Rehabilitation of the Injured Athlete - Case Study Example

Rehabilitation of the Injured Athlete Elaine C Dixon Academic Research Professional rugby player, 20-year old Simon, was tackled during a game last week, which caused his right shoulder to become dislocated. A magnetic resonance imaging (MRI) scan revealed that his glenohumeral joint has been severely damaged, including a superior labrum from anterior to posterior (SLAP) lesion, which is an injury to the superior labrum, the rim of cartilage in the socket near the joint’s biceps anchor attachment (Reinold, 2008) (Abrams and Safran, 2009). Simon is scheduled to have arthroscopic surgery, which utilizes small incisions made with special instruments and a viewing scope for this common labral injury (Funk, 2011), two weeks from now, and he is anxious to resume play quickly. To accomplish this a rehabilitation program is being developed by a specialized team. The program will encompass total recovery, involving pre-habilitation and the actual rehabilitation process – including targeted treatment and exercises, aimed at returning Simon to his rugby team and game as soon as possible. The shoulder consists of three bones the clavicle, scapula, and humerus, and two joints, the acromioclavicular and glenohumeral joints (Quinn, 2006). The bones are connected to each other by ligaments, while they are connected to muscles by tendons (Quinn, 2006). These structures, along with the rotator cuff muscles, cooperate to provide motion, mobility, and strength to the very movable shoulder joint which is quite unstable and prone to injury from impact (Quinn, 2006). Nevertheless, the 13 muscles in the shoulder joint, offer biomechanical protection which provides a measure of stability to this vulnerable and unstable joint (Funk, 2011). Simon’s collision caused his dislocated shoulder joint, where an extreme rotation occurred violently twisting his shoulder upward and backward, causing the humerus to jump out of the glenoid, and delivering intense pain and weakness in the arm, presumably because the rotator cuff was damaged during the impact (Cunha, 2011). The four tendons in the rotator cuff are connected to four muscles which turn the arm inward, upward, and outward (Cunha, 2011), and are responsible for stabilizing the humerus in the socket (Erstad, 2010). Simon’s collision caused the joint capsule, cartilage, and rotator cuff ligaments, which keep the shoulder intact, to tear (Wedro, 2011). The resultant pain signalled the need for medical attention. The injured shoulder would first have been tied in a makeshift sling, before Simon was rushed to a doctor (Cunha, 2011) (Mayo Clinic Staff, 2009). Most likely he was given pain killers and then quickly examined by the doctor, who probably touched the shoulder from the side to see whether the humeral head was in position (Cunha, 2011). Simon probably grimaced at the pain in the front of the shoulder, caused when the doctor bent his elbow or turned his wrist, indicating a SLAP lesion (Pesic, 2011). The doctor would then x-ray the injury to confirm the diagnosis and ascertain whether there were broken bones (Cunha, 2011). Having found no broken bones, the doctor would first determine whether the SLAP lesion could be treated non-surgically through shoulder rest and medication to lessen inflammation (Pesic, 2011). Simon would naturally be removed from active play (Pesic, 2011). SLAP lesion physical therapy would be done by stretching and strengthening the muscles surrounding the rotator cuff and scapula, through special exercises (Pesic, 2011). Cold therapy, which can be a three-hour application of ice packs or a massage, could also be done to reduce swelling and pain (Pesic, 2011). The RICE technique of rest, ice, compression, and elevation of the shoulder would also be applied (“Cold Therapy,” 2011). If those measures are not successful, surgery would be scheduled. Maunder (2011) feels that Simon should be prepared mentally and physically for surgery to increase his chances of success. Prehabilitation would give him an opportunity to ask questions and learn about his role in his upcoming rehabilitation programme, which should make him mentally ready for surgery (Maunder, 2011). He would also be more realistic about the timeframe for his recovery (Maunder, 2011). A shoulder dislocation is an acute injury, so there are possible inflammatory reactions, pain and swelling, and poor functioning of the surrounding muscle system, causing stiff joint and weak muscles (Maunder, 2011). Rehabilitation is necessary before surgery to minimize muscle weakening (Maunder, 2011). Maunder (2011) further states that prehabilitation aims to rapidly reduce pain and swelling, restore movement range, regain muscular control of the limb, and encourage proprioceptive awareness. RICE stops tissue bleeding and reduces pain perception when the ice is applied as a compress for 10-15 minutes at two-hour intervals (Maunder, 2011). Resting the elevated arm allows gravity to help reduce swelling (Maunder, 2011). Exercises which gently mobilize and stretch the muscles, like using a rope and pulley system, help to restore movement range (Maunder, 2011). Isometric contractions followed by isotonic exercises against light resistance must be closely monitored to prevent aggravation of the joint (Maunder, 2011). Proprioceptive exercises such as pushing a soft ball onto the wall with one arm then rolling the ball in different directions help to increase awareness of joint movement, which is important before surgery (Maunder, 2011). Corrective arthroscopic surgery involves a procedure known as reduction which either removes torn cartilages, or simply re-attaches them (Pesic, 2011). Although the procedure sounds simple, some patients require mild sedation or a general anaesthetic to help relax the body (Cunha, 2011). After surgery the arm could be immobilized using an external rotation brace for better results (Paterson et al, 2010). Simon would be scheduled to visit an orthopaedic doctor a few days after surgery, for another examination to check on the maintenance of the relocation (Cunha, 2011). Physical therapy, designed to restore comprehensive movements and strengthen the shoulder muscles, will resume to help the return to full functioning (Cunha, 2011). The Angelfire website (“Shoulder Dislocation,” 2011) suggests a program of exercises, including wall crawls, pulleys, and cane exercises, to restore the functioning of the shoulder’s stabilizing muscles, and improve the strength, endurance, and power of the muscles primarily responsible for shoulder movement (Cunha, 2011) . Simon’s rehabilitation will involve Gray and Gray’s (2011) three progressive stages. In the first stage, retraining the glenohumeral joint’s and scapula’s stabilizers, through isolation and activation, is done with the assistance of a physiotherapist (Gray and Gray, 2011). Though not a long phase, successful rehabilitation is completely dependent on it, and should not be abandoned until mastered (Gray and Gray, 2011). The scapula should be set back onto the rib cage (Gray and Gray, 2011). For this, the fingers should be held in line with the pectoral muscle, and the tip of the shoulder drawn away from them for 10 seconds, and repeated 10 times (Gray and Gray, 2011). This scapula-setting exercise should be done daily, 5-6 times, until mastered (Gray and Gray, 2011). Light gym work can be done between the routines. During the second stage, the stabilizers and movers continue to be strengthened with simple exercises for isolating specific muscles, strongly emphasizing correct movement or motor patterns (Gray and Gray, 2011). This phase features a progression of nine exercises for improved strength and endurance (Gray and Gray, 2011). The first exercise is a scapular protraction and retraction push up where the elbows are extended, the chest is dropped toward the ground and Simon pushes up through the chest, taking three seconds to descend and two to return (Gray and Gray, 2011). In the second exercise, the dynamic hug, a piece of theraband is placed across the shoulder blades, the elbows are extended and the shoulders are pushed forward as the hands are brought together, using two seconds to extend and three seconds to rest (Gray and Gray, 2011). The third exercise, the scapular retraction with weights, is done by bending horizontally on the floor, with a heavy dumbbell in hand, the shoulder blade is drawn toward the spine, favouring the inferior angle, not the upper portion, being careful not to engage the neck muscles, taking two seconds to come up and three seconds to descend (Gray and Gray, 2011). The serratus punch is the fourth exercise, and the theraband is again placed across the scapula and held in both arms, the leading arm is jabbed forward and rotated inwards, focusing on moving both shoulder blade and arm forward, and returning to the start position slowly (Gray and Gray, 2011). An advanced scapular retraction and protraction is the fifth exercise, where Simon lies over a ball with his upper body suspended; with the elbows extended and locked, the chest is moved toward the ground, shoulder blades going together, then pushed back up to start position (Gray and Gray, 2011). Exercise six is the theraband internal rotation, in which the theraband is tied to an immovable object, the elbow is bent to 900, and keeping it away from the side, rotate the band towards the stomach (Gray and Gray, 2011). Step walking is the seventh exercise, where the hands are placed on either side of a step, then moved alternately onto the step, then returned to starting position, keeping shoulder blades forward (Gray and Gray, 2011). In the eighth exercise, the bent over row, a weight is placed in the hand and the shoulder blade is retracted so that the inferior border is closer to the spine, the weight is then lifted up to the waist while the elbow is bent (Gray and Gray, 2011). The final exercise in this phase is the cable rows, where Simon pulls ropes towards himself as the shoulder blades are simultaneously pulled back, ensuring that the shoulders are not elevated (Gray and Gray, 2011). These exercises should be rotated and mastered, with close attention paid to frequency, intensity, progression, and load, while maintaining form (Gray and Gray, 2011). The third stage emphasizes strengthening exercises for muscle balance and enhanced stability, as well as skill training including falling or rolling techniques and plyometric exercises, featuring cross body movements in several directions (Gray and Gray, 2011). The first of six exercises is the windmill, which starts in a push up position followed by a movement onto one shoulder when the body is rotated to one side, preventing a shoulder collapse and maintaining a neutral alignment (Gray and Gray, 2011). The second exercise, the four-point kneeling on a ball with leg elevation, maintains balance as the shoulder blades are used as stabilizers after both hands and legs are placed on the ball and then one leg is extended behind (Gray and Gray, 2011). The reverse throws are next, where the theraband is again tied to a firm object; facing the band this time, the arm is drawn back and up into a throwing position using the shoulder blade and arm, without elevating the shoulder, then slowly returning arm to start position, while arm and shoulder blade are released (Gray and Gray, 2011). The medicine ball push up is fourth, where each hand is placed on a medicine ball and a push up is done without the balls touching each other (Gray and Gray, 2011). The fifth exercise is the forward roll, where a fall and a roll are executed over each shoulder (Gray and Gray, 2011). In the plyometric heave, the final exercise in the phase, a dumbbell is placed in front of one foot and the opposite hand is used to lift it diagonally across the body until the arm is vertical, then returned slowly to the original position (Gray and Gray, 2011). These exercises should be done independently of other strength training programs, again focusing on frequency, intensity, and progression (Gray and Gray, 2011). A program for returning to play after injury can involve goals with dates for recording achievements (“Return to Play,” 2011). These would become a guide for Simon’s support team and himself as they work towards achieving full fitness (“Return to Play,” 2011). The return to play achievement can also be more dependent on Simon’s progression through recovery rehabilitation, than on a timeframe, where he has to achieve progressive predetermined goals specific to his playing position (Funk, 2011). This could take from 3-6 months, but with his determination Simon could return to play after four months of rehabilitation (Funk, 2011). Returning to play necessitates regaining proprioception, the body’s ability to sense joints movements and limbs positioning crucial to coordination in rugby (“Using Proprioception,” 2011). The proprioceptive system consists of receptor nerves in the muscles and ligaments in joints, which work with the brain to produce appropriate movements (“Using Proprioception,” 2011). These receptors are damaged along with joints or ligaments, and decrease proprioceptive ability, making Simon vulnerable to re-injury (“Using Proprioception,” 2011). Fortunately, specific exercises can retrain Simon’s proprioceptive ability, and speed his return to play (“Proprioception Exercises,” 2011). There are four such exercises which start with him sitting on a ball while partially using his limb, and progressing to Simon balancing on a wobble board (“Proprioception Exercises,” 2011). Simon’s injuries are typical of his chosen contact sport, rugby, which makes him vulnerable to injuries (Akhtar and Robinson, 2010). Nevertheless, after injury, rehabilitative measures can be taken to positively prepare him for surgery if necessary (Angelfire, 2011). These involve plans for pre-habilitation, rehabilitation, and a speedy return to play, using external rotation bracing immobilization (Patterson et al, 2010) physiotherapy, varied exercises at different stages, and medication (Angelfire, 2011). Works Cited Abrams, Geoffrey D, & Safran, Marc R. (2009, November 30). Diagnosis and management of superior labrum anterior posterior lesions in overhead athletes. Br J Sports Med 2010;44:311-318. doi:10.1136/bjsm.2009.070458. Akhtar, M A, & Robinson, C M. (2010). Generalised ligament laxity and shoulder dislocations after sports injuries. Br J Sports Med 2010;44:i3. doi:10.1136/bjsm.2010.078972.9. Retrieved from http://bjsm.bmj.com/content/44/14/i3.3.abstract?sid=16b60d47-853a-4b03-a9de-fc8840eaebe1 Cunha, John P, DO. (2011). Shoulder dislocation. Retrieved 26 April 2011 from http://www.emedicinehealth.com/shoulder_dislocation/article_em.htm Cunha, John P, DO. (2011). Shoulder dislocation symptoms. Retrieved 26 April 2011 from http://www.emedicinehealth.com/shoulder_dislocation/page2_em.htm#Shoulder Dislocation Symptoms Cunha, John P, DO. (2011). Shoulder dislocation treatment. Retrieved 26 April 2011 from http://www.emedicinehealth.com/shoulder_dislocation/page5_em.htm#Shoulder Dislocation Treatment Cunha, John P, DO. (2011). Medical treatment. Retrieved 26 April 2011 from http://www.emedicinehealth.com/shoulder_dislocation/page6_em.htm#Medical Treatment Cunha, John P, DO. (2011). Next steps – Follow-up. 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Retrieved 27 April 2011 from http://www.sarugby.co.za/boksmart/pdf/BokSmart%20-%20Shoulder%20Injury%20Prevention%20Practical%20guidelines.pdf Maunder, Tracy. (2011). Prehabilitation: Why you must rehab before the operation. Retrieved 30 April 2011 from http://www.sportsinjurybulletin.com/archive/prehab.htm Mayo Clinic Staff (2009, September 1). Dislocated Shoulder. Retrieved 2 May 2011 from http://www.mayoclinic.com/health/dislocated-shoulder/DS00597/METHOD=print Paterson, W H., Throckmorton, T W., Koester, M., Azar, F M., Kuhn, J E. (2010, December 15). Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. J Bone Joint Surg Am. 2010 Dec 15;92(18):2924-33. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21159993 Pesic, Milos. (2011). Slap lesion physical therapy treatment before and after surgery. Retrieved 27 April 2011 from http://ezinearticles.com/?Slap-Lesion-Physical-Therapy-Treatment-Before-and-After-Surgery&id=344825 PhysioRoom. (2011). Using proprioception to enhance rehabilitation. Retrieved 27 April 2011 from http://www.physioroom.com/injuries/supplements/proprioception.php#top PhysioRoom. (2011). Proprioception exercises. Retrieved 27 April 2011 from http://www.physioroom.com/injuries/supplements/proprioception_exercises1.php Quinn, Elizabeth (2006, September 16). Shoulder anatomy and physiology. Retrieved 27 April 2011 from http://sportsmedicine.about.com/cs/shoulder/a/shoulder1.htm Quinn, Elizabeth (2007, December 10). Shoulder dislocation. Retrieved 27 April 2011 from http://sportsmedicine.about.com/cs/shoulder/a/shoulder2.htm Reinold, Mike (2008, November 10). What exactly is a SLAP lesion? Top 5 things you need to know about a Superior Labral Tear. 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