After a dislocation of the shoulder has occurred there are a number of resulting problems that may appear. A Bankart lesion is when there is a detachment of the anterior part of the labrum from the rim of the cavity. A Superior labrum Anterior Posterior (SLAP) lesion occurs less frequently than Bankart lesions, in SLAP lesions, the labrum detaches from its usual location along the top margin of the shoulder cavity. This detachment is associated with clicking sounds, locking of the shoulder, and/or a feeling that the shoulder is not right. Multi directional instability may also result as the tendons ligaments and muscle providing stability to the shoulder are stretched and loosened. Freddie (1994)
After a dislocation has occurred the shoulder must be put back into joint as soon as possible a process known as reduction. There are many documented methods of reduction but all involve the use of some form of contertraction. This is the use of a balancing opposing force during traction. A strong continuous pull is applied to a limb so that bones can be returned to their natural position. Kent (1994). In the case of a shoulder there are many ways this can be applied each method used depends upon the injury sustained, the treating doctor and the available resources.
3.Performers history
In the case of this injury the performer suffered a dislocated shoulder after a tackle. The injury occurred when the left arm was abducted approximately 90 degrees, the arm was wrapped around the attacking player and the shoulder made contact with the player. As the attacking player was knocked backwards the left arm was trapped underneath the legs of the attacking player and as the player and arm impacted the floor, the shoulder dislocated.
As soon as this happened the performer was aware of the problem and was substituted immediately and was taken to hospital where x-rays confirmed the shoulder was anterioly dislocated.
This was not the first dislocation the performer had experienced, previously he had dislocated the same shoulder when being tackled, again this was an anterior dislocation caused by landing on an outstretched arm. This first dislocation occurred at the age of 18 and was treated by immobilisation for 6 weeks and then physiotherapy for a further 6 weeks. The physiotherapy involved the movements described in section 5 after which the subject was able to restart training and playing rugby. After approximately 12 months from restarting training the shoulder began to develop problems when the arm was working near the maximum range of movement. The performer sought medical help and was referred to a shoulder consultant who diagnosed instability in the left shoulder and again recommended more specialised physiotherapy, and not performing any contact sports or exercise which require the arm to be near the maximum range of movement.
After this second bout of physiotherapy no more problems with the shoulder were reported and some of the physiotherapy exercises were incorporated into the training programme of the performer to continue the strengthening.
This second dislocation therefore was unexpected without any warning. However it falls in line with the previous research regarding reoccurrence rates of dislocation as reviewed earlier. After reduction in the hospital it was advised that the consultant should be again contacted for a thorough shoulder examination and possible plans to reduce the likelihood of further dislocations or damage to the shoulder.
In order to assess the shoulder the following tests were used (gained from Donatelli 1997).
- Load and shift test- This test is used to determine how loose the shoulder ligaments are. There are several variations of this test in use. One of the most common involves having the patient lie flat on the back so that the centre of the shoulder blade is on the edge of the bed. The arm is held out at 90o from the side to see how much movement there is the anterior direction (and the posterior direction. The distance the arm can be moved in this position can be scored for a rough indication of the shoulder's stability or instability
- Sulcus test- This test is used to determine how loose the shoulder ligaments are in the inferior direction. The patient stands or sits with the arms hanging by the side. The patient's arm is then pulled down on and looks to see if a dimple-like sulcus appears in the shoulder. The sulcus is due to the humerus sliding down over the surface of the joint leaving a gap at the top which resembles a dimple in the skin of the shoulder. Around 25% of people with multidirectional instability show a sulcus of 2 centimetres or more when their arm is pulled down
- Apprehension test: This test puts the shoulder in a position where the patient may become apprehensive that it is about to dislocate. The examiner will want to know this and will look for signs that the patient is apprehensive. Lying on the back, the arm is extended 90o from the side and externally rotated. From this position, the examiner will continue to externally rotate the patient's arm. This is the position that puts the most strain on the ligaments which normally stop the shoulder from dislocating anteriorly. If those ligaments are weak or damaged, the shoulder may feel like it is going to pop out of joint which is what the physician wants to know.
- Relocation test- This test is performed immediately after the apprehension test. While the arm is still in the position where it felt like it was going to pop out of the socket, the humeral head is pushed backwards. This is in the opposite direction to where it was being pushed in the apprehension test. If the humeral head has started to slide forward, this test will push it back into place and should lessen any feeling of apprehension that the arm is about to pop out of joint.
After performing the tests it was found the performer had multi directional instability of the shoulder and was suffering from a Bankart lesion and SLAP lesion with the possibility of a compound fracture on the head of the humerus. The consultant recommended surgery to fully determine the extent of damage and to repair the injuries. This diagnosis was accepted and a date for surgery was set.
4.Management of the injured shoulder
In order to correct the injuries sustained the consultant first had to determine how much damage had been done to the shoulder. This was to be done using keyhole surgery to look inside the shoulder and then the damage would be corrected using suitable methods, in this case open surgery was used while the subject was under anaesthetic.
On looking at the shoulder the subject was found to have a Bankart lesion, a SLAP lesion and multi directional instability. These injuries were then surgically repaired using the following procedures. The notes on the procedures were taken from the discussion with the consultant who explained the procedures.
- Bankart lesion repair- consists of detaching and later reattaching the humeral insertion of the subscapularis tendon, and also reattaching the labrum to the anterior glenoid cavity with sutures through the bone or with suture anchors. With the open technique, the shoulder loses on average 12degrees of external rotation following anterior stabilisation, probably because the subscapularis tendon is shortened after the detachment/reattachment process. There are a number of variations on this but the biggest comparisons can be seen between the open procedure and the keyhole procedure. Because keyhole is less invasive than open surgery, this procedure tends to preserve the range of movement for external rotation, and to reduce the risk of osteoarthritis. However, 7%-17% of shoulders redislocate if they are repaired using arthroscopic anterior shoulder stabilisation whereas only 5% of unstable shoulders redislocate if repaired using open surgical procedures (Newberg)
- SLAP lesion repair- this lesion is repaired again by sutures to the bone re attaching the labrum
- Multidirectional instability repair-there are a number of procedures to correct this, the procedure relevant to the performer in this case was the anterior capsular shift. This can be used for a large amount of anterior instability but it is particularly useful for patients with multidirectional shoulder instability. For this, slack in the capsule is reduced by making a T-shaped cut through the capsule, overlapping the anterior and inferior margins of the cut, and then stitching the overlapped part of the capsule
After the surgery the shoulder is immobilised in a removable splint for 9 weeks. After this period there is a slow and gradual physiotherapy process aimed at increasing the range of movement over a 6-month period.
5. Post operative physiotherapy for the shoulder
After the surgery and the period of immobilisation the shoulder has limited movement and strength due to the build up of scar tissue and the atrophy of muscles that have not been used. It is the aim of the postoperative physiotherapy to gradually get back the movement and muscular strength to the levels prior to the operation and to strengthen the muscles which normally help to prevent inadvertent dislocation. To achieve this, the physiotherapy programme must consider all parts of the shoulder in particular, its muscles and tendons, ligaments, and neuromuscular control. The rotator cuff muscles of the shoulder must work together to keep the shoulder still while moving the arm. Weakness affecting the balance of these muscles needs to be identified and corrected from the outset of rehabilitation. This is achieved by various resistance exercises using a theraband (a tough elastic band) in which it is used to provide resistance in planes of movement that the rotator cuffs function in to provide strength. As well as developing strength it is also important to develop stamina as when the muscles responsible for stability tire the shoulder may become unstable again.
The exercises to begin with are simple pendulum exercises using the weight of the arm and gravity as resistance. The exercise is performed while slightly bent over with the arm hanging loosely the arm is then gently moved in a circle controlled at all times. The range of movement is increased each time to the maximum the shoulder will allow. The next stages of rehabilitation involve exercises using a stick. The stick is held in both hands with the non-injured arm guiding the other arm the stick is raised (flexion) to the maximum range. The stick is also used in the same guiding manner for internal and external rotation where the injured arm is pushed with the stick and the uninjured arm. Gradually the range of movement should increase. The next phase after increasing the range of movement is to strengthen the muscles by using the theraband as resistance for the movements shown in figure 1.2. These exercises should be performed in front of a mirror in order to aid in proprioception, as the shoulder should be moved in a similar manner to the uninjured shoulder. After this phase weights are introduced to further the resistance.
Following the surgery and physiotherapy the shoulder will allow performance to continue after a suitable level of physical preparation has occurred. However the procedure does have a 5% chance of further dislocation as highlighted previously in research by Newberg.
In order to minimise the chances of a further dislocation rotator cuff exercises will be introduced into the training plan and will continue to be adapted and performed on a regular basis.
References
Donatelli, R. A. (1997). Physical therapy of the shoulder 3rd Ed. Edinburgh: Churchill Livingstone,
Freddie H. F. (1994). Sports injuries : mechanisms, prevention, treatment. London: Williams & Wilkins.
Kent, M. (1994). The Oxford Dictionary of Sports Science and Medicine. Oxford: Oxford University Press.
Kralinger, F.S., Golser. K,, Wischatta. R, Wambacher M, Sperner, G.. (2002). Predicting recurrence after primary anterior shoulder dislocation. American Journal of Sports Medicine. 30(1):116-20
Marieb, E.N. (1998). Human Anatomy and Physiology. London: Scott Forsman Addison Wesley.
Newberg, A.H. (1987). The radiographic evaluation of shoulder and elbow pain in the athlete. Clinical Sports Medicine. 6(4):785-809.
Postacchini, F. Gumina, S. Cinotti, G. (2000). Anterior shoulder dislocation in adolescents. Journal of Shoulder and Elbow Surgery. 9(6):470-4
Rowe, C.R. (1956). Prognosis in dislocations of the shoulder. Journal of Bone Joint Surgery. 38A(5), 957-77.
Tortora, G.J., Anagnostakos, N.P. (1990). Principles of anatomy and physiology 6th Ed. London: Harper Row.
Electronic sources
Figures 1.1a, 1.1b and 1.2 gained from http://www.smasa.asn.au/fact_sheets/fact_shoulderpain.html
Accessed:2/3/2002
Author:unknown
Unpublished Material
Case Notes
