Athlete Rehabilitation Programme for a Cricketer - Case Study Example

 Introduction A cricketer suffered an acromio-clavicular joint sprain a.k.a shoulder separation to their left shoulder when they landed from an attempted catch. Aside from the need to hold the structure using tape and straps, the patient received an early stage cryotherapy and pain relief for the injury. Two weeks after the injury, the patient has to start going through a functional rehabilitation. After discussing the anatomical structure of acromio-clavicular joint, the aetiology of the acromio-clavicular joint sprain, the purpose of the initial treatment given to the patient, and the importance of assessing and recording the ROM and strength baseline of the patient; a rehabilitation programme will be designed and demonstrated in order to enhance the patient’s recovery. Anatomical Explanation behind the Acromio-Clavicular Joint The acromio-clavicular joint is a joint located at the patient’s top of his shoulder. As a junction between the clavicle a.k.a. collarbone and the acromion, the shoulder joint is formed at the junction where the clavicle – collarbone, scapula – shoulder blade, and the humerus – arm bone meets. With this three major bone structure, the shoulder blade and the collarbone forms the joint socket whereas the arm bone with a round head fits into the joint socket (Marieb 2004, pp. 138 – 139). Since the joint acts as a pivot, the main function of the acromio-clavicular joint is to allow us to raise our arm above the head area. In other words, the acromio-clavicular joint enables us to rotate our arms 360O. Other than acting as a pivot, the acromio-clavicular joint stabilizes three ligaments known as: the acromioclavicular, coracoacromial, and coracoclavicular ligaments. The acromioclavicular ligament connects the clavicle with the acromion of the scapula. By restraining the posterior translation and movements of the clavicle, the acromioclavicular provides stability across the joint (NISMAT 2007). Extending from the coracoids process to the acromion, the coracoacromial ligament controls both the anterior and posterior part of the lateral clavicle whereas the coracoclavicular ligament which is consists of the conoid and trapezoid ligaments connect the clavicle with the coracoids process of the scapula (NISMAT 2007). Aetiology of Acromio-Clavicular Joint Sprain Acromio-clavicular joint sprain occurs when the either one of the three ligaments that holds the acromio-clavicular joint is physically disrupted. Specifically disruption in the acromio-clavicular joint caused by direct force due to sports activities could result to shoulder separation. In this particular case study, a cricketer suffered an acromio-clavicular joint sprain when he accidentally landed on his left shoulder from an attempted catch. Depending on the degree of physical injury, acromio-clavicular joint sprain can be categorized using Grade I for minimal joint disruption up to Grade III which signifies severe physical injury. In line with this, Grade II injury is caused by the tearing of the acromio-clavicular ligaments and sprain in the coracoclavicular ligaments (Culp & Romani, 2006). Furthermore, Culp and Romani (2006) explained that Grade I injury is caused by a lateral force which causes the development of an isolated sprain in the acromio-clavicular ligaments whereas Grades II and III are injuries which could have resulted from a superolateral force. Purpose of the Initial Treatment The purpose of the initial treatment that was given to the patient was to prevent further physical damage by holding the structure using tape and straps. Since pain is one of the most immediate signs and symptoms of sprain, the patient was subjected to a cryotherapy and pain medications like non-steroidal anti-inflammatory drugs and analgesic medications (Culp & Romani, 2006). Specifically the use of cryotherapy was necessary in order to minimize cellular metabolism and promote vasoconstriction which is necessary in order to control the degree of inflammation and minimize pain and spasm (Weber, 2009). It is not advisable to make the patient immediately participate in a tedious physical rehabilitation exercise right after the acromio-clavicular joint sprain since doing so could result to more serious physical injury which could make the patient loss the overall functionality of his left arm and shoulder (Merrick, Jutte, & Smith, 2003). In fact, patients who just had an acromio-clavicular joint sprain should have an active rest and avoid painful exercises for three days after the injury (Physio Works, 2010a). Since it is normal for joint and muscle sprain to develop signs and symptoms related to inflammation, the application of ice therapeutic approach is effective in terms of promoting the patient’s blood circulation which significantly reduces inflammation in return. Pre-requisites of the Proposed Rehabilitation Programme for Acromio-Clavicular Joint Sprain The proposed rehabilitation programme for a client with acromio-clavicular joint sprain should include physiotherapy and the use of other pain relieving modalities. In line with this, the proposed rehabilitation programme should first concentrate more on the use of pain modalities like ultrasound, interferential therapy, electrical stimulation, transcutaneous electrical nerve stimulation (TENS) and/or other forms of electrotherapy before increasing the time allocated for physiotherapy programme (Medic8, 2010). The rationale behind this approach is to first reduce and minimize the degree of pain and joint stiffness associated with the acromio-clavicular joint sprain before subjecting the patient to undergo repeated physical movements in the left arm and shoulder. In general, a successful rehabilitation programme as a form of treatment for acromio-clavicular joint sprain is highly dependent on the ability of the physical therapist to conduct a skillful examination and accurate diagnosis (Meister, 2000). Therefore, the physical therapist should assess and record the patient’s baseline range of motion (ROM) and strength on left arm and shoulder through the use of strength tests like internal and external rotator cuff strength, supraspinatus strength, and the palpation of bicipital groove before subjecting the patient to physiotherapy exercises (NISMAT, 2007; Culp & Romani, 2006). Other necessary tests includes the acriomio-clavicular joint testing aside from other forms of physical exam like the apprehension test, laxity test, impingement test, hawkin’s test (NISMAT, 2007). In general, range of motion test includes internal and external rotation, forward flexion, and internal rotation up to 90O forward flexion whereas the acromio-clavicular joint testing includes palpating the affected area, cross-arm horizontal adduction test (NISMAT, 2007). (See Appendix I – Photos of ROM and Other Related Strength Tests on page 10 – 12) Conducting the ROM test should be done actively with the patient’s own physical strength and capacity combine with passive participation of the physical therapist when evaluating the patient’s pain or when the patient’s movement is restricted (NISMAT 2007). In line with this, recording the baseline is an important step when developing a rehabilitation programme for patients with acromio-clavicular joint spasm. Likewise, this information will enable the physical therapist to determine any signs of improvements in the patient’s physical condition. Proposed Rehabilitation Programme for Acromio-Clavicular Joint Sprain As soon as the pain have subsided, it is necessary to instruct the patient to gradually move his arm further above his head, behind his back, and slowly across the opposite side of his shoulder. Therefore, repeating the said movements for at least 3 to 4 times a week could enhance the recovery period of the patient. In promoting a normal biomechanical movement, performing shoulder-related stretches is crucial part of enabling the patient to become accustomed of moving his arms around the shoulder (Physio Works, 2010b). Since shoulder muscles could tighten or weaken when stressed, physical therapists should take note not to over stretch the patient’s arm when the muscle tightens when performing shoulder stretches. When the patient is able to move his left arm and shoulder without pain, it is necessary for the patient to stretch the affected part gently to avoid developing stiffness on the injured area. Although pain can be felt by the patient when stretching the affected part, the degree of pain would gradually subside as soon as the scar tissue matures. This will take place approximately up to 6 weeks from the time of injury. Specifically the rotator cuff is referring to a group of tendons and muscles that functions in the stabilization of the shoulders (Morag et al., 2006). Therefore, it is crucial on the part of the physical therapist to focus on strengthening the patient’s rotator cuff muscles as soon as pain from sports injury is lessen particularly when a patient suffers from acromio-clavicular joint sprain. Since the rotator cuff functions as the main stabilizer of the shoulder, focusing the rehabilitation exercise programme on strengthening the patient’s rotator cuff muscles could enable the physical therapist protect the patient from experiencing the different types of rotator cuff injuries including the tendonitis, tears in the rotator cuff, and/or shoulder impringement syndrome (Physio Works, 2010c). It is very important not to subject the patient to heavy exercises like bench press or push-ups since this type of exercises could further injure the patient. It is also necessary to limit the patient’s lifting and other related physical activity for the certain period of time like 3 weeks. Instead of heavy exercises, the proposed rehabilitation programme should include light active range of motion (AROM) exercises like PROM forward elevation, PROM w/ wand in external scapular plane, short lever sub maximal deltoid isometric exercises, manually guided scapula mobilization technique, side-lying external rotation, propped external rotator, lateral raise with internal rotation (LRIR) (Maschi and Fives 2010, pp. 449 – 500). Since each patient has their own degree of injury, physical therapists should design the rehabilitation programme based on the specific needs of the patient. (See Appendix II – Photos of Proposed Rehabilitation Exercises on page 13 – 14) For instance: Horizontal adduction and overhead movement should be avoided immediately after the injury because this type of ROM exercises could subject the patient from further harm. Depending on the physical recovery of the patient, the physical therapist could gradually increase the degree of physical movements like pushing the door open and lifting light weights to strengthen his shoulder muscles as soon as the patient is no longer feeling any pain (Culp & Romani, 2006). Weeks Proposed Exercises Description Purpose 0 - 3 PROM Forward Elevation A passive exercise that allows the patient to support the left arm with right hand when raising the arm from 45O up to the ceiling. Promotes arm flexibility necessary to enable the patient perform ADL. Strengthens anterior deltoid. PROM w/ Wand in External Scapular Plane Similar to PROM Forward except that the patient is instructed to hold on a long wood on both sides when raising arm up to the ceiling. Short Lever Sub maximal Deltoid Isometric Exercises Instruct patient to flex elbow 90O to act as a short lever arm when performing forward, flexion, abduction, and extension isometric exercises in his hand. Manually guided Scapula Mobilization technique Assist patient in side-lying position. Therapist guides the patient to actively move scapula in different positions like protracted or retracted and elevated or depressed. 4 – 7 weeks onwards Side-lying External Rotation Patient lies on a bench sideways. Arms on the side is flexed roughly 90O. With a pacing of 2 sec. up and 4 sec. down, instruct patient to rotate arm with a 5 lb. dumbbell up 45O towards the ceiling. Strengthens the supraspinatus, subscapularis, infraspinatus, and teres minor. Propped External Rotator Flexing the left arm up to 90O on elbow with forearm resting on the dumbbell, instruct patient to sit perpendicular to the dumbbell and raise dumbbell up towards the forearm slowly. Strengthens the infraspinatus and teres minor. Lateral Raise w/ Internal Rotation (LRIR) Instruct patient to hold dumbbell and internally rotate the left arm and raise arms sideways until the dumbbell is just below the patient’s shoulders. Strengthens the supraspinatus. Conclusion When designing a rehabilitation programme for a patient with acromio-clavicular joint sprain, physical therapist should assess and record the patient’s ROM and strength to serve as a benchmark when assessing the effectiveness of the designed exercise programme. Three to four weeks after the injury, physical therapists should focus on relieving the pain and light active and passive exercises for the patient depending on his physical condition. On the 4th to 7th week onward, the programme should focus on strengthening the patient’s rotator cuff to prevent the development of tendonitis, tears in the rotator cuff, and/or shoulder impringement syndrome. *** End *** Appendix I – Photos of ROM and Other Related Strength Tests External Rotation Internal Rotation Internal Rotation @ 90O Forward Flexion Forward Flexion Shoulder Abduction: Active Test Acromioclavicular Joint Testing Palpation of AC Joint Cross-Arm Horizontal Adduction Test Glenohumeral Laxity and Apprehension Apprehension Test Laxity Test Impingement Test Hawkins’s Test Strength Tests External Rotator Cuff Strength Internal Rotator Cuff Strength Supraspinatus Strength Palpation of Bicipital Groove Source: NISMAT, 2007 Appendix II – Photos of Proposed Rehabilitation Exercises PROM Forward Elevation in Scapular Plane PROM w/ Wand in External Scapular Plane Short Lever Sub maximal Deltoid Isometrics Side-lying Manual Scapular Mobilization Technique Source: Maschi and Fives 2010, pp. 500 – 501 Side-Lying External Rotation Source: Palo Alto Medical Foundation, 2010 References Culp, L., & Romani, W. (2006). Physical Therapist Examination, Evaluation, and Intervention Following the Surgical Reconstruction of a Grade III Acromioclavicular Joint Separation. Physical Therapy , Vol. 86, No. 6, pp. 857 - 869. Magee, D. (2002). Orthopedic Physical Assessment. 4th ed. In Culp LB and Romani WA (eds) "Physical Therapist Examination, Evaluation, and Intervention Following the Surgical Reconstruction of a Grade III Acromioclavicular Joint Separation . Marieb, E. (2004). Essentials of Human Anatomy & Physiology. 7th Edition. Pearson Education South Asia Pte. Ltd. Maschi, R., & Fives, G. (2010). Retrieved June 12, 2010, from Chapter 40 - Rotator Cuff Repair: Arthoscopic and Open: http://www.hss.edu/files/Ch_40_Rotator_Cuff_Repair.pdf. Medic8. (2010). Retrieved June 12, 2010, from Electrotherapy : Sports Injury Treatment: http://www.medic8.com/healthguide/sports-medicine/treatments/electrotherapy.html. Meister, K. (2000). Injuries to the Shoulder in the Throwing Athlete: Part Two: Evaluation/Treatment. American Journal of Sports Medicine , Vol. 28, p. 587. Merrick, M., Jutte, L., & Smith, M. (2003). Cold modalities with different thermodynamic properties produce different surface and intramuscular temperatures. Journal of Athletic Training , Vol. 38, No. 1, pp. 28-33. Morag, Y., Jacobson, J., Miller, B., De Maeseneer, M., Girish, G., & Jamadar, D. (2006). MR imaging of rotator cuff injury: what the clinician needs to know. Radiographics , Vol. 26, No. 4, No. 1045-1065. NISMAT. (2007, March 8). Retrieved June 12, 2010, from Physical Examination of the Shoulder: http://www.nismat.org/orthocor/exam/shoulder.html. Palo Alto Medical Foundation. (2010). Retrieved June 12, 2010, from Shoulder Impingement (Bursitis, Tendonitis: http://www.google.com.ph/imgres?imgurl=http://www.pamf.org/sports/king/images/shoulder_3.jpg&imgrefurl=http://www.pamf.org/sports/king/shoulder.html&h=100&w=150&sz=5&tbnid=BY0GzSnf4IvLFM:&tbnh=64&tbnw=96&prev=/images%3Fq%3DSide-Lying%2BExternal%2BRotation. Physio Works. (2010a). Retrieved June 12, 2010, from Immediate Injury Treatment. What to do the First Few Days Post-Injury: http://www.physioworks.com.au/_webapp_44860/Immediate_Injury_Treatment. Physio Works. (2010b). Retrieved June 12, 2010, from Shoulder Stretches. Why are Shoulder Stretches Important?: http://www.physioworks.com.au/_webapp_44922/Shoulder_Stretches. Physio Works. (2010c). Retrieved June 12, 2010, from Rotator Cuff Strengthening Exercises. The Importance of Strengthening the Rotator Cuff: http://www.physioworks.com.au/_webapp_44868/Rotator_Cuff_Strengthening_Exercises. Weber, K. (2009, August 4). moji. Retrieved June 12, 2010, from The Technical Benefits of Icing: http://www.gomoji.com/education/technical-benefits-icing. Read More