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Chronic Shoulder Instability in X Games Athlete

Chronic Shoulder Instability in X Games Athlete. Marty Fontenot, PT, DPT, SCS Mountain Land Physical Therapy Salt Lake City, UT. Initial Consultation. 30 yo male X-Games: BMX biker Snowboarder 15 yr Hx of shoulder problems. Consultation - Subjective. Hx of shoulder problems

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Chronic Shoulder Instability in X Games Athlete

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  1. Chronic Shoulder Instability in X Games Athlete Marty Fontenot, PT, DPT, SCS Mountain Land Physical Therapy Salt Lake City, UT

  2. Initial Consultation • 30 yo male • X-Games: • BMX biker • Snowboarder • 15 yr Hx of shoulder problems

  3. Consultation - Subjective • Hx of shoulder problems • 15 yo: R shldr dislocation #1 while biking: immobilized for 6 wks (no PT) • 18 yo: Fx R wrist • 20 yo: R shldrseperation while snowboarding • 21 yo: R shldr dislocation #2 biking: PT 8 wks then Bankart repair • 24 yo: L elbow dislocation biking: PT 6 wks • 26 yo: R shldr dislocation #3 biking: PT 8 wks • Frequent subluxations: “learned to live with it” • What else do you want to know?

  4. Consultation - Subjective • Occupation: Physical Therapist in acute care setting • R handed • Functional Limitations: • High level activities (biking, snowboarding, skiing, etc.) • Overhead activities (long hair!) • Work: transfers in particular • Putting bikes / snowboards on top of car • Sleeping (constant subluxations)

  5. Which of the following special tests is NOT a test for impingement? • Neers • Yergasons • Hawkins Kennedy • All of the above are impingement tests

  6. Which of the following is NOT a test for shoulder instability? • Load and shift test • Apprehension test • Obrien’s test • Relocation test

  7. Objective data • What do you want to evaluate

  8. Consultation - Objective • Observation: slumped R shldr, atrophy of posterior cuff • AROM: Full but noticeable abberantmvmts & compensatory shrug • Scapulohumeral rhythm: poor w/ winged scapula, decr’d eccentric control • MMT: • ER: 4-/5 • Scap stabilizers (MT, Rhomboids): 3/5 • Subluxation w/ LT position & IR testing • Special Tests: All (+) • Neers, Hawkins/Kennedy, Apprehension, Load/Shift, Sulcus, Clunk Test, O’Brien’s • Functional Test: subluxation on 2nd push-up • Sensation: (+) parasthesia in R lateral forearm

  9. So what do you think… what’s our next step? Refer!

  10. Refer – Orthopedic Specialist • Significant Bankart tear • 2 – 9 o’clock position • Large Hill-Sachs lesion • 50% of posterior humeral head • Anterior bone loss • > 1/3 of anterior glenoid missing

  11. Surgery – Latarjet Procedure • 3/8/10: Open Latarjet procedure performed (4 hours) • Latarjet (Bristow) Procedure: • Distal coracoid transfer into bony defect (w/ labral repair) • Purpose: • Reconstruction of this bony deficit using autograft bone • Create dynamic sling to further stabilze GH jt • Indications: • > 20-25% loss of anterior glenoid bone associated w/ gross shoulder instability (Garcia et al)

  12. Latarjet Procedure – Effective? • Matthes et al (2007) – “Oldie but goldie: Bristow-latarjet procedure for anterior shoulder instability” • 93% success rate of non-dislocation after procedure • Hantes et al (2010) – “Repair of an anteroinferiorglenoid defect by the latarjet procedure: quantitative assessment of the repair by computed tomography” • Large bony defects (25%-30%) of the anterior glenoid can be adequately treated by the Latarjet procedure. • Beran et al (2010) – “Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review” • Effective at preventing recurrent instability but more research needed to follow the long-term effects of reconstruction on the development of glenohumeralarthrosis

  13. Shoulder Anatomy

  14. Shoulder Anatomy

  15. Latarjet Procedure • Deltopectoral approach (incision along axillary fold) to expose conjoint tendon at coracoid process

  16. Latarjet Procedure • Corcoacromial ligament released • Coracobrachialias & SH biceps origins remains intact • Osteotomy of coracoid at the “knee”: 1.5 cm • Coracoclavicular ligaments remain to preserve AC joint

  17. Latarjet procedure • Subscapularis split with “T” to expose GH joint • The anterior-inferior border of the glenoid is exposed. • The coracoid bone block is loaded onto the awl.

  18. Latarjet Procedure • A guide pin is inserted through the cannulated awl • The compression screw is inserted through the bone block to the glenoid

  19. Latarjet Procedure • Proper alignment verified with imaging

  20. Return to PT… What do we want to find out during Initial Evaluation? • Date: 5/5/10 (8 wks s/p) • Op Report: What exactly was done in surgery • Latarjet procedure • Labral repair • Resurfacing (bone graft) of Hill-Sachs lesion • MD restrictions: • SLOW rehab! • 90% ROM of contralateral • X-rays: bone growth/healing on schedule • Pt Goals: • Biking • STG: Return to mountain biking by end of summer • LTG: One more try at X-Games!

  21. Initial Evaluation - Objective • Posture: • Donning sling • Compensatory shrug • Observation: • Atrophy of R shldr girdle • Good scar mobility • Sensation • Parasthesia of lateral forearm • Where do we start with our POC?

  22. Which impairments do you want to address first? • ROM only • ROM and strength at shoulder and elbow • ROM, strength and motor control including scapula • Just strength around scapula since physician wants slow rehab

  23. Plan of Care • What interventions would you use?

  24. Initial Plan of Care

  25. 1st Progress Note – 4 wks of PT • Date: 6/4/10 (12 wks s/p) • No sling • How do we progress treatment from this point?

  26. Progression of Treatment

  27. 2nd Progress Note – 8 wks of PT • Date: 7/2/10 (16 wks s/p) • Should we be concerned about the lack of biceps strength?

  28. Decrease Biceps Strength: Differential Diagnosis?

  29. Musculocutaneous Nerve Palsy • Motor innervation: • Biceps brachii, Brachialis, Coracobrachialis • Sensory innervation: • Lateral forearm • Occurs in less than 1% of patients (Yoneda et al) • Usually secondary to scar tissue adhesion • NCV tests revealed increased latency between proximal & distal musculocutaneous nerve • How do we treat it? • Deep tissue mobilization • Usually recovers on it’s own (6-12 months)

  30. Progression of Treatment – Dynamic Stabilization Phase • Goal: Increase dynamic stabilization with advanced CKC exercises Ummm… not so much!

  31. Progression of Treatment – Advanced Dynamic Stabilization Phase • Goal: Increase dynamic stabilization with functional activities

  32. Progression of Treatment – Advanced Dynamic Stabilization Phase • Goal: Increase dynamic stabilization with functional activities

  33. Results Currently 6 months s/p • ROM: At least 90% with all motions • Strength: • At least 4+/5 for all • Biceps 4/5 • Sensation: improved in forearm • Function: • No limitations at work • Biking • Mountain biking • BMX – jumping 25 ft!

  34. References • Hantes ME, Venouziou A, Bargiotas KA, Metafratzi Z, Karantanas A, Malizos KN. Repair of an anteroinferiorglenoid defect by the latarjet procedure: quantitative assessment of the repair by computed tomography. Arthroscopy. 2010 Aug;26(8):1021-6. • Matthes G, Horvath V, Seifert J, et al. Oldie but goldie: Bristow-latarjet procedure for anterior shoulder instability. J OrthopSurg (Hong Kong). 2007; 15(1):4-8 • Beran MC, Donaldson CT, Bishop JY. Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systemic review. J Shoulder Elbow Surg. 2010 Jul;19(5):769-80. Epub 2010 Apr 14. • Yoneda M, Hayashida K, Wakitani S, Nakagawa S, Fukushima S. Bankart procedure augmented by coracoid transfer for contact athletes with traumatic anterior shoulder instability. Am J Sports Med. 1999; 27(1):21-26 • Jones D WJ. Shoulder instability. In: Chapman MW, Lane JM, Mann RA, Marder RA, McLain RF, Rab GT, Szabo RM, Vince KG. Chapman’s OrhopedicSurgergy.Vol 2, 3rd ed. Lippincott Williams and Wilkins. • Hovelius L, Sandstrom B, Saebo M. One hundred eighteen bristow-latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for fifteen years: Study II – the evolution of dislocation arthropathy. J Shoulder Elbow Surg. 2006; 15(3):279-289

  35. Insidious Onset of Leg Pain in Olympic Ski Racer Tara Fontenot, PT, DPT, ATC United States Ski and Snowboard Association

  36. Initial Evaluation-Subjective 23 yr old female professional ski racer 4th degree black belt in Tai Kwon Do

  37. Initial Evaluation-Subjective • Jan 2009, c/o leg pain with insidious onset • Pain described as an ache 2-4/10 • Intermittent sharp pain down outside of anterior/lateral aspect of L leg • Intermittent numbness and tingling • Pain only when in ski boot-does not hurt at other times during the day • Pain relieved by removing ski boot • Does not want to take medicine for pain • Hx of L knee scope 4/2008

  38. Subjective-What else do you want to know? • What event does she ski • Does it affect her skiing? • Where in the season is she? Does she have any breaks coming up? • How long in ski boot before pain begins?

  39. Objective • Palpation: TTP over proximal fibular region • What originates there????? • No visible swelling/edema • ROM of ankle and knee WNL • MMT: 5/5 DF of hallux, tib ant, gastroc/soleus, peroneals, inverters • Joint mobility of ankle and knee (tibio-femoral and tib-fib) normal • Balance: Slightly decreased on L (tested on bosu ball) • LQS: myotomes 5/5 B, dermatomes equal and intact, reflexes normal • Distal pulses strong What else do you want to look at?

  40. Use the resources available to you!

  41. Consider Anatomy when Forming Differential Dx

  42. Differential Diagnosis SpinalStenosis Peripheral Nerve Entrapment Boots Medial Tibial Stress Syndrome Muscle Strain Compartment Syndrome Disc Herniation (Fredrickson, et al)

  43. Referral/Imaging • Refer to orthopedist for further work-up • Unfortunately, Hailey is out of the country from Jan-March (10 weeks) • Cortico steroid injection provides no relief

  44. Treatment • Daily PT during 10 weeks consists of: • Cold therapy (ice massage, cold tub, ice wraps) • Kinesio Taping • Retrograde edema massage, SASTM • Stretching • NSAIDs • What are our PT goals during this time? Further concerns?

  45. Flash Forward: 3/24/2009 • 2008-2009 Season has ended • Pain now 4-6/10. • Pain continues to be mostly when in ski boot but now experiences intermittent pain with dryland training as well • LE ROM/Strength still all normal

  46. Question: Which imaging test(s) is/are most appropriate at this stage? • X-Ray Only • X-ray and EMG and compartment measure test • MRI • CT Scan

  47. MD Testing • 1st MD visit: MD orders x-ray, EMG, pressure test, follow-up w/ MRI • All results normal • MD suspects Peroneal N. entrapment

  48. Role of MRI in Diagnosis(Gaeta, et al) • The sensitivity of an MRI following exertion is comparable to intracompartmental pressure measurement in diagnosing chornicexertionalcomartment syndrome • MRI can show muscular neurogenic edema in the subacute phase of neuropathy and atrophy with fatty degeneration in the chronic phase of nerve degeneration • This can be used to diagnose nerve entrapment syndrome if the results of the EMG are normal

  49. (Gaeta, et al)

  50. Summer 2009 • Athlete has break in skiing from April-August 2009 (Does not return to PC until July) • Pain should improve, but doesn’t • She begins to feel pain even at rest • Long car rides/travel exacerbate pain • Begins to experience pain/numbness/tingling in R leg as well • What next???????

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