CLINICAL NOTES MINOR SHOULDER INSTABILITIES by Gisela Lauterbach C h ro n ic m in o r s h o u ld e r in s ta b ilitie s are c o m m o n ly fou n d w ith h ig h -v e lo c ity a c ti­ v itie s s u c h a s th ro w in g a n d the ten n is serv e , an d in s w im m in g . It re fe rs to ch ro n ic m ic r o -tr a u m a in v o lv in g th e s ta b ilis in g m e c h a n is m s o f th e g le n o h u m e r a l jo in t, le a d in g to su b lu x a tion o f the h u m e ra l h ead d u rin g s p o rtin g a c tiv ity . It h a s also been d esc rib ed as o c c u lt in s ta b ility , o c c u lt re ­ c u rrin g g le n o h u m e ra l s u b lu x a tion o r fu n c ­ tion al in sta b ility . S ig n s an d sy m p to m s a re o fte n v a g u e an d p r e s e n t w ith a n im p in g e m e n t-lik e c o n d itio n w h ic h s ee m s to b e re s is ta n t to th erap y . D iag n o sis an d the tre a tm e n t o f this c o n d itio n th e re fo re o ffe rs a g r e a t c h a l­ len g e to the th erap ist! T h is c o n d itio n m a y re s u lt fro m • D iso rd e r o f the p a s siv e s ta b ilis e rs o f the jo in t, eg h y p e r-e la s tic ity o f the c a p su le, lab ral tears. • L o ss o f fu n ctio n a l s ta b ility o f the jo in t, d u e to w e a k n e ss , lo ss o f e n d u ra n c e or la c k o f c o o r d in a tio n o f th e m u sc le s o f the s h o u ld e r g ird le. T o a p p rec ia te the p r e s e n ta tio n an d a p ­ p ro a c h to tre a tm e n t o f this c o n d itio n , the b io m e c h a n ic s an d m u s c le firin g p a tte rn o f th ro w in g m u st b e u n d e rs to o d , in o rd er th at the p rin c ip le s c a n b e a p p lied to o th e r s p o rtin g ac tiv itie s, s u c h as th e ten n is serv e a n d s w im m in g . T h ro w in g c a n b e d iv id ed in to fo u r stag es: 1. W in d -u p , w h ic h c o n s is ts o f sh o u ld e r flex ion ; 2. C o c k in g , w ith a b d u c tio n , fo llo w e d b y h o riz o n ta l e x te n s io n a n d fu ll la tera l ro ­ tation ; 3. A c c e le ra tio n u n til the b a ll le a v e s the h a n d ; 4 . F o llo w -th ro u g h w ith fo rw a rd flex ion an d m e d ia l ro ta tio n o f the sh o u ld er. W in d -u p : T h e ro ta to r c u ff c o n tra c ts to s ta b ilis e the h e a d in the g le n o id . S u p ra sp i- n a tu s is m o s t a c tiv e b e tw e e n 8 0 an d 110° o f a b d u c t io n , w h e r e a s i n f r a s p in a t u s a n d teres m in o r a c tiv ity in c re a se s te a d ily to­ w a rd s fu ll elev a tio n . It is th is c o n tra c tio n th a t is m o s t im p o rta n t fo r c e n tra lis a tio n o f th e h e a d . T o e l e v a t e a n d a b d u c t th e s h o u ld e r, the sca p u la m u s t ro ta te la tera lly an d elev a te. S c a p u la r ro ta tio n re q u ire s a " f o r c e c o u p le " c o m p o s e d o f th e u p p e r tra p ez iu s, lo w er tra p e z iu s, le v a to r s c a p u ­ lae an d s erra tu s a n te rio r. W ith o u t this s ta ­ b ilis a tio n a b o u t the S T jo in t, the g len o id w ill lo se its o p tim a l u p w a rd d irec ted p o s i­ tio n , p r e d i s p o s in g to s u b a c r o m ia l im ­ p in g e m e n t. T h e e ffe c tiv e w e ig h t o f the u p p er lim b w ill in c re a se , p la c in g a b n o rm a l s tre sse s on the ro ta to r cu ff. T h is w ill lead to w e a k n e ss an d fa tig u e o f th e s u p ra sp i- n a tu s, w ith fu rth e r loss o f stabilisa tio n . F u ll tru n k e x te n s io n / ro ta tio n an d p elv ic ro ta tio n c o n trib u te to the sta g e o f w in d -u p . C o c k in g c o n sis tin g o f h o riz o n ta l e x te n ­ s io n (30°) and lateral ro ta tio n (160-180°). T h ro u g h o u t this sta g e the ro ta to r c u ff c e n ­ tralises the h ead . Fu ll e x te rn a l ro ta tio n is a c h iev e d b y the p o s te r io r d eltoid an d the lateral ro ta to rs, w h ile th e m id d le trap eziu s a n d the rh o m b o id s a d d u c t the scap u la. S e r r a tu s a n te r io r s ta b ilis e s th e s c a p u la a g a in s t the th o racic w all. E cc e n tric c o n ­ tractio n s o f the s u b s ca p u la ris d ec e lera tes th e m o v e m e n t , w h i l e te r e s m a jo r , la- tissim u s d o rsi, an d p e c to ra lis m a jo r c o n ­ trol the la st d eg re e s o f la tera l ro ta tio n and p re v e n t e x c e ss iv e a n te rio r tra n sla tio n o f the h u m e ru s in the g le n o id . C o o rd in a tio n an d c o r r e c t a c tiv a tio n o f th ese m u sc le s th e re fo re is im p o rta n t to m in im ise o v e r ­ s tra in o n the a n te rio r p a rt o f the jo in t. A c c e le r a tio n : P ec to ra lis m ajor, s u b s c a ­ p u la ris, la tissim u s d o rsi an d teres m a jo r a c t c o n c e n t r i c a l l y a s m e d ia l r o t a t o r s . L o w er an d u p p er tra p ez iu s an d serra tu s a n te rio r c o n tra c t c o n c e n tr ic a lly to h o ld the s ca p u la ro ta ted an d to m o v e it latera lly . F o llo w -th r o u g h c o n s i s t s of. fo r w a r d flex io n an d m ed ia l ro ta tio n o f the sh o u ld e r jo in t. E cc e n tric a c tiv ity in p o s terio r d elto id , s u p r a s p in a tu s , in fr a s p in a tu s a n d teres m in o r con tro l the m e d ia l ro ta tio n . E c c e n ­ tric c o n tra c tio n s o f the m id d le trap eziu s, r h o m b o id s , p e c t o r a l i s m a jo r a n d la-1 tiss im u s d o rsi p ro v id e the d e c e lera tin g force. W ith in s ta b ility th ere a p p e a rs to b e a c o m p e n s a to ry in c re a se in a c tiv ity o f the b ic e p s a n d the s u p r a s p in a tu s m u sc le s. D im in ish e d a c tiv ity o f serra tu s a n te rio r oc- .cu rs, w h ic h d im in is h e s p ro tra c tio n o f the s h o u ld e r, th erefo re p la cin g m o re stress on the a n te rio r restra in ts. D im in ish e d lev els o f a c tiv ity o f p ec to ra lis m ajor, s u b s c a p u ­ la ris, la tissim u s d o rsi an d o f in fra s p in a tu s h a s a ls o b e e n fo u n d . T h is im b a la n c e , w h e th e r it is p a rt o f the p rim a ry p a th o lo g i­ c a l p ro c ess o r s ec o n d a ry to it, a d d s to the a n te rio r in s ta b ility an d m u st b e ad d ressed s p e cific a lly d u rin g re h a b ilita tio n . Clinical presentation: • P a in w ith o v e r h e a d a c tiv itie s , e ith e r d u r in g la te c o c k in g / a c c e le r a tio n or d u rin g fo llo w -th ro u g h . T h e y a re o ften v a g u e an d d ifficu lt to lo ca lis e to an y s p e cific p o sitio n o f the jo in t. • C o m p la in t o f w e a k n e ss , e sp e c ia lly in the p o sitio n o f la te co c k in g . D ifferen ce b e tw e e n m in o r in s ta b ility a n d im p in g e ­ m e n t s y n d r o m e a r e t h e r e f o r e v e r y su b tle. • A p p re h e n sio n a sso c ia te d w ith certa in m o v e m e n t, b u t fre q u en tly u n a b le to tell w h e th e r this is tru e a p p r e h e n sio n or a n tic ip a tio n o f p ain . • P a in fu l c a tc h e s , p a in fu l in tra -a rtic u la r c lic k in g o r " d e a d a r m " s y n d ro m e m ay b e p re s e n t in th e la te c o c k in g p h ase. • T h e h is to r y s e ld o m re v e a ls a s p e cific in ju ry , b u t m o v in g p a in s ite s in v a rio u s s ea s o n s o f p la y , w h ic h h a v e b e e n re sis­ ta n t to th erap y . On examination: • T h e p a tie n t m a y p re s e n t w ith fu ll or e x c e ss iv e ra n g e o f p h y s io lo g ic a l m o v e­ m e n ts, w ith p a in a t lim it, p a rtic u la rly a b d u c tio n an d la tera l ro ta tio n o r h o ri­ z o n ta l flex io n a n d m e d ia l ro ta tio n . L a t­ eral ro ta tio n m a y b e lim ite d b y sp asm , e sp e c ia lly in a b d u c tio n , o r m a y b e e x ­ cessiv e. • E n d fee l is o fte n lo o se, le ss o f a lig a m e n ­ tou s tig h te n in g . • R e s is te d c o n t r a c ti o n o f r o t a t o r c u f f m u sc le s a re p ain free. • S ta b ility tests m a y b e n e g a tiv e . • D iffe r e n tia tio n b e tw e e n le sio n s o f the s u b a c r o m ia l s tr u c tu r e s a n d o f in s ta ­ b ility c a n b e d e te r m in e d b y a d d in g c o m p re s sio n o r d is tra c tio n to full e le v ­ ation , as d es c rib ed b y M a itla n d . • L o ss o f p r o p r io c e p tio n , as w ith a n y in­ ju r y o f a jo in t. • M u s c le s tre n g th : A c o m m o n m ista k e is to test s tre n g th o n ly . M u s c le c o n tro l and e n d u ra n c e a re fu n c tio n a lly m o re im ­ p o rta n t. O n a s s e s s m e n t o f m u s c u la r c o n t r o l a n o r m a l s c a p u l o h u m e r a l rh y th m m a y b e e v id e n t o n a c tiv e e le v ­ a tio n an d a b d u c tio n . H o w e v e r, a fte r re p e titio n o f m o v e m e n t, o r e lev a tio n u n d e r a lo a d , u n c o n tr o lle d s c a p u la r p a tte rn s m a y b e re v e a le d . T h is m a y b e m o re e v id e n t d u rin g lo w e r in g w h e n the sc a p u la r s ta b ilis e r s fu n c tio n e cc e n tri­ cally . C a r e fu l r e p e titio n a n d a n a ly s is o f the sp o rtin g a c tiv ity m a y b e n e c e ss a ry to re p r o d u c e th e s y m p to m s a n d m u sc u ­ lar c o n tro l s h o u ld b e a s se s se d in v a rio u s fu n ctio n a l p o sitio n s. Rehabilitation: T h e g o al o f r e h a b ilita tio n is to re tu r n the in d iv id u a l to p re -in ju ry s ta tu s, n a m e ly full m o v e m e n t, s tre n g th , e n d u ra n c e , c o o r d in a ­ tion an d s p eed . Principles of treatment: • In fla m m a tio n an d p ain m u st b e treated locally . • R e -e d u c a te s y n c h ro n y o f m o v e m e n t. It is im p o rta n t n o t to s ta rt s tre n g th en in g e x e rc is e s u n til s y n c h ro n y o f m o tio n o f the s h o u ld e r g ird le c o m p le x th ro u g h a n o rm a l ra n g e h a v e b e e n a c h iev e d ! T h e first a im is to im p ro v e the s ta tic s ta b ility o f th e s c a p u la , fo r e x a m p le s d u rin g c o ­ c o n tra c tio n e x e r c is e s o f the ro ta to r cuff, P N F p a tte rn s o f the s c a p u la , an d seated p u sh u p . M id d le fib re s o f tra p ez iu s are e x e rc ise d in the p ro n e p o s itio n , in itia lly w ith lim ite d la te r a l r o ta tio n . S tre n g ­ th en in g fo r the s e r ra tu s a n te rio r is v ery im p o rta n t for re a s o n s m e n tio n e d ear- I* T 1 4 * 4*1■1 n il.............flrm iiiiiiJf R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) lier. E xam ples are p u sh ups, initially against the w all, progressing towards the flo o r, m o v in g p a st th e n o rm al m ovem ent into protraction of the sca­ pula. ' • Im p rove d ynam ic co n tro l ab ou t the shoulder joint. E xercises are initiated in a neutral position w here control o f the m ovem ent is retained. Short lever exer­ cises are used, for exam p le bilateral shoulder flexion, w ith the elbow s in 90° flexion. These are progressed towards the position of instability, and towards the m ovem ent of the sporting activity. As control im proves, the rotator cuff m u s cle s a re e x e rcise d c o n c e n tr ic a lly and eccentrically against resistance, for e x a m p le w ith s u r g i c a l tu b in g o r w eights. Strengthening only the lateral rotators for posterior instability and the medial rotators for anterior .instability fails to recognise the entire function of the cuff. • Increase m uscle strength and end ur­ ance. O nly w hen full control of m ove­ m ent is achieved, can resistance be in­ creased. W eight training is included using low w eights at high repetitions to em phasise endurance. Isokinetic exer­ cises, concentrating on the rotators, are' instituted initially in the neutral posi­ tion. High speed, 180-240° are used, again to em phasise the control and en­ d u ran ce. F ro m the n eu tral p o sition these exercises are progressed towards 90° of abduction. • Re-educate proprioception. By im prov­ ing m uscular control, jo in t and m uscle afferents are stim ulated, thereby elicit­ ing reflex activity and im proving m us­ cular control, jo in t and m uscle afferents are stim ulated, thereby eliciting reflex activity and im proving proprioception. A d d itio n a l e x e r c is e s , w ith w o b b le board and ball are included. • Im prove flexibility. O ptim al control re­ q u ire s a p ro p e r b a la n c e o f m u scle length betw een agonists and antagon­ ists to prevent further stress on gleno­ hum eral and subacrom ial structures. • Introduce the sporting activity. The spe­ cific m ovem ents are included into the rehabilitation program w ithin lim its of pain. Initially em phasis is on fluidity and control of m ovem ent. Start with s m a ll r a n g e m o v e m e n ts fo r s h o r t period s grad u ally pro g ressing range and tim e, concentratin g on accuracy and control. P rogression o f exercise is alw ays deter­ m in e d b y th e c o n t r o l o f m o v e m e n t, presence o f pain or related sym ptom s, and never by time! If the patient can throw at previous perform ance levels w ithout dis­ com fort, he/she may return to com peti­ tion. N ever forget to inclu de low er ex­ tremity and trunk strength w ork into the training program . R ehabilitation of the m inor shoulder in­ stability can be very com plex. H ow ever, w ith careful analysis o f the m uscle firing pattern , and correctio n thereof starting proxim ally w ith the scapula control, good results can be achieved. It m ust be kept in m ind, that conservative treatm ent is not sufficient if disorders of the passive sta­ bilisers are present. P ost-operatively the sam e principles of treatm ent are follow ed, w ith close liaison betw een the patient, su r­ geon and therapist. This paper was presented at the Congress of the South African Sports Medicine Association, Cape Town, March 1993. IN MEMORIAM - KATHLEEN OLIVE SWEET Nee HARRIS, MCSP Died suddenly in Fish H oek on 30 A ugust 1993. She trained at M anchester Royal Infirmary, qualifying as a Chartered P hysiotherapist in 1952. Shortly afterwards she came to South A frica and settled in the Cape. She joined the Cape Provincial A dm inistration in 1961 and worked her way through the ranks, becom ing a grade 1 physiotherapist in 1967, and a principal in 1974. From 1969 she was based at the South Peninsula Group of Hospitals, and was eventually responsible for physiotherapy services within the group, until she retired. It was through her efforts that the Neuro Rehabilitation Centre, now based at the Lady Michaelis Hospital, was established. As a person she was quiet, charm ing, and courteous, and her staff and colleagues found her ever helpful, caring, ready to listen, and dependable. A lthough generally self-effacing she was always able to offer sound, construc­ tive advice, and what she said was worth listening to. She was noted for her steady persistence in the face of (som etimes strong) opposition until she had achieved her objectives. She held her profession in high esteem and served on many com m ittees aimed at enhancing patient care. She had an incredible zest for life, and her interests w ere wide ranging. She was a mem ber of International Training for Communication (ITC), and was very involved with C om m unity Projects, particularly those aimed at young people. At the time of her death she was actively involved in teaching English to underprivileged children. She loved the outdoors, and the W estern Cape m ountains were very special to her. She enjoyed hiking, and following adventure trails. Tw o of her latter exploits were: Rafting down the Orange River with her two grandchildren, and exploring Bushmanland on a Camel! She was an avid reader, good with her hands, and an active mem ber of the Historic Club of Sim onstown. She was a devoted wife, m other and grand­ mother. H er sudden and untimely death has com e as a great shock to those of us who were privileged to know her, and w e extend our heartfelt condolences to Leonard, Alison and Hennie, grandchildren Hannes and Nicky, and to all mem bers of her w ider fam ily circle. \ If yo u ’d lik e to w o rk in th e US, c o n ta c t HPI. W e ’ve h e lp e d m o re physical th e ra p is ts fin d g r e a t jo b s in A m e ric a th a n any o th e r re cru iter. Top pay, e x p e rt lic e n s in g a n d visa p ro cessin g. F e es p a id by your e m p lo y e r. IIIIIIHPi T h e L e ad er in In te rn a tio n a l H e a lth c a re R e c ru itin g 8 1 2 O a k Street, W in netka, IL 6 0 0 9 3 U S A (R everse C h arg es ) 7 0 8 -4 4 1 -8 3 8 4 F a x :7 0 8 -4 4 1 -8 4 0 1 I f R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )