Shoulder subluxation

[Sally22]

Hi, just wondering if anyone can advise me.

I have been asked to see a young athlete who subluxed his shoulder a couple of weeks ago. The specialist has decided to treat the injury conservatively. Am I right in thinking that treatment will be aimed at regaining full ROM and rotator cuff strength? Is anyone aware of any restrictions, i.e. should we be avoiding external rotation?

Thank you

Sal

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[theshoulderguy]

Hi Sally, working with shoulders is great fun but sometimes a little daunting.

My advice would be to just focus on the fundamentals and be confident before you start the examination that you have done a full history the enables you to start the clinical reasoning process.

This will set you up for a great treatment plan based on specific information.

What I would want to know would most likely include:

*Age of patient and the nature of their activity, including training and playing volume, a what time in the game the injury occurred (fatigue)?

*History of the injury including mechanism of injury and direction of subluxation or dislocation?

*Was the injury a first time injury or do they have a previous history of similar events.

*Can you confirm that there is no pathology present i.e. a labral tear etc Have they been investigated - MRI?

*What is their ROM like now 2 weeks later - get them to demonstrate and you observe.

*Pain location and behaviour etc

*What positions or activity do they avoid at present?

*Does the shoulder feel unstable to them

That's a start anyway Sally.

On examination I always get the patient to show me how they move first, I observe and take note of overall build, thoracic kyphosis, posture control, scapula orientation & stability, muscle patterning errors and then I look at cuff activation through a gentle ER muscle test to see if the cuff (shoulder) initiates the movement or do other muscles compensate (which is usually the case).

Treatment Aims:

*Start Small but Aim Big!

*Focus on good cuff activation through abduction range first before moving to an upper body strength program.

*When initiating ER activation use the mid range of motion i.e. avoid end of range ER where control is likely to be deficient.

*Timeframe is likely to be 6 months for both local and higher cortical integration.

*Full functional ROM with excellent cuff and scapula control and the end of the day.

*Include lower kinetic chain involvement in your shoulder rehabilitation.

What to avoid?

*Missing signs and symptoms of underlying pathology

*Thinking that strengthening comes first.

*Not educating your patient about what is going on, what needs to be done and how long it is going to take

*Moving too quickly without adequate attention to posture, lower kinetic chain elements, core stability, quality scapula and cuff control.

*Giving too much tactile feedback - Less appropriate and targeted feedback is actually MORE

*Using loads that are way too heavy - light loads are harder to detect and control so always start there and only move on when they can perfect control of that.

*Using old school gym based exercises as the main stay of your strengthening program.

Well Sally I just had a bad case of verbal diarrhoea but I hope that helps you. Let me know?

Remember: Think Differently!

Cheers

Luke

PS: I have just started a FB Fan Page too so come and "LIKE" it if you found this post helped you.

The Shoulder Guy

[Sally22]

Hi Luke,

Thanks a lot for your post- really informative! I wondered if you could just expand on one part please? You stated -'Focus on good cuff activation through abduction range first before moving to an upper body strength program', by this do you mean to monitor at what point in abduction scapula movement is taking place? Or is there more to it than that?

Thank you again, I think I have found your fb page!

Sal

[theshoulderguy]

Hi Sally, thanks for the FB like.

My page is really going places and will look much better in a few weeks. If you want to keep in contact then just post questions there or just watch out for the occasional post from me.

IMO it is pretty hard to monitor all things going on when someone raises the arm up? You know...scapula upward rotation, muscle patterning sequence, scapulohumeral rhythm etc. It becomes a bit easier with practice.

What I meant by -'Focus on good cuff activation through abduction range first before moving to an upper body strength program' was to make sure that your patient has a nice stable looking scapula through abduction first without load and then make sure your patient has a nice stable looking scapula through abduction range with a very light external rotation load.

That load to initiate cuff (external rotation) activation could be a light resistance theraband.

You want your patient to have good external rotation activation on a stable scapula at 0 degrees abduction, 45 degrees all the way to 90 degrees and higher if the task/sport requires it.

Now here's a HUGE tip! (Keep it Secret Okay?)

The #1 mistake most physio's make is to tell their patient's to pull the arm/elbow into the side or forcefully into a towel when doing external rotation in neutral abduction or start by squeezing a pillow to your side to "engage the cuff". This tends to put the shoulder into a "co-contraction" with the larger internal rotators (Pecs and Lats) working more predominantly and not the external rotators (see Karen Ginn's work).

So a sign of good external rotation cuff control is when the arm can freely externally rotate but also maintain a level of relaxation not co-contraction. The arm has to be relaxed. Don't allow your patient's to pull the arm to their side as a way of cheating, because they will want too. The arm needs to just hang by the side in a relaxed way and the focus should be on strict pure rotation with relaxation.

If it seems too hard for the patient it probably is... so go slow and get good activation first then the strength will come.

I hope this helps you Sally.

Feel free to comment about this post on my FB page.

All the Best

Luke

The Shoulder Guy

[junior_physiotherapist]

Well, Nice informative post,,,,,,,,,,,,,,,

May here i can ask please to reformulate the steatments into other simple words:

Avoid
*Moving too quickly without adequate attention to posture, lower kinetic chain elements, core stability, quality scapula and cuff control.

*Giving too much tactile feedback - Less appropriate and targeted feedback is actually MORE
*Using old school gym based exercises as the main stay of your strengthening program.

[theshoulderguy]

Hi Junior Physio, just to clarify for you.

This is a generalisation but most physio's in their enthusiasm to help patients and to strengthen the shoulder, move too quickly through to a strengthening phase. But what comes first?

The fundamentals are often overlooked and this includes the focus on ideal muscle activation patterns and ensuring the scapula and cuff stabilisers are actively and correctly recruited prior to any strengthening phase is commenced.

When learning new skill or re-learning an old one like reaching or external rotation, tactile feedback will help the motor and sensory learning process. What we know is that appropriate and timely targeted feedback is often better than too much or too little feedback.

Finally, bench press and lat pulldowns or other similar exercises that predominately train either chest or back IMO should be left until the very end of a shoulder stability and strengthening program.

Why?

They are not whole body focused and do not engage the larger muscular kinetic chains. They rely on strict technique and put the shoulders into a position outside what I call "The Shoulder Safe Zone".

This can lead to undue stress on the shoulder joint, cuff and anterior capsule and ligamentous structures. The bench press is the No 1 killer of shoulders in the gym so Think Differently and include other shoulder stability exercises.

Cheers

Luke (The Shoulder Guy)

Find me on Facebook if you would like to know more.

[junior_physiotherapist]

WAW,


Thanks a lot of for all.........................

[naveenedin]

hi there
thanks for innovative ideas. May i get more details about karen ginn's work and your concept about shoulder safe zone. i havent heard of neither of that before, would you mind sharing please.

[theshoulderguy]

Hi Naveenedin, Karen Ginn is a researcher at the University of NSW in Australia and I like the way she thinks. Search for some of her articles etc

The "Shoulder Safe Zone" is a concept that I use to describe where not to put the shoulder during rehab, gym based exercise etc. The "Safe Zone" is one where the elbows are kept in the scapula plane be it in standing, sitting or supine. The scapula plane is the limit of motion for things like rows, bench, overhead press, ER at 90 ABD etc.

As a rough estimate, stand up and pretend to wave good bye to someone...your arm position is pretty close to scaption in a nice and neutral relatively relaxed position. This position helps the HOH contact the sweet spot of the glenoid.

Check it out and use this principle for better results.

Cheers

Luke (The Shoulder Guy)


PS: For more tips and to keep in touch with me, go ahead and LIKE my Facebook Fan Page.

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