Managing Shoulder Dislocation & Impingement with Chiropractic
What you need to know
FAQ about the Shoulder
How Chiropractic Can help
01
How Chiropractors help Shoulder Pain
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Following brief immobilisation and cryotherapy use for pain control during the initial 1 to 2 weeks following an acute instability event,
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In general, following the initial immobilisation period, patients will be weaned from sling use, followed by targeted therapy goals focusing on achieving full active/passive ROM and gradual progression to strengthening exercises that focus on dynamic glenohumeral stabilisers and periscapular stabilisers.
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When ROM and strength are comparable to the normal side, sport-specific drills can be initiated, and a return to play with a brace can be considered.
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Rehabilitation performed in a supervised setting may improve results, although the time to return to sport varies by the program. In most situations, return to play is given consideration after about 2 to 3 weeks.
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What are AC Dislocations
Ac dislocations
Acromioclavicular (AC) joint dislocations are common in a young and active population, especially in people performing contact sports. Full recovery with a fast and high rate of return to sport is desirable
Acromioclavicular (AC) joint injuries are common in young athletes with an incidence of 9.2 per 1000 person-years . The incidence of AC injuries is higher in contact sports and is highest in adults in their 20s
The acromioclavicular (AC) joint is a diarthrodial joint in the shoulder between the distal clavicle and the acromion. The AC joint is stabilized by muscular and ligamentous structures including the deltoid and trapezoid muscles and the capsular, AC, and coracoclavicular ligaments .
AC joint separation is common among athletes and occurs following a traumatic injury to the shoulder
This injury is roughly 10 times more frequent in men than in women .
AC joint separation accounts for 9% of all shoulder injuries but 40% of all sports-related injuries .
The mechanism of injury is typically a fall or a direct blow to the shoulder with the arm adducted
The prevalence of concomitant labral injuries and AC joint dislocation was approximately 27%.
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Signs and Symptoms of anterior joint instability
Anterior Shoulder Instability
Anterior shoulder dislocation is the most common joint dislocation in the human body.
The shoulder’s anatomy allows for greater flexibility with inherent instability as the trade-off. The recurrence rate after an adequate initial conservative management varies from 72% to 100% in the adolescent population group. Delayed surgical management of a recurrent shoulder dislocation will lead to the development of secondary osteoarthritis of the shoulder in a very young patient. Surgical options for such a complication are limited and results often shortlived. Rotator cuff tears are another common injury associated with anterior shoulder dislocation, with the rate varying between 7% and 32% commonly affecting patients older than 40 years and rising with advanced age.
Consistent clinical signs of the anteriorly dislocated shoulder include:
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Patients walk with their injured shoulder dropped, slightly abducted, externally rotated and being supported by the contralateral limb.
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Loss of deltoid contour (square shoulder).
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Loss of deltopectoral groove definition (or fullness of the deltopectoral groove).
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The humeral head is palpated under the deltopectoral groove.
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Emptiness of the glenoid fossa on palpation
Axillary nerve neuropraxia is the most common neurological deficit found in anterior shoulder dislocation
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What are SLAP LESIONS
SLAP LESIONS : Superior Labrum Anterior to Posterior Tears.
SLAP LESIONS
Superior-labrum anterior to posterior (SLAP) tears are common injuries in athletes, present in up to 26% of shoulder arthroscopies They often occur due to trauma in athletes, or secondary to overuse among overhead athletes. Among young athletes, type II SLAP tears are the most common subtype, and are characterised by superior labral fraying with a detached biceps anchor
They found that 87% returned to their pre-injury level of play with biceps tenodesis and only 20% returned following SLAP repair.
MANAGING SHOULDER INSTABILITY
The repetitive stress of the overhead mechanism, specifically excessive abduction and external rotation, places overhead athletes at risk for instability. Although anterior shoulder instability (ASI) is the most common pathology plaguing this athlete population, posterior and multidirectional instability also occur and require attention to detail in their diagnosis and management
This “normal adaptation” can progress to pathologic dysfunction in a number of ways including glenohumeral internal rotation deficit, internal impingement due to tightening of the posterior capsuloligamentous structures, and a relative loosening of the anterior structures, superior labral tears, biceps tendon injuries, and rotator cuff tendinopathy or tears
Chiropractic and Rehabilitation of the shoulder
Everything you need to know
01
Surgery or Chiropractic Care
Surgery or Chiropractic Care
TREATMENT FOR SHOULDER CONDITIONS
Immobilisation in internal versus external rotation for 1 - 6 weeks
86% return to sport rate with no sling immobilisation after initial dislocation
Research - non op shoulder instability average missed 10.2 days of sport
36% did not have a recurrence
30% recurrence but could COMPLETE the season
33 recurrence and NOT able to complete season
Subluxation 5.3 more likely to RTP vs dislocation
Recurrence rate in athletes younger than 30 who elect non surgical management is 3 times HIGHER than having surgical repair ( 3 days vs 7 days )
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Return to play following bankart repair
Adolescent athletes who undergo Bankart repair for traumatic anterior shoulder instability have an 81.5% rate of RTS to preinjury levels of play at an average of 5 months following surgery
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Posterior VS Multidirectional instability
Posterior shoulder instability (PSI) resulting from repetitive microtrauma in throwing athletes may present as decreased throwing velocity or pain rather than subjective instability, so a high clinical suspicion is required for diagnosis . Etiologies of PSI in baseball players (besides throwing) include diving with an outstretched arm and “batter’s shoulder” where there is posterior subluxation of the lead shoulder during the batting motion
Multidirectional instability (MDI), or instability in two or more directions, is common in sports such as swimming, where generalized laxity of the shoulder joint affords the athlete a competitive advantage but can evolve to cause pain and dysfunction of the joint
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Rehab Muscles to focus on
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rotator cuff activity is low during low-load closed-chain exercises such as bench or wall slides •
pectoralis minor may be inhibited by performing ER, with preference in an open kinetic chain
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serratus anterior is more activated during elevation exercises than isolated protraction exercises
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rotator cuff activity is low during low-load closed-chain exercises such as bench or wall slides -
Shoulder Dislocation
What is Anterior Shoulder Instability?
Anterior Shoulder Instability. Glenohumeral instability encompasses both dislocation and subluxation events, and instability events commonly affect the general population. Approximately 1% to 2% of the general population will experience a glenohumeral dislocation in their lifetime The young, active, athletic population is particularly susceptible to shoulder instability events. Over 95% of shoulder instability events occur in the anterior direction Presence or absence of accompanying soft-tissue hyperlaxity Causes of soft tissue hyperlaxity, including patulous capsular laxity, can be congenital or secondary to repeated microtrauma, major trauma, multiple instability events, recurrences, or a combination of these factors. 72% of shoulder dislocations occurred in men The highest incidence rate (80.5 per 100000 person-years) occurred in male patients aged 16 to 20 years The highest incidence rate in female patients occurred in women aged 61 to 70 years The overall incidence rate in male patients was 40.4 per 100000 person-years The athletic population Greater than 85% of all instability events occurred in males 85% of instability events were subluxation episodes, while the remaining 15% were dislocation events Shoulder movements occur secondary to the dynamic and coordinated articulations at four distinct joints: Sternoclavicular Acromioclavicular Glenohumeral Scapulothoracic Static and Dynamic Stabilisers The static stabilisers include the glenohumeral articulation, the labrum, the glenohumeral ligaments, rotator cuff interval structures, and the negative intra-articular pressure. The dynamic stabilisers consist of the rotator cuff muscles, the deltoid, and the scapular and periscapular stabilizers Alterations in the static and dynamic scapular movements present in the setting of glenohumeral instability. Scapular dyskinesia is reportedly present in up to 80% of instability patients. Biomechanical studies analyzing the at-risk scapular posturing leading to pathologic anterior tensile loads and shear forces include excessive: Anterior tilting Internal rotation Protraction
What are Sternoclavicular joint problems
Sternoclavicular Joint Injury. he sternoclavicular joint is a diarthrodial joint composed of the sternum and clavicle. It is stabilized by the posterior capsular ligament which provides the most anterior-posterior stability and the anterior sternoclavicular ligament which restricts superior displacement. The costoclavicular ligament helps provide medial clavicle and anterior first rib stability. The interclavicular ligament passes over the sternum to provide medial traction of both clavicles. The inter-articular disc ligament attaches to the first rib and also provides stability of the sternoclavicular joint. In between the two articular surfaces and within the joint space is a fibrocartilaginous articular disc which functions as an important shock absorber. It is the only synovial articulation between the upper limb and axial skeleton. The subclavius muscle also supports the integrity of the joint. There are vital anatomic structures behind the clavicle which include the innominate artery and vein, vagus nerve, phrenic nerve, internal jugular vein, trachea, and esophagus. The medial clavicle physis appears in late adolescence and does not ossify until the age of 25 Movement of the joint occurs from transmission of movement from the scapula and the rest of the shoulder girdle. In abduction, the sternoclavicular joint has 35 degrees of range. Anterior-posteriorly it can move 70 degrees. There is also a rotational component. Injuries to the sternoclavicular joint can be traumatic or atraumatic. In traumatic injuries, the mechanism is usually a high energy injury such as a motor vehicle accident or injury during contact or collision sports. A sprain of the joint can occur when no laxity or instability occurs. Sternoclavicular joint injuries are categorised as the following 3 stages: Stage I: Sprain (ligaments intact) Stage II: Subluxation (tearing of sternoclavicular ligaments; costoclavicular ligaments intact) Stage III: Dislocation (tearing of all ligaments) Instability can further be described as follows: Degree: subluxation or dislocation Direction: anterior or posterior Etiology: traumatic or traumatic (congenital, developmental, spontaneous) Severity: sprain, subluxation, dislocation Duration: acute, chronic, recurrent, congenital The prognosis for sternoclavicular injuries is generally favourable. In sprains or grade I injuries, the ligamentous structures are intact, and patients will make a full recovery in 1 to 2 weeks. In grade II injuries in which there was a traumatic or spontaneous subluxation, recovery takes longer. There is a possibility of cosmetic sequelae but typically not functional sequelae
Who gets Shoulder Injuries ?
Incidence of shoulder injury Shoulder injuries and sports-related shoulder pain are extensive burdens for athletes performing a shoulder loading sport, such as tennis, handball, volleyball, and swimming but also gymnastics, field hockey, or lacrosse. Shoulder injury rates depend upon many variables such as type of sports, sex, level of performance, and age but are reported to be between 18% and 61% in overhead throwing or smashing sports and up to 90% in elite swimmers How throwing sports cause shoulder problems The overhead throwing motion is a highly complex movement in which the individual body segments need to work together in a sequenced and coordinated way for an integrated functional movement, also referred to as the kinetic chain . Throwing is considered one of the fastest human motions performed, and maximum humeral internal rotation (IR) velocity reaches about 7000 to 7500°/s . Extreme amounts of external rotation (ER) in the range of 165° to 175° are achieved by the throwing extremity during the late cocking phase . Other sports, such as swimming, are characterised by an enormous amount of repetitive movements. Competitive athletes may swim 10 to 14 km a day, 6 or 7 days a week. This equates to 16 000 shoulder revolutions per week (2500 revolutions per day)
Return To Play Advice with Shoulder Impingement
Return to play Limited evidence suggests that less than three in four athletes return to their previous level of sport participation after SLAP injury intervention. Despite the long history of the condition, SLAP injuries remain a prevalent problem in both overhead throwing athletes as well as contact athletes. After shoulder dislocations Return to play: The general understanding is that the patient must be pain free and have at least 90% of the range of motion and strength comparative to the uninjured side. This would normally take 2–3 weeks in conservatively treated patients RETURN TO PLAY SHOULDER AC shoulder joint separation - RTP after surgery 2 to 12 months , most common 6 months The shoulder has the GREATEST range of motion of any joint in the human body Return to play after arthroscopic repair 86% Three months after surgery for non contact vs 6 months contact sports Things to look out for : Pain free range of motion over 80% of strength compared to contralateral side was achieved. Internal ROM shoulder be LESS than 20 degrees Difference in total ROM should not be more than 10 degrees Regarding rotator cuff strength, in general, overhead athletes often exhibit sport-specific adaptations leading to a relative decrease in the strength of the external rotators and thus muscular imbalance in the rotator cuff
