This includes the progression from an initially reparable tear to an irreparable tear, as well as inferior postoperative outcomes of chronic tears compared with acutely fixed tears. When nonoperative treatment is applied to overhead athletes and active patients, the re-dislocation rate is even higher [ 3 , 61 ]. However, with increasing age, the re-dislocation rate in patients treated nonoperatively decreases substantially making nonoperative treatment an option [ 12 ].
Another risk factor for recurrent instability is engaging or off-track Hill—Sachs lesions, as reported in recent literature recommending operative treatment [ 57 , 73 ]. Given his age and the absence of any rotator cuff tear or other concomitant pathology, he was deemed low risk for re-dislocation. Therefore, nonoperative treatment was pursued, which was successful with no recurrent subluxation or dislocation.
Furthermore, the injury pattern should be taken into account. The overall goal of physical therapy is to progress through glenohumeral strengthening and stabilization, thus reducing the probability of recurrent instability. Return to full activity is mostly allowed when there is symmetrical shoulder strength of the scapulothoracic and glenohumeral joints, as well as functional shoulder range of motion [ 12 , 57 ].
Of note, immobilization in external rotation is reported to be very uncomfortable and, therefore, could reduce patient compliance. Overall, careful consideration of the injury mechanism, patient demands, and concomitant injuries associated with anterior shoulder instability are crucial when deciding on nonoperative vs. If treated nonoperatively, immobilization in internal rotation seems to be more comfortable and shows equal outcomes to immobilization in external rotation and thus should be preferred, according to current literature findings. Inflammation of the long head biceps tendon LHBT can lead to damage and weakening of surrounding supporting structures, thereby causing LHBT instability.
Nonoperative treatment of five common shoulder injuries
In turn, instability can place increased stresses on the LHBT, which subsequently increase inflammation. This cycle can predispose the LHBT to rupture. This is also the case for patients suffering from biceps reflection pulley lesions because these lesions do not heal and symptoms worsen over time. NSAIDs can provide short-term benefit for swelling and pain control.
However, there is little evidence that they are efficacious in treating chronic tendon injuries [ 13 ]. Multiple case reports discuss the risk of tendon rupture with steroid injections, and caution should be exercised when injecting steroid around the LHBT [ 2 , 13 ]. Corticosteroid injections alone will likely provide short-term anti-inflammatory effects for most LHBT disorders. Because these injections have the potential to reach the glenohumeral joint, the anesthetic of choice, used in combination with corticosteroid, should be ropivacaine, as it is found to be less chondrotoxic than bupivacaine [ 62 ].
Other evolving nonoperative treatment options for LHBT disorders include prolotherapy dextrose solution, sodium morrhuate , platelet-rich plasma differing concentrations of platelets, white blood cells, red blood cells, and activated and inactivated platelets , and stem cells circulating stem cells, adipose-derived, bone marrow aspirate, bone marrow aspirate concentrate, amniotic membrane-derived. The choice to utilize one of these treatment options varies from patient to patient and condition to condition, and current research is beginning to thoroughly evaluate these interventions and to standardize treatment protocols [ 21 , 23 , 45 , 46 , 49 ].
Indications for these injections include pain impairing athletic performance, connective tissue laxity impairing athletic performance, and pain impairing rest and quality of life [ 49 ]. Future research is needed to determine which LHBT disorders respond best to, and what patient populations are the most suitable candidates for, such procedures. Injury classification is the single most important factor in determining the most appropriate treatment of acromioclavicular AC joint injuries.
In , Rockwood and colleagues developed the classification system that is most widely used for AC joint injuries today [ 79 ]. Type-VI injuries, which are rarely seen, involve rupture of both AC and CC ligaments with inferior displacement of the distal clavicle underneath the acromion; the trapezius and deltoid fascia are disrupted [ 74 , 79 ]. Reasons cited for nonoperative failure included unremitting pain, weakness, instability, and dysfunction in spite of physical therapy.
It is hypothesized that an unstable clavicle causes pain and functional deficits. Typical nonoperative treatment consists of primary immobilization and subsequent active rehabilitation [ 15 ]. However, evidence to support the efficacy of specific rehabilitation protocols is limited [ 15 ]. The number of bone parts and concomitant displacement mainly influences the treatment strategy of proximal humeral fractures. Nonoperative treatment of two-part fractures with early rehabilitation has been found to be at least as efficacious as surgical treatment in injuries with minimal displacement [ 29 ].
However, well-designed comparative studies of operative vs. Lesser tuberosity fractures with internal rotation impingement may also benefit from surgery if nonoperative management fails [ 52 ]. No statistical difference was reported between the groups with regard to Neer score, return to activities of daily living, and union rates [ 17 , 18 ].
The data demonstrate that the Constant score diminishes with advancing age and degree of displacement. However, when calculated based on age-adjusted Constant score, the older patients actually had better scores than the younger patients [ 14 , 17 , 18 , 34 ]. Although surgical treatment of complex fracture patterns is generally advocated, the efficacy of operative vs.
The study concluded that these results must be considered in the context of variable patient demographics.
However, patients must understand the expectations with this treatment approach and comply with the accompanying restrictions. While the literature supports early mobilization, it is important to ensure that further fracture displacement does not occur. In patients suffering from anterior shoulder instability, careful consideration of the injury mechanism, patient demands, and concomitant injuries associated with anterior shoulder instability are crucial when deciding on nonoperative vs. In patients with structural instability of the biceps tendon complex, or in any individual who continues to have symptoms of pain after nonoperative treatment, surgery is favored.
Pogorzelski, E. Fritz, and J. Godin declare that they have no competing interests. This article does not contain any studies with human participants or animals performed by any of the authors. National Center for Biotechnology Information , U. Obere Extremitat. Obere Extrem. Published online Feb Jonas Pogorzelski , M. Fritz , M.
Godin , M. Imhoff , M. Millett , M. Erik M. Jonathan A. Andreas B. Peter J. Author information Article notes Copyright and License information Disclaimer.
Treatment of The Non-operative, Unstable Shoulder - Wright Physical Therapy
Millett, Email: moc. Corresponding author. Received Nov 30; Accepted Jan Open Access. This article is distributed under the terms of the Creative Commons Attribution 4. Abstract Economic pressure highlights the critical need for appropriate diagnosis and treatment of various shoulder pathologies since under-diagnosis and under-treatment can result in increased costs to society in the form of disability and lost production.
Keywords: Rotator cuff tears, Shoulder injuries, Tendinitis, Acromioclavicular joint, Humeral fractures, proximal.
Introduction Shoulder pain is one of the most common musculoskeletal complaints accounting for at least 4. Open in a separate window. Biceps tendinitis Indications for nonoperative treatment of long head biceps tendinitis Inflammation of the long head biceps tendon LHBT can lead to damage and weakening of surrounding supporting structures, thereby causing LHBT instability. Acromioclavicular joint injuries Indications for nonoperative treatment of acromioclavicular joint injury Injury classification is the single most important factor in determining the most appropriate treatment of acromioclavicular AC joint injuries.
Treatment Typical nonoperative treatment consists of primary immobilization and subsequent active rehabilitation [ 15 ]. Proximal humeral fracture Indications for nonoperative treatment of proximal humeral fractures The number of bone parts and concomitant displacement mainly influences the treatment strategy of proximal humeral fractures. Compliance with ethical guidelines Conflict of interest A. References 1.
Allen L. Long head of biceps tendon: anatomy, biomechanics, pathology, diagnosis and management. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. Bone Joint Surg. Biceps tendon and superior labrum injuries: decision making. Instr Course Lect. Satisfaction, function and repair integrity after arthroscopic versus mini-open rotator cuff repair. Bone Joint J. Current concepts in the treatment of acromioclavicular joint dislocations.
ISAKOS upper extremity committee consensus statement on the need for diversification of the Rockwood classification for acromioclavicular joint injuries. Shoulder Elbow Surg. Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis. J Bone Joint Surg Am.
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