Shoulder Joint Sport Injuries (Dislocation) PDF

# Athletic Shoulder Related Injuries (Shoulder Pathological Instability / Dislocation) Dr. Samiah Alqabbani DPT414 1446 ## Outlines - Relevant Biomechanics of Shoulder Dislocation Injuries - Key Assessment for Shoulder Instability - Post-Surgical Rehabilitation for Shoulder Dislocation Surgerie...

# Athletic Shoulder Related Injuries (Shoulder Pathological Instability / Dislocation) Dr. Samiah Alqabbani DPT414 1446 ## Outlines - Relevant Biomechanics of Shoulder Dislocation Injuries - Key Assessment for Shoulder Instability - Post-Surgical Rehabilitation for Shoulder Dislocation Surgeries - Return to Sport Criteria ## Shoulder Instability - The anatomical structure of the shoulder girdle permits multiplanar range of motion. As a result, it requires a balance of **stability** and **mobility** to allow functional activities, which is achieved through coordinated activity of both passive and active structures. - Instability vs. Laxity? - Laxity is a nonpathological, objective finding of capsuloligamentous integrity, concerning the degree of passive translation without associated symptoms. - Shoulder Instability is a "Pathological condition characterized by symptoms of pain and apprehension, which occur with abnormal translations of the humeral head." ## Relevant Biomechanics - The total contact surface area of the humeral head with the glenoid is about 30%, which means that the joint has limited osseous constraints so that stability is primarily provided by soft tissue components. - An individual's age plays a profound role in risk of recurrent instability, with recurrence rates upward of 85% to 95% in individuals younger than 25 years old. Activity level has been hypothesized to be an additional risk factor. - In the young athletic individual with a loose capsule and a relatively large humeral head in comparison to a shallow and small glenoid fossa, the glenohumeral joint is predisposed to anterior instability. These factors make shoulder joint extremely susceptible to anterior dislocation. - When a dislocation occurs, it usually results in a detachment of the anterior inferior labrum from the glenoid fossa, known as a Bankart lesion. - Bankart lesions occur in 87% to 100% of first-time dislocations. ## Types of Shoulder Dislocations - Glenohumeral instability is classified into two categories: traumatic and multidirectional. - **Type 1:** Atraumatic, multidirectional, frequently bilateral, responsive to rehabilitation (Borne loose). The first line of treatment for should be rehabilitation. If conservative rehabilitation fails, surgical intervention may be considered in the form of an inferior capsular shifting procedure. - **Type 2:** Traumatic unilateral lesion resulting in a Bankart lesion that usually requires surgery (torn loose). The treatment priority is surgical stabilization using an anterior labral reconstruction procedure. - A common finding following traumatic dislocation is a Hill-Sachs lesion, which is a cortical depression of the humeral head occurring when it contacts the glenoid labrum during dislocation or relocation. - The "SLAP" lesion refers to a superior labral tear occurring in an anterior to posterior direction. This type of injury is often associated with tensile overload forces frequently seen in the overhead-throwing athlete, but it may also occur because of biceps load during a shoulder dislocation. ## Traumatic Shoulder Instability - Traumatic shoulder injury can result in damage to multiple structures about the shoulder girdle, including soft tissue (muscle-tendon unit) rupture, capsular tearing, and glenoid and/or humeral head fracture. - Simonet et al showed that 82% of young athletes had recurrent dislocation compared to only 30% of nonathletes of similar age. - Acute traumatic anterior shoulder dislocations are more common than traumatic posterior dislocations. - When associated bony injury to the humeral head (Hill-Sachs lesion) is present in conjunction with anteroinferior capsulalateral disruption,**immediate surgical intervention is indicated** to restore anatomical alignment and glenohumeral joint arthrokinematics. ## Risk factors - Young age - High-demand contact sport - Previous history of ipsilateral traumatic GH dislocation - Presence of Hill-Sach lesion - Presence of Bankart lesion - Rotator cuff insufficiency (ipsilateral side) - Undetected ligamentous laxity ## Sport Specific Consideration During Rehabilitation | SPORT | SPECIFIC CONSIDERATION | | :---------- | :----------------------- | | Football | Throwing | | | Contact | | | Protection - Bracing | | Baseball | Throwing | | | Pitching | | | Hitting | | Tennis | Serving | ## Key Examination Principles - Assessing GH instability (sulcus sign) - Active and Passive ROM Assessment: The goal is to guide the athlete through extreme ranges of motion while carefully monitoring their response. - Assessing Shoulder Stability: The physical therapist should ask if the movement causes the athlete to feel as if the shoulder might slip or pop out. - Recognizing Instability Signs: If the athlete reports a sensation of "giving way" or instability, this is crucial information. - Caution During Further Examination: When such sensations occur, the therapist should proceed with caution during further assessments to avoid exacerbating potential instability. Note that if the subject is treated post surgically, active and passive ROM have specific restrictions). - Several tests are used to assess instability ## Examination - Tests for Shoulder Instability | | Patient Position | Findings | | :--- | :--- | :--- | | **Apprehension** | *(see image for patient position)* | Patient reported apprehension and/or pain | | **Relocation** | *(see image for patient position)* | Decrease in apprehension and/or pain when position force is applied | ## Surgical Intervention for Shoulder Traumatic Injury - Although shoulder dislocation is typically treated conservatively, there is a growing trend toward early surgical intervention to restore function and reduce the risk of recurrence. - A collaborative approach is essential, where the physical therapist works closely with the surgeon to guide the treatment progression based on the specific surgical outcomes and patient status. - Surgical options for shoulder stabilization may include Bankart repair, arthroscopic anterior stabilization, and SLAP repair. These procedures are aimed at restoring shoulder function and reducing the risk of recurrent dislocations. ## Phases of Post-Surgical Rehabilitation (Bankart Repair) - Shoulder instability following surgical stabilization is managed using a structured 5-phase rehabilitation protocol. - **Phase 1 (0-4 weeks post-surgery):** This phase focuses on maximum protection of the repair. The aim is to allow healing and minimize stress on the surgically repaired structures (active ROM is avoided and only passive ROM). - **Phase 2 (4-6 weeks post-surgery):** During this phase, progressive stretching and active motion exercises are introduced. The goal is to gradually restore movement while maintaining the integrity of the repair. - **Phase 3 (6-10 weeks post-surgery):** known as the minimal protection phase, the emphasis shifts toward achieving full range of motion (ROM) and initiating muscle strengthening to ensure proper shoulder function. - **Phase 4 (10-16 weeks post-surgery):** This advanced strengthening phase focuses on building muscle strength and endurance in preparation for return to sport or regular activities. - **Phase 5 (4-9 months post-surgery):** The final phase involves a gradual return to sport-specific training, ensuring full recovery and minimizing the risk of re-injury. - The specific interventions within each phase are tailored to the individual's presentation and functional status. Common interventions include ROM exercises, strength training, and progressive loading based on the patient's progress and goals. ## Phase 1 (0-4 weeks) - The first phase of rehabilitation focuses on maximum protection of the repair. Initial ROM restrictions (such as avoiding ER beyond 0°) protect the re-attachment from tensile forces that could disrupt the repair. - During the first week, the patient's glenohumeral joint is kept completely immobilized using a sling and bolster 24 hours/day, which protects the shoulder in approximately 20° of abduction in the scapular plane. - During the first postsurgical week, wrist and hand motion is started, as the patient tolerates. - Between postoperative weeks 1 and 2, modalities for pain and inflammation are utilized. - Passive shoulder ROM is allowed within the following limits: flexion up to 90°, abduction to 45°, IR to the patient's belly within the scapular plane (45°), and ER to 0°. - During the second week, wrist and hand active movement may progress to gentle strengthening and manually resisted scapular elevation and retraction are permitted. - Weeks 2 through 4 allow for increased shoulder PROM, progressing flexion up to 130°, abduction to 90°, and ER to 30° with the arm at the side of the body and to 50° with the shoulder at 45° of abduction. Internal rotation is gradually restored based on the patient's tolerance. Wrist/hand movement continues and elbow AROM is added. - Submaximal shoulder isometrics (ER, IR, abduction, adduction, flexion, and extension) begin between weeks 2 and 4. ## Phase 2 (4-6 Weeks) - Phase 2 includes progressive stretching and an active movement phase. - Between weeks 4 and 5, shoulder PROM is gradually increased in all planes of motion to patient tolerance. While restoration of full ROM is desired at 10 to 12 weeks post-surgery, it should not be achieved before then to reduce the risk of a "stretched out" repair. - Shoulder AROM goals during phase 2 are abduction to 90°, ER to 70° at 45° of abduction, and 60° at 90° of abduction. - Between weeks 5 and 6, if the patient is meeting shoulder ROM goals, the physical therapist introduces gentle progressive resistance exercises for the rotator cuff. - Progression into rotator cuff specific movements is based on ensuring that scapulothoracic control is maintained to avoid compensatory scapular elevation movement patterns. Biceps and triceps strengthening may be prescribed as well as proprioception drills emphasizing neuromuscular control between weeks 5 and 6. ## Phase 3 (6-10) - Phase 3 This is considered the strengthening phase of the rehabilitation protocol. - The physical therapist must closely monitor the patient for compensatory movement patterns. - Early, uncontrolled compensatory scapulothoracic substitution patterns delay the ability to generate forces through the rotator cuff, resulting in delayed strengthening and probable delayed return to sport. ## Phase 4 (10-16) - The fourth phase involves advanced strengthening and plyometric activities in addition to continuation of the previously prescribed parascapular and rotator cuff specific strengthening, that typically include CKC activities within a protected ROM. - By weeks 10 and 12, shoulder AROM is gradually increased to normal end-range goals. Rotator cuff and scapular strengthening exercises are advanced within bio-mechanically correct movement patterns, Proprioception and closed kinetic chain (CK) neuromuscular control drills are progressed according to the patients abilities and continually advanced as ROM is restored. - While the third and fourth phases of rehabilitation have some inherent overlaps in goals and interventions, activity progression is dependent on how the athlete progresses. - For example, to avoid compression forces to the anterolateral joint surfaces that could aggravate the repair, the therapist encourages the athlete to avoid midline crossover movements. - CKC activities may include wall push-up progressions, seated serratus press-ups with strict control of biomechanically correct movements. The most common compensatory movement pattern involves early scapular elevation concurrent with glenohumeral flexion or abduction resulting in a "shrugging" type movement pattern. - Plyometric and advanced CKC exercises are initiated such as Plyoball wall drills and 1-arm rebounder drills ## Phase 4 (10-16) - Between 10 and 12 weeks post surgery, shoulder ROM goals should be focused on achieving 5° short of full flexion and ER as compared to uninvolved shoulder. - External rotation (at 90° abduction) should be limited to 90° and not overstretched. - Internal rotation (at 90° abduction) should be approximately 10° short of the uninvolved shoulder. - Because stretching will continue to occur over time, it is desirable to leave the Bankart-repaired shoulder just short of full end-range movement during rehabilitation. - At week 12, the athlete may begin gym-based strengthening 3 to 4 times per week. - Typical exercises include seated rowing, front latissimus pull-downs, and biceps and triceps strengthening. Dumbbell chest press may be performed with the patient sitting on the ground and avoiding crossing the midline of the body. ## Phase 5 (post 16-weeks) - The final rehabilitation phase, known as the return to activity phase, begins 4 months following an anterior stabilization procedure. - The criterion to progress into the final phase is based on obtaining full shoulder active and passive ROM and strength equivalent to 90% of the contralateral side. - The goals of this phase are to gradually progress sports activities to unrestricted participation. - It is during this phase that interval-based programs are prescribed and increased intensity. - The decision for full, unrestricted clearance to sport is based on performance of functional testing such as the upper extremity stability test. ## Closed Kinetic Chain Upper Extremity Stability test - Assess glenohumeral, scapular, and core stability through endurance, based closed-chain dynamic movement. - Place two lines on floor at distance of 3 ft apart. Patient assumes push-up position and moves hands alternately back and forth between lines as fast as possible. Number of taps recorded at 15 and 30 s ## ER more than 90 - Assess posterior rotator cuff endurance before and after sport-specific training - Patient stands facing wall. Anchor resistance band to wall at patient's head height. - Patient holds band with involved arm in 90° abduction. Patient rotates band to end-range ER while maintaining abducted position ## Rehabilitation Consideration - Summary - Considering the extent of surgical stabilization required for overhead athlete, a conservative return-to-activity program is recommended. - The first phase emphasizes pain control, protection of surgical repair to promote tissue healing, and normalization of ROM and neuromuscular control. - The second phase progresses the athlete to activities focused on re-establishing coordinated upper extremity movement and muscular endurance. ## Rehabilitation Consideration - Summary - At 4 months postsurgical stabilization, the physical therapist would expect athlete to present with full, pain-free active ROM without compensation patterns, good scapular control during motion and strengthening activities, and the ability to perform all prescribed strengthening exercises with little to no pain (2/10 on the visual analog scale) - The Third Phase of rehabilitation should emphasize enhancing glenohumeral and scapular muscular endurance, as well as overall neuromuscular control of the shoulder girdle during sport-specific movement patterns and positions. ## Rehabilitation Consideration - Stressors - It is essential that the physical therapist carefully considers, modifies, and monitors the stresses placed on each reconstructed tissue to ensure protection of the surgical repair while promoting progression in functional ability. - Following anterior stabilization, the anteroinferior capsule is most notably stressed when the shoulder is placed in ER above 90° of abduction. Therefore, ER motion must be obtained systematically following an intentional progression, particularly for an overhead athlete who requires this mobility for sport. - In the earlier rehabilitation phases, the athlete demonstrated the necessary physical performance, including functional motion, muscular strength and endurance, and appropriate body control. As the athlete is preparing for return to his sports, it is appropriate to begin stressing these tissues in overhead ranges of motion. ## Objective Performance-Based Tests for Return to Sport | Test | Return to play performance criteria | | :--- | :--- | | ER > 90° | Pre-throwing session: 1 min of repetitions with medium-resistance elastic band. Post-throwing session: 30 s of repetitions with medium-resistance elastic. There should be no loss in timing or control during repetitions. | | Closed Kinetic chain upper extremity stability test (CKCUE; Hand tap test) | 15 s: 18 taps (male), 20 taps (female). 60 s: 90 taps | | Shoulder dyskinesia test | Normal or only subtle dyskinesia following throwing session | ## Criteria for Return to Play | DOMAIN | EXPECTED OUTCOME | | :---------------- | :---------------------------------------------------------------------- | | pain | No pain at rest | | ROM | Full, pain free rotational ROM | | Strength | MMM 5/5 in all – handheld dynamometer >= 90% of uninvolved UE following throwing session | | Muscle performance | ER/IR 2:3 ration : strength of ER should be at least 2/3 the strength of IR of the same UE | | Scapular stability | Open chain: normal or subtle scapular dyskinesis during shoulder elevation with 3-Ib dumbbells for 10 repetitions. Closed chain: 90 repetitions in 1 min on CKCUE stability test| | Outcome measure | Disability of the arm, shoulder, and hand (DASH) outcome. Measure: < 5% disability. DASH-sport; < 10% disability| ## Evidence Based Practice ## Return to Play After Shoulder Instability Surgery in National Collegiate Athletic Association Division 1 Intercollegiate Football Athletes (2017) - Overall Return to Play (RTP): 85.4% of players who underwent arthroscopic surgery without additional procedures **returned to play.** - **Subsequent Injuries:** - 15.6% of athletes who returned to play sustained subsequent shoulder injuries. - 10.3% experienced recurrent instability, resulting in further surgery. - **RTP by Type of Repair** - Anterior labral repair: 82.4% RTP. - Posterior labral repair: 92.9% RTP. - Combined anterior-posterior repair: 84.8% RTP. - Open repair: 88.9% RTP. - **RTP by Player Utilization:** - 93.3% of starters returned to play. - 95.4% of regularly utilized players returned to play. - 75.7% of rarely used players returned to play. - **Game Participation:** - Percentage of games played increased from 49.9% before the injury to 71.5% after surgery. - Athletes who played more games before the injury were more likely to return to play. - 91% of athletes who were starters before the injury returned as starters post-surgery. - **Scholarship Status:** Significantly correlated with RTP outcomes. ## High Rate of Return to Sport in Adolescent Athletes Following Anterior Shoulder Stabilization: A Systematic Review (2019) - This systematic review analyzed 11 studies involving 461 adolescent athletes, with a mean age of 15.7 years and an average follow-up of 48.8 months. Key findings include: - **Procedures:** 392 patients (400 shoulders) underwent arthroscopic Bankart repair, while 69 patients had open procedures. - **Rehabilitation Outcomes:** - 81.5% of athletes returned to pre-injury levels of competition at an average of 5.3 months post-surgery. - The overall recurrence rate of instability was 18.5%, with a 12.1% rate of revision surgery. - **Risk Based on Sport Type:** - Contact athletes had a 31.1% recurrence rate and 13% underwent revision surgery. - Collision athletes showed a lower incidence, with a 10.4% recurrence rate and 1.4% requiring revision surgery. ## Return-to-Sport Criteria After Upper Extremity Surgery in Athletes - A Scoping Review, Part 1: Rotator Cuff and Shoulder Stabilization Procedures (2021) - This review included 52 studies with a total of 2,706 athletes (2,206 male, 500 female) with a mean age of 28.8 years. The studies were divided into two groups: 14 studies in the Rotator Cuff Surgery (RCS) group and 38 studies in the Shoulder Stabilization Surgery (SSS) group. Key findings include: - **Return to Sport (RTS) Criteria:** - Time from surgery was the most commonly reported RTS criterion, featured in 71% of studies, including 93% in the RCS group and 63% in the SSS group. - Muscle strength (48%) and range of motion (44%) were frequently reported criteria in nearly half of the studies. - Less commonly reported criteria included absence of pain, completion of sport-specific tests, proprioception, radiographic evaluation, patient-surgeon agreement, pain-free throwing, and satisfactory scapulothoracic mechanics. - The conclusion highlights that time since surgery is the most commonly reported return-to-sport (RTS) criterion after rotator cuff or shoulder stabilization surgery in athletes, while muscle strength and range of motion are also frequently used. However, there is significant variation in how RTS criteria are defined and applied across studies. This suggests a need for clearer, more standardized quantitative and qualitative RTS criteria to ensure a safe return to sport for athletes undergoing these procedures. ## Summary - The physical therapist should consider involved tissues, healing time, and specific imposed demands of the desired sport in forming the treatment plan (StARTT). - Following arthroscopic anterior stabilization of the shoulder rehabilitation with return-to-sport goals must include intentional planning and thorough communication of appropriate timelines and criteria for advancement. - The physical therapist should consider involved tissues, healing time, and specific imposed demands of the desired sport in forming the treatment plan. - Careful application of return-to-sport criteria and adherence to protocols are essential for safe progression through the rehabilitation process. ## References - Robins, R. Judd, et al. "Return to play after shoulder instability surgery in National Collegiate Athletic Association Division I intercollegiate football athletes." The American journal of sports medicine 45.10 (2017): 2329-2335. - Kasik, Connor S., et al. "High rate of return to sport in adolescent athletes following anterior shoulder stabilisation: a systematic review." Journal of ISAKOS 4.1 (2019): 33-40. - Griffith R, Fretes N, Bolia IK, et al. Return-to-Sport Criteria After Upper Extremity Surgery in Athletes—A Scoping Review, Part 1: Rotator Cuff and Shoulder Stabilization Procedures. Orthopaedic Journal of Sports Medicine. 2021;9(8). doi:10.1177/23259671211021827