pathology: shoulder dislocation

yogabook / pathologie / shoulder dislocation

shoulder dislocation

Definition of

Dislocation of the glenohumeral joint , predominantly traumatic, after initial dislocation but also due to inappropriate trauma or simply by placing the arm endorotated overhead.
Dislocations are:

  • in 95-97% anterior (luxatio subcoracoidea): when the arm is extended dorsally during a fall, it dislocates forward
  • in 2-4% posterior (Luxatio infraspinata): due to cramp , electrical accident, is often overlooked
  • in 0.5% inferior (luxatio infraglenoidalis/axillaris): due to a fall on the frontally abducted arm

other forms are even rarer, such as dislocation erecta , an anterior inferior dislocation in which the arm falls into wide frontal and slight lateral abduction .
Bayley divided into

  1. traumatic structural
  2. atraumatic structural
  3. habitual non-structural (positional instability: muscular imbalance )

whereby the transitions between the three are fluid.
Gerber divides it as follows:

  1. caught dislocation
  2. unidirectional instability without hyperlaxity
  3. unidirectional instability with hyperlaxity
  4. multidirectional instability without hyperlaxity
  5. multidirectional instability with hyperlaxity
  6. arbitrary dislocation

A classification according to Neer and Forster differentiates according to the direction of the dislocation , the classification according to Matsen distinguishes primarily between traumatic and atraumatic:

  1. the atraumatic usually shows multidimensional instability and is bilateral
  2. the traumatic one is due to adequate trauma leading to unidirectional instability and a Bankart lesion resulting in

Note : The first traumatic shoulder dislocation develops into chronic recurrent dislocation, and the first atraumatic shoulder dislocation develops into habitual dislocation .

The incidence of dislocation is M:W 3:1. Children under 14 are hardly affected at 0.5%, while 14-17 year olds are affected at 4%. The incidence decreases with age. . 30% of shoulder instabilities are multidirectional In 50% of shoulder hyperlaxities, there is instability of many ligaments in the body.

The damage that during anterior dislocations occurs to the anterior labrum is classified into:

each with subtypes. In the classic anterior dislocation , damage also occurs to the cartilage surface of the humeral head, the Hill-Sachs lesion (posterosuperior impression fracture through the anterior edge of the glenoid ). In general , the greater the laxity of the joint at the time of dislocation , the less severe the Hill-Sachs lesion . If the defect hooks during lateral abduction with exorotation of the arm onto the anterior edge of the glenoid , this is referred to as an engaging Hill-Sachs lesion . If the dislocation was posterior , this leads to a reversed Hill-Sachs lesion.

Caused

Predisposing

  1. except for the traumatic-structural type: capsular dysfunction, muscular imbalances , scapular dyskinesia , impaired proprioception , glenoid dysplasia, hypoplastic labrum , Ehlers-Danlos syndrome, Marfan syndrome
  2. Risky sports with high forces and accelerations: climbing, gymnastics

diagnosis

  1. on palpation Dislocated humeral head
  2. in anterior dislocation : inspectively protruding acromion and flattened contour of the deltoid
  3. Clarification of the extent of the injury using MRI
  4. in traumatic cases: precise trauma history, frequency and triggers of reluxations
  5. clinical: is the the subluxation or dislocation position causing
    • Laterally abducted-exorotated, the shoulder tends to anteriorly dislocate
    • Frontally abducted -endorotated , the shoulder tends to posteriorly dislocate
    • a hanging, belatated arm (carrying) tends the shoulder to inferior dislocation

Symptoms

  1. Strong, stabbing pain and atraumatic redislocations are also hardly painful
  2. Swelling, possibly hematoma
  3. changed contour of the shoulder
  4. sometimes pronounced reduction in strength/painfully limited range of motion and exertion of force
  5. painful, springy fixation in a dislocated position
  6. for posterior: menhir posture (like Obelix, as a protective posture)
  7. There is also an injury to the long biceps tendon : painful and pain-restricted flexion of the elbow joint
  8. If nerves are injured: symptoms such as paresthesia, numbness

Complications

  1. Ligament and cartilage damage such as SLAP lesion
  2. Accompanying Bankart lesion : avulsion of the inferior capsule – labrum complex resulting in an unstable shoulder and risk of re-dislocation
  3. rare: nerve damage due to dislocation
  4. Risk of reduxation, regardless of the damage pattern, approx. 10%

therapy

  1. Analgesia (e.g. NSAIDs), especially for reduction anesthesia . The pain can last up to approx. 2-3 weeks. If pain still remains after 3 weeks, further evaluation is necessary
  2. If necessary, cool in the acute stage
  3. Exclusion of nerve and vascular injuries as well as fractures
  4. If necessary, orthoses : usually Gilchrist bandage, also: thorax abduction splint or abduction cushion, other anti-luxation orthoses
  5. as quickly as possible (within 30 minutes) reduction (various methods, the oldest by Hippocrates), if necessary under anesthesia, X-ray control. Usual methods: Arlt, Kocher, Manes, Hippocrates, Milch, Stimsen, White and Milch, Fares (Fast, Reliable, Safe: under rhythmic oscillations in the form of a rhythmic handshake, the arm is increasingly abducted, from 90° the exorotation is increased). The reduction must be done slowly and gently, otherwise nerves can be damaged!
  6. Immobilization: depending on severity, age 1 to 6 weeks. In most cases, protection from stress is prescribed for 6 weeks, or 8-12 weeks depending on the case. Especially in the case of anterior dislocation , force in the direction of exorotation should be avoided for at least 7 weeks. Typical leg-stressing cyclic sports such as jogging , running and cycling should be possible again after 3 months. Overhead sports such as swimming, tennis and volleyball may only be practiced again after 6 months at the earliest. For specific risky sports such as martial arts or handball, a break of at least 9 months applies. Before resuming any type of training, you must be free of pain and be able to bear full (sport-specific) resilience. The following are important for the decision:
    • whether shoulder dislocations preceded it
    • Previous damage to the shoulder
    • how bad the pain was
    • the reduction method used
    • Presence and degree of functional impairment post repositionem
    • Presence and degree of a feeling of instability
    • Presence and degree of neurological deficits or circulatory disorders
    • physical constitution
    • Sports behavior
    • Age of the patient
    • everyday and professional requirements
    • Did it affect the dominant arm?
  7. for traumatic anterior or inferior dislocations Surgery may be indicated . The older you get and the lower the level of sporting activity and physical demands, the more conservative treatment is required.
  8. for post-traumatic anterior or inferior dislocation or anterior instability Surgery may be indicated . Younger people are also more likely to undergo surgery because of the known high rate of redislocation. As with the first dislocation, the older you get and the lower the level of sporting activity and physical demands, the more conservative the treatment is.
  9. Habitual dislocations can be treated conservatively if they occur rarely and the functional limitations are minor or if the patient is older and less physically/athletically active. are usually operated on. On the other hand, more common dislocations in people who are active in sports
  10. Physiotherapy and stabilizing muscle training on your own initiative (!), especially the muscles that counteract the direction of dislocation. in the strengthening In addition to the scapulohumeral muscles, the truncohumeral and truncoscapular muscles must also be included
    All training must be painless. These measures may only begin after the immobilization phase, in which injuries heal as much as possible and the pain subsides. Passive mobilization by the PT after approx. 3 weeks. Active and passive mobility are subsequently maintained or improved with exercise therapy and further healing is promoted. Promoting healthy, dislocation-preventing posture as well as awareness and elimination of risky posture and movement patterns.
  11. If there are accompanying injuries to the cartilage or labrum : minimally invasive surgery
  12. If necessary, taping
  13. In typical cases, early reduction and optimal follow-up care should not result in any restrictions in everyday life and sports

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:

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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