1. Shoulder Dislocation Presented By: Katie Mullen, Steven Shatzer, Kate Sparks, and Nick “Swoop” Weiss

2. What is Shoulder Dislocation? Dislocation: separation of two bones where they meet at the joint Subluxation: incomplete separation Stability of the Shoulder Because shoulder is the most mobile joint in the body, it has the highest likelihood of dislocating. Unidirectional Instability Multidirectional Instability Among the most common traumatic injury of the shoulder 1

3. Mechanism of Injury Traumatic Injury “A shoulder dislocation can occur with an injury such as when you "fall the wrong way" on your shoulder or outstretched arm, forcing the shoulder beyond its normal range of movement and causing the humerus to come out of the socket.” Most often occurs during contact sports But everyday accidents such as falls can also cause the joint to dislocate Athletes, non-athletes, children, and adults can all dislocate their shoulders. 1

4. Signs and Symptoms With most shoulder dislocations, you will feel the humerus coming out of the socket, followed by: Pain Unable to move the arm Awkward appearance of the shoulder 1

5. Complications Nerve and/or blood vessel damage Symptoms of this include: numbness in your arm or hand discoloration of arm or hand cold feelings in your arm Bankart Lesion Rupture of Rotator Cuff Hill-Sachs Lesion 1

6. Case Study - 30 y/o Jiu Jitsu Athlete Testing: Global ROM = reduced 20 0 and painful; Apprehension/Relocation = (+) Treatment: Week 0-1 IFC & Microcurrent Immobilized 10-15 0 ER Scapular Stability (low row, robbery, lawnmower), ROM, isometrics Week 1-2 Continued Self-ROM using unaffected limb Codman sets (Pendulum) Week 2-3 Active Release Techniques Slow/controlled end-range mobs in external rotation (NO abd) Terminal range isometrics w/resistance AROM exercises (avoid combined ER + abd) ‘Wall alphabet’ Weeks 3-5 Continued Dynamic strengthening exercises 6lbs MB pass on rebounder Pushups kneeling position Proprioception Rhythmic stabilization Upper body rocker board balancing

7. Case Study - Continued Weeks 5-7 Bench press, reverse grip pull-downs, dead-lifts, squats, lunges, core strengthening (i.e. bird-dog, side-bridge, abdominal crunch) Proprioception Progression Upper body rocker board balancing w/ Swiss ball under pelvis Isometric exercise in external rotation & abduction Slow, gradual, passive shoulder mobilizations Weeks 7-8 Plyometric exercises Stability pushups MB throws against rebounder w/arm in ext rotation and abducted position Plyometric bench press on Smith machine Return To Sport: Full ROM, strength comparable to unaffected limb, and apprehension/relocation test = negative

8. Treatment Plan Protection Phase Protect healing tissue Immobilization (>3 wks for patients younger than 30; 1-2 wks for older pts.) Activity restriction (6-8wks) Promote Tissue Health Grade II mobilizations Controlled Motion Phase Mobilization Anterior glide is CONTRAINDICATED Proper positioning (abd 55 degrees, horiz. Abd 30 degrees) Increase Strength and Stability of Rotator Cuff and Scapular Muscle IR and ER muscles need to be strengthened Return to Function Phase Functional Control: balance, coordination, endurance Full activity

9. Home Exercise Program Protection Phase Codman Sets (Pendulum) Isometric Exercises into flexion, ext, abd, add, ER, IR With shoulder in neutral position against torso Controlled Motion Phase Push-ups using table Progress to full pushup for return to function phase PNF techniques Triceps pull downs Return to Function Planks Med ball chest passes

10. DEMO

11. What The Research Says on Non-Surgical Rehab Seven key factors to consider in non-operative rehabbing an unstable shoulder: 1.Onset of Pathology 2.Degree of Instability (subluxation vs dislocation) 3.Frequency of dislocation (acute vs chronic) 4.Direction of Instability (Anterior vs Posterior vs Multidirectional) 5.Accompanying Pathologies 6.End Range Neuromuscular Control 7.Premorbid Activity Level Wilk KE, Macrina LC, Reinold MM. Non-Operative Rehabilitation for Traumatic and Atraumatic Glenohumeral Instability. North American Journal of Sports Physical Therapy: NAJSPT. 2006;1(1):16-31.*

12. What The Research Says on Surgery Mean Incidence of recurrent dislocation in pt. population between the ages of 21-30 is 67%, with pts in 30s and 40s being less than 20% Age of pt is one of highest predictors “Our statistical findings also clearly showed that physical therapy and immobilization do not reduce the risk of recurrence.” (Kralinger) “The nonoperative group showed a high incidence of redislocation (94.5%) compared with the operative group (4%).” (Larrain) Most research suggests operative measures after first traumatic anterior shoulder dislocation in young, especially athletic, patients Larrain MV, Botto GJ, Montenegro HJ, Mauas DM. Arthroscopic repair of acute traumatic anterior shoulder dislocation in young athletes. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2001;17(4):373-377. Kralinger FS, Golser K, Wischatta R, Wambacher M, Sperner G. Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med. 2002;30(1):116-120.

13. Take Home Message 1.THERE IS NO ONE “FIX ALL” SOLUTION FOR SHOULDER DISLOCATION 2.Know the stages of treatment progression and mold exercises that fit in those stages to your patient and their needs 3.PT isn’t always the best option, know that surgery may be a better solution for your patient 1.NICK IS DUMB, COOL, BUT STILL DUMB

14. References 1.Shoulder Dislocation: Overview. American Physical Therapy Association. 2011. Available at: http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=6ff15f22-4f2f-46a0-bf91-3aa80ecf393b. Accessed July 1, 2016. 2. Morphopedics. Physical Therapy Management Of Shoulder Dislocation -. http://morphopedics.wikidot.com/physical-therapy- management-of-shoulder-dislocation. Accessed July 11, 2016.