ShoulderInstability: Keeping)it)Simple!) Instability... · CliniciansChallenge •...

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  

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