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Total Shoulder
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Total Shoulder - October 6, 2006 9:50:00 AM
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ehanso
Posts: 355
Joined: September 14, 2004
From: Minnesota
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Right handed 70 yo male 10 months post R TSA. Previously had multiple dislocations of the shoulder and a distal biceps tendon tear. Prior to surgery had limited flexion, abduction, and Ext Rot. Today AROM flexion 75*, Abd 60*, Ext Rot 25*, Int Rot 45*. Strength 4-/5 in all motions. Has an audible and palpable snapping at 60* flexion and 35* abd. Pain is localized at the biciptial groove. There is laxity in the inferior capsule. Pt states it feels like the shoulder want to dislocate at the end range of flexion and abduction.
Any thoughts on treatment, prognosis, precautions. Thanks.
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Re: Total Shoulder - October 7, 2006 12:55:00 AM
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pt4pt
Posts: 13
Joined: September 22, 2006
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it would be really a fantastic case..
as i do not know what type of treatment had he taken.. but i i`m working with post op ortho case i would put him in hydrotherapy and let him do AROM for at least 30 min. 3 tims/week plus AROM in Gym (gently) and try to strech the tight pectoralis as it decreases the abd Range
i hope i helped u
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Re: Total Shoulder - October 7, 2006 2:36:00 AM
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SJBird55
Posts: 2439
Joined: May 10, 2004
From: Michigan
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Technically is the strength 3-/5 because he is unable to elevate his extremity through the full amount of normal motion? I'm assuming the 4-/5 is within available range of motion.
Is his current presentation different than it was 3 months ago? Prior to his shoulder arthroplasty, was there also a concurrent rotator cuff tear? If there was a concurrent rotator cuff tear, from what I have seen, mobility doesn't improve. If his rotator cuff was intact at the time, what has happened to change his presentation to his current state? Anything - did he fall, catch himself from falling, lift something heavy? When he does elevate his shoulder does he basically do a shoulder shrug with the movement, so it looks goofy?
With the original procedure, was the capsule addressed?
What was the mode the patient began therapy? Direct access or referral? If referral who referred - primary care physician or surgeon?
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Re: Total Shoulder - October 7, 2006 4:31:00 AM
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rv36116
Posts: 216
Joined: August 5, 2006
From: Texas
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My one question would be how is his internal rotation? Can he get back to get his wallet out of his pocket?
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Re: Total Shoulder - October 7, 2006 3:22:00 PM
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ehanso
Posts: 355
Joined: September 14, 2004
From: Minnesota
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pt4pt, I wish I had access to a therapeutic pool for him.
SJ, I treated him post op and he did not get functional range or strength at that time. His motion is slightly worse than at the time of discharge from his initial post op treatment. I am uncertain if he had a cuff tear prior to surgery. He has not fallen but spent most of the summer fishing (this did not require much ROM). He does elevate the scapula at end range. Yes 4-/5 is through available motion. He was referred by the surgeon. He did state that toward the end of his initial rehab he felt like his shoulder would slip almost like it wanted to dislocate while stretching the shoulder into flexion. I am not sure if the capsule was addressed in the initial procedure. BTW what is your experience with thermal shrinkage of the capsule?
Rob his IR is restricted as noted above. He cannot get to his wallet. (his wife likes that lol)
Thanks for the input. Keep it coming.
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Re: Total Shoulder - October 8, 2006 3:52:00 PM
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SJBird55
Posts: 2439
Joined: May 10, 2004
From: Michigan
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I haven't treated anyone in the geriatric population that has underwent thermal shrinkage of the capsule. A few high schoolers and college aged males are the population I have treated. They seemed to do well with the procedure. They returned to sport without any difficulties. Prior to surgery their biggest complaint was the simple fact that with certain activities the shoulder was so unstable that the head of their humerus felt like it was in their armpit or slopping in and out of joint.
If you can think back... did you feel like the shoulder felt unusual when you were stretching it into flexion?
What's his passive range of motion in supine like?
I've never observed a total shoulder arthroplasty, so I'm not sure of the procedure. In my opinion, there are 3 potential aspects to consider: the integrity of the capsule, the integrity of the rotator cuff and the components and the center of rotation and the whole biomechanical process.
I'd recommend further diagnostic testing to assess the integrity of the rotator cuff, I'm not sure what would be recommended that could assess both the rotator cuff and the capsule. If he has a rotator cuff deficiency, I highly doubt that physical therapy will provide the desired outcomes. If he does have a deficient rotator cuff, a reverse prosthesis will resolve his functional problems. Fluoroscopies are also fun to watch... probably not what most surgeons would order, but it is enlightening to see how the bones are moving with the attempt at movement...
By this point in time, he should be doing much better than he is. He could get a second opinion.
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Re: Total Shoulder - October 20, 2006 2:34:00 AM
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SJBird55
Posts: 2439
Joined: May 10, 2004
From: Michigan
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Recent article that mentions stability of TSA:
Glenohumeral kinematics following total shoulder arthroplasty: A finite element investigation.
J Orthop Res. 2006 Oct 17;
Authors: Hopkins AR, Hansen UN, Amis AA, Taylor M, Emery RJ
The osseous geometry of the glenohumeral joint is naturally nonconforming and minimally constrained, and the joint's stability is maintained by action of the rotator cuff muscles. Damage to these muscles is often associated with joint degeneration, and a variety of glenoid prostheses have been developed to impart varying degrees of stability postoperatively. The issues of conformity and constraint within the artificial shoulder have been addressed through in vivo and in vitro studies, although few computational models have been presented. The current investigation presents the results of three-dimensional finite element analyses of the total shoulder joint and the effects of design parameters upon glenohumeral interaction. Conformity was shown not to influence the loads required to destabilize the joint, although it was the principal factor determining the magnitude of humeral head translation. Constraint was found to correlate linearly with the forces required to dislocate the humeral head, with higher constraint leading to slightly greater humeral migration at the point of joint instability. The model predicts that patients with a dysfunctional supraspinatus would experience frequent eccentric loading of the glenoid, especially in the superior direction, which would likely lead to increased fixation stresses, and hence, a greater chance of loosening. For candidates with an intact rotator cuff, the models developed in this study predict that angular constraints of at least 14 degrees and 6.5 degrees in the superoinferior and anteroposterior axes are required to provide stable unloaded abduction of the humerus, with larger constraints of 18 degrees and 10 degrees necessitated by a dysfunctional supraspinatus. The tools developed during this study can be used to determine the capacity for different implant designs to provide resistance to excessive glenohumeral translations and reduce the potential for instability of the joint, allowing surgeons to optimize postoperative functional gains on a patient by patient basis. (c) 2006 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
PMID: 17048256 [PubMed - as supplied by publisher]
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