[Case Studies] How do you manage atraumatic shoulder instability? with Anju Jaggi

In this episode with Anju Jaggi, we discuss a case study she recently completed on a dancer with atraumatic shoulder instability. We explore:

• Difference between traumatic and atraumatic stability
• Previous imaging, use of MRarthrogram and role of imaging in shoulder instability
• Objective examination of an unstable shoulder 
• Special testing of an unstable shoulder
• Treatment of the unstable shoulder

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Anju is a Consultant Physiotherapist & Clinical director of Therapies at the Royal National Orthopaedic Hospital (RNOHT). She has over 25 years experience managing shoulder & elbow disorders with a specific interest in complex atraumatic shoulder instability. She has lectured internationally, published work in the field of shoulder rehabilitation; with over 30 peer reviewed publications and up to 5 book chapters. 

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Transcript

SPEAKER_00 0:02

Welcome to this episode of Case Studies by Physio Network. Today I'm joined by Andrew Jaggy to discuss a real case of atriumatic shoulder instability in a dancer. Andrew is a consultant physiotherapist and shoulder specialist at the Royal National Orthopedic Hospital with a particular interest in shoulder instability, complex shoulder pain and rehabilitation. Her clinical expertise, research background, and working in developing shoulder instability practice make her an ideal guest to help us unpack this challenging presentation. In this episode, we work through the case step by step from initial subjective history all the way through to differential diagnosis, subjective assessment, and also mainly our management and treatment. We explore the key clinical reasoning required when managing atraumatic instability, particularly in a dancer where control, confidence, range, low tolerance, and performance demands all need to be considered. Andrew then talks us through the management approach, including rehabilitation priorities, movement retraining, education, graded exposure, and how treatment was adapted in the case and as it progressed. And also always, we reflect on what went well and what you as a listener can take away to make your practice even better and increase your confidence dealing with atriumatic shoulder instability. Most importantly, we finish by drawing out some key clinical lessons for you as our listeners. This episode will be particularly useful if you're working with any patients with shoulder instability, any hypermobility-related presentations or complex movement patterns in athletes andor your general population. You're gonna love this episode. There's some real key takeaways, and I know it's gonna build your confidence treating a traumatic shoulder instability. I'm James Armstrong and this is Case Studies. Andrew, great to have you on the podcast. Today we're talking through a case study of atraumatic shoulder instability in a dancer. So without further ado, let's kick off straight away. Talk us through the patient presentation and we'll guide our uh how the patient presented and what we did and what you did, in fact, and how that patient went through this this treatment journey.

SPEAKER_01 2:15

Okay, yep, great, thank you. So this is a 16-year-old female, but she's right-handed, presented in a clinic. I actually saw the patient jointly with one of our orthopedic surgeons at the time. Most of the time, you you know, I see these patients on my own. But she had come to us because she'd already had failed physiotherapy treatment. So she's a keen dancer, she wants to have a professional career. Her instability was an anthro-inferior direction. She'd already had about three episodes by the time she got to us. And the previous hospital had done an MRAM. An MRAphrogram is usually the investigation of choice because it gives us a much better idea around the capaciousness of a capsule. You can get a better view of all the soft tissues, the labrum, and just capsular laxity. So any type of instability, a gold standard is to get an MRA while an MRI. And yeah, so she came to Clinic really having had these three episodes. I think the initial one, and again, we have this thing about well, what do we describe as atraumatic? And probably the best way to describe that is that trauma is usually when you've had a high forced velocity injury. Some people say you need to have a document evidence of dislocation, and then you need to see associated pathology. So if you reverse that, an atraumatic type of history will usually be associated with something quite low level. Or a good way to describe it is think about an activity that you and I would do if we and it would usually stay on if it's a normal shoulder. Does that make sense? So throwing a ball, reaching for a laptop. So atraumatic histories tend to be something quite innocuous, and then also usually there may never be a full dislocation and/or no associated pathology. So she basically was putting a light switch, she was trying to reach for a light switch. She then obviously, while she was on the bed, she fell forward and then she felt the shoulder feel as if it had come out, but it looked really asymmetrical and odd when she looked herself in a mirror. Now, what's interesting with a lot of these patients is they can sometimes just pop them back in. So again, we probably suspect she just had a partial subluxation, put it back in. But then the second time it happened when she was doing a cartwheel, it took a bit longer to put back in, and then her third happened dancing. So now we've got a situation where how do I put this? You've got a loosey-goosey shoulder, she's female, probably quite hyperlax anyway. She's a dancer, so laxity is not really a major issue here, but laxity probably has predisposed her a little bit more to the looseness of her shoulder. And it may be that with that initial fall, she had more of a muscular strain rather than a structural injury. And now, subsequently, when she's trying to put her arm into those extremes, there may just not be that muscular balance to keep it stable. So that's essentially the history. The thing that makes this patient easy, so kind of giving some top tips here, she essentially doesn't come with a huge amount of pain. Okay, so the primary problem is my shoulder feels loose and it's starting to come out when I don't want it to. But we don't have high levels of associated pain. Uh more complex group is often ones you will have quite high levels of associated pain, both muscular and neuropathic. And then we get into the whole spectrum of the fact that their shoulder is just part of a much bigger picture, such as hypermobility spectrum disorder. So then there is also element of chronic pain, mental health, comorbidities, and so forth. So I I want to kind of stress with this is that the vast majority, whether they be trauma or atraumatic, are actually relatively straightforward to treat. These are what we call your type two, born a bit loose or become a bit loose and then end up symptomatic. And they don't necessarily have to be overly complicated to treat.

SPEAKER_00 6:07

See, they've come with a bit of a history. What's your go-to in terms of starting to look at this patient and look at how you start putting together a little bit of a plan of management?

SPEAKER_01 6:16

So I'm going to work through systematically. So we always kind of go look, feel, move. So from a looking perspective, just look for any odd asymmetries. And what I mean by that is particularly with sometimes with young girls, is there any kind of postural or idiopathic scoliosis? We haven't got the time to delve into kind of scapular dynesia. But one other big element here is that with some multi-directional instability, the scapular control can often be a driver. Just don't mistake poorly placed scapula for probably a poor spinal alignment. Does that make sense? So just good standard. Look at the patient, do they stand straight? Is there anything else that's looking relatively asymmetrical or abnormal that could be driving some of this? But in this particular case, posture's good, no obvious asymmetries. And I would routinely, with people who come with loose shoulders, look at the bait and score in terms of do they present with generalized hyperlaxity? That isn't a diagnosis of any kind of syndrome. It's just to give you a measure that people might just be generally lax jointed. So look at thumbs, knuckles, elbows, knees, as well as looking at just what is the laxity at the shoulder. So once you've had a look, it can sometimes be helpful to palpate or feel muscles. We talk about abnormal muscle patterning or people sometimes having muscles that are on tension, such as pecs, lats, maybe bracing or fixing their shoulders. And what I think I would say with that now is that yes, there may be aberrant muscle tension where you wouldn't necessarily expect it. But then you've got to step back and think, well, why is that? Is it that you're seeing abnormal muscle recruitment because actually the patient's anxious, kinesophobic, scared, actually they're bracing their shoulder because they're worried because it's going to drop out? Is it that these muscles are guarding or overworking because other muscles are weak? Does that make sense? So muscle patterning in itself is a presentation. It's then trying to reason through what are the drivers. In this particular case, she wasn't guarding, she wasn't fixing or bracing anything. There was nothing particularly abnormal in the way her muscles were were at rest or even when she moved.

unknown 8:30

Okay.

SPEAKER_01 8:30

Okay.

SPEAKER_00 8:31

Yeah.

SPEAKER_01 8:31

Then you go really to I would start moving. So standard, look at external rotation at neutral. Okay, so with the arm at zero abduction, get them to take their arms out. If you gain 90 degrees or more, that is regarded as laxity within the shoulder. So we have a kind of normative view in shoulders, but we would say that anything above 90 degrees of external rotation can be regarded a lax shoulder. Then get them to do flexion, elevation, how far are they happy moving? Do they get to the range? And if when they're moving, do you note any odd subluxation? Is the shoulder partially popping in and out? And or are you seeing any abnormal motor strategy, such as overusing certain muscles or seeing an associated winging or imbalance of the shoulder blade? So once you've done your standard movements, what you could do from there is a bit like we do with cuff-related shoulder pain, you could choose to do some symptom modification. So for instance, if you're seeing someone getting to just above shoulder height, but then they're guarding or they're anxious, they feel apprehensive, there's no reason why you then can't do things like try and get them to shrop their shoulder up and lift the arm, try to get them to push out and lift. What you're then doing is have I got a way in here to change the strategy and make them feel symptomatically better? You could step and reach, you could bring in a bit of kinetic chain, you could also use an element of distraction. Can we try and get you to reach to the top corner of the door? All of which can start giving you a few clues of what is driving the instability here. Then what I would do, and because this is a the more simpler of case, she she moves relatively well, she's got a full range of movement, there's no obvious kinesis, is then to kind of work out, okay, well, is there a weakness here? And that's where you can start to look at a bit more of strength tests. Preferably for me, I like to put them into prone lying. So lie them on the couch, put them on the stomach, take the kinetic chain out of the equation, and then basically try and position the arm into 90-90 external rotation and look for any positive lag signs and inability to hold the arm there. Is there problems with stamina control? Can they take resistance? Because what we're trying to work out here is why does she have ongoing instability? And is it because there is now a bit of weakness related to this?

SPEAKER_00 10:59

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SPEAKER_01 11:26

So I I would look at strength, I would also look at how good is scaption, can you hold the arm straight? Can you bring the shoulder blade through your movement? We know that in order to get end range elevation, you've got to get good upward scapular control as well. But now with a lot of our work, we know that it's never about isolated muscles, about muscles working all together. So has she got the balance and strength to be able to take her arm to the extremes that she needs to go? Has it got the control there? And then also has it got the stamina. So for me, it's look, feel, move. Special tests you can choose to do is obviously test for apprehension. It can be important to know which direction. So you would usually do your apprehension tests as we put in the case study. So your anterior apprehension test of which she was positive. A job's relocation is essentially your kind of putting the ball of the socket, but the ball back into the socket passively, you repeat the position. If it feels better, it's indicating to you that there was probably a degree of anterior instability. So she is presenting with essentially good range of motion, nothing abnormal in terms of odd recruitment strategies. She doesn't seem to be fearful or kinesophobic. She's just finding it difficult to perform at the level she wishes to. Okay. And there is positive anterior apprehension. The only other thing to add, and this is only because she came having had failed physio, if you're in general practice primary care and you're not worried about significant trauma, I don't think you need to be worrying about imaging. If you are in primary care and you're worried that there may be trauma, then obviously you should do an X-ray just to check there hasn't been any sort of pathological fracture or anything going on. The reason we did an MR arthrogram is because these patients come to us having had failed physiotherapy treatment, they're coming for a specialist opinion. An MR arthogram is just really important to do. So you've just excluded any other reason why the shoulder may be unstable. And in this particular case, we weren't surprised to see that essentially it was normal. And just to add, if those who are interested, that now it's Stanmore and we've published our work, that in these loose, lax shoulders that are atraumatic and have no obvious structural pathology, even if they're lax, there's very little benefit in offering these people surgery in terms of tightening the capsule or doing some kind of encapsular shift. We we know through our work that randomized clinical trial is shown that a placebo operation shows the same benefits as actually doing a shift. I think we can comfortably say that atraumatic instability, 80% of patients should respond to a good strength training programme. And in the 20% that fail, it probably is unlikely to be structural reasons. It may be more likely to do with other complexity, such as adherence to excise, motivation, mental health issues, chronic pain, an inability to perhaps engage or manage a rehab program. But it's not it's not necessarily meaning that surgery will answer the issue.

SPEAKER_00 14:33

Absolutely.

SPEAKER_01 14:34

So in terms of exercise, this was a really nice patient because she was really, you can see she's a dancer. Her goals and her perspectives is she wants to get back to what she loves doing, and this is curtailing her. So it actually only took about two sessions, I think. But what I did was I got her into that position of where she wasn't getting the stamina. And and I think the key thing here is challenge them where they need to be challenged. Does that make sense? Yeah. Staying too safe within a safe zone may not get you to where you need to get to. So all of the stuff we've talked about, I used a couple of towels to start with just to offload the weight of the arm, but you could get it to start using some weights, fairly standard, build up capacity, endurance, try and practice this over a period of four or five times in a week. We know we know consistency is what's key here. So if people engage with very simple strength program and you do it on average three or four times a week, and you do it for up to 12 to 16 weeks, there's an 80% chance you're going to get better. And that's often what I say to patients. It's a bit like the couch to 5K analogy. Get going, get confident, start getting strength back. There's a good chance this is going to get better. And she was highly motivated and compliant, which is probably why after just a couple of sessions, she was already feeling better. The other thing to add, and I think this really came back from what the patient shared, was for her, when I asked her, what do you think were the key elements in why we got you better and not the previous video? The main things that came out for her was reassurance and education. The reassurance of the imaging didn't show anything wrong. And she felt that we challenged her at the right level. So her previous video had given her exercises, but they hadn't felt as targeted or as specific as perhaps we'd done. And she felt that it was much, much more focused on her needs. And I think in essence, that it kind of summarizes what most patients we know will do well. We know the prognostic indicators are if they understand the problem, they're provided early reassurance, they're given the right information at the start, they identify a goal, and they've got high self-efficacy. They will do well. Interestingly, even if you give slightly different exercises. I I'd actually say is, well, okay, from her perspective, I gave her specific exercises, I looked at where it was we we targeted that. But I would also say that a big component of this was because she saw an orthopedic surgeon with me. We did a scan, we reassured her, we explained the atiology of atraumatic shoulder instability. And I would almost say is that even if he'd given a theroband or some calf or PF pattern or a or a step and resist exercise, I would be optimistic that you'd get a similar result.

SPEAKER_00 17:29

And it comes back to that confidence that you build in the patient, doesn't it? To then create that self-advocacy and that buy-in to create consistency and persistency with the with the exercise programme, like you've just said there. So a lot of that comes down to how that was established, and you did it very quickly because it's something that you're confident with yourself.

SPEAKER_01 17:48

Yeah, and look, it comes with expertise. Clearly, I see a lot of these patients. So being able to give an expert opinion, being able to know what you're saying goes a long, long way. But I think communication is absolutely key. I think to reassure people is these are not overly, they don't have to be overly complex. Multidirectional instability can be challenging to treat, but I would say the ones that are challenging is because of all the other comorbidities associated with it, not the element of the fact that it's biomechanically multi-directionally unstable, in my opinion. So usually exercise, targeted, done in the right way, getting consistency, getting good compliance will get a good 80 to 90% of these patients better. It's kind of a bit like this sounds, yeah, but it's doing the simple stuff well, really. And the simple stuff is understanding the problem, reassuring the patient, and being able to give expert professional advice in the right way.

SPEAKER_00 18:47

Andrew, thank you so much. I think there's a lot there, and uh, hopefully, and I'm sure listeners will take away some confidence when they next encounter some atraumatic instability in clinic and be able to use that confidence, as we said, to help their patients understand the issues and get them bought into a really good rehabilitation programme over those 12 to 16 weeks, which we know, as you say, many patients can do really well.

SPEAKER_01 19:11

Brilliant, great, thank you.

SPEAKER_00 19:12

Thanks, Angie.