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Biomechanics/Anatomy
Home Shoulder Labral Tear Meniscal Injury Achilles Tendon Rupture ACL Tear Anterior Glenohumeral Instability Plantar Fasciitis Rotator Cuff Tear Ulnar Nerve Transposition
http://www.mountnittany.org/articles/healthsheets/6918 The Glenohumeral joint is similar to a golf ball and tee in structure. It allows for a large arc of movement that leaves it susceptible to instability. Laxity is normally asymptomatic and is a physiologic motion that is necessary for proper glenohumeral movement while instability is an abnormal symptomatic motion of the glenohumeral joint. Stability as well as mobility of the glenohumeral joint is provided through static and dynamic stabilizers. Static stabilizers include capsular ligaments, the glenoid labrum, articular cartilage surface contact forces, and negative intra-articular pressure. The ligaments that are responsible for stability are the superior glenohumeral ligament (SGHL), the middle glenohumeral ligament (MGHL), and the inferior glenohumeral ligament (IGHL). The SGHL limits anterior and inferior translation of the humerus when adducted. The MGHL limits anterior translation in the mid-range of shoulder abduction. The IGHL is the primarily responsible for limiting anterior subluxation of the humeral head when the shoulder is abducted beyond 45°. Dynamic stabilization is provided by the rotator cuff muscles which add a compressive effect as well as the long head of the biceps and the muscles that stabilize the scapula.
Mechanism of Injury Instability can be classified based on frequency, etiology, direction and degree. Anterior instability is the most common type of instability, accounting for roughly 90% of all dislocations. The rate of incidence increases for men as well as contact athletes. The mechanism responsible for an anterior dislocation is a forced external rotation and abduction of the humerus. This is most often seen in athletes that reach up to block a pass as in basketball or football. Microtrauma of the shoulder can be caused by repetitive overhead activities. A fall onto an elevated outstretched arm and a direct force to the posterior humeral head also account for mechanisms of injury.
http://bleacherreport.com/articles/475243-sabans-alabama-is-ranked-1-but-dont-dismiss-urban-meyers-florida-gators
Signs and Symptoms Obtaining an accurate diagnosis of glenohumeral instability can be difficult, therefore several points must be considered when assessing the patient. A thorough history and clinical examination are necessary as radiographs typically do not provide additional information. Asymptomatic shoulder laxity must be differentiated from symptomatic instability. Other pathological conditions may be present, such as rotator cuff impingement. No single test may be used to diagnose glenohumeral instabilities. A thorough subjective evaluation will assist the examiner in identifying the often vague symptoms associated with nontraumatic glenohumeral instability. Symptoms may include activity related global pain, aching, looseness and reports of slipping of the joint. Transient neurological symptoms may be reported and must be differentiated from cervical radiculopathy and thoracic outlet syndrome. Anterior instability may be present with pain with overhead activities or when the shoulder is in an abducted and externally rotated position. Patients with glenohumeral instability often present with scapular dyskinesia, including winging and protraction. Inspection of both shoulders is necessary to identify differences between the symptomatic and asymptomatic sides. The examination should begin with the asymptomatic shoulder. Ligamentous hyperextensibility should be assessed using the Beighton scale. A score ≥ 4 out of 9 indicates generalized joint laxity.
Orthopedic tests used to identify laxity may not be used alone to diagnose instability. It is the replication of the patient’s sense of instability that differentiates asymptomatic laxity to laxity with instability. The sulcus sign is used to assess inferior laxity. Laxity may be graded according to the inferior translation of the head of the humerus. Movement < 1cm is graded as 1, 1-2 cm movement is graded as 2 and > 2 cm is graded as 3.
The presence of pain, dysesthesia or apprehension with the sulcus sign may indicate instability. Anterior laxity may be assessed with passive external rotation. The presence of passive external rotation >90 indicated hyperlaxity. The load and shift test and the anterior and posterior drawer tests examine the amount of translation present when the ligaments are not under tension.
Provocation tests such as the anterior apprehension test , the relocation test and the posterior apprehension test may be more sensitive since they replicate the patient’s symptoms with instability.
Treatment: Duration-how long would you typically see this patient? Depends on severity of the instability and whether or not there was a surgical intervention Non-surgical: 6-8 weeks, Surgical: 12 weeks Protocols
Aronen & Regan Noted a lack of regimented protocols for treatment of shoulder instabilities at the time Looked at 20 male members of the Navy with acute primary anterior shoulder dislocations Put subjects through a specific strengthening program emphasizing IR and shoulder adduction After 3 years the subjects had a 75% success rate, that is, only 25% experienced re-injury Re-injury occurred at a rate of 50-90% in non-surgical patients then, which is similar to current rates. Wilk et al note the following 7 factors to consider when treating shoulder instability: 1) Onset of the pathology 2) Degree of instability 3) Frequency of dislocation 4) Direction of the instability 5) Concomitant pathologies 6) End range muscular control 7) Premorbid activity level Conservative Anterior Instability Protoco… Details Download 103 KB
Post Surgical Protocol.pdf Details Download 27 KB
Non operative Rehabilitation for Traumat… Details Download 496 KB Conservative Protocol: (Dutton) PHASE I Goals Reestablish non-painful ROM Retard muscle atrophy Avoid placing anterior capsule under stress (abduction and ER) Shoulder hyperextension is contraindicated Interventions: ROM Exercises Pendulums Circumduction Rope and Pulley: Flexion, AB to 90 L-Bar: Flex, AB, IR with arm in scapular plane, ER w/ arm in scap plane( progress arm to 90 AB as tolerated) Posterior capsule stretching: sleeper Upper extremity ergometer Strengthening exercises Isometrics: Flex, AB, Ext, IR (multi angles), ER (scapular plane) Weight-shifts (closed chain exercises) Criteria for progression to Phase II Full ROM, minimal pain/tenderness, “Good” MMT of IR, ER, Flex, & AB PHASE II Goals Regain and improve muscular strength Normalize arthrokinematics Improve neuromuscular control of shoulder complex Interventions Initiate isotonic strengthening Flexion, AB to 90deg, IR, Sidelying ER to 45deg, Shoulder shrugs, Ext, Hor AD, Supraspinatus, Push-ups Initiate Eccentric (Theraband) exercises at 0deg AB IR, ER Normalize arthrokinematics of the shoulder complex Continue joint mobilization Patient education of mechanics and activity modification of activity/sport Improve neuromuscular control of shoulder complex Initiation of PNF Rhythmic stabilization drills Continue use of modalities (as needed): Ice, electrotherapy Criteria for progression to Phase III Full non-painful ROM, no palpable tenderness, continue progression of resistance exercises Multiple protocols call for dynamic RTC strength of 80% of unaffected side prior to beginning practical overhead activities. PHASE III Goals Improve strength Improve neuromuscular control Prepare patient/athlete for activity Interventions Continue use of modalities Continue posterior capsule stretching Continue isotonic strengthening (progressive resistance exercises) Continue eccentric strengthening emphasize PNF Initiate Isokinetics Flex-Ext, AB-AD,IR-ER, Hor AB-AD Initiate plyometric training Theraband, Wall push-ups, Medicine ball, Boxes Initiate Military Press Precaution-avoid excessive stress on anterior capsule Criteria for progression to Phase IV Full ROM, No pain/tenderness, Satisfactory isokinetic test, Satisfactory clinical examination Phase IV/Return to activity Goals Maintain optimal level of strength , power, and endurance Continue all exercises as in phase III Continue posterior capsule stretches Continue modalities as needed Follow-up: isokinetic test, Progress interval program, Maintenance of exercise program EXERCISES Isometric exercises. Flexion, extension, internal rotation, external rotation, abduction, adduction. Isotonic exercises– Flexion in supine, then standing, abduction (thumb up), external rotation while lying on opposite side, external rotation while prone, internal rotation with theraband, wall push-ups, biceps curl) Perform with free weights only (No theraband - except IR #6). Repetitions – 20-50 reps before adding/progressing in weight. Start against gravity without weight; progress as tolerated to: 2 oz. (dinner knife) 4 oz. (tuna can) 8 oz. (soup can) 1 lb. weight 2 lbs., 3 lbs., etc. Goals: Overhead athlete: 3-5 lbs x 50 reps. General rehab candidate: 1-3 lbs x 30-50 reps. Progress weight as tolerated – pain free Scapular stabilization exercises– Scapular retraction, scapular depression, extension, horizontal abduction, Scapular clocks Proprioception (countertop), Proprioception (wall), wall push-ups, Proprioception (hands and knees). Stand Up Paddling Fitness with Suzie Cooney - Core Workout
Stand Up Paddling Fitness with Suzie Cooney - Core Workout http://www.naishsurfing.com/2012/sup-fitness-more-on-the-core.html Recall the Reinold study(thanks Allison) found the following shoulder exercises most beneficial: Supraspinatus: Full can Infraspinatus/Teres Minor: SLER Subscap: IR at 0 Serratus: Pushup plus Lower trap: Prone full can Middle trap: Prone Row Upper trap: Shrug Rhomboids/levator: Prone row Surgical Intervention: (per Handoll H.H., et al’s systematic review) Patient's