Preventing the POP! – An Absolute Balance Case Study

This article outlines a recent patient’s return to work exercise rehabilitation programme prescribed by an Absolute Balance Exercise Rehabilitation consultant.

For those of you that have suffered a shoulder dislocation, I’m sure you would know that they can be quite a painful and unpleasant experience. Although most shoulder dislocations are the result of an impact or external force on the shoulder joint, there can often be underlying structural contributors.

Some people can have lax/hypermobile shoulder joints, others may have a shallow shoulder capsule meaning their humeral head has less surface holding it within the gliding socket. Then to add insult to injury, having a dislocation may cause damage to the articulating surface of the humerus and/or labarum which can make subsequent dislocations more likely. (Shoulder & Knee, 2019)

There are few studies present on the effectiveness of exercise rehabilitation for traumatic anterior shoulder dislocations. However, those studies completed indicate that structured exercise can be an effective, non-operative means of decreasing the risk of future dislocations (Kirkley, 1999). Non-recurrence rates ranged from 53-83% where the age of the data samples ranged from 18-30 (Patient age of 27). These results were collected years after completing a 6-week exercise intervention that included strengthening of the shoulder internal rotators and adductors. (Yoneda, 1982)

Due to a history of recurring left shoulder dislocations, our patient was advised to undergo the Laterjet procedure. This open shoulder surgery prevents anterior dislocation by attaching a bone graft that acts as physical a barrier for the humeral head. The conjoint tendon (originating from the biceps muscle) is left attached to the bone graft (from the Coracoid process) which then acts as a ‘sling’ that provides up to 60% of the joint’s enhanced stability. Repair of the Labarum then further increases joint stability. (K. Cutbush Shoulder Clinic, 2019)

As a Surveyor, our patient’s role is semi-laborious with duties including but not limited to: Lifting and carrying buckets of pegs (10kg), carrying survey poles (5kg) up to 1km, climbing a steep land faces, and hammering pegs/posts into the ground.

Figure 1: Presence of ‘winging’ at Week 3 versus the improved scapula control seen at Week 9

Early stages of the programme targeted scapular positioning and postural control, particularly to reduce scapula ‘winging’ (See Figure 1). Strengthening and proprioceptive exercises (Such as Exercises 1 and 2) encourage coordinated activation of the Serratus Anterior to prevent posterior displacement of the scapula when loading the shoulder. The aim ultimately being to reduce shoulder instability that may have contributed to prior shoulder dislocations.

Exercise 1: Ball roll outs

Exercise 2: Dumbbell Serratus Pull Overs

As the studies mentioned earlier suggested, rotator cuff stability is an essential aspect of rehabilitation. Cable internal rotation (See Exercise 3) builds shoulder stability, mimics the motion of swinging a hammer and allows the internal rotators to stretch under load during the eccentric phase. This can assist with improving external rotation range which is reduced as a result of surgery.

Exercise 3: Cable Internal Rotations

Our patient was able to meet (and exceed) the critical physical demands of their job role and has been cleared for pre-injury duties. Upon completion of the programme, our patient was able to deadlift 40kg, squat 40kg, seated row 36kg, complete full push ups and overhead press 20kg.

Critical factors in the success of this case were the early diagnosis, intervention, rehabilitation and return to meaningful employment. Although our patient did not return to full duties straight away, they were able to commence light duties and gradually incorporated more physical tasks as his medical team collaboratively advised it was safe to do so.

Keiran Kowalski (B – Clin.Ex.Phys)
Accredited Exercise Physiologist, (AEP) (ESSAM) (ACSM)

 

References

Kennethcutbushcom. 2019. Shoulder Clinic. [Online]. [1 April 2019]. Available from: https://kennethcutbush.com/shoulder-surgery/shoulder-surgery/arthroscopic-latarjet

Kirkley A, Griffin S, Richards C, Miniaci A, Mohtadi N. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder. Arthroscopy. 1999;15:507–514.

Shoulderandkneesurgerycomau. 2019. Shoulder and Knee Surgery Perth. [Online]. [1 April 2019]. Available from: https://www.shoulderandkneesurgery.com.au/shoulder-conditions/dislocated-shoulder-instability-perth/

Yoneda B, Welsh RP, MacIntosh DL. Conservative treatment of shoulder dislocation in young males. J Bone Joint Surg. 1982;64B:254–255.