Recurrent Shoulder Recurrent Shoulder DislocationDislocation

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Anatomy of the ShoulderAnatomy of the Shoulder

Shoulder DislocationsShoulder Dislocations

Case StudyCase Study

Rehabilitation Pick ListRehabilitation Pick List

Anatomy of the ShoulderAnatomy of the Shoulder

ArticulationsArticulations

SternoclavicularSternoclavicular

AcromioclavicularAcromioclavicular

ScapulothoracicScapulothoracic

GlenohumeralGlenohumeral

Anatomy of the ShoulderAnatomy of the Shoulder

LigamentsLigaments

Where?Where?What?What?

SternoclavicularSternoclavicular

Anatomy of the ShoulderAnatomy of the Shoulder

LigamentsLigaments

Where?Where?What?What?

Acromioclavicular Acromioclavicular

Anatomy of the ShoulderAnatomy of the Shoulder

LigamentsLigaments

Where?Where?What?What?

GlenohumeralGlenohumeral

Anatomy of the ShoulderAnatomy of the Shoulder

Joint CapsuleJoint Capsule

LooseLooseUnrestricted ROMUnrestricted ROMReinforcedReinforced

Anatomy of the ShoulderAnatomy of the Shoulder

ArticularArticular CartilageCartilage

Covers joint surfacesCovers joint surfacesDeepens glenoid Deepens glenoid fossafossaMinimizes loads and stressMinimizes loads and stress

Anatomy of the ShoulderAnatomy of the Shoulder

Glenoid LabrumGlenoid LabrumDense, fibrous structureDense, fibrous structureOvalOvalDeepens glenoid Deepens glenoid fossafossaStabilityStability

Anatomy of the ShoulderAnatomy of the ShoulderMusculatureMusculature

Motions?Motions? *Stability*StabilityFlexionFlexionExtensionExtensionAbductionAbductionAdductionAdductionHorizontal AbductionHorizontal AbductionHorizontal AdductionHorizontal AdductionInternal RotationInternal RotationExternal RotationExternal RotationCircumductionCircumduction

Anatomy of the ShoulderAnatomy of the ShoulderMusculatureMusculature

Acting on the HumerusActing on the HumerusAnterior Anterior

Pectoralis MajorPectoralis MajorBiceps Biceps BrachiiBrachiiCoracobrachialisCoracobrachialisDeltoidDeltoid

PosteriorPosteriorDeltoidDeltoidTeresTeres MajorMajorLatissimusLatissimus DorsiDorsiTriceps Triceps BrachiiBrachii

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Anatomy of the ShoulderAnatomy of the Shoulder

MusculatureMusculature

Acting on the ScapulaActing on the ScapulaAnteriorAnterior

SerratusSerratus AnteriorAnteriorPectoralis MinorPectoralis Minor

PosteriorPosteriorLevatorLevator ScapulaeScapulaeTrapeziusTrapeziusRhomboideusRhomboideus MajorMajorRhomboideusRhomboideus MinorMinor

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Anatomy of the ShoulderAnatomy of the Shoulder

MusculatureMusculatureRotator Cuff Rotator Cuff

Anatomy of the ShoulderAnatomy of the Shoulder

BursaeBursae

SubacromialSubacromial

Anatomy of the ShoulderAnatomy of the Shoulder

Nerve and Blood SupplyNerve and Blood Supply

Brachial plexusBrachial plexusC5C5--T1T1

SubclavianSubclavian arteryartery

Anatomy of the ShoulderAnatomy of the Shoulder

Nerve and Blood SupplyNerve and Blood Supply

Shoulder DislocationsShoulder Dislocations

Dislocation vs. Dislocation vs. SubluxationSubluxation??

Shoulder DislocationShoulder Dislocation

Fast FactsFast Facts50 % of ALL dislocations50 % of ALL dislocations95 % anterior95 % anterior85 % caused by trauma recur85 % caused by trauma recur

Shoulder DislocationsShoulder Dislocations

Mechanism?Mechanism?Anterior vs. posteriorAnterior vs. posterior

Forced abduction, external rotation, extensionForced abduction, external rotation, extensionForced adduction, internal rotation; FOOSHAForced adduction, internal rotation; FOOSHA

Shoulder DislocationsShoulder Dislocations

Defects following dislocation?Defects following dislocation?

HillHill--SachsSachsSLAPSLAPBankartBankart

Shoulder DislocationsShoulder Dislocations

HillHill--Sachs lesionSachs lesionPosterior lateral aspectPosterior lateral aspectCompressionCompression

Shoulder DislocationShoulder Dislocation

Superior Labrum Superior Labrum AnteroposteriorAnteroposterior Lesion Lesion (SLAP)(SLAP)

10 to 210 to 2Affects bicepsAffects biceps

Shoulder DislocationsShoulder Dislocations

BankartBankart LesionLesionArthroscopic vs. openArthroscopic vs. openAnterior labrumAnterior labrum

Shoulder DislocationsShoulder Dislocations

Chronic Instability Chronic Instability –– Increasing laxity due to repeat Increasing laxity due to repeat

incidents, trauma, genetics, or neuromuscular deficitsincidents, trauma, genetics, or neuromuscular deficits

Signs and SymptomsSigns and SymptomsSportSportClickingClickingPainPainWeaknessWeakness

Shoulder DislocationsShoulder Dislocations

Chronic InstabilityChronic Instability

Signs and SymptomsSigns and SymptomsLaxity Laxity –– Drawer testsDrawer testsApprehensionApprehensionJob RelocationJob RelocationSulcusSulcus

Shoulder DislocationsShoulder Dislocations

Chronic InstabilityChronic Instability

ManagementManagementConservative vs. surgicalConservative vs. surgical

Case StudyCase Study19 year19 year--old male, collegiate catcherold male, collegiate catcherNo previous historyNo previous historyJune 14June 14thth, 2004, 2004Left shoulder dislocationLeft shoulder dislocationMechanismMechanism

Summer ball Summer ball –– Dove awkwardly back to 1Dove awkwardly back to 1stst basebaseReducedReduced

ImmobilizerImmobilizerContacted ATCContacted ATC

Second opinionSecond opinion

Case StudyCase Study

June 17June 17thth, 2004, 2004Seen by Dr. Seen by Dr. TheutTheut –– OrthopaedicOrthopaedic Associates of GRAssociates of GR

IrritableIrritableLimited ROMLimited ROMXX--ray ( ray ( -- ))

Surgery vs. therapySurgery vs. therapyAbduction Abduction slingsling

Case StudyCase StudyFebruary 7February 7thth, 2005, 2005Repeat left shoulder dislocationRepeat left shoulder dislocation

MechanismMechanismTarps following practiceTarps following practice

““Slipped outSlipped out”” & & ““felt like it went out towards the felt like it went out towards the bottombottom””ReducedReduced

ExaminationExaminationLimited ROMLimited ROMSlight swellingSlight swelling(+) Apprehension, Job Relocation, (+) Apprehension, Job Relocation, SulcusSulcus, Anterior , Anterior Load and ShiftLoad and Shift

Case StudyCase StudyApril 2April 2ndnd, 2005, 2005Repeat left shoulder Repeat left shoulder dislocationdislocationMechanismMechanism

High inside fastballHigh inside fastballReducedReducedSurgerySurgery

* * Number of occurrencesNumber of occurrences

Case StudyCase StudyApril 14April 14thth, 2005, 2005Dr. Dr. TheutTheutExaminationExamination

Good ROMGood ROM(+) Apprehension and Job relocation(+) Apprehension and Job relocationNo gross instabilityNo gross instabilityGood strengthGood strengthNo evidence of multidirectional instabilityNo evidence of multidirectional instability

MRIMRISurgical planSurgical plan

Arthroscopic with open optionArthroscopic with open option

Case StudyCase Study

August 16August 16thth, 2005, 2005Arthroscopic Arthroscopic BankartBankart RepairRepair

Left shoulder instabilityLeft shoulder instabilityTear of anterior inferior and superior labrumTear of anterior inferior and superior labrum

http://www.drstoller.com/education_bankart.htmhttp://www.drstoller.com/education_bankart.htm

Case StudyCase StudyRehabilitation Sheet Rehabilitation Sheet ––

August 31August 31stst, 2005, 2005

GoalsGoalsNormal, pain free Normal, pain free ROMROMNormal strength Normal strength Normal Normal arthrokinematicsarthrokinematics and and proprioceptionproprioceptionPain free ADL Pain free ADL Return to full activity Return to full activity

BankartBankart Repair 8/16/05Repair 8/16/05Date: ________Date: ________Pain Scale : 0 1 2 3 4 5 6 7 8 9 10 Pain Scale : 0 1 2 3 4 5 6 7 8 9 10

Goniometry:Goniometry:

TodayToday NormalNormalFlexionFlexion

________________ 180180____ExtensionExtension

________________ 50__50__AbductionAbduction

________________ __180__180__Internal RotationInternal Rotation

________________ __ 9090____External RotationExternal Rotation

________________ __ 9090____Exercises:Exercises:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Comments:Comments:

Case StudyCase StudyRehabilitation ProtocolRehabilitation Protocol

Days 1&2Days 1&2ImmobilizationImmobilizationPendulumPendulumAvoid ext. rot.Avoid ext. rot.Isometrics to distal Isometrics to distal jointsjointsModalitiesModalitiesCardioCardio

Weeks 1Weeks 1--66Sling while upSling while upPROMPROMScapular strengthScapular strengthIsometricsIsometricsModalitiesModalitiesCardioCardio

Case StudyCase StudyRehab Protocol ContinuedRehab Protocol Continued

Weeks 6Weeks 6--1212AROM & PROMAROM & PROMDynamic strengtheningDynamic strengtheningRROMRROMCardioCardio

Weeks 12Weeks 12--2424Increase strengthIncrease strengthIsokineticIsokinetic testingtestingSport specificSport specificReturn to sportReturn to sport

Case StudyCase Study

AthleteAthleteCooperativeCooperativeMotivatedMotivatedEnthusiasticEnthusiasticDid not missDid not miss

Obstacles?Obstacles?

Case StudyCase Study

Returned to play December 12Returned to play December 12thth, 2005, 2005Lifting, overhead activities (bench & military)Lifting, overhead activities (bench & military)

GoalsGoalsPre seasonPre season““Play the whole season without getting hurtPlay the whole season without getting hurt””““Win MIAAWin MIAA””

Rehab Pick ListRehab Pick List

What is it?What is it?

Rehab Pick ListRehab Pick List

Why should we use/develop rehab pick lists?Why should we use/develop rehab pick lists?

Way to organizeWay to organizeWay to rememberWay to rememberSpecific to your institutionSpecific to your institutionMore interesting for athleteMore interesting for athleteSimple, fast, and effective way to make daily Simple, fast, and effective way to make daily rehab programsrehab programs

In Review:In Review:

Anatomy of the ShoulderAnatomy of the Shoulder

Shoulder DislocationsShoulder Dislocations

Case StudyCase Study

Rehabilitation Pick ListRehabilitation Pick List

Who has the first question?Who has the first question?

You donYou don’’t want t want thisthis to be YOUR athlete to be YOUR athlete ……

Shoulder dislocations Shoulder dislocations WILL happenWILL happen

By knowing the By knowing the anatomyanatomy, , being being familiarfamiliar with these with these

types of injuries, and types of injuries, and developing developing pick listspick lists for for

your rehabilitation programs your rehabilitation programs you will quickly and you will quickly and

effectively return your effectively return your athletes to the games they athletes to the games they

love.love.

ReferencesReferencesPrentice, William E., (2003). Prentice, William E., (2003). ArnheimArnheim’’ss Principles of Athletic Training: Principles of Athletic Training:

A CompetencyA Competency--Based Approach. Based Approach. New York: McGraw Hill.New York: McGraw Hill.

ShoulderDoc.co.ukShoulderDoc.co.uk. (2003). . (2003). Acute Shoulder Dislocations.Acute Shoulder Dislocations. Retrieved Retrieved January 10January 10thth, 2006, from , 2006, from http://www.shoulderdoc.co.uk/index.asphttp://www.shoulderdoc.co.uk/index.asp

Get Smart Body. (2006). Get Smart Body. (2006). Muscular System.Muscular System. Retrieved January 20Retrieved January 20thth, , 2006, from 2006, from http://www.getbodysmart.com/ap/muscularsystem/menu/menu.htmlhttp://www.getbodysmart.com/ap/muscularsystem/menu/menu.html