Rehabilitation for MDI in the Female Athlete John Dale PT, DPT, SCS, ATC, CSCS Andrew Naylor PT, DPT, SCS
Disclosure No relevant financial relationship exists
Session Learning Objectives Discuss etiology of multidirectional shoulder instability in the female athletes Identify rehabilitation techniques for this population Review outcomes of rehabilitation vs surgery
Definition/Anatomy Symptomatic instability of the GH joint in more than one direction, one of which is inferior More severe cases have been reported in female patients Capsular redundancy is a predisposing factor Increased laxity of the inferior capsular pouch and a defective capsular rotator interval Raynor et al. Am J Sports Med. 2016
Multidirectional Instability Often described as apprehension or inability to perform specific tasks May not be related to a traumatic event If traumatic, often a subluxation versus a complete dislocation Multifactorial etiology involving anatomical, biochemical, and neuromuscular abnormalities
Instability Joint Examination Joint mobility assessment Normal vs Pathological Load and shift test Sulcus sign Apprehension Test 52% sens, 99% spec PPV 97.9%, NPV 72.8% Relocation Test 45.8% sens, 54.4% spec PPV 43.9%, NPV 56.3% Surprise Test 63.9% sens, 98.9% spec PPV 98.2%, NPV 77.9% Clustering improves accuracy Merolla G et al. Eur J Orthop Surg Traumatol. 2015
Scapular Weakness/Dyskinesia SICK Scapula Scapular malposition Inferior medial border prominence Coracoid pain/malposition DysKinesis of scapular mvmt Scapular Assistance Test Increased winging with IR Separation with Weightbearing Movement faults compared to other side
Treatment Rest Control Inflammation Modify Usage Treatment Medical Rehabilitation Return to play RTP Interval Sport Program Local vs Global Stabilization Dynamic Stabilization/Proprioception Scapular/RTC Strength Maintain/Restore ROM
Soft Tissue Mobilization Posterior Shoulder Inc in IR and Horiz Add ROM post tx 40-80s of treatment Laudner K et al. IJSPT. 2014 Latissimus Dorsi Subscapularis Al Dalah J Phys Ther Sci. 2014 Pec Major/Minor Serratus Anterior Upper Trapezius Laudner et al. IJSPT. 2014
Strengthening Exercises Improve strength Build Endurance Improve neuromuscular activation Can be used post-performance to fatigue out muscles after sport Can be used pre-performance for warm up Warm-up to throw, don t throw to warm up! Wilk KE and Macrina LC. Oper Tech Sports Med 2014
Scapular Stabilization
Neuromuscular Reeducation Sequencing of movement Prone I s T s Y s Tactile Cuing Visual Feedback Taping Kinesio/McConnell Posture shirts Addresses: Sport specific movements Varied rate of movement Kinesthetic feedback Unexpected change in environment Wilk KE and Macrina LC. Oper Tech Sports Med 2014
PNF Patterns/Manuals Scapular Elevation/Depression Protraction/Retraction Manual Resistance Exercise Serratus Punch D2 Pattern Sidelying ER Prone Exercises
Manual Rhythmic Stabilization Local Stabilizations Varied Positions Early phase on table Late phase in ½ kneeling or athletic stance Eyes open and eyes closed Additional weights or bands Varied times to build endurance Find the weakness in range of motion
Closed Chain Stability
Proprioception Drills
Local vs Global Stabilization Lumbopelvic Control Core Control Scapulothoracic stability Glenohumeral stability Reinold MM and Curtis AS. J Int Sports Phys Ther. 2013
CKCUES Test 108 subjects with and without SIS for reliability testing Each performed 4 reps, last 3 for stats CKCUES showed excellent reliability Scores greater in active vs. sedentary and SIS MDC ~2.05-3.91 touches
Ability of subjects with MDI to use proprioception to complete UE repositioning tasks was evaluated. 12 subjects with MDI and 12 controls No error was seen between were blindfolded and asked to reproduce symptomatic and asymptomatic limbs a self selected target position in the MDI group 10 reps completed 3D motion analysis was used to track position and error Subjects with MDI showed significantly greater hand position error than control subjects Subjects with MDI may have reduced capacity to use proprioception to refine and control movement.
4 studies met inclusion criteria Exercise was favored over surgery for patient reported outcome measures Surgery was favored for impairment outcome measures Concluded the effect of exercised-based management compared to surgery for MDI is difficult to determine due to participant heterogeneity and bias across studies Warby SA et al. J Shoulder Elbow Surg 2014
Purpose: to determine outcomes of capsulorrhaphy with suture anchors in males and females and those with traumatic vs atraumatic onset. Cohort Study, prospective collection, retrospective review Outcomes: Intraoperative findings Level of sports participation Patient satisfaction ASES, SANE, DASH, and SF-12 PCS scores Return to sport 41 patients (25 male, 20 female) Atraumatic 22, Traumatic 23 shoulders 64% had labral tears 16.7% experienced instability post op Conclusion: APC with suture anchors effective and safe for patients with MDI. Labral tears found even in patients with classic atraumatic onset Male patients and those with traumatic onset had more favorable outcomes. Females may be more challenging with post operative subluxations and need for rotator cuff interval procedures
Take Home Points Patience and completeness of rehabilitation program Address scapular AND rotator cuff function Balance open and closed kinetic chain stabilization Complete core and full body movement skills Surgery a good option AFTER failure of rehab
References Warby SA et al. The effect of exercise-based management for multidirectional instability of the glenohumeral joint instability: a systematic review. J Shoulder Elbow Surg; 2014(23): 128-142. Johansson K. Multidirectional instability of the glenohumeral joint: an unstable classification resulting in uncertain evidence based practice. Br J Sports Med. 2016; 50(18): 1105-6. Raynor MB et al. Outcomes after arthroscopic pancapsular capsulorrhaphy with suture anchors for the treatment of multidirectional glenohumeral instability in athletes. Am J Sports Med. 2016; epub ahead of print. Reinold MM and Curtis AS. Microinstability of the shoulder in the overhead athlete. Int J Sports Phys Ther. 2013; 8(5):601-615. Kibler BW and Sciascia A. The role of the scapula in preventing and treating shoulder instability. Knee Surg Sports Traumatol Arthrosc. 2016; 24:390-397. Bahu MH et al. Multidirectional instability: evaluation and treatment options. Clin Sports Med. 2008; 27:671-689. Beasley L et al. Multidirectional instability of the shoulder in the female athlete. Clin Sports Med. 2000; 19(2): 331-349. Barden JM et al. Dynamic upper limb proprioception in multidirectional shoulder instability. Clin Orthop. 2004; 420:181-189. Wilk KE and Macrina LC. Rehabilitation for patients with posterior instability and multidirectional instability. Oper Tech Sports Med. 2014; 22: 108123. Merolla G et al. Multidirectional instability of the shoulder: biomechanics, clinical presentation, and treatment strategies. Eur J Orthop Surg Traumatol. 2015; 25: 975-985. Tucci et al. Closed Kinetic Chain Upper Extremity Stability Test: a reliability study in persons with and without shoulder impingement syndrome. BMC Musculoskeletal Disorders. 2014; 15: 1-9. Laudner et al. Acute effects of instrument assisted soft tissue mobilization for improving posterior shoulder range of motion in collegiate baseball players. Int J Sports Phys Ther.. 2014; 9(1): 1-7.