simulated Bankart lesion indicated increasing contact area and pressure with increasing amounts of external rotation up to 45 Additional studies are warranted in this area to better define the ideal range of immobilization in external rotation
27 Rotator Cuff Repair When a Rotator Cuff Tendon tears a surgeon will repair or reattach the tendon to the Greater Tuberosity of Humerus. The use of an abduction immobilizer is currently widely used because of evidence suggesting that vascularization is improved and tension on the repaired tendon(s) is minimized in this position. 40 Ultrasling III/AB diminishes strain on the tendons during recovery Olivier A. Int J Sports Phys Ther April; 7(2):
28 Rotator Cuff Repair Sample Protocol Immobilization: Amount of abduction depends on tear and what is required to keep tension on repair at a minimum In the early post-op period abduction pillow helps decrease pain even in low tension tears. Abduction pillow (tension minimized with arm at degrees of abduction) Medium tears: up to 6 weeks Large tears: 6 weeks Massive tears: 8 weeks Sling only (if there is minimal tension on repair) or after transition from abduction pillow. Small tears: 1-3 weeks Medium tears: 3-6 weeks Large or massive tears: 6-8 weeks John S. Rogerson, MD, SC Orthopaedic Surgeon Wisconsin USA
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30 Indications Rotator cuff repair Bankhart procedure Post manipulation Shoulder Fusion Shoulder replacement Capsular shift Dislocation There are as many rehab protocols as the number of surgeons/pts
31 Which brace for which indication/patient? First surgery or conservative? Understand the Surgeons post-operative protocols What degrees of abduction are required? Degree of AB? Is external rotation is required? Degree of ER? Patient selection (age, weight etc) Patient compliance Demonstrate the fitting of the product Where possible ask the Surgeon/customer to try it Always do patient measurement BEFORE surgery for the rigid elbow/shoulder braces (avoid pain after surgery)
32 Competitor Products - Breg Adjustable arm sling Universal products Uncomfortable strapping No exercise ball Shoulder abduction pillow Varying degrees of abduction - 10º - 75º Inflatable air pillow (Immobilization?)
33 Competitor Products - Ossur UNI sling Universal products Uncomfortable strapping No exercise ball Unsuitable for larger patients Shoulder abduction wedge Varying degrees of abduction - 45º or 90º Wedge shape pillow No air circulation around underarm
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