yogabook / pathologie / shoulder dislocation

shoulder dislocation

Definition of

Dislocation of the glenohumeral joint, predominantly traumatic, in 95-97% anterior dislocation (arm extended dorsally during a fall dislocates forwards), 2-4% posterior(spasm, electrical accident, often overlooked), 0.5% inferior (fall onto the frontally abducted arm), others even rarer. Bayley divides into traumatic structural, atraumatic structural, habitual non-structural, Gerber as follows:

1. hooked dislocation
2. unidirectional instability without hyperlaxity
3. unidirectional instability with hyperlaxity
4. multidirectional instability without hyperlaxity
5. multidirectional instability with hyperlaxity
6. Arbitrary dislocation

Cause

Predominantly traumatic

Predisposing

1. except for the traumatic-structural type: capsular dysfunction, muscular imbalances
2. high-risk sports with high forces and accelerations: Climbing, gymnastics

Diagnosis

1. palpatorily dislocated humeral head
2. inspectorially protruding acromion and flattened contour of the deltoid
3. Clarification of the extent of the injury by MRI

Symptoms

1. Severe, stabbing pain
2. Swelling, possibly hematoma
3. Changed contour of the shoulder
4. Partly pronounced reduction in strength/painfully restricted range of motion and exercise of strength
5. Painful, springy fixation in a luxated position
6. posterior: Hinkelstein posture (like Obelix, as a protective posture)
7. there is a simultaneous injury to the long biceps tendon: painful and pain-restricted flexion of the elbow joint
8. In case of nerve injury: symptoms such as paresthesia, numbness

Complications

1. Ligament and cartilage damage such as SLAP
2. concomitant Bankart lesion: avulsion of the inferior capsule-labrum complex with unstable shoulder and risk of dislocation
3. Rare: Nevus damage due to dislocation
4. Reluxation risk independent of the damage pattern approx. 10%

Therapy

1. Analgesia (e.g. NSAIDs), especially for reduction also anesthesia. The pain can last up to 2-3 weeks. If pain persists after 3 weeks, a further examination is necessary
2. Cool if necessary in the acute stage
3. Exclusion of nerve and vascular injuries and fracture
4. If necessary, orthoses: mostly Gilchrist bandage, also: thoracic abduction splint or abduction cushion, other antiluxation orthoses
5. Reposition as quickly as possible (within 30 minutes) (various methods, the oldest from Hippocrates), if necessary under anesthesia, X-ray control. Usual methods: Arlt, Kocher, Manes, Hippokrates, Milch, Stimsen, Fares (Fast, Reliable, Safe: under rhythmic oscillations in the form of rhythmic hand shaking, the arm is increasingly abducted, exorotation is increased from 90°)
6. Immobilization: 1 to 6 weeks depending on severity and age. Rest is usually prescribed for 6 weeks before exertion, or 8-12 weeks depending on the case. Exercise in the direction of exorotation is avoided for at least 7 weeks, especially in the case of anterior dislocation. Typical leg-emphasizing cyclic sports such as jogging, running and cycling should be possible again after 3 months. Overhead sports such as swimming, tennis and volleyball may be resumed after 6 months at the earliest. For specific high-risk sports such as martial arts or handball, a break of at least 9 months applies. Before resuming any type of training, the patient must be free of pain and fully fit for the sport in question. The following are important for the decision
   1. whether shoulder dislocations preceded
   2. previous damage to the shoulder
   3. how severe the pain was
   4. the reduction method used
   5. the presence and degree of functional limitation post-reduction
   6. Presence and degree of a feeling of instability
   7. Presence and degree of neurological deficits or circulatory disorders
   8. Physical condition
   9. Sports behavior
   10. Age of the patient
   11. Everyday and occupational requirements
   12. did it affect the dominant arm?
7. Surgery may be indicated for traumatic anterior or inferior dislocation. With increasing age and the lower the level of sporting activity and physical demands, the more conservative the treatment.
8. Surgery may be indicated for post-traumatic anterior or inferior dislocation or anterior instability. Younger people are also more likely to undergo surgery due to a known high rate of dislocation. As with initial dislocation, the older the patient and the lower the level of sporting activity and physical demands, the more conservative the treatment.
9. Habitual dislocations can be treated conservatively if they occur infrequently and the functional restrictions are minor or the patient is older and less physically/athletically active. In contrast, more frequent dislocations in physically active people are usually operated on.
10. Physiotherapy and stabilizing muscle training on your own initiative (!), especially of the muscles that counteract the direction of dislocation. All training must be pain-free. These measures may only begin after the immobilization phase, during which injuries heal as far as possible and the pain subsides. Passice mobilization by the PT after approx. 3 weeks. Active and passive flexibility are subsequently maintained or improved with movement therapy and further healing is promoted. Promotion of healthy, luxation-preventing posture as well as awareness and elimination of risky posture and movement patterns.
11. For concomitant injuries to cartilage or labrum: minimally invasive surgery
12. Taping if necessary
13. In typical cases, early reduction and optimal follow-up treatment should not result in any restrictions in everyday life and sport

Asana practice

In the case of instability of the shoulder joint, it is generally necessary to avoid inadequately exorotated frontal abduction in particular, but also forceful exorotation in the early stages. Lateral ab duction is not possible anyway without wide exorotation and therefore poses less of a risk. The stabilization program proposed by San Antonio University in Texas (e.g. https://arthro. ch/wp-content/uploads/SanAntonio_Schema.pdf) recommends six exercises to be performed with a Theraband:

• Exorotation of the arm with the upper arm in place
• Endorotation of the arm with the upper arm in place
• Frontal abduction with depressed and retracted scapula
• Retroversion for depressed and retracted scapula
• Lateral abduction with depressed and retracted scapula Endorotation with 90° laterally abducted upper arm

It should be noted that working with the Theraband can only provide a very uneven torqueprogression. A deflected cable pulling machine (eccentric) is able to provide an optimal torque progression, not only adapted to the changing direction of the pulling arm, but also according to the force-length function. But even without this effort, effectiveness can be increased if the position of the body in relation to the pulling direction of the Theraband or the pulling direction of the Theraband is changed by changing its anchor point, so that work can be done with several, significantly different directions. The same applies when working with dumbbells, except that the direction of pull can only be changed by the position of the body in space, as the direction of pull of the dumbbells always corresponds to the direction of gravity. For exorotation, the forearm can make a horizontal movement with the upper arm in place or a frontal movement with the upper arm laterally abducted by 90°, i.e. move in the transverse plane or in the frontal plane. One example is the important
exorotation of the upper arm in the shoulder joint. Possible movements include

1. the standing exorotation with Theraband described in the San Antonio diagram with the arm positioned between an exactly frontal and 90° exorotated(lateral) position of the forearm, sitting or standing
2. … similarly with altered rotation in relation to the anchor point of the Theraband Exorotation of the upper arm while lying down with the Theraband anchored inferiorly (e.g. at the foot)
3. Exorotation of the upper arm in a sitting or standing position with a Theraband placed at shoulder height and fixed with a foot or chair leg on the same side
4. Exorotation of the upper arm with dumbbell while sitting or standing with 90° lateral elbow with or without upper arm supported
5. Exorotation of the upper arm with dumbbell in a lying position with the elbow placed at 90° laterally, with the hand lifting from the floor to just under 90°. Great attention must be paid to the retraction and depression of the shoulder blade
6. Variation of the last two exercises by placing the upper body on an incline bench. With the inverted incline bench (head lower than pelvis), the possible errors (insufficient retraction and depression of the shoulder blades) are even more pronounced and the usable ROM is more limited. The classic incline bench with adjustable backrest should be the optimum for working with the dumbbell (or barbell, but then the available ROM is limited by the upper body).
7. Exorotation of the upper arm with dumbbell in lateral position with upper arm supported on the flank
8. Exorotation of the upper arm on a cable pulling machine with the cable running over the pulley on the floor, preferably on an adjustable inclined bench

Endorotation should be practiced less than exorotation and also not with a frontally abducted or laterally abducted arm, as the tendency to dislocate is significantly increased in both cases. In this case, the upper arm should be placed against the upper body. In the first phase after the immobilization prescribed for a shoulder dislocation, exorotation should also only be practiced very moderately, as any excessive traction can lead to a dislocation.

Frontal abduction can be performed standing with a Theraband anchored to the foot or sitting with a Theraband anchored to the foot or chair leg. Executions with dumbbells are proven classics
upper grip, but also in the lower grip, are proven classics of strength training. If, in addition to shoulder instability, there is also
impingement, the upper angles cannot be used. The posture may only be performed until the impingement-associated pain occurs (at around 70°). In this case, it may be advisable to perform the exercise lying down, where the maximum strengthening is achieved around 0° frontal abduction in accordance with the effect of gravity and 70° is considered the upper limit anyway, as the effect of the exercise decreases too much from this point onwards in accordance with the cosine angle function.

Similar to frontal abduction, lateral abduction can also be performed using various techniques. Again, you can use the pulley, machine, dumbbell and Theraband. The classic technique is to perform it with anoverhand grip, but it can also be practiced with an underhand grip from time to time. A combination of frontal abduction and lateral abduction also targets the biceps brachii, whose lateral head with its tendon running through the sulcus contributes to the stability of the shoulder joint. This is of course contraindicated in the case of a dislocated long biceps tendon.

Retroversion is usually performed from a slightly frontally abducted position. The greater the frontal abduction at the beginning, the more relevant the grip technique(overhand grip or underhand grip) becomes, as it leads to significantly different rotation of the upper arm in the shoulder joint and therefore to different responses of the adductor muscles of the shoulder joint. In principle, retroversions can also be performed with
can also be performed with the arm laterally abducted. If the arm is held in reasonably constant lateral abduction, this also serves to strengthen the lateral abductors such as the supraspinatus and deltoid muscles.
deltoid.

In the San Antonio scheme, adduction of the upper arm does not occur at all, although the adductors of the upper arm such as teres major, teres minor,
latissimus dorsi can provide additional stability. The teres minor as an exorotating muscle is particularly interesting here.

No special mention is made in the San Antonie scheme of the
biceps. Although they are also strengthened during frontal abduction, they are supported by two other muscles, the coracobrachialis and deltoideus pars clavicularis. Simple biceps curls(elbow joint flexion against the force of gravity of a dumbbell, cable pull or Theraband) strengthen the biceps at least as well and help to center the humeral head by pulling its long tendon of origin.
humeral head. Scott curls (upper arms placed on an incline) are less suitable here than those starting with the upper arm vertical, as the former primarily strengthen the brachialis from the starting position and the latter strengthen the
brachialis from the starting position and place great demands on the insertion of the biceps at the radius.

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