Traumatic dislocations of the shoulder, generally speaking, if we're seeing those people sort of above the age of 25 and they're not doing high-level contact support in the sense that there's no significant bony damage or a high risk of recurrence, then I think we can get these people going a lot more confidently. And there shouldn't be a reason, quite a few of them, to even end up probably needing surgery.
SPEAKER_01:For many clinicians, the unstable shoulder can be a daunting prospect and getting these patients back to sport can also prove challenging. In this episode we're joined by Andrew Jaggi to discuss the unstable shoulder. We explore in detail the muscles we should focus on in rehabilitation of the unstable shoulder and we also look at time frames regarding when and how we should get a shoulder moving post-injury and post-surgery. Andrew has recently completed a masterclass with the Physio Network called Treating the Unstable Shoulder where she goes into far more detail on shoulder instability and you can watch this whole masterclass now with our seven-day free trial. Just click on the link in the show notes. Andrew has worked at the Royal National Orthopaedic Hospital for 25 years managing complex shoulder dysfunction. She lectures internationally, has published papers and book chapters relating to shoulder management and is leading and developing research for allied health professionals within her organisation, collaborating with commercial and academic partners. This is a great insight into what is a superb masterclass. I know you're going to pick up some true clinical pearls from this episode. Also, if you like the podcast, give us a rating or review. It really does help spread the word and get us into more ears across the globe. I'm James Armstrong and this is Physio Explained. Andrew, thank you so much for coming on to the podcast today. It's brilliant to have you on. I, for one, am really excited about this. I've followed lots of the things you do, and I know you've done a masterclass for us. So this is going to be really interesting, us talking about the unstable shoulder. So thanks for coming on.
SPEAKER_02:No, it's an absolute pleasure.
SPEAKER_01:Brilliant. So we're going to be covering rehabilitation of the unstable shoulder today. This is kind of a snippet of the masterclass that you've done for the Physio Network. So we're going to kickstart it with specific muscles that we should focus on. Are there specific muscles that we should be focusing on?
SPEAKER_02:I think the quick answer is that when we look at the literature, the most common direction for shoulders to dislocate is anteriorly. And we do often see problems with the subscapularis muscle in those instances. So whether there's an increased tensile loading on the muscle when the shoulder goes into that direction, but subscapularis seems to be quite important in terms of anterior instability. However, in saying that, We've also got some literature to say that external rotation strengthens weaker, particularly when your arm is at the 90-90 Abra position, so that position of apprehension. Coming back to your question, I think in some ways you could almost say, well, it's probably all the rotator cuff because it all has to work in synchrony with regards to stability. So my simple answer to that question is that we've got to probably not just think about isolated muscles, but think of the fact that there's a combination of muscles, not just calf, but also scapula, thoracic muscles all working together. And when we're even exercising, we're never isolating one muscle alone. But when it comes to instability, I think there's a bit of a debate at the moment in that, is it more of the anterior cuff that perhaps takes more of the sort of impact compared to the posterior cuff? And therefore, you might find some papers or some people typically focusing or saying early on in rehab, there were certain parts of the cuff you should focus on. But I think the bottom line is, is strengthen it all.
SPEAKER_01:Yeah, as a global unit.
SPEAKER_02:Yeah.
SPEAKER_01:Yeah. And maybe completely irrelevant, but would you say that it changes or your focus becomes more focused when you're looking at an atraumatic compared to a traumatic instability?
UNKNOWN:Yeah.
SPEAKER_02:Well, atraumatic gets more complicated because obviously we get the element of multi-directional instability and we've got people complaining of instability in more than one direction. So there is then the question is you're not just dealing with perhaps the anterior cuff to stop the shoulder coming forwards or the posterior cuff to stop the shoulder going back. But actually, you probably do need to do a combination of all of them. The other thing as well that becomes more important in atriatic instability is we think the scapula has more of a primary role. So the orientation of the shoulder blade. So probably from a rehab point of view, actually thinking about trapezius function and thinking about using the upper trapezius, the force couple between trapezius and serratus. to make sure that the scapula does properly upwardly rotate, because with a lot of people with inferior instability and atraumatic, there's that tendency for the ball to drop down. And in fact, some of the rehab programs around atraumatic instability, which I draw upon in my masterclass. So in the masterclass, we'll talk a lot about programs that are out there from Marcus Bateman and Watson's group. And actually, then Watson's group focuses a lot on the scapula position before they'll even start loading the deltoid and the cuff.
SPEAKER_01:Right. Perfect segue there. Absolutely perfect. When we're talking about an acute dislocation, for instance, how quickly should we be encouraging movement and particularly loading of the shoulder after that injury?
SPEAKER_02:So it's well established now that you do not need long periods of immobilization in the sling. So I think that the standard recommendation is anything from sort of about 10 days to two weeks following an acute traumatic dislocation. And that's really resting the sling to allow any swelling, sort of any inflammation, hematoma to settle down. But it's more a comfort element. Immediately, patients can probably start doing isometrics. And I've touched upon the fact that don't just do resisted external rotation, but also external. internal rotation. And a good exercise that you can actually do right from the beginning is the belly press. The belly press test is often used to test subscap, but actually on a pillow, just gently pushing in, because we've talked about the fact that subscap is quite important. So I think isometrics early, as comfort allows. But usually for some of these patients, once you've relocated the shoulder or the knee, they're often more comfortable, and some are quite happy to start moving straight away. So I think the advice now is to movement as soon as the patient feels comfortable to do, but it can usually take a week or 10 days for some pain post-trauma to settle, isometrics, and then very much getting people returning back to confidence and doing what they really wish to do, usually everything from four weeks onwards. In this situation, it's not post-surgical, so we're not waiting for any kind of surgical repair to have to take. This is very much getting them going during the injury.
SPEAKER_01:Definitely. So you said that it's patient centred. It's looking at when the patient is there. But we're going to get some patients who maybe have a bit of a prolonged fear, anxiety and sort of kinesiophobia. And should we be discussing that with patients? Should we be quite open with that, do you think?
SPEAKER_02:Yeah. And again, we haven't got a huge amount of literature to draw upon, but I think our experience now, and we've just done a bit of a Delphi consensus with a group of experts in the shoulder field. This was actually post-stabilization surgery. But I think some of us are very much the opinion is that we've got to also not instill our own fear into that. So we've often said, oh, well, that's a position of it coming out, therefore avoid it. probably actually what we should be doing early on. You're saying to the patient, well, actually, the sooner we get you there, and the sooner we get you developing functionality of muscles and strength there, the more chances are you're going to get that. And in fact, I think once patients know that everything's okay, my shoulder's back where it needs to be, I haven't got any major significant damage, or if I strengthen my muscles, I actually think patients are not that fearful. They're quite keen. And remember here as well, James, we're generally talking about a young population group. done this as a result of sport or an injury, and they're therefore sometimes quite keen to get back. For some of these patients, they might actually be holding them back a little bit because it's like saying, well, have you really got the sort of essentials required to get you back to that level? Obviously, don't forget, though, about the elderly population because that's another group that we do see dislocations in. So I think that idea of fear, of being really anxious about moving their shoulder, But we now know that even with the elderly, if they've got a fracture associated dislocation, early movement, getting confidence back is definitely the recommended way of managing them. But yeah, we have to have those conversations. And we as the clinicians have got to instill that confidence back. And we've also got to be fearful about it too.
SPEAKER_01:Yeah, it's contagious, isn't it? It really, really is.
SPEAKER_02:Yeah, it is, of course. And also because if you're unsure about stressing more damage, if you're unsure about the pain, But, you know, traumatic dislocations of the shoulder, generally speaking, if we're seeing those people sort of above the age of 25 and they're not doing high-level contact sport, in the sense that there's no significant bony damage or a high risk of recurrence, then I think we can get these people going a lot more confidently. There shouldn't be any reason, quite a few of them, to even end up probably needing surgery. It's probably the group that are performing high-level sport contact, very young, And obviously with significant bony damage to their shoulders. We're probably thinking that the recurrence rates can be quite high. But again, some pre-rehab is going to always work in their favor. And again, I touch upon in the masterclass, the program that's been piloted out in Denmark. where they used the SINEX program, which was basically a 12-week program of kind of neuromuscular control exercises, including weight-bearing, some throwing tasks, as well as cuff strength. And that was done with your first time anterior dislocated shoulder. And they followed that program. And a significant amount of people did not need to go on to have surgery. So I think this idea of early rehab, getting people going post-traumatic dislocation is probably the direction of travel now rather than immobilizing them for six weeks as we're used to.
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SPEAKER_01:You also see, I know I have done in clinical practice, potentially partly my doing is if you do have that fear of movement, then you have a horrendous amount of other complications that can pursue after in altered mechanics and changes of movements, particularly in the shoulder.
SPEAKER_02:Yeah, I mean, obviously, you know that my area is very much with the atraumatic group, but I think you could let me talk about muscle packing, compensatory strategies. And I think you're absolutely right. If you stop moving or you adapt or you get into a situation where you're almost so sensitized to the idea of your shoulder coming out, you will then sometimes overprotect it and therefore contract other muscles to try and compensate. And we see that all the time, typically in a complicated multi-direction stability group where big global muscles start to overtake. It's so hard to know what chicken or the egg is, but you're absolutely right. Fear will create an abnormal motor strategy. And then that in itself starts to create this deconditioning, this use over fear. So the quicker we can get in, the better. I was going to just let people know that there has been a big NIHR trial that was done here in the UK, the ARTISAN trial, where they compared one session of physiotherapy following a few sessions of physiotherapy following a traumatic dislocation. Now, I'm not party to be able to share the results just yet, but they're imminently going to be published and they're out for dissemination. But again, people were encouraged to start moving and to get going pretty early on from referral from AV. So, Everything we've talked about is going to be really important. And I think it's a bit of what you said. If you get that all in on that first session, advice, reassurance, simple exercises to follow, allow the patient to identify their own self-safe zones, them load when they feel happy. That's probably a simple, easy way to get people going.
SPEAKER_01:Definitely. We're getting people going early. That's great. We've talked about that population that wants to get back to sport. Where are we now with a consensus of what are we looking for to enable us as clinicians and patients as the patients to know when are they ready?
SPEAKER_02:Unfortunately, I don't think we do have a consensus, sadly to say. And again, yet another thing that we did as part of our Delphi, did people have an established idea of when to return people to play after stabilisation surgery? And I can tell you the variation was anything from one year to some people saying, well, why don't you just let the patient decide? So we really haven't got a consensus. I would say in terms of clinical practice, and I've always used this, I think, from very early on in my career, it's kind of some of the simple stuff. A good balance of strength, having the flexibility, the range of motion you require, a good degree of being able to react quickly, so speed and co-perception, and then obviously confidence. Now, you probably have to have a bit of a foundation in order to get the confidence. So I would say that Probably a lot of these people, it's about talking to the patient. When do you feel ready? Are you ready? The psychological stress of going back to play. So thinking about psychological readiness is really important. Also, if they're a competitive level, at what time of season are you returning them? Early? Late? Have they been doing some training pre-season? Are they actually fit enough? Because we know that injury rates increase if they haven't got the fitness levels right. So it depends on what level you're treating patients. But it's very much a dialogue between the coach and the team. Does that make sense? So when are these people ready to go back? Have they got the endurance? Have they got the stamina? Threat-wise, when in throwing athletes, for instance, usually we still kind of go on a bit of a ratio of strength. So internal rotation strength generally increases. should be about 20% to 30% of your body weight. So if you have got the ability to strength test with a handheld dynamometer, that can be helpful. And then external rotation is usually two-thirds of your internal rotation strength. So effectively, what you want to be looking for is that you want to make sure that they have got good enough internal rotation strength. That should definitely be stronger than external. Again, you can take that as a you're looking at at least two-thirds strength in external rotation power. Now, you could also, if you wanted to, use their non-affected side as your reference point. But again, that can be tricky because it depends if it's their dominant or their non-dominant. Because your dominant side, some athletes, it's been reported as your dominant can be anything from 10% to 40% stronger than your non-dominant. So... that can be a bit tricky to kind of find out what's right, how they reach the adequate strength for them. In the webinar that I've done, I actually referenced Margie Old's work because she's done a nice sort of return to play group of exercises that you can test the patient out. And they're a combination of both open and closed chain exercises. So you get the patient to perform and then gives you some kind of physical objective criteria on when they may be ready to return the patient back. We've obviously got other tests. I know Ben Ashworth uses his force plate measurement to give a good objective measure for some athletes back. But I think for your average in the clinic type patient, just check strength ratios are pretty good. The range of motion is there. And put the patient through their paces. You know, take the arm to extremes in a lying position. Get them to throw and catch from an extreme position. Get them to weight back. Get them to clap. Brilliant.
SPEAKER_01:We've covered absolutely loads, to be honest. I wasn't quite sure we'd get through all of this. So four things we've really covered there. And I know it's lots that people could be taking away from this. And I think also... a massive amount of enticement to check out the masterclass that you've done so thank you for your time today and you really really appreciate it for those listening a reminder that if you want to learn more about rehabilitation but the unstable shoulder as a whole then do be sure to check out the masterclass which we've linked in the show notes below so do check that out and once again a massive thank you to Angie for your time today and coming on to the
SPEAKER_02:podcast thank you thank you James it's been a pleasure
SPEAKER_01:thank you take care