Anterior Shoulder Dislocation

Jerod Miller

Overview

Condition Overview Case information Surgical decision Immobilization Therapeutic Exercise Phases Results References

Condition Overview

Glenohumeral joint is the most dislocated joint in the body1

90-98% of shoulder dislocations are in the anterior direction1

Most important factor influencing recurrent dislocation was being within the ages of 21-30 years Patients who perform in high contact

sports within this age range should seek surgical stabilization surgery.2

Case Information

Patient is 27 year old male Professional basketball player Recently had third recurrent

dislocation of left shoulder during basketball play

Has come to physical therapy after surgical stabilization using a Latarjet procedure.

Surgical Decision3

Patients are predisposed to recurrent dislocation if they are of young age, have a bony defect, have a history of recurrence, and have an active lifestyle These are relative indications for bony

augmentation

Surgical Decision3

Latarjet Procedure Procedure includes the severing of coracoid

process, including the tendons of coracobrachialis and short head of biceps brachii, feeding of the bony piece and tendons through a horizontal cut of the subscapularis tendon, and then attaching the bone to the anterior portion of the glenoid.

Originally open surgery but is changing to arthroscopic

Show very low rates of recurrence after procedure

Immobilization4

Patient was immobilized in an adducted and internally rotated position Shown to be just as effective as

immobilization in abduction and external rotation but less obtrusive to patient.

Examination and Evaluation Significant swelling of shoulder region PROM assessed goniometrically of shoulder abduction,

extension, internal rotation, external rotation, and flexion. Compared bilaterally. Left shoulder abduction: 0-100 Left shoulder internal rotation: 0-30 Left shoulder external rotation: 0-20 Left shoulder flexion: 0-100 Left shoulder extension: 0-30 Right Shoulder abduction: 0-180 Right shoulder internal rotation: 0-70 Right shoulder external rotation: 0-90 Right shoulder flexion: 0-180 Right shoulder extension: 0-60

MMT not performed so as to protect the newly surgically repaired soft tissue.

Plan of Care

Phase one: tissue repair (1-4 weeks) Phase two: PROM and AROM (5-8

weeks) Phase three: Strength focused (8-12

weeks) Phase four: Functional Training (12+

weeks)

Phase One: Tissue Repair5,6,7,8

First 1 to 4 weeks concerned with protecting healing tissue while maintaining joint PROM, reducing swelling, and maintaining lower arm blood flow and musculature. Ranging of shoulder abduction, flexion, extension, IR, and

ER 3 times daily for 5 repetitions through tolerated ROM▪ Extra attention should be placed on not stressing anterior capsule

Stimulating exercises for distal joints▪ Ball squeezes 3 sets, 10 reps▪ Elbow extension/flexion and wrist flexion/extension,

supination/pronation, and radial/ulnar deviation AROM 3 sets 10 reps

Ice should be used as needed for swelling Patient immobilized constantly

Phase Two: PROM and AROM5,6,7,8

Now that tissue is adequately healed, exercises progress to stretching to increase PROM and begin AROM training Stretching of shoulder abduction, flexion,

extension, IR, ER for 3 sets of 30 seconds per day AROM of flexion, extension, abduction, ER, and IR

of the left shoulder 3 sets of 5 repetitions per day Continue with same distal UE stimulating

exercises and icing. Patient should begin to wean off of

immobilization

Phase Three: Strengthening5,6,7,8

Patient has regained PROM WNL and focus shifts to strengthening AROM for Left shoulder flexion, extension, internal

rotation, external rotation, and abduction for 5 repetitions of full AROM every day.

Isometric exercises for shoulder abduction, flexion, extension, IR, and ER using correct breathing patterns for 20 seconds for 5 reps every day. ▪ These exercises will progress to dynamic strengthening

exercises involving therabands, dumbbells, and cable machines as the patient achieves adequate isometric strengthening and joint stability.

Phase Four: Functional Training5,6,7,8,

The focus of this stage is to retrain the individual specifically to regain skill, strength, and stability during activities directly related to occupation or desired activity outcomes.

In this case: Starting with non-contact basketball

skills▪ Shooting, dribbling, running down court

Progression should focus on increasing speed, intensity and eventually full contact play

Results

If proper progression and safety is followed ensuring that recurrent dislocation does not happen, patient should regain ADL abilities and return to full contact play or occupational responsibilities.

With Latarjet procedure Low amounts of recurrent dislocations

because of new bony barrier3

References

1. Emedicine.medscape.com. Shoulder Dislocation Surgery: Background, Epidemiology, Etiology. 2015. Available at: http://emedicine.medscape.com/article/1261802-overview#. Accessed July 29, 2015.

2. Kralinger F, Golser K, Wischatta R, Wambacher M, Sperner G. Predicting recurrence after primary anterior shoulder dislocation. The American Journal Of Sports Medicine [serial online]. 2002;(1):116. Available from: General OneFile, Ipswich, MA. Accessed July 29, 2015.

3. Dumont G, Fogerty S, Rosso C, Lafosse L. The arthroscopic latarjet procedure for anterior shoulder instability: 5-year minimum follow-up. The American Journal Of Sports Medicine [serial online]. 2014;(11):2560. Available from: General OneFile, Ipswich, MA. Accessed July 29, 2015.

4. Whelan D, Litchfield R, Wambolt E, Dainty K. External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial. Clinical Orthopaedics And Related Research[R] [serial online]. 2014;(8):2380. Available from: Academic OneFile, Ipswich, MA. Accessed July 29, 2015.

5. Shi L. Anterior Stabilization Of The Shoulder: Latarjet Protocol. 1st ed.; 2015. Available at: https://shoulder.uchicago.edu/sites/shoulder.uchicago.edu/files/uploads/Latarjet.pdf. Accessed June 14, 2015.

6. Capeci C. Rehabilitation Protocol: Latarjet Coracoid Process Transfer. 1st ed.; 2015. Available at: http://www.craigcapecimd.com/pdf/shoulder/latarjet-coracoid-transfer-rehab-protocol.pdf. Accessed June 14, 2015.

7. Atlanta Sports Medicine. Latarjet Protocol. 2011. Available at: http://atlantasportsmedicine.com/latarjet-protocol/. Accessed June 14, 2015.

8. Rehabilitation Guidelines For Anterior Shoulder Reconstruction With Arthroscopic Bankart Repair. 1st ed.; 2015. Available at: http://www.uwhealth.org/files/uwhealth/docs/sportsmed/SM_bankart_repair.pdf. Accessed June 14, 2015.