PHYSIOTHERAPY IN THE

MANAGEMENT OF
RECURRENT SHOULDER
DISLOCATION
BY
DEPARTMENT OF PHYSIOTHERAPY
68 NIGERIAN ARMY REFERENCE HOSPITAL, YABA
8/12/2021
 2
PRESENTERS

• PT Sanni Hauwa
• PT Nnadozie Uchechi
• PT Ajayi Folami
• PT Akingboye Oluwaseyi
OUTLINE
•CASE STUDY
•INTRODUCTION

•ANATOMY

•EPIDEMIOLOGY

•AETIOLOGY

•CLASSIFICATION

•DIAGNOSIS

•MANAGEMENT

•CONCLUSION

•REFERENCES
 4

CASE STUDY

 NAME: Lt. X

 AGE: 32 Years old

 SEX: Male

 ADDRESS: Lagos

 RELIGION: Christianity

 OCCUPATION: Military Officer

 5
HISTORY OF PATIENT COMPLAINT

 PC: pain and limited ROM at right shoulder

 HX: Patient had recurrent right shoulder

dislocation dating back to about 16 years ago.

 Had about six episodes out of which two were in

2018.

 The last occurred during his military training while

trying to cross an obstacle on 17/09/18.
 HISTORY CONTD
6

 Reduction was carried out about two hours later

under anaesthesia which left him with;

 Shoulder pain

 Muscle weakness

 Paraesthesia

 Loss of ROM of the shoulder joint

 Loss of function
 7

 Inability to give military complement (salute).

 Swelling of the shoulder joint

 HISTORY CONTD
8

 PMHx: Non significance.

 DHx:: Analgesics.

 FSHx: Patient is a young bachelor, just

commissioned into the Nigerian Army and
works as an engineer, drinks alcohol
occasionally but does not smoke.
 9

FIG 1:INCISION LINE AT SHOUDER JOINT

 10

FIG 2:INABILITY TO RAISE THE ARM

 11

FIG 3:INABILITY TO SALUTE

 OBSERVATION
12

Patient walked into the department with an

arm-sling on the right upper limb.

The arm was immobilized

wrongly( internally rotated)

Patient was not in any obvious pain distress.

 13
INVESTIGATIONS

X-Rays: AP + lateral (Shoulder joint).

which showed Anterior dislocation of the

humeral head from the acromial fossa.

 14
OBJECTIVE ASSESSMENT

 B.P-130/85 mmHg

 VAS-7/10

 GMP-3/5

 Sensation- Numbness with pins and needles in the

fingers

 Brachial Muscle girth (15cm above the olecraneon

process) Right-31cm, left-34cm.
 15

ASSESSMENT CONTD

motion active passive

Shoulder flexion 95 140

Shoulder extension 30 40

Shoulder abduction. 95 130

Shoulder external rotation. 30 50

Shoulder internal rotation. 60 70

 16

FIG 4:SHOULDER EXTERNAL ROTATION

 17

FIG 5:SHOULDER INTERNAL ROTATION

ANALYSIS OF FINDINGS 18

 Patient had pain, muscle weakness, swelling,

disuse atrophy, paraesthesia, loss of ROM.

 Patient was incapacitated in his military work

and his ADL was compromised.
 19
GOALS OF MANAGEMENT

SHORT TERM (0-3 WEEKS)

To relieve pain

To prevent swelling

To regain full pain free ROM

To prevent scar tissue formation

To preserve the physiological functions of the muscles.

 MEDIUM TERM (3-6) 20

 To relieve pain

 To regain and maintain full ROM

 To strengthen weak muscles.

 To prevent scar tissue.

 To begin functional training of the shoulder

joint.
 LONG TERM (6-12) 21

 To regain full ROM.

 To regain muscle girth, strength, power and

endurance.

 To participate in sport related activities.

 To return back to military work.

 To resume full ADL.

 
 22

APPOINTMENT

The patient was given an appointment of thrice a

week to which he complied, each session lasted
about 45 minutes.
 MEANS OF TREATMENT 23

SHORT TERM (3-6 weeks)

 Shoulder immobilization with a sling in external rotated

position.

 Oedema massage for pain and inflammation

 24

 Full passive ROM as comfortable to gain more ROM.

 Active assisted ROM.

 Isometric exercises for strengthening.

 Ultrasound therapy at the incision site- 10 minutes

 REVIEW AFTER 4 WEEKS 25

 VAS-4/10

 GMP-4/5

 Apparent resolution of swelling

 Sensation- numbness, pins and needles

became mild and transcient.
 26

REVIEW AFTER 4 WEEKS

motion active passive

Shoulder flexion 130 170

Shoulder extension 30 40

Shoulder abduction 130 160

Shoulder external rotation 40 45

Shoulder internal rotation 60 75

 MEDIUM TERM (3-6 WEEKS) 27

 SWD to the shoulder-10 minutes.

 STM with analgesics.

 Faradic stimulation of right shoulder muscles- 15

minutes.

 Free active exercises: Wall-wheel, turning a knob in

clockwise direction, throwing (10 repetition each)
with progression.
 28

FIG 6:WALL-WHEEL EXERCISE SIMULATION (FAE)

 29
LONG TERM (6-12 WEEKS)

 FAEs continued to the right UL.

 Resisted Active Exercises to the right UL (pulley, modified

push-ups).

 Elastic-band exercises for strengthening.

 Home programme (Shoulder exercises).

 30

FIG 7:RESISTED ACTIVE EXERCISE (ELASTIC BAND)

 31

FIG 8:PULLEY EXERCISE

 32
REVIEW AFTER 12 WEEKS

 VAS-1/10

 GMP-5/5

 Brachial muscle girth (15cm above the olecranon

process. Right-32 cm, left-34cm)

 Sensation- numbness, pins and needles were

abolished.
 33

REVIEW AFTER 12 WEEKS

motion active passive

Shoulder flexion. 170 180

Shoulder extension 40 45

Shoulder abduction 170 175

Shoulder external rotation. 70 75

Shoulder internal rotation, 80 90

 34

FIG 9:EXTERNAL ROTATION

 35

FIG 10:INTERNAL ROTATION

 REVIEW CONTD
36

 The patient could still not fully externally rotate the shoulder as it’s
required to salute, he could only salute using trick movement.

 However, right scapula mobilization was carried out as it was found to be

immobile
 37

SCAPULAR MOBILIZATION
 38

EXTERNAL ROTATION (SALUTATION)

 39

PATIENT RAISING HIS AFFECTED HAND

 40

PATIENT EXTERNALLY ROTATING BOTH SHOULDERS

 41
CONCLUTION

 Lt x is a 32 year old soldier who presented at the physiotherapy

department on account of pain and limited ROM at the right
shoulder post putti platt capsuloraphy. He was managed using
various physiotherapy modalities such as ultrasound therapy,
short wave diathermy, exercises etc for about 13 weeks and was
returned to his premorbid state.
 42
INTRODUCTION

 The shoulder is a synovial joint composed of three bones:

humerus, scapula, and clavicle.

 The shoulder joint is the body's most mobile joint.

 It can turn in many directions. BUT, this advantage also makes

the shoulder an easy joint to dislocate.

 Partial dislocation of the shoulder is referred to as subluxation.

 43
ANATOMY

The shoulder complex, composed of the clavicle, scapula, and

humerus, is an intricately designed combination of four joints

 Glenohumeral joint

 Sternoclavicular joint

 Acromioclavicular joint

 Scapulothoracic joint
ANATOMY OF THE SHOULDER 44
Blood supply of the shoulder joint. 45
Innervations of the shoulder joint. 46
 47
Stabilizers of the shoulder joint

 The shoulder joint is stabilised by two groups of stabilizers

a. The static stabilizers
b. The dynamic stabilizers
 STATIC STABILIZERS 48

1. GLENOID
LABRUM
2. JOINT CAPSULE
3. LIGAMENTS
• Glenohumeral
Ligaments:
• Coracohumeral
Ligament:
• Coraco-acromial
Ligament
 DYNAMIC STABILIZERS 49

INTRINSIC MUSCLES: Known as

the scapulohumeral muscular
group, are deeper muscles which
originate from the scapula and /or
the clavicle and insert on the
humerus
 Supraspinatus
 Infraspinatus
 Subscapularis
 Teres minor
 50
DEFINITION OF SHOULDER
DISLOCATION

 A dislocated shoulder occurs when the humerus separates from

the scapula at the glenohumeral joint (Good and MacGillivray,
2005).

 It has the greatest range of motion of all joints and most

susceptible to dislocation and subluxation (Good and
MacGillivray, 2005).
 51
DEFINITION OF SHOULDER
DISLOCATION

 A partial dislocation (subluxation) means the head of the upper

arm bone (humerus) is partially out of the socket (glenoid).

 A complete dislocation means it is all the way out of the socket.

Both partial and complete dislocation cause pain and
unsteadiness in the shoulder.
 52
EPIDEMIOLOGY

 Greek study, 308 patients (170 men and 138 women).

 Falling (92%). of reductions were in the ED.

 Recurrence rate in all ages was 50%. (Chalidis et al,

2007).
 53
EPIDEMIOLOGY CONTD

Sex

 Peak incidence in men aged 20-30 years (with a male-to-female

ratio of 9:1) and in women aged 61-80 years (with a female-to-
male ratio of 3:1).

Age

 Occurs more frequently in adolescents than in younger children.

 Older adults are also susceptible . (Chalidis et al, 2007).

 54
AETIOLOGY

 ANTERIOR SHOULDER DISLOCATION

 POSTERIOR SHOULDER DISLOCATION

 INFERIOR SHOULDER DISLOCATION

 55
AETIOLOGY

 Anterior shoulder dislocation:

Rupturing or detaching the anterior capsule from its

attachments (volleyball spike, falling on an outstretched
hand).

 Posterior dislocations:

Severe internal rotation and adduction .

 56
AETIOLOGY CONTD

Inferior dislocations (luxatio erecta).

 Shoulder is dislocated inferiorly.

 80% have fracture of the greater tuberosity or tear of the rotator cuff.

 60% have neurological compromise.

 3.3% of vascular compromise.

 57
CLASSIFICATION/PATHOPHYSIOLOGY

Anterior

 Over 95% of shoulder dislocation cases are anterior.

 Damages the axillary artery and axillary nerve

 A patient with injury to the axillary nerve will have difficulty in

abducting the arm from approximately 15° away from the body
 58
CLASSIFICATION/PATHOPHYSIOLOGY

Anterior

 When an anterior dislocation results from a traumatic event, the

humeral head stretches resulting in a loss of integrity of the
anterior ligamentous capsule

 resulting in a detachment of the anterior inferior labrum

ILLUSTRATION SHOWING ANTERIOR 59
SHOULDER DISLOCATION
RADIOGRAPH SHOWING ANTERIOR SHOULDER
DISLOCATION 60
PICTURE SHOWING CLINICAL PRESENTATION OF
ANTERIOR SHOULDER DISLOCATION 61
 62
CLASSIFICATION/PATHOPHYSIOLOGY

Posterior

 Posterior dislocations are occasionally due to electric shock or

seizure

 may be caused by strength imbalance of the rotator cuff muscles

 often go unnoticed, especially in an elderly patient and in the

unconscious trauma patient.

 average interval of 1 year between injury and diagnosis

 63
CLASSIFICATION/PATHOPHYSIOLOGY

Posterior

 The light bulb sign refers to the abnormal AP radiograph

appearance of the humeral head in posterior shoulder
dislocation.

 When the humerus dislocates it also internally rotates such that

the head contour projects like a light bulb when viewed from the
front
RADIOGRAPH SHOWING LIGHT BULB SIGN 64
 65
CLASSIFICATION/PATHOPHYSIOLOGY

Inferior

 Inferior dislocation is the least likely form (in less than 1%)

 also called luxatio erecta because the arm appears to be

permanently held upward or behind the head

 is caused by a hyper abduction of the arm that forces the

humeral head against the acromion

 high complication rate

 66

FIGURE SHOWING DISLOCATION OF THE SHOULDER JOINT

 67
DIAGNOSIS

 it is important for us to know the results of imaging to help guide

us in our treatment process

 may include plain radiographs, CT or MRI scans.

 Pre-reduction radiographs are necessary to determine direction

of the dislocation and to asses for any associated fractures
SPECIAL TESTS

SULCUS SIGN
 In this test the examiner applies a downward pressure on the
humerus by pulling at the level of the wrist, and at the same
time observes the lateral aspect of the deltoid region.
 If a sulcus appears in this region, the test is considered to be
positive for shoulder instability

68
SULCUS TEST 69
 70
MANAGEMENT APPROACHES

 Following an anterior shoulder dislocation, reduction by a clinician is

the amongst the first line of treatment. Alongside the use of NSAIDS
to manage pain.

 Suggested approach — No clear evidence exists supporting the

superiority of any one of the many methods used to reduce anterior
shoulder dislocations (Hendey, 2016) (Kuhn, 2006). The method
employed depends on clinician preference and the patient's condition.
 71

REDUCTION OF
ANTERIOR
SHOULDER
DISLOCATION
 72
MANAGEMENT APPROACHES

Reduction techniques:
 Scapular manipulation
 Upright technique
 Prone technique
 External rotation technique
 Traction countertraction
 Spaso technique
 Fares technique and many more.
 73
MANAGEMENT APPROACHES

Physiotherapy Management following reduction maneuver

 Following a reduction maneuver, a patient is going to come down with a

complication of pain.

 This can be managed through the use of cryotherapy.

 Followed with rest, immobilization and subsequent free active exercises

as patient progresses to resisted exercises.
 74
MANAGEMENT APPROACHES

Physiotherapy Management following reduction maneuver

 The resisted exercises should focus on isotonic strengthening before isokinetic

strengthening.

 The first musculature to rehabilitate is that of the scapula, serratus anterior, and
then rhomboids.

 The deltoids follow, and finally the rotator cuff.

Following a case where there is recurrent dislocation due to shoulder instability,

there is an indication for surgical repair.
 75
MANAGEMENT APPROACHES

Surgical Management

 Indications for repairing an anteriorly unstable shoulder are not obvious

 The patient and surgeon must consider the possible outcomes based
on the patient's activity level
 76
MANAGEMENT APPROACHES

Surgical Management

 In the case of a patient who has experienced dislocation fewer than 3

times, attempting an arthroscopic repair is reasonable

 Persons with truly recurrent dislocations (more than 3 times). In these

cases, patients may want to risk the possibility of stiffness in return for
the stability created by an open Bankart repair.
 77
MANAGEMENT APPROACHES

Surgical Management

 Many options exist for the surgical repair of anterior glenohumeral

instability.

 Arthroscopy provides the least invasive repair.

 Open shoulder repairs include Putti-Platt, Bristow, Magnuson-Stack,

inferior capsular shift, Eden-Hybbinette, and the Bankart procedures.
 78
MANAGEMENT APPROACHES

Surgical Management

Arthroscopic repair has potential advantages including improved

cosmesis, less post-operative pain, shorter operative time, decreased
blood loss, better preservation of external rotation, and avoidance of
subscapularis related complications

 Rate of nerve injury was 2.2% in the open group, compared with 0.3%
in the arthroscopic group
 79
PUTTI-PLATT CAPSULORRHAPHY

 The flexible cord (tendon) of the subscapularis muscle is cut and

then reattached to the head of the upper arm bone (humerus)
(Karthik, 2020).
 80
COMPLICATIONS

 Persistent pain

 Recurrent subluxation or dislocation

 Residual weakness of the shoulder

 Paraesthesia of the musculocutaneous nerve.

 Limitation of external rotation

 Impairment of function.

 Osteoarthrosis of the glenohemeral joint (late)

 81
PHYSIOTHERAPY

0-3 WEEKS

 Sling (Immobilization). The shoulder should be kept in external

rotation immediately after surgery.

 Full Passive ROM as comfortable for the patient because of pain at

the shoulder joint and surrounding tissues.
 82
PHYSIOTHERAPY

0-3 WEEKS

 Active Assisted ROM should be initiated as early as possible to

avoid more complications.

 Isometrics & Closed Chain

 Scar tissue formation prevention using ultrasound therapy and also

to promote tissue healing.
 83
PHYSIOTHERAPY

3-6 WEEKS

 Pain relieving modalities like NSAIDs can be used.

 SWD, IRR can also be used to relieve pain based on the progress
made by patient.

 Scar tissue formation prevention (US)

 84
PHYSIOTHERAPY

3-6 WEEKS

 Electrical muscle stimulation can be used for weak muscles of the

shoulder joint.

 Active assisted can gradually progress to active exercises.

 Open chain exercises can be initiated.

 85
PHYSIOTHERAPY

6-12 WEEKS

 Return to Sports Rehabilitation can begin.

 Patient can start resisted active exercises and attempt to use the
hand like the unaffected.
 86
PROGNOSIS

 Substantial increase in range of motion is not to be

expected.

 The mild decrease in pain may be sufficient to satisfy the

patient.

 If the osteoarthritic changes are advanced, a total

replacement may be necessary.
 87
PROGNOSIS CONTD

The rehabilitation time before the patient can return to sport

is usually about 6 months with the Putti-Platt operation
(Owens et al, 2011).
 88
CONCLUSION

Open-surgical repair procedure is being phased out in the western

world for arthroscopy because of its extensive surgery, time required,
cosmetic appearance and other attending complications. If it must be
done, the patients occupation, age must be considered because of
the prognosis and physiotherapy must be done as appropriate.
 89

THANK YOU!
REFERENCES
 
90
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 REFERENCES CONTD
91
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 REFERENCES CONTD
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 REFERENCES CONTD
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