Embed Size (px)
Citation preview
Shoulder Instability: Keeping it Simple!
Jo Gibson MCSP MSc.
Shoulder Instability: Keeping It Simple
• Relevance of ClassificaCon • Patho-‐physiology – the evidence base • When to speak to our surgeons ☺
• RehabilitaCon essenCals
Shoulder Instability: Keeping it Simple
Spectrum • Individual • AcCvity • History of onset
Wilk & Macrina 2014, Sadeghifar et al 2014
The Challenge of Diagnosis
DiagnosCc Criteria subgroups • Unreliable • Lack validity • Alter incidence • Spectrum of causes
STANMORE CLASSIFICATION
Jaggi A , Lambert S Br J Sports Med 2010;44:333-‐340
(TUBS)
(AMBRI)
ClassificaCon: Keeping it Simple?
• Torn out • Worn out
• Falls out ? • Pulled out ? • = Out of control
Clinicians Challenge
• “IdenCfy the driver behind the dysfuncCon and focus rehabilitaCon towards the most relevant aspect for the individual”
Barre9 2015
I -‐ TraumaCc Structural
• Significant trauma • Oaen Bankarts • Usually unilateral • No abnormal movement paberning
• Require surgical repair
Mechanism Mabers: SubjecCve Hx
TraumaCc DislocaCon: One Size Does not fit All!
• Decisions affecCng Management – The presence of associated injuries (e.g. Rotator cuff tear)
– Age of the paCent – Sex of the paCent – Pre-‐morbid acCvity levels
Wilk et al 2014, Lambert 2010
Age and Sex-‐Specific EsCmated Probability of Recurrent Instability within the First Two Years Aaer a Primary Gleno-‐humeral DislocaCon
Age Males Females
15 0.86 0.54
16 0.84 0.51
17 0.81 0.48
18 0.78 0.45
19 0.75 0.42
20 0.72 0.40
21 0.69 0.37
22 0.66 0.34
23 0.62 0.32
24 0.59 0.30
25 0.56 0.28
26 0.53 0.26
27 0.50 0.24
28 0.47 0.22
29 0.43 0.20
30 0.41 0.19
Robinson et al 2006,2010
TraumaCc Instability: Factors associated with poor outcome
ConservaCvely managed • Reduced IR/ER ROM
• Reduced IR/ER strength • PropriocepCve deficits
Sadeghifar et al 2014, Fyhr et al 2015
TraumaCc Instability: Operate or Not?
For Surgery
• Risk of recurrence -‐ Age
• Incidence degeneraCve changes
• Dynamic system • Restore anatomy
Against Surgery
• Incidence labral pathology in asymptomaCc pts
• 60-‐70 % stability GHJ dynamic system
Gigis et al 2014, Robinson 2010, Dickens et al 2014
The Superior Labrum: To Operate or not
For Surgery
• TraumaCc history • Unable to RTP • MRA matches clinical presentaCon
Against Surgery
• High incidence superior labral pathology in asymptomaCc
• Overuse pathologies do less well
Kibler 2013, Funk 2014
TraumaCc Instability: Can we predict who will do well with
ConservaCve Treatment?
• Apprehension – ? PredicCve recurrence – High or low risk only – ? Decision making
• Importance of tesCng technique
Milgrom et al 2014, Safran et al 2010, Speer 2010
The Challenge of Clinical Assessment in Labral Pathology
• One test is not enough • Current recommendaCons SLAP -‐ O’Briens -‐ Dynamic Labral shear -‐ Biceps Load II -‐ Speed’s
• History and mechanism and clinical picture are key (70%)
Jones 2012, Kibler 2014, Michener 2013
ClassificaCon?
• Torn out • Worn out
• Falls out ? • Pulled out ?
History & Mechanism Maber !
Type II: Falls out
• AtraumaCc (??)
• Capsular DysfuncCon • MDI • Posterior-‐inferior • Not uncommonly bilateral
Hess et al (2005) Cools et al (2006) Ilyes &Kiss (2005) Teyhen (2008)
Type II: What the evidence says
• Timing problem rotator cuff/scapula
• ↓ PropriocepCon
• ↓ FaCgue resistance
• ? Hypermobility
Jaggi et al 2010,Adib et al 2005, Hakim & Grahame 2003, Simmonds & Keer 2007
Type II: What the Evidence Says • Balance • Posture • Joint PosiCon Sense
• Matching arm posiUon
• Target pracUce
Shumway & Wollaco9 2008, Hess et al 2005, Gibson 2010, Radwan 2014
Type II: What the Evidence Says
• Change in threshold corCcospinal response LT & infraspinatus
• ↓ feedback mechanisms • Altered neural control • ?Neurodevelopmental
Alexander CM 2007 Hundza & Zehr 2007
• 80% beber with exercise programme
• 47% athletes get beber with exercise
Type II: What the Evidence Says
Burkhead & Rockood 1992, Misamore 2002, Barre9 2015
Type II: Young Athletes
• Background of laxity • Don’t stop everything!
• Direct trauma and extension injuries
• FaCgue over season • Monitoring
Ren 2013, Barre9 2015
Type II : What the evidence says
Role of Surgery • PlicaCon/Shia • Not a stand alone soluCon
• Creates a window of opportunity
• Beware the hyper-‐mobile paCent
Sinopidis et al 2008, Walch 2011
ClassificaCon?
• Torn out • Worn out
• Falls out ? • Pulled out ?
• Abnormal muscle recruitment
• No structural damage
• Clues • Key drivers • Central Control
Type III : Pulled Out
Jaggi & Lambert 2010, Barre9 2015
Type III: Pulled Out
• Reduced acCvity and Cme domain of reflex acCvity LT, infraspinatus, deltoid and supraspinatus
Barden et al 2005
Type III: What the Evidence Says
Anterior Instability
• PM 60% • LD 81% • AD 22% • ISP Inhibited
Posterior instability
• LD 80% • AD 18% • ISP inhibited
Jaggi et al 2012
BUT!: Clinical assessment idenCfies paberning in 93% of paCents but not the main muscle responsible!
What Next?
Type III: The Reality?
• Don’t panic! • It’s the same! • Cross-‐over • Common compensatory paberns
• Key quesCon : can I change it?
Improvement tests
• Compression • Hand grip • Posterior cuff • Short to long lever Plus • KineCc Chain
Magarey & Jones 2003 Dark et al 2007 Lin et al 2005 Suprak 2007
AtraumaCc Instability: Can I change it?
AtraumaCc Instability: Can I change it?
• Single leg balance (trendelenberg)
• Single leg squat • Step stand (contralateral) • Improvement tests
AtraumaCc Instability: Can I change it?
And if I can’t change it?
• Pain • Neuro-‐developmental • Psychological
What are we dealing with?
Somatosensory changes at a corCcal level
• Loss of precision • DisrupCon movement
commands
• Changes in sensory funcCon
• AlteraCons in the percepCon of body part
Assessment Tools
• TPD • TacCle discriminaCon
• Lea/right judgement
Tip: Pain & descriptors
Lotze and Moseley 2007, Gibson 2010
Neuro-‐developmental
Neurodevelopmental Aspects • Angels in the snow • Reciprocal imitaCons
• Other tools
Shafer et al 2008 Barkus 2006
Instability: The Story So Far
• Cuff -‐ Doesn’t switch on
-‐ Doesn’t control translaCon
• Muscle sequencing
• PropriocepCve deficits • Postural control/KineCc chain • Central consideraCons
Struyf et al 2014,
RehabilitaCon EssenCals Local System
• Switch on-‐ pre-‐set • DirecCon specific recruitment
• Through range • FuncConal relevance
Ginn 2012 David 2000 Kibler 2010
FacilitaCon • Stretch/distracCon • Compression
• Hand grip/pincer grip • Isometrics
RehabilitaCon EssenCals Sensorimotor System
Rio et al 2013, Woolaco9 2012, Manske 2013
RehabilitaCon EssenCals: Sensorimotor System
PropriocepCve Tools • Weight bearing
• Resistance • TacCle/Touch • Tape/Lycra • PNF techniques • Isometrics
DirecCon specific • FacilitaCon through range • FuncConal relevance • Movement is organised funcConally not anatomically in the motor cortex
RehabilitaCon EssenCals Rotator Cuff
Rotator Cuff: DirecCon Specific
• RotaConal control of rotator cuff through range
Ginn & Jaggi 2013
The KineCc Chain
• Thorax • Scapula • Cuff
RehabilitaCon EssenCals The KineCc Chain
• Shoulder doesn’t funcCon in isolaCon • Dynamic integraCon enhances local recruitment paberns
• Enhances sensorimotor input
• Motor cortex funcConal paberns
Sciascia 2012, Khazhadyiat et al 2013, Cools et al 2012
• PNF • Thorax/KineCc chain rotaCon • Lawnmower/Robbery
• ProtracCon with lunge • ER with step back/step-‐up
RehabilitaCon EssenCals The KineCc Chain
Remember?
• ROM • Strength • PropriocepCon • Movement/recruitment pabern
• ? Timescales
Ginn et al 2012, Cools et al 2012, Barrett 2015
Know what you are dealing with
• Exclude anatomical or neurological deficit
• History & mechanism & age maber
• What improves symptoms the most?
• If can’t change consider neuro-‐developmental, central corCcal change, psychological
Shoulder Instability: Keeping It Simple
• Relevance of ClassificaCon • Patho-‐physiology – the evidence base • When to speak to our surgeons ☺
• RehabilitaCon essenCals
@shouldergeek1
