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adduction with internal rotation and the patient was fearful to

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use her upper extremity. On examination, she had diminished sensation over the lateral deltoid, mild weakness with resisted shoulder abduction with the arm at the side and elbow ﬂexion. Remaining upper extremity myotomes were normal compared to the uninvolved side. Bilateral upper extremity deep tendon reﬂexes, and radial pulses on the involved side were normal. Cervical active range of motion (ROM) was normal in all planes with a “stretch” on the right cervical spine noted with left cervical side bending. ere was a negative Spurling’s test. e upper limb neurodynamic test (median nerve bias

2) reproduced tingling sensation into the hand on the right upper extremity. Active shoulder ROM on the left was full and demonstrated normal scapulohumeral rhythm. e patient was reluctant to elevate her right upper extremity, but able to perform shoulder forward elevation to 50°, external rotation (ER) to 30° with the arm at the side, and internal rotation (IR) with posterior reach to the L5 level. Passive ROM was limited by pain and apprehension to 90° forward elevation and 30° ER at 0° of abduction. e patient had a positive sulcus sign. Resisted shoulder ER and IR isometrically with the arm at the side was strong and mildly painful.

musculature may be helpful to provide active stabilization

to the joint given potential structural lesions associated with

anterior dislocation.

e patient was seen by a shoulder surgeon 2 weeks later, 3 weeks following the dislocation. Magnetic resonance imaging conﬁrmed a Bankart lesion and Hill Sachs lesion, that was considered an on-track lesion, following an anterior dislocation. Sensation had returned and strength of the biceps with the arm at the side was normal. A follow up visit with the surgeon was scheduled in 8 weeks and she was encouraged to continue the course of physical therapy for strengthening.

Prognosis and plan of care

e patient wanted to try to restore her function and return to sport with non-operative interventions given prior success with rehabilitation a few years ago. Given 1 month remaining in the season and discussion on risks for recurrence, the patient decided to forgo the remainder of the season and focus on rehabilitation. She was started on a progressive rehabilitation program to achieve her goal. Discussion of timeline for progression and return to sport was dependent on progress with the exercise program and meeting milestones for recovery to return to soccer as a goalie.

Diagnosis

e patient experienced an anterior dislocation with potential brachial plexus injury, likely transient as no apparent signiﬁcant neurological motor loss was detected. e patient had an appointment scheduled with a shoulder surgeon in 2 weeks. Neurological status was planned to be monitored as treatment was initiated in collaboration with the patient.

Intervention

Active assistive elevation in supine was initiated in painfree ROM. Submaximal isometric shoulder exercises were prescribed in all planes, in neutral shoulder position, progressing to maximal contractions as tolerated. Scapular setting and retraction exercises were also initiated. Low grade self-neural mobilization exercise of the median nerve was also instituted.

Based on best-evidence for primary anterior dislocations,

when is it safe to start to wean from the sling?

a. 7 to 10 days. b. 4 weeks. c. 3 weeks. d. Not necessary if the patient is comfortable.

e correct answer is a. 7 to 10 days. A meta-analysis of randomized trials showed immobilization for a shorter 1-week duration did not increase risk of recurrence as compared to longer periods of immobilization as discussed in Traumatic

Instability, in Level ree: Rehabilitation Classication and Intervention portion of the monograph. Engaging in protected

use of the shoulder and early activation of the surrounding

3. What is the best evidence-based rehabilitation program following a traumatic anterior dislocation that has shown to be eﬀective in restoring short-term function at 12 weeks?

a. Electrical stimulation to the posterior rotator cuﬀ,

strengthening, and plyometrics.

b. Rockwood instability rotator cuﬀ and scapular

strengthening program.

c. SINEX strength, coordination, balance, proprioception,

and closed chain exercises.

d. Watson neuromuscular strengthening and scapular

upward rotation exercises.

e correct answer is c. SINEX strength, coordination,

balance, proprioception, and closed chain exercises. As discussed in the Traumatic Instability, in Level ree: Rehabilitation Classication and Intervention portion of the monograph, the SINEX program includes strengthening, coordination, balance, proprioception, and closed chain exercises. In a randomized controlled trial, the SINEX program achieved better levels of shoulder function at 12 weeks compared to the standard care consisting of elastic band resisted rotator cuﬀ and scapular exercises described by Rockwood. e Watson neuromuscular control program emphasizing scapular upward rotation with strengthening was evaluated in and intended for patients with multidirectional instability. Electrical stimulation to the posterior rotator cuﬀ has been proposed in patients with recurrent posterior shoulder instability.

e patient was seen 3 times a week and progressed over

8 weeks so that she was able to complete the Basic portion of the SINEX program including elastic band resisted full arm

elevation sitting on an exercise ball, resisted glenohumeral IR

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and ER at 120° of elevation, push-ups from a plank position with feet on a ball, repeated reaching while balancing a large exercise ball palm up eyes closed, and rapid shoulder ﬂexion using laser pointer into hitting a target located in front of her on a wall. ese were then progressed to elite levels in the SINEX program to unilateral stance and higher loads, including plyometrics with hands leaving the ground with push-ups.

At 10 weeks following the injury, she had full active ROM without pain. ere was mild apprehension at end-range of ER with the arm at 90° that improved with isometric muscle contractions. Shoulder isometric strength with hand-held dynamometry showed 85% strength of the uninvolved and an ER:IR ratio of 0.7. Her conﬁdence was much improved and she did not demonstrate or express fear with movement with rehabilitation.

What is the most appropriate tool to evaluate her physical performance to advance the patient’s return to sport progressions?

a. Western Ontario Shoulder Instability Index (WOSI).

b. Single Assessment Numeric Evaluation (SANE). c. Timed Functional Arm and Shoulder Test (TFAST). d. Closed Kinetic Chain Upper Extremity Stability Test

(CKCUEST).

e correct answer is d. Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST). e CKCUEST is a functional performance test for stability that would mimic some of the patient’s sport-speciﬁc tasks as a goalie. e WOSI is an instability condition-speciﬁc patient-rated outcome measure. e SANE is a single rating 0-100% relative to their “normal,” considering pain, functional ability or disability, and satisfaction. e TFAST is a function performance test for lower-level upper extremity functional demands. ese tools are discussed in the Patient Treatment Outcomes portion of the monograph.

e patient was progressed for 2 more weeks including sport practice and drills. She was discharged at week 12 following the dislocation after meeting strength, ROM, and functional performance goals. She had plans to return next session. At discharge her SANE was 95% and WOSI was 90%.

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

Appendix.

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Exercise Loading Progression for Rotator Cuﬀ Musculature

Exercises across stages of irritability and post-operative phases based on systematic review of electromyographic (EMG) signal intensity as a percentage (%) of maximum voluntary contraction (MVC).

386

Phase I Passive/Assistive Progressive Exercises with Rotator Cuﬀ EMG

Less an Pendulum Exercise (<11% MVC)

Assisted external rotation (ER) - note start position is neutral (not extended) and slightly abducted

*Can also be done upright: wall assisted ER

Supine press-up (punch with elbow bent)

*Can progress to lying supine on a 30-40° inclined wedge

Forward bow (hands resting on table)

Supine active-assisted elevation

Pendulum (EMG 11% of MVC) - correctly performed small passive range of motion encouraged

Phase II Progressive Exercises Active Assistive to Active

With EMG of Supraspinatus <30% of MVC

Towel slide sagittal/medial/scapular planes

Ball roll (assisted)

Appendix.

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Continued

Wall slide supported

Phase II—Continued

Standing press-up/active ﬂexion elbow bent shoulder press, progressing to elbow straight

Supine ﬂexion with elbow straight

Phase III Endurance Light Resistance Phase

EMG <49% of MVC with emphasis on good motor control

Resisted ER

*less EMG signal intensity when done without a towel

Shoulder extension

Rows

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

Appendix.

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Continued

Resisted internal rotation

Forward punch

Side lying ER

*weight can be added as progression nears 50% MVC

Phase III—Continued

Prone ﬂexion and extension

*prone horizontal abduction (90° and 120°) has much higher EMG signal nearing 80% MVC and is reserved for Phase IV

Dynamic hug

Standing press-up/active ﬂexion elbow bent to 90° elevation (ﬂexion or scapular plane abduction)

*Resisted strengthening above 90° (the third picture) is reserved for next phase

Appendix.

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Continued

Phase IV Strengthening Primarily for Patients Returning to Higher Demand

Full can abduction (scapular or coronal plane)

Work or Sport Activities With EMG signal >50% MVC

Prone horizontal abduction (at 90° and 120° abduction)

Standing resisted horizontal abduction

Standing ER at 90° elevation, scapular plane progressing to abduction

High row

Resisted internal rotation at 90° abduction

Academy of Orthopaedic Physical erapy, APTA.

For personal use only. No other uses without permission.

Appendix.

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Continued

Resisted diagonals with D2 pattern

Phase IV—Continued

Push up with plus starting on table progressing to ﬂoor

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