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Presentation given in fall of 2008.
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Chris Blake,MA,LATC,CSCSOwner/Pro CoachPro Athletic Training & Development, LLC
95% of anterior shoulder dislocations due to shoulder instability caused from traumatic injury [1]Patients’ age at time of injury is inversely related to recurrence rate. [1]Younger than 20 years, recurrent dislocation rates as high as 90% in athletic population [1]
Starting Point in Rehabilitation
Ages 20-25 recurrent dislocation rates between 50-75% [1]Older than 40 years, lower rates of instability, higher rates of rotator cuff tears. [1]Rotator Cuff and Parascapular Musculature offers Dynamic Stabilization.
1st Time DislocationOther Damage Control
RC TearsLabral Tears/Repairs
Howell and Galinat: Labrum contributes 50% of the total depth of socket. Labrum damage in Bankhart lesion plays into recurrences.
Chondral defects.Osseous lesions
Very Controversial Decision Based On:
AgeSportActivity LevelInjured Athlete
Bottoni et al 88% follow-up at an average of 3 year, recurrent instability was noted in 11.1% of arthroscopic group versus 75% of nonop group [2]
Not many open being performed.
Risk of InfectionPatient Comfort LevelCosmetic Reasoning
Either Open or Arthroscopic…..It Doesn’t Make A Big Difference Rehabilitation-wise*
* Some rehab protocols state aggressive for Open Bankart Repair.
NonoperativeImmobilization in a sling for approx. 1 weekRange of motion exercises as tolerated with progression to strengthening.Strengthening Phase: Emphasis on Periscapular and Dynamic Stabilizers. [1]Later Stages: Proprioception and Dynamic Stabilization along with Sport Specific Situations.
Post-Op Bankart RepairShoulder Immobilization 4 weeks.
Pendulum exercises?AROM of the elbowMaintain Light Grip Strength
At 4 weeks:Supine Forward Elevation/Flexion to 90 deg.ER Limited to 15-20 degreesSling use is discontinued 4-6 weeks, Submax Isos
6-8 Weeks:Pulleys, Cane ER, Supine Flexion
NonoperativePace of Rehab Based on comfort level.Limit ER to 45 degrees for first 4-8 weeks, then to 90 degrees 8-12 weeks.12 weeks: Athlete will feel good. Test out shoulderAvoid: Overhead Presses
Upright Rows Deep Bench Press Dips
• A Good-Solid RC Program is a Must!!!!
Post-Op Bankart Repair6-8 Weeks Contin:
Scapular SqueezesLight to Max Iso’s (8 wks)ER to 70 @ 90/90 degrees (8 wks)*Flexion to Full (8 wks)*
8-12 WeeksBegin Light Sport Cord RowsContinue to work Periscapulars
12 Weeks: The Gloves Come Off!!!!
Full ROMBack/Shoulder/Chest exercises
WK 1-2 WK 3-4 WK 5-6 WK 7-8 WK 8-10 WK 10-12
SLING X X
PROMFF: 60 90 135 FULL FULL FULL
SCAPTION: 60 115 135 FULL FULL FULLIR: 45 60 FULL FULL FULL FULL
ER: 0-10 15-20 30 70 @90/90FULL @ 90
abd. FULLABDUCTION: X 75-85 120 160 FULL FULL
begin 90/90
ISOMETRICSFF: X SUBMAX MAX DISCONTINUE DISCONTINUE
ABD: X SUBMAX MAX DISCONTINUE DISCONTINUEIR: X SUBMAX MAX DISCONTINUE DISCONTINUEER: X SUBMAX MAX DISCONTINUE DISCONTINUE
AAROMFF: X to 90 only to 135 TO TOL. TO TOL.
ABD: X X to 120 TO TOL. TO TOL.IR: X X TO TOL. TO TOL. TO TOL.ER: X X to 30 TO TOL @ 0 TO TOL.
begin 90/90AROM
FF: X X X TO TOL.ABD: X X X TO TOL.IR: X X X TO TOL.ER: X X X TO TOL.
begin 90/90
WK 1-2 WK 3-4 WK 5-6 WK 7-8 WK 8-10 WK 10-12
ISOTONICSFF: X X TO TOL. TO TOL. TO TOL. TO TOL.
ABD: X X TO TOL. TO TOL. TO TOL. TO TOL.IR: X X TO TOL. @0 TO TOL. @0 TO TOL. begin 90/90ER: X X TO TOL. @0 TO TOL. @0 TO TOL. begin 90/90
SCAP STAB. X NO RESIST TO TOL.
WK 1-2 WK 3-4 WK 5-6 WK 7-8 WK 8-10 WK 10-12
SLING X X X
PROMFF: 60 90 90 135 FULL FULL
SCAPTION: 60 90 90 135 FULL FULLIR: X 0-15 35@45abd 45 @90/90 FULL @10wks FULL
ER: 15-20 25-30 90 90 @90/90 FULLto functional (throwers)
ABDUCTION: 45 60 135 FULL FULL FULLbegin 90/90
ISOMETRICSFF: X SUBMAX MAX DISCONTINUE DISCONTINUE
ABD: X SUBMAX MAX DISCONTINUE DISCONTINUEIR: X X MAX DISCONTINUE DISCONTINUEER: X SUBMAX MAX DISCONTINUE DISCONTINUE
AAROMFF: X to 90 only to 90 only TO TOL. TO TOL.
ABD: X X to 90 only TO TOL. TO TOL.IR: X X X to 45 only TO TOL.ER: X X TO TOL TO TOL TO TOL.
begin 90/90AROM
FF: X X X TO TOL. TO TOL.ABD: X X to 90 only TO TOL. TO TOL.IR: X X X TO 35. @0 TO TOL.ER: X X TO TOL TO TOL. TO TOL.
ELBOW/WRIST TO TOL TO TOL TO TOL
WK 1-2 WK 3-4 WK 5-6 WK 7-8 WK 8-10 WK 10-12
ISOTONICSFF: X X X TO 90deg TO TOL. TO TOL.
ABD: X X X TO 90deg TO TOL. TO TOL.IR: X X X X at 0 abd begin 90/90ER: X X TO TOL. @0 TO TOL. TO TOL. begin 90/90
TRICEPS X X X no overhead TO TOL.BICEPS X X X TO TOL TO TOL.
SCAP STAB. X NO RESIST NO RESIST TO TOL
Notes: begin diagonals at 14-15 weeks
Full A/PROM at 12 weeks 10 weeks, IR at 12 weeksavoid posterior glides for first 8 weeksmay begin wall push ups at 8 weeks, progressive after 10 weeks
16 weeks Post-op/Post-injury
Closed Kinetic Chain ExercisesDynamic Rhythmic StabilizationIncrease Sets, Decrease Reps, Increase Resistance.Maintain ROMReturn To Sports Training is a Sports Medicine Team Decision
Year-round TrainingIncluding In-season Training program.
Football, Ice Hockey, Lacrosse, Wrestling, Gymnastics, Swimming: You Have To Go All Out!!!Train them Like Hell!!!!But Be Smart About It!!!
Overhead Lifts??????
Deep ROM Bench PressesDipsHeavy Overhead LiftsUpright RowsSnatch CleansOverhead Kettlebell Exs
Risk Outweighs Reward….
[1] Dodson CC, Cordasco FA. Anterior Glenohumeral Joint Dislocations. Orthop Clin N Am 39 (2008): 507-518.
[2] Cox CL, Kuhn JE. Operative Versus Nonoperative Treatment of Acute Shoulder Dislocation in the Athlete. Current Sports Medicine Reports. Vol. 7(5), September/October (2008): 263-268.
[3] Kim SH, Ha KI, Jung MW, Lim MS, Kim YM, Park JH. Accelerated Rehabilitation After Arthroscopic Bankhart Repair for Selected Cases: A Prospective Randomized Clinical Study. Arthroscopy.(2003) Sep;19(7):722-31.
[4] Jakobsen BW, Johannsen HV, Suder P, Sojbjerg JO. Primary Repair Versus Conservative Treatment of First-Time Traumatic Anterior Dislocation of the Shoulder: A Randomized Study with 10-Year Follow-up. Arthroscopy. (2007) Feb;23(2):118-23.
[5] Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic Treatment of Anterior-Inferior Glenohumeral Instability: Two to Five-Year Follow-up. The Journal of Bone and Joint Surgery. Vol. 82-A, no. 7, July (2000): 991-1003.