Appraisal of a shoulder injury.

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Appraisal of a shoulder injury 1.Anatomy and physiology of the shoulder. The shoulder joint consists of the head of the humerus which articulates with a shallow socket in the upper part of the scapula the joint is defined as a typical ball and socket joint. A number of muscles attach and run around the joint to provide movement and stability the main structures of the shoulder can be seen in figures 1.1a and 1.1b Figures 1.1a (left) and 1.1b; (right) main structures at the shoulder joint In addition to the structures above the shoulder joint has a number of other muscles surrounding and attaching to it. These include the biceps, pectoralis major, latissimus dorsi and a group of muscles termed the rotator cuffs. The rotator cuffs are the subscapularis, supraspinatus, infraspinatus and teres minor muscles which cross the joint to insert into the humerus, thereby also helping to stabilise the shoulder joint. The tendons from the rotator cuff surrounds the capsule and blends with it Marieb (1998). The number of muscles and their associated tendons surrounding the shoulder offer the major form of support to the joint from the anterior aspect. A further structure to offer stability to the shoulder joint is the Glenoid Labrum which is a fibrous lining to the joint and increases the depth of the socket further enclosing the head of the humerus. Tortora (1990). The head of the humerus and the socket of the scapula are enclosed by a capsule that is relatively large and loose and is lined by a thin, smooth synovial membrane.


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.


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.

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