1. Anterior Shoulder Dislocation
Sarah Popernack, SPT
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2. Condition Identification & Context1
Atraumatic hypermobility (chronic) or traumatic instability (acute)
Laxity of ligaments or repetitive overhead activities/ loading of joint
Anterior: most common, motions of abduction and external rotation stress anterior structures of glenohumeral (GH) joint
Less common: posterior instability (forces against flexed humerus) and inferior instability (typically rotator cuff weakness), multidirectional
Traumatic dislocation: separation of articular surfaces, acute incident

3. Condition Identification & Context1
Impairments in structure and function
Pain and muscle guarding
Posterior structures of GH joint tight
High risk of recurrent dislocation, especially in younger patients
Activity limitations and participation restrictions
Inability to reach or lift to the horizon
Restricted ability to participate in sports
Restricted movements to complete ADLs- dressing, grooming

4. Patient Record and Relevant Findings
History2,3
Tests and Measures1
20-year-old male, pitcher on college baseball team- atraumatic hypermobility predisposed to traumatic instability
Immobilized in sling for 4 weeks
Pain 3/10 at rest, 8/10 with activity
Pain and dependent on others with ADLs (dressing, bathing)
Primary concern: returning to baseball in the following season
Ibuprofen and icing to temporarily relieve pain
Deficits in PROM of shoulder abduction, extension, external rotation; empty-end feels due to pain
Deficits in MMT of shoulder internal and external rotation, adduction
Positive apprehension test on R shoulder

5. Most Important Problem to Address
Expected Outcomes1
1. By session 24, patient will increase PROM of right shoulder abduction to a “normative” value of 180 degrees in order to gain the range needed to pitch for baseball.
2. By session 24, patient will increase strength to 5/5 for the rotator cuff muscles (shoulder internal and external rotators, shoulder adductors) in order to increase stability of the right shoulder complex so that the patient can safely return to sport with lower risk of recurrent dislocation of the anterior shoulder. Along with increased stability, the patient will have increased endurance to be able to tolerate repetitive motions inherent in pitching for baseball.
3. By session 24, patient will be able to complete dressing and bathing with a pain score of 0/10 to enhance quality of life when completing activities of daily living.
4. By session 24, patient will report a changed score of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire from 35/100 at the initial evaluation to 1/100 before discharge so that participation restrictions are minimal and the patient is able to return to a high-functioning quality of life.
Ultimate goal: returning to pitch for baseball
Precautions: initial healing/ protection phase- external rotation should be completed with elbows at sides, staying less than deg. beyond neutral, abduction to 90 should be avoided1
Contraindications: extension beyond 0 deg.1

6. Prioritized Intervention: Weeks 1-31
Literature
Case Condition Interventions
Increase shoulder mobility: grade 3 mobilization, posterior joint structures passively stretched with self-stretching (horz. Add)
Increase stability and strength of rotator cuff and scapular muscles
Internal rotators and adductors protect anterior joint
External rotators strong to resist anterior glide in external rotation/ abduction motions
Scapular stability for shoulder function and scapular alignment
Exercises:
Isometric resistance in pain-free range
Partial weight-bearing and stabilization exercises
Wand, Gear shift exercises
Protective weight bearing
Seated-> standing
Isometric, manual resistance
HEP: horizontal adduction self- stretching, self-applied isometrics against a wall, wall washing

7. Isometric manual resistance
Wall Washing
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Self-applied isometrics
Wand exercises

8. Prioritized Intervention: Weeks 3-91
Literature
Case Condition Interventions
Dynamic resistance limited to 50 degrees ext. rotation
3 weeks- supervised isokinetic resistance for internal rotation and adduction 180 deg. Per second or higher
Progression to 90 degrees of shoulder flexion, not abduction
5 weeks- all shoulder motions incorporated into exercises on isokinetic or mechanical equipment except 90 deg. Abduction with external rotation
Isokinetic system
BodyBlade
Dynavision
HEP: Extension, abduction, internal rotation self-stretching, Theraband exercises, weighted ball

9. Shoulder extension BodyBlade Weighted ball Theraband
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Weighted ball
Theraband

10. As seen at APTA’s 2016 NEXT Conference
Dynavision
Increase shoulder ROM
Increased reaction time
Quick changes of direction
Explosive movements for return to sport
Used for many populations and patient conditions
onal.com/athletic

11. Prioritized Intervention: Weeks 9-121
Literature
Case Condition Interventions
Return to function:
Restore control- balance in strength of shoulder/ scapular muscles
Coordination of scapulothoracic and arm muscles
Endurance for shoulder instability exercises
Stability improves, progress to: eccentric to maximum load, increasing speed and control of combined motions, simulating desired functional patterns
Upper body ergometer
Theraband
Chest passes and overhead throws
Dynavision
HEP: Theraband, weighted ball, Aquacise at Michael J. Zone recreation center

12. Overhead throws Chest passes Theraband
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Chest passes

13. Results1
Test and Measures
Expected Outcomes
PROM in shoulder abduction, extension and external rotation within 5 degrees of “normative” values
MMT of shoulder internal and external rotation, adduction 5/5 (3/5 at initial visit)
Negative apprehension test
1/100 DASH questionnaire
0/10 pain at rest, throughout the day and after independently completing ADLs
Ability to return to baseball as determined by: no muscle strength imbalance, coordination with skilled movements is present, apprehension test is negative

14. Findings Compared with Literature
Case Condition Findings
Full rehabilitation takes 2.5 to 4 months1
Patients younger than 20 typically require surgery, patients older than 30 typically get treated conservatively (PT) 2
Ability to safely return to sport is determined upon three criteria1
Patient was seen for 24 sessions for a total of 12 weeks1
Patient is 20, treated conservatively because of the large amount of rehabilitation time post-season2
Patient progression throughout the plan of care to meet the three criteria1

15. References
Kisner Colby L. Therapeutic Exercise: Foundations And Techniques. 6th ed. Philadelphia, PA: F. A. Davis Company; 2012:
Wang RY, Arciero RA, Mazzocca AA. The Recognition and Treatment of First-Time Shoulder Dislocation in Active Individuals. Journal of Orthopaedic and Sports Physical Therapy. 2009;39(2):
Matthew S, Fahrner J, Stevenson H, Lowe R, Burns SA. Shoulder Dislocation. Physiopedia, universal access to physiotherapy knowledge. Accessed June 18, 2016.