853: Shoulder Stability and Movement Coordination Impairments

PT diagnosis for shoulder instability

Multidirectional or UL instability

shoulder instability Definition

Laxity in the joint capsule, disruption to the labrum or dynamic stabilizers that results in excessive translation of the humerus on the glenoid fossa, leading to loss of function

What contributes to stability at the shoulder

• superior GH ligament: limits anterior and inferior translation in humeral add

• Middle GH: limits anterior and inferior translation primarily up to 45 degrees abd

• Inferior GH: limits anterior, posterior, and inferior translation in >45 degrees abd

• Labrum helps to further prevent translation of GH jt by 20%

• RTC muscles and biceps tendon act as dynamic stabilizers

Main S+S with shoulder instability

• apprehensive about moving shoulder

• Vague shoulder pain with and w/o perception of instability

• Reports of shoulder feeling loose or slipping out

• Clicking or grinding with shoulder motion

• Pain with activity, sports, ADLs

• May have visible deformity

• Swelling and bruising

• Neural symptoms possible d/t irritation or compression with dislocation

• Frank dislocation

Aggs for shoulder instability

• any movement resulting in shoulder being in ABD and ER

• OH activities

• Lifting

• Hand behind back

• SIdelying for prolonged period

• ADLs

Eases for shoulder instability

• avoidance of Aggs

• RICE

• NSAIDs

24 hr pattern for shoulder instability

• may have morning stiffness

• Pain will increase with increased activities

Classification of shoulder instability

Based on:

• mechanism of injury: traumatic or a traumatic

• Direction

  • Unidirectional: anterior, posterior (rare), or inferior (not usually in isolation)

  • Multidirectional

• Frequency: primary or recurrent

Thomas and Matsen Classification

• most widely used

• TUBS: traumatic unidirectional instability w/ Bankart lesion

• AMBRI: atraumatic, multidirectional, BL laxity, rehab, recommended

Stanmore classification

• triangular system that helps PTs diagnose instability and prioritize treatment

• Three subgroups recognizing a continuum exists between pathos

  • Polar 1: trauma related instability with a structural deficit in the GH jt

  • Polar 2: atraumatic instability with a structural deficit

  • Polar 3: no structural deficits but abnormal muscle control

FEDS classification

Frequency, etiology, direction, severity

Two key subgroups

1. Primary or recurrent traumatic anterior dislocation (unidirectional instability)

   1. Posterior dislocation

2. Atraumatic instability AKA multidirectional instability

Subluxation

Partial dislocation of the humeral head on the glenoid fossa so it is no longer in its typical position

• frequently occurring with repetitive motions

• Can contribute to or result from muscle and soft tissue damage, laxity

• Typically reduces spontaneously immediately after occurring

Dislocation

When the humeral head fully disarticulates from the glenoid fossa

• often due to trauma

• Requires medical assistance for reduction

Anterior MOI for subluxation or dislocation

• trauma into forced ER, ABD and posterior force at GH jt

• Traction to joint in anterior direction

• FOOSH with arm abducted and ER

• Blunt trauma P to A direction

Posterior MOI subluxation or dislocation

• FOOSH w/ arm flexed, add, IR

• Blunt trauma AP direction

Complications that may occur from subluxation or dislocation

• hill-sacks lesion

• Fracture to anterior glenoid rim

• Bankart lesion

• Peripheral nerves from brachial plexus can be compromised/damaged

  • Especially common to axillary nerve

• Vascular damage

  • Brachial artery most susceptible

  • Loss of vascular supply is an emergency situation

S+S of an acute dislocation

• intense shoulder pain that is debilitating

• Inability to move the arm

S+S of subluxation

Generalized shoulder pain, vague in location or may vary

Objective examination for subluxation or dislocation

• NV assessment will be necessary

  • Neuro exam for UQ and check distal pulses

• Postural observation

• Movement exam: ant. Tilted scap, elevated scap with shoulder flexion

• ROM will be guarded and limited due to pain or apprehension depending on acuteness

• + anterior apprehension relocation cluster or + posterior apprehension test and sulcus sign

PT management for subluxation or dislocation of shoulder

• goal is to reduce the risk of them

• Acute reduction

  • Will focus on short period of immobility and working to restore ROM w/o over stressing capsule

• Once irritability and ROM are improved, strengthening will be key

  • RTC, scap stabilizers, proprioception exercises, trunk stabilization exercises

• Manual therapy as appropriate

Medical management for subluxation or dislocation of shoulder

• pharm: oral NSAIDs and pain meds

• Conservative: brief period of immobility in sling, PT

• Surgery: if traumatic mechanism, surgery recommended

• Imaging

  • X-ray will show acute fractures, hill sachs lesion

  • MRI will show labral and RTC tears

Bankart repair

Reattachment of inferior labrum and capsular tightening

Anterior capsular shift

Open procedure that overlaps upper and lower portions of the capsule, tightening it

Thermal capsulorrhaphy

Arthroscopic procedure that thermally shrinks the anterior capsule

Primary or recurrent traumatic anterior dislocation

• the most common type of unidirectional instability

  • Arm forced into excessive abd and ER

• 90% of recurrent ones occur within 2 yrs if the primary one

  • Higher risk in younger males

Risk factors for primary or recurrent traumatic anterior dislocation

• age

  • 15-29 yrs old

  • > 70 yrs

• Sex

  • 7x more likely in young males

• High contact sports

• History of previous dislocations

• PMH of hypermobility disorder

Objective examination for primary or recurrent traumatic anterior dislocation

• observe for swelling or bruising, deformities

• ROM should be normal unless limited due to guarding

• Be cautious w/ PROM and accessory glides due to possibility of frank dislocation

• Abnormal scapular positioning at rest and movement with AROM

• Likely strength deficits in RTC and scap stabilizer muscles

• Neuro exam

• + apprehension relocation release test cluster

Treatment considerations for primary or recurrent traumatic anterior dislocation

• immobilization in traditional sling for 1 week

  • Longer immobilization does not reduce risk of recurrence

• Key to initiate pt edu and reassurance early to combat fear avoidance

  • This can lead to abnormal motor patterns and muscle recruitment

• Good to initiate RTC and periscapular muscle strengthening early, w/ isos

• Closed kinetic chain activities

• Neuro re-ed and motor control

Graded motor imagery phase 1: laterality training

• seeks to improve accuracy of cortical representation of the body part

• Accuracy norm = 80%

• Recognition speed norm = 1.5-2.5

• Looking for symmetry BL

Graded motor imagery phase 2: explicit or imagined motor imagery

• the process of thinking about moving without actually moving

• Start with imagining the movement on the uninvolved side, or distally from painful side on involved side and work to area of interest

• Pt provided with pictures of several different shoulder movements

• Can progress to adding more external stimuli

Graded motor imagery phase 3: mirror visual feedback

• performing movements with uninvolved arm in a mirror to trick the brain into thinking the affected arm is moving

• Start with simple pain free movements and progress towards more complex

• Exercises performed for 5-10 mins, 4 or more times daily

Primary or recurrent traumatic posterior direction

• rare!

• Commonly d/t trauma or fall from seizure

• Higher incidence of this in football lineman compared to active males in other sports

• Higher success rates with non surgical management

• Will likely have pain and get symptoms with shoulder flexion, adduction, and IR movements

Treatment for Primary or recurrent traumatic posterior direction

• usually work into shoulder protraction to ease stress on posterior capsule

• Studies indicate decreased RTC strength and increased lats activity in those with this

  • May benefit from NMES to infraspinatus during ROM and functional activities

Medical management for Primary or recurrent traumatic posterior direction

• pharm: oral NSAIDs

• Conservative: bring period in sling, PT

• Surgery: if traumatic mechanism, surgery typically recommended

• Imaging

  • X-ray, MRI without IV contrast, and MR arthrogram

Atraumatic instability or multidirectional instability

• less common than traumatic unidirectional

• Lacks clear history or MOI

• Main causes

  • Repetitive micro trauma due to OH movements

  • Congenital abnormalities related to hyperlaxity

Atraumatic instability or multidirectional instability Contributing factors

• hx of previous subluxation or dislocation

• Inadequate glenoid concavity

• Muscle imbalance

• Deficits in NM control

• Connective tissue disorder

Symptoms of Atraumatic instability or multidirectional instability

• apprehensive about moving shoulder

• Vague shoulder pain w/ and w/o perception of instability

• Reports of shoulder feeling loose or slipping out

• Clicking and/or grinding with shoulder motion

• Pain with activity, sports, ADLs

• Dislocation with ADLs

• May have visible deformity

• Swelling and bruising

• May get N/T or transient weakness d/t neural irritation

Objective exam for Atraumatic instability or multidirectional instability

• observe for swelling or bruising, deformities

• Neuro exam

• ROM should be normal unless guarded

• Be cautious with PROM and accessory glides due to possibility of frank dislocation

• Abnormal scap positioning at rest and movement with AROM

• Beighton score >5/9

• Excessive humeral head translation beyond the glenoid rim in 2 directions

  • Need positive tests for at least 2 directions of apprehension

• + sulcus sign

PT management for Atraumatic instability or multidirectional instability

• immobilization: trying to wean as early as possible

• Good to initiate RTC and periscap muscle strengthening early, w/ isos

• Emphasis on NM control is superior to general strengthening

• Address strength deficits in RTC and scap musculature

• Exercises ideally performed to fatigue

• Progressions should include trunk stability and proprioception

Medical management for Atraumatic instability or multidirectional instability

• pharm: oral NSAIDs

• Conservative: brief period in sling, PT

• Surgery

  • Capsular shift: open procedure that overlaps upper and lower portions of the capsule, tightening it

  • Thermal capsulorrhaphy: arthroscopic procedure that thermally shrinks the anterior capsule

• Imaging

  • X-ray, MRI w/o IV contrast, MR arthrogram

Hill sachs lesion

• compression fracture or osteochondral defect of the posterolateral aspect of the humeral head

• Most common w/ abd and ER injuries

  • Often associated with anterior instability or dislocation of the GH joint

  • Humeral head is forced anteriorly and due to capsulolabral structures being torn or stretched resulting in a hatchet compression fracture defect

Grade 1 hill sachs lesion

Defect in articular surface down to but not including the subchondral bone

Grade 2 hill sachs lesion

Lesion includes subchondral bone

Grade 3 hill sachs lesion

Lesion causes large defect in subchondral bone

Predisposing factors for hill sachs lesions

• recurrent dislocation (especially anteriorly)

• Trauma

• Hx of recurrent dislocations

• Age (young and active)

Hill sachs lesion contributing factors

• generalized laxity

• System disease that contributes to laxity or decreased joint integrity

• Activity with repetitive microtrauma to shoulder

S+S of hill sachs lesion

• deep ache in posterior aspect of the shoulder

• Motion guarding

• Limited ability to reach > shoulder height

Aggs for hill sachs lesion

• OH activities

• Loading GH jt

• Closed chain activities

Eases for hill sachs lesion

• rest

• Ice

• Avoiding Aggs

24 hr pattern for hill sachs lesion

• deep ache may be worse at night

• Stiffness first thing in AM

• Pain is activity dependent

Objective exam for hill sachs lesion

• undetected it may mask as RTC injuries, but will not improve within same timeframe as RTC

• Posterior humeral head TTP

• Shoulder held in guarded posture

• Humeral head may be positioned anteriorly

• Poor scapulothoracic rhythm will be noted

• Weakness and pain may be present with resisted shoulder abd or ER

acute PT management for hill sachs lesion

• modalities

• Soft tissue mobs

Later PT management for hill sachs lesion

Work on stability of GH jt with RTC, scap stabilizer, deltoid, and lat strengthening

Joint mobs: GH posterior or inferior glides may be helpful, will depend on findings

Post op PT management for hill sachs lesion

• immobilization in sling for 2-6 weeks

  • May start with scap stabilization, wrist/elbow/hand exercises

• Restoring pain free ROM: PROM>AAROM>AROM

• Strengthening of the RTC, deltoid, and scap stabilizers

• May require months of rehab

Medical management for hill sachs lesion

• pharm: oral NSAIDs and pain meds

• Conservative: non surgical management recommended for small osseous defects

• Surgery

  • Usually to address concomitant injuries along with larger defects

  • Arthroscopic techniques: remplissage (defect is filled with soft tissue)

  • Open techniques: laterjet procedure

• Imaging: xray, MRI

Brachial plexus injuries due to dislocation

• rare but serious

• Symptoms range from transient weakening or sensory loss to total permanent paralysis of the UE

  • Stretch injuries may worsen prognosis

Brachial plexus injuries due to dislocation Pathobiological mechanisms

• typically impacts the infraclavicular portion of brachial plexus

• Neuropraxia and axonotmesis make up majority of the injuries

• Neuropraxia: conduction blocked temporarily

• Axonotmesis: axon damaged but surrounding tissue intact

• Neuro thesis: most severe, severs the nerve

• Axillary nerve most often affected

Diagnostic tools for Brachial plexus injuries due to dislocation

EMG should be done 3 weeks after injury to ensure fibrillation potentials will be evident

Imaging for Brachial plexus injuries due to dislocation

MRI w/ and w/o contrast appropriate

Conservative management for Brachial plexus injuries due to dislocation

• first signs of reinnervation can be detected at 2-4 months post injury

  • Supports rationale for “wait and see”

• Sensory recovery precedes motor recovery

• Deep pressure sensation may indicate best recovery potential

• Surgical intervention considered if no improvement within 6 months

PT management for Brachial plexus injuries due to dislocation

• treatment should occur early and expected to be prolonged

• Focus of treatment is to improve and maintain ROM to prevent contractures

• Address joint hypomobility

• Aid in helping to maintain muscle bulk during reinnervation

• Sensory exercises with different textures and shapes

• Pain will need to be managed: nociceptive and neuropathic

Surgical management for Brachial plexus injuries due to dislocation

• surgical options recommended optimally between 3-6 months following insult

  • If no signs of recovery present

  • Earlier intervention can help reinnervation before end plate degeneration, decrease pain, and limit scar tissue or neuroma formation

• Microsurgical decompression often surgery of choice early after trauma to improve nerve conductivity

• Nerve resection and grafting not usually recommended initially

Brachial plexus injuries due to dislocation: lifespan

Many of these occur during childbirth

• due to difficult vaginal delivery

  • Shoulder dystonia or breech, prolonged labor, forceps delivery

• Caused by excessive stretch of the strcuture

• Males > females

• Right side > left side

• Can range from mild palsy to flaccid paralysis

Erb (duchenne) palsy

Caused by nerves from C5 and C6

Best prognosis for spontaneous recovery

Klumpke (dejerine) palsy

• results from injury to nerve fibers at C8 and T1

• Rare

• Damage to sympathetic fibers of T1 root results in horners syndrome

• Poor prognosis for spontaneous recovery

Upper and middle trunk injury

Lesions to C5, C6, C7

Brachial plexus injuries due to dislocation: lifespan conservative management

Observation and daily passive exercises by parents

First line of treatment for all obstetric brachial plexopathies while awaiting return of function

Brachial plexus injuries due to dislocation: lifespan surgical management

• microsurgical nerve grafting

  • If lacking antigravity biceps function between 3-9 months

• Nerve transfer

Imaging for Brachial plexus injuries due to dislocation: lifespan

May get radiographs to rule out humeral or clavicular fracture

S+S of labrum pathology

• clicking and popping in shoulder with movement

• Catching with movement

• Diffuse shoulder pain

• Diffuse thoracic pain

Nature of symptoms for labrum pathology

Achy, may be pain free

Aggs for labrum pathology

• OH activity

• Lifting

• Hand behind lower back

• Computer/desk work

Eases for labrum pathology

• scap retraction

• Rest

• NSAIDs

Snyder classification of SLAP lesions

• type I lesion: marked by fraying of the superior labrum, biceps intact

• Type II lesion: fraying of the superior labrum with a detached biceps anchor; majority of lesions are this

• Type III lesion: bucket handle tear of the superior labrum, biceps intact

• Type IV lesion: bucket handle tear of the superior labrum with a tear of biceps tendon

• Type III and IV more severe and type II most common

S+S of SLAP lesions

• deep shoulder pain

• Popping with rotation, movements

• Feeling of tightness in posterior shoulder

• Fatigue with OH movements, “dead arm”

Bankart lesion

• tear of the anterior/inferior labrum from 3-6:00 position

• Typically occurs with anterior shoulder dislocations

• Often occurs with hill sachs lesions

• Affects pts <35 yrs old

labrum pathology Objective exam

• posture and observation

  • Likely aberrant scap motion and positioning

• ROM

  • May note crepitus, clicking or popping with AROM/PROM

  • May see deficits in GH IR and pain with passive ER in 90 deg abd

• Strength

  • Deficits in RTC and scap stabilizers

• Joint mobility

  • May have posterior capsule tightness

labrum pathology Special tests

• O’Brien test - previously a staple but again best in cluster

• Best supported tests: anterior slide test, biceps load test, passive compression test

• Others: Yergason’s, compression rotation

SLAP lesion surgical options

Debridement of the labrum

Anchoring of the labrum and/or the biceps attachment

Bankart lesion surgical options

• debridement of the labrum Anchoring

• Anchoring of the labrum and/or inferior GH ligament/joint capsule

• Capsular shift