Schoenstein 1 Case Study: Chronic Shoulder Subluxation Jessica Schoenstein Pathology and Evaluation II Dr. Sterner Schoenstein 2 Case Study: Chronic Shoulder Subluxation Jessica Schoenstein Objective: To present the case of a twenty-one year old female basketball player with chronic shoulder subluxation with multidirectional glenohumeral instability and an associated SLAP lesion of the glenoid labrum. Background: This athlete is a women‟s basketball player at the Division III collegiate level. She suffered her initial injury in her senior year of high school and has since suffered seven additional subluxations- the most recent occurring during a playoff game this year. She chose to not wear the shoulder brace that had kept her shoulder from subluxing during the season and during a jump-ball play she was thrown to the ground and landed on her shoulder with her elbow flexed under her side. When evaluated by the Rowan University physician, he concluded that she also had a SLAP lesion but has yet to receive any radiographic conformation. Differential Diagnosis: AC joint sprain, biceps tendinitis, impingement syndrome, brachial plexus, rotator cuff tear. Treatment: Initially the athlete was removed from the game, was iced, and put in a sling. She was uncompliant for approximately a month following the end of the season. Since then she has been doing home rehabilitation focusing on strengthening the scapular stabilizers and rotator cuff musculature. She will undergo arthroscopic surgery following graduation in 2009 to repair the SLAP Lesion and additional ligamentous damage. Uniqueness: This athlete had successfully prevented subluxation of her shoulder by wearing a shoulder brace during all games, but decided against its use during the playoffs- ultimately resulting in another subluxation. It is possible had she chosen to wear the brace, she may not have been injured during the game. Conclusion: The athlete has chosen to postpone surgery until after graduation but will continue to do rehabilitation in preparation for arthroscopic surgery. Key Words: Chronic Shoulder Subluxation, Multi-directional instability, SLAP Lesion. Word Count: 299 Schoenstein 3 Personal Data: In the case of this particular shoulder injury, it occurred in a twenty-one year old female athlete who plays for the women‟s basketball team at Rowan University. Standing at five- foot-eight inches tall, this shooting guard has had a long history of chronic shoulder subluxation and multidirectional glenohumeral instability of her dominant right limb. During her pre-season physical examination, she lacked full range of motion in her right arm when attempting the inferior scratch. She stated that in addition to her shoulder injuries, she had previously been diagnosed with asthma and suffered a grade one concussion. In the fall of 2007, she suffered a grade one hamstring and quadriceps strain. Chief Complaint: This athlete‟s original injury occurred in January of 2004 when she went for a lay-up but fell and landed on the tip of her shoulder. Since the original injury, her shoulder has subluxed eight times: three times during her freshman year of college, four times during her sophomore year, and once during her junior year. After her sophomore year she purchased a shoulder brace in an attempt to prevent further subluxations. Until the NJAC games she had worn the shoulder brace faithfully, but made the decision that she no longer wished to wear the brace in the tournament. The most recent subluxation injury occurred on February 25th, 2008, at an away game during the NJAC tournament. The athlete went for a jump ball and an opposing player pulled her to the ground. She described that she felt her shoulder, “go down,” when she fell. Because of her history of glenohumeral instability she immediately knew that her shoulder had subluxed. On the bench she was evaluated as to eliminate an injury that would warrant immediate referral and then was iced and put in a sling; she did not return to play. She did not present with any obvious deformity, was able to move in all ranges of motion, did not have any numbness or tingling, and Schoenstein 4 had normal pulses in her arm. The following day a more thorough evaluation was completed in addition to seeing the doctor. Result of Physical Examination: Upon evaluation, the athlete presented with some compensatory motions and guarding of the shoulder; however there was no gross deformity. She was able to actively move to 90* of glenohumeral flexion and abduction. Both external rotation and horizontal abduction were limited and painful. Internal rotation was full and painless and horizontal adduction was limited and painless. For strength, elbow flexion tested three-plus out of five. She was unable to do other tests for strength. The athlete elicited pain during palpation of the biceps tendon, the greater tuberosity and lesser tuberosity of the humerus, and over the acromioclavicular joint. In addiction to this, the athlete was point tender below the supraspinatous. Both circulatory and neurological testing was within normal limits. The special tests preformed on this athlete were the Sulcus Sign which elicited a positive result for both pain and instability, and the Piano Key Sign which was negative. Since the athlete had a known history of multidirectional glenohumeral instability, no other shoulder instability tests were preformed. The doctor preformed an O‟Brien‟s test which elicited positive results indicating a SLAP lesion of the glenoid labrum.3 The athlete was not sent for any radiographic testing but did discuss surgical options with the doctor. Results of Medical History: As of mid-April 2008 the athlete had yet to receive any recent radiographic testing, the most current imaging available was taken after her initial injury in 2004. The athlete discussed surgical options with the doctor with the primary focus on repairing the SLAP lesion of the glenoid labrum. The athlete made the decision to not have surgery this year initially because it would interfere with her spring break, and secondly because of the possibility that she would not be ready to return to play for her senior year. This decision was most likely in Schoenstein 5 her best interest because it is possible for complete return to activity following the recovery time to take upwards of one year.2 Diagnosis: The athlete presented within this case study has been correctly diagnosed with having multidirectional glenohumeral instability with associated chronic shoulder subluxations. Several factors led to this conclusion including the description given by the athlete at the time of the most recent acute subluxation. She described her shoulder „going down‟ which is an accurate account of subluxed or dislocated joints. In addition to this, the athlete had several previous shoulder subluxations and would have a good basis for comparison. The athlete is also known to have, and has tested positive for, multidirectional glenohumeral instability- predisposing her to other shoulder injuries like subluxations and dislocations.4 Treatment and Clinical Course: During the season, prior to the most recent subluxation, the athlete was compliant in doing rehabilitation focusing primarily on neuromuscular control and strengthening the scapular stabilizers. Following practice, the athlete would come in to the athletic training room to be stretched and iced. At the beginning of the season the athlete played with a shoulder spica on but decided to purchase a shoulder brace for better support. She had worn this brace at every game, except during the playoff game that she was injured. After the most recent injury, goals were established for her rehabilitation progress. The first goal was to have less pain during activity and for her to sublux less. The second goal was to make the rotator cuff and scapular stabilizers stronger.1 For strength exercises, the athlete performed Phillie‟s Exercises, dips, push up plus‟, up right rows, internal and external rotation with the Thera-Band, and chest presses.3 For neuromuscular control exercises the athlete preformed BOSU push ups, wall dribbles, body blades, and walked on her hands. Schoenstein 6 The athlete will undergo arthroscopic surgery to repair the SLAP lesion of the glenoid labrum. Arthroscopic stabilization has been shown to have improved overall results than nonsurgical treatment.1 Since the athlete will not be receiving surgery for over a year, she will continue to do the nonsurgical rehabilitation. The non-surgical treatment consists of strengthening the rotator cuff and scapular stabilizers while stretching the pectoralis minor muscle and the posterior capsule.1 Criteria for Return: Following her future surgery to repair the SLAP lesion of the glenoid labrum, the athlete will continue the rehabilitation that was done prior to the surgery. For approximately the first six weeks following the surgery, the athlete will wear a sling and will begin to work on regaining range of motion and strength.2 Once the athlete no longer wears the sling, more intense rehabilitation with neuromuscular control will be initiated. Although every patient who undergoes shoulder surgery has different recovery times, there is generally a four-phase rehabilitation procedure. The first phase is what is known as a protection phase and usually lasts until the sixth postoperative week. This period is integral for proper healing by introducing gentle range of motion exercises that prohibits excessive stress on the newly operated joint.2 The second phase is an intermediate phase that occurs approximately from the sixth to twelfth weeks. The goal of this period is for the patient to move in a full, pain- free range of motion, increase strength, and regain neuromuscular control.1, 2 The third phase spans the twelfth through twentieth weeks. This phase focuses primarily on dynamic strengthening exercises and encompasses more aggressive rehabilitation that aims to increase strength, endurance, power, and neuromuscular control.2 The fourth phase is return to activity and spans the forth to eight months following the operation. In order for the athlete to qualify moving to the fourth phase, she must be able to move through a complete range of motion Schoenstein 7 without pain, apprehension, or tenderness.2 The athlete will continue the exercises done throughout the rehabilitation process, gradually progressing to sport specific skills. For this particular athlete, she will focus on overhead motions that are involved with basketball like shooting, passing, defending, and throwing. The athlete must then go through a thorough evaluation by the physician in order to be cleared to return to play.2 Discussion: Glenohumeral instability occurs all too frequently in athletes who participate in overhead sports. If left untreated it is possible for additional shoulder pathologies to develop. In the case of this athlete, her multidirectional instability was left untreated and ultimately led to the additional injuries of chronic shoulder subluxation and a SLAP lesion of the glenoid labrum. Some unique aspects of this case include the fact that the athlete has yet to receive any diagnostic testing but has already discussed surgical options with physicians. As of right now, they have diagnosed her with a SLAP lesion but it remains ungraded. Another interesting aspect of this case study is that the athlete had successfully managed her subluxations this year by wearing a shoulder brace, but during the one game she did not wear it, she fell and subluxed her shoulder. It is possible that had she been wearing the brace at the time of the injury she may not have subluxed her shoulder at all. The athlete chose at the completion of this winter season to postpone surgery until after her graduation. Her initial reasoning behind the choice to postpone the surgery was nominal at best. One should not make the decision for surgical correction based on the fact that it would interfere with spring break. Allotment for substantial rehabilitation time could have been accomplished had the athlete made the decision to undergo surgery this spring. Ultimately, however, it is the athlete‟s decision on what she feels is best for her and her future career. Schoenstein 8 Conclusions: This athlete has been known to be moderately uncompliant with rehabilitation dependent on her scheduling of time and vacations. This could indicate the possibility for re- injury in the following season if the athlete makes the decision to not consistently partake in rehabilitative exercises. In addition to this, post-operatively, the athlete will need to remain routine and dedicated to the program established for her due to the intricacy and the time required for proper shoulder rehabilitation ultimately leading to her return to activity.1,3,4 In the case of this particular athlete, it is advisable to generate a specific at-home rehabilitation procedure for her to follow for the remainder of her collegiate basketball career. It is unlikely that she will consistently do the rehabilitation in the athletic training room in preparation for next season. In order to best prevent the possibility of a future occurrence of a subluxation, it may be best to create a rehabilitation program that is easy for her to routinely do at home. Schoenstein 9 References 1. Budoff, Jeffrey E., and Eugene M. Wolf. "Arthroscopic Treatment of Glenohumeral Instability." The Journal of Hand Surgery 31.8 (2006): 1387-1396. Science Direct. Google Scholar. 29 Feb. 2008. 2. McCarty, Eric C., Paul Ritchie, Harpreet S. Gill, and Edward G. McFarland. "Shoulder Instability: Return to Play." Clinics in Sports Medicine 23.3 (2004): 335-351. Science Direct. Google Scholar. 29 Feb. 2008. 3. Nadler, Scott F., Andrew L. Sherman, and Gerard A. Malanga. "Sport-Specific Shoulder Injuries." Physical Medicine and Rehabilitation Clinics of North America 15.3 (2004): 607-626. Science Direct. Google Scholar. 21 Feb. 2008. 4. Watch, Gilles, Pascal Boileau, Christine Levigne, Alain Mandrino, Phillipe Neyrett, and Simon Donell. "Arthroscopic Stabilization for Recurrent Anterior Shoulder Dislocation: Results of 59 Cases." Arthroscopy: the Journal of Arthroscopic & Related Surgery 11.2 (1995): 173-179. Science Direct. Google Scholar. 29 Feb. 2008.