1. Jerod Miller

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

3.  Glenohumeral joint is the most dislocated joint in the body 1  90-98% of shoulder dislocations are in the anterior direction 1  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

4.  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.

5.  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

6.  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

7.  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.

8.  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.

9.  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)

10.  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

11.  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

12.  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.

13.  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

14.  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 barrier 3

15. 1. Emedicine.medscape.com. Shoulder Dislocation Surgery: Background, Epidemiology, Etiology. 2015. Available at: http://emedicine.medscape.com/article/1261802-overview#. Accessed July 29, 2015. 1. 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. 2. 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. 1. 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. 2. 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. 3. 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. 4. Atlanta Sports Medicine. Latarjet Protocol. 2011. Available at: http://atlantasportsmedicine.com/latarjet- protocol/. Accessed June 14, 2015. 5. 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.