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Neuromuscular retraining for multidirectional instability of the shoulder--a case study.

ABSTRACT

Multidirectional instability of the shoulder is a challenging clinical presentation that often requires surgical management. The presentation, assessment and physiotherapy management of a patient with multidirectional shoulder instability are described in this case. The patient presented with a long history of shoulder subluxation/dislocation in a variety of positions. The primary management was neuromuscular retraining of the concavity-compression mechanism of the rotator cuff and of the scapular stabilisers. The patient attended nine physiotherapy sessions over a 29-week period. His Western Ontario Shoulder Instability Index score decreased from 53% to 14% during the treatment period, and was 10% eight months after discharge. He was able to return to all sporting activities without limitation, and he was no longer experiencing shoulder subluxation/dislocation. Darlow b (2006): Neuromuscular retraining for multidirectional instability of the shoulder--a case study. New Zealand Journal of Physiotherapy 34(2): 60-65.

Key words: shoulder; joint instability; rehabilitation; physiotherapy

Key Points

* Neuromuscular dysfunction is likely to be present in patients with multidirectional instability

* A symptomatic improvement with compression of the glenohumeral joint may indicate a positive response to a concavity-compression retraining programme

* The subject of this case study demonstrated a significant improvement in symptoms and function following a neuromuscular retraining programme

INTRODUCTION

Shoulder instability is defined as an inability to maintain the humeral head centred in the glenoid fossa during active motion (Abboud and Soslowsky, 2002; Magarey and Jones, 1992; von Eisenhart-Rothe et al., 2002). Patients with symptomatic instability in two or more directions are considered to have multidirectional instability (McFarland et al., 2003). Many patients with multidirectional instability have an atraumatic onset (Remia et al., 2003).

Patients with atraumatic instability demonstrate a loss of humeral head centring in various arm positions (Inui et al., 2002; von Eisenhart-Rothe et al., 2002). This loss does not reduce with muscle activity, suggesting an alteration in neuromuscular control (von Eisenhart-Rothe et al., 2002). Altered neuromuscular control has also been indicated by EMG studies of muscle activation patterns in subjects with anterior instability (Glousman et al., 1988; Kim et al., 2001; Myers et al., 2004) and generalised joint laxity (Kronberg et al., 1991).

There is no consensus in the literature on the most appropriate form of exercise management during rehabilitation of shoulder instability (Falla et al., 2003). It has been reported that physiotherapy is of limited value in the treatment of symptomatic multidirectional instability (Choi and Ogilvie-Harris, 2002), or in patients with generalised ligament laxity (Ide et al., 2003).

Panjabi (1992) proposed a model of spinal stability based upon the interaction of passive, active and neural control subsystems. This model has previously been related to the glenohumeral joint (Hess, 2000). Neuromuscular retraining aims to improve the function of the active and neural control subsystems with the goal of enhancing dynamic stability (Hess, 2000; Magarey and Jones, 2003a). The muscular compression of the convex humeral head into the concave glenoid fossa (concavity-compression) is one mechanism by which stability is improved (Abboud and Soslowsky, 2002; Lee et al., 2000; Lippit et al., 1993). The rotator cuff muscles are primarily compressors of the glenohumeral joint, effectively stabilising against shear forces throughout the range of motion (Lee et al., 2000; Lippit et al., 1993). The contribution of different components of the cuff varies depending upon the position (Blasier et al., 1997; Lee et al., 2000).

The concavity-compression mechanism is active in all glenohumeral positions (Abboud and Soslowsky, 2002; Halder et al., 2001; Lee et al., 2000; Lippit et al., 1993). Only low compressive forces, such as those from resting muscle tone, are required to produce a large resistance to translation (Halder et al., 2001; Makhsous et al., 2004; Schiffern et al., 2002). When the concavity-compression mechanism is activated, a maximal translational force is required to minimally translate the humeral head from its centred position; however, translation beyond this point to complete dislocation requires only low forces (Halder et al., 2001). This suggests that only low forces may be required to produce symptomatic translation of the humeral head when there is dysfunction within the concavity-compression mechanism.

Retraining of the concavity-compression mechanism, in association with the scapular stabilisers, has been proposed as a method of improving shoulder stability (Magarey and Jones, 2003a). The aim of this case is to illustrate the use of these techniques in the management of a patient presenting with multidirectional instability of the shoulder.

CASE DESCRIPTION

Presentation

James, a physically active 19-year-old, presented in December 2003 with a constant ache in his left shoulder. He reported that his shoulder had dislocated and spontaneously reduced while punching at Kung Fu two weeks previously. His shoulder had been uncomfortable since that time, and he had been experiencing clicking and painful catches. He was unable to sleep on his left side or participate in Kung Fu or American Football. James had consulted his general practitioner who had referred for ultrasound investigation and physiotherapy.

James reported a long history of his shoulder "going out" in various positions with minimal force. This occurred multiple times per week and he was unable to recall when it had begun, but it was more than four years ago. He was able to self-reduce, but sometimes had to lift a heavy object to facilitate this. When his shoulder dislocated, James experienced paraesthesia in his dorsal forearm and hand, as well as shoulder pain for the following two to three days.

James had a Western Ontario Shoulder Instability Index (WOSI) score of 53%. The WOSI, developed by Kirkley et al. (1998), has been shown to be reliable and responsive in assessing shoulder instability populations. A higher WOSI score indicates greater instability symptoms.

Physical examination (notable findings)

James had bilateral scapular protraction and downward rotation. He had generalised joint hypermobility, with a Beighton Score [greater than or equal to] 7/9 (knee hyperextension not assessed). Active elevation of his left shoulder was limited to 130[degrees] by pain, and there was inadequate eccentric scapular control. He had full internal and external rotation with end of range pain. James had mild weakness and pain with resisted supraspinatus contraction. This was tested at 60[degrees]abduction in the scapular plane with internal rotation.

The Anterior Apprehension Test (Rowe and Zairns, 1981) produced pain and apprehension at 40[degrees] external rotation. The Relocation Test (Jobe et al., 1989) increased his symptoms; however longitudinal compression of the glenohumeral joint (in the apprehension position) decreased the symptoms and allowed increased external rotation. The Anterior Drawer Test (Gerber and Ganz, 1984) at 80[degrees] abduction was hypermobile and pain free; at 100[degrees] abduction it was hypermobile and produced pain and apprehension. The Posterior Drawer (Gerber and Ganz, 1984) and Sulcus Sign (Neer and Foster, 1980) produced pain and apprehension that prevented mobility assessment.

Hawkins (Hawkins and Kennedy, 1980) and Neer (Neer, 1983) impingement tests were both very painful. O'Brien's Active Compression Test (O'Brien et al., 1998) and the Biceps Load Test (Kim et al., 1999) were both negative for a labral tear.

Investigation

X-ray and ultrasound examinations demonstrated a slightly hooked acromion, but no other abnormality was noted.

CLINICAL REASONING

The differential diagnosis after the subjective examination included glenohumeral instability, a rotator cuff tear/tendinopathy, subacromial impingement, and a glenoid labrum lesion.

A hypothesis of glenohumeral instability was supported by the repeated episodes of the shoulder "going out", the neural symptoms when this occurred, and the requirement of a traction force to facilitate reduction. The variety of positions and activities with which subluxation/dislocation occurred indicated that the instability might be multidirectional. The lack of an initiating traumatic event and James's generalised joint hypermobility indicated that the instability might be due to joint laxity.

Objectively, the reproduction of pain and apprehension with Anterior Apprehension, Anterior Drawer, Posterior Drawer, and Sulcus Sign tests supported the hypothesis of multidirectional instability. McFadyen et al. (2003) recommend that instability symptoms be reproduced in at least two directions before a diagnosis of multidirectional instability is made. Symptomatic instability was reproduced in all three directions in James's case. It was not surprising that his symptoms worsened with the Relocation Test, given that his shoulder was also unstable in a posterior direction.

A rotator cuff lesion was supported by the pain location, the symptoms with active elevation, and the pain and weakness with resisted supraspinatus contraction. However, this hypothesis was negated by the ultrasound scan. The active range of movement achieved also negated a rotator cuff tear. James's inability to sleep on his left side and the positive impingement tests supported an impingement syndrome; however taking into account the other findings (above), this was considered more likely to be secondary to his glenohumeral instability (Magarey and Jones, 1992).

Subjectively, a labral lesion was supported by the pain site and mechanical symptoms of clicking and painful catches. However, this hypothesis was negated by the lack of mechanical signs during movement testing and the negative labral load tests.

James was diagnosed with multidirectional instability of his left shoulder.

During the physical examination, a modification of the Anterior Apprehension Test was used, whereby the test was repeated with the application of glenohumeral compression via the distal humerus. The improvement in range and symptoms with simulation of the concavity-compression mechanism indicated that James might respond to a programme aimed at its retraining.

MANAGEMENT

James received nine treatments over a 29-week period. Management involved education, taping, and neuromuscular retraining of glenohumeral concavity-compression and scapular stability. This programme was progressed as shown in Table 1.

The taping technique used at session two (Figure 1) was designed to retract and upwardly rotate the scapula (Mottram, 1997). The scapular muscle retraining programme was based upon techniques described by Mottram (1997). The initial focus was on retraining scapular setting with appropriate stabilising muscles. Glenohumeral movements and resistance were added as control improved.

[FIGURE 1 OMITTED]

Concavity-compression retraining was initiated with James seated with approximately 40[degrees] glenohumeral abduction and the forearm supported (Figure 2). A gentle longitudinal traction force was applied to the humerus to distract the glenohumeral joint. James was instructed to gently resist this force via subscapularis contraction, while the muscle belly was palpated in the axilla posterior to pectoralis major. This technique for retraining the concavity-compression function of the rotator cuff is similar to the Dynamic Relocation Test developed by Guy David and described by Magarey and Jones (2003b). Subscapularis was chosen due to the ease of isolated palpation (Magarey and Jones, 2003b), and the ability it gives to simultaneously feel for unwanted contraction in pectoralis major, latissimus dorsi, or biceps brachii. Simultaneous contraction of other rotator cuff muscles can also be observed.

[FIGURE 2 OMITTED]

Once James was able to perform a concavity-compression contraction without substitution from movement synergists, the traction facilitation was removed while he performed the same contraction. At this point, James was also taught to self-palpate his subscapularis (as well as undesirable substitution strategies) for use during home practice.

Initially, concavity-compression retraining was progressed by moving the glenohumeral joint into more challenging positions, then by adding active movement while maintaining the contraction (Magarey and Jones, 2003b). Further progressions involved activating the concavity-compression mechanism with: activities of daily living; in conjunction with scapular stabilisers; with resistance; and finally with plyometric activities.

James's WOSI score decreased to 26% at 13 weeks, and 14% at his final appointment (28 weeks after the initial consultation). At telephone follow-up four weeks after his final appointment, James reported that his shoulder had not subluxated/ dislocated, he had been able to increase the resistance when using a Total Gym (Total Gym Fitness, LLC, 1230 American Blvd., West Chester, PA 19380.) at home, and he had competed at the Kung Fu National Championships without any problems. Thirty four weeks after his final appointment James had a WOSI score of 10%. He reported that his shoulder had been "feeling excellent" and had not subluxated/dislocated since his last follow-up. He was competing at Kung Fu and American Football without limitation.

DISCUSSION

The neuromuscular retraining programme described in this case report followed principles previously described by Comerford and Mottram (2001), Magarey and Jones (2003a), Mottram (1997) and O'Sullivan (2000). Isolated control of the local muscle system was developed first. Secondly, muscles were trained to control motion. Finally, this control was integrated into functional activities.

The improvement in the Anterior Apprehension Test that James experienced with longitudinal glenohumeral joint compression indicated that he might respond to a concavity-compression retraining programme. The feeling of improved stability and decreased pain was also useful for patient education, and improving compliance with the neuromuscular retraining programme. Magarey and Jones (2003b) recommend reassessing abnormalities of control found with their Dynamic Rotary Stability Test following facilitation of the concavity-compression mechanism. Enhanced control indicates a good prognosis with a dynamic rehabilitation programme. In this case, when rotation at 90[degrees] abduction was commenced as an exercise, the marked improvement in the anterior apprehension position also indicated a positive response to the retraining programme.

The efficacy of the concavity-compression retraining programme described by Magarey and Jones (2003b) has not yet been investigated (Magarey and Jones, 2003a). In contrast to these techniques, biceps contraction was discouraged in the current case. While contraction of the long head of biceps has been shown to significantly increase the torsional rigidity of the glenohumeral joint (Rodosky et al., 1994), its use to increase stability may be a maladaptive compensatory mechanism. Kim et al. (2001) found that in stable shoulders biceps was electromyographically silent with external rotation performed in different positions of abduction, but active in all test positions in unstable shoulders. Glousman et al. (1988) found increased biceps activity in throwers with unstable shoulders. Repetitive traction of the long head of biceps during activities of daily living or sport may cause superior anteroposterior labral tears or degenerative lesions due to the continuous tensile load (Abboud and Soslowsky, 2002; Andrews et al., 1991; Hunter et al., 1992; Kim et al., 2001).

When motion was added to concavity-compression retraining, the focus was on contraction of the rotator cuff prior to activation of the movement synergists, and maintaining this contraction until after the movement synergists had relaxed. This pattern of pre-activation has been shown to be present during rotation in normal shoulders (David et al., 2000).

The taping technique and scapular muscle retraining aimed to improve glenohumeral stability by upwardly rotating and retracting the scapula, as well as providing a stable base for rotator cuff function. This technique has not been researched in an instability population. Itoi et al. (1992) demonstrated that superior inclination of the scapula prevents inferior displacement of the humeral head. It has also been suggested that glenoid retroversion is important for counteracting anterior displacement of the humeral head (Hess, 2000). Ide et al. (2003) reported improved rehabilitation outcomes for multidirectional instability patients who utilised an orthosis designed to upwardly rotate the scapula during an eight week exercise programme. The tape appeared to effectively maintain James's scapula in an upwardly rotated, retracted position, similar to Itoi's brace. The tape may have had an additional proprioceptive effect as a result of cutaneous stimulation (Cools et al., 2002). While scapular taping techniques have demonstrated limited (Ackermann et al., 2002), or no change (Cools et al., 2002) in scapular muscle EMG activity, it is of interest that James's shoulder did not subluxate/ dislocate while wearing the tape (Figure 1), whereas it had dislocated twice in the previous week.

The 76% improvement in WOSI score between the initiation of treatment and long-term follow-up demonstrated a large improvement in James's shoulder stability (Kirkley et al., 2003). James's subjective reports and unimpeded return to full sporting activities supported the improvement demonstrated by the WOSI outcome measure.

The author was not able to identify any studies evaluating the effects of neuromuscular retraining for glenohumeral instability, or comparing such programmes to traditional rehabilitation programmes. Ginn and Cohen (2005) recently compared a neuromuscular retraining programme to i) cortisone injection and ii) multiple physical modalities in the treatment of shoulder pain. After five weeks, all groups had improved significantly, without significant differences between groups. However, patients with shoulder instability were specifically excluded from that study.

A neuromuscular retraining programme requires a sustained commitment from the patient over a long period of time; however, it may prevent the requirement for surgical intervention. Demonstration of glenohumeral joint compression producing a symptomatic improvement is required before initiation of a concavity-compression retraining programme. This is necessary to indicate a positive response to both the patient and the clinician.

ACKNOWLEDGEMENTS:

At the time of writing the author was working for the University of Otago's Victoria Physiotherapy Clinic, Wellington.

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Ben Darlow, MSportsPhysio (Curtin), BPhty (Otago), MNZCP Centre de physiotherapie et de reeductation fonctionnelle, Clinique Generale-Beaulieu, Geneva, Switzerland

ADDRESS FOR CORRESPONDENCE

Ben Darlow, c/- MFAT (Geneva), Private Bag 18-901, Wellington, New Zealand. Email: bendarlow@gmail.com
Table 1. Exercise progression.

Session Patient reported Glenohumeral stability
 measures of progress interventions

1 WOSI = 53% Education
(16.12.03) CC activation with humerus
 supported at 40[degrees]
 abduction in scapular plane

2 Shoulder quite sore & CC activation at increased
(22.12.03) dislocated a number of ranges of supported abduction
 times

3 Shoulder feeling better CC activation with active
(09.01.04) Did not dislocate while external rotation -- humerus
 taped supported at 40[degrees]
 abduction in scapular plane
 CC activation with ADL

4 Feeling achy due to CC co-activation with LFT/
(23.01.04) having a cold LIFT during active external
 Exercises going well rotation and progressed to
 70[degrees] abduction

5 Shoulder has not CC activation with supine IR-ER
(02.03.04) dislocated for ages at 90[degrees] abduction

6 Shoulder feeling good Reviewed CC activation with
(18.03.04) supine IR-ER at 90[degrees]
 abduction
 WOSI = 26%

7 Subluxated shoulder Reviewed CC activation with
(01.04.04) while performing a one supine IR-ER at 90[degrees]
 armed cartwheel abduction
 Standing resisted ER-IR at
 90[degrees] abduction

8 Shoulder has not Standing resisted and free
(15.04.04) subluxated/dislocated ER-IR in varying positions of
 since last appointment abduction/flexion with varying
 positions of trunk rotation

9 Shoulder feeling good Total Gym exercises
(01.07.04) Able to perform sudden ER-IR at 90[degrees] abduction
 movements against no 150[degrees]-0[degrees]
 resistance (punching/ flexion with SA facilitation
 blocking) without Sitting 0[degrees]-90[degrees]
 problem flexion with LFT/UFT/SA
 Occasional subluxation co-activation
 the day after Diagonal patterns
 exercising at home Overhead large ball throws
 on Total against wall -- bilateral,
 Gym (not as painful as progressing to unilateral
 previously)
 WOSI = 14%

Session Patient reported Scapular stability interventions
 measures of progress

1 WOSI = 53% Education
(16.12.03)

2 Shoulder quite sore & LFT retraining prone
(22.12.03) dislocated a number of LFT/UFT co-contraction sitting
 times Taped scapula in upward rotation

3 Shoulder feeling better LFT/UFT co-contraction with
(09.01.04) Did not dislocate while active flexion to 90[degrees]
 taped -- reset between lifts
 LFT/UFT co-contraction with ADL

4 Feeling achy due to LFT/UFT co-activation with CC
(23.01.04) having a cold Increase flexion repetitions
 Exercises going well without relaxing LFT/UFT
 between lifts
 LFT/UFT co-activation with
 elevation in abduction as
 well as flexion
 SA retraining prone forearm
 support

5 Shoulder has not Reviewed exercises from previous
(02.03.04) dislocated for ages session
 Isometric LIFT contraction with
 30[degrees] abduction in
 sitting -- 10s holds

6 Shoulder feeling good Reviewed LFT/UFT co-activation
(18.03.04) with elevation in abduction as
 well as flexion
 WOSI = 26%

7 Subluxated shoulder SA co-activation with LFT/UFT
(01.04.04) while performing a one during elevation in
 armed cartwheel flexion/abduction

8 Shoulder has not SA contraction with hand against
(15.04.04) subluxated/dislocated wall at static positions
 since last appointment (90[degrees]-160[degrees]).
 To progress to sliding hand
 between 0[degrees] &
 160[degrees]
 LFT/UFT/SA co-activation with
 full range flexion and
 abduction

9 Shoulder feeling good Total Gym exercises
(01.07.04) Able to perform sudden ER-IR at 90[degrees] abduction
 movements against no 150[degrees]-0[degrees]
 resistance (punching/ flexion with SA facilitation
 blocking) without Sitting 0[degrees]-90[degrees]
 problem flexion with LFT/UFT/SA
 Occasional subluxation co-activation
 the day after Diagonal patterns
 exercising at home Overhead large ball throws
 on Total against wall -- bilateral,
 Gym (not as painful as progressing to unilateral
 previously)
 WOSI = 14%

CC = Concavity-Compression; LFT = Lower Fibres of Trapezius;
UFT = Upper Fibres of Trapezius; ADL = Activities of Daily Living;
SA = Serratus Anterior. WOSI = Western Ontario Shoulder Instability
Index
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Publication:New Zealand Journal of Physiotherapy
Geographic Code:8NEWZ
Date:Jul 1, 2006
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