Risk factors contributing to shoulder dislocations.

Shoulder dislocations are a common injury, especially among young athletes (Ahmed, 2019). It is stated to be the most frequently dislocated joint large joint in the human body (Mackenzie, 2013). Many consider this to be due to the anatomical structure, suggesting that the difference between the small glenoid cavity and the large humeral head makes this joint extremely susceptible to dislocation (Gaballah, Zeyada, Elgeidi, & Bressel, 2017). Shoulder dislocations can occur anteriorly, posteriorly and inferiorly, however anterior shoulder dislocations are by far the most common (Jones et al, 2019; Ahmed, 2019; Gaballah et al 2017). Inferior glenohumeral dislocations only account for approximately 0.5% of all shoulder dislocations (Plaga, Looby, Feldhaus, Kreutzmann & Babb, 2010). Posterior glenohumeral dislocations account for approximately 3% of all shoulder dislocations (Mackenzie, 2013). Whereas anterior glenohumeral dislocations account for approximately 95% of all shoulder dislocations (Olds, Ellis, Donaldson, Parmer & Kersten, 2015).

Primarily, one of the biggest risk factors for anterior, posterior and inferior shoulder dislocations is previous shoulder dislocations. Previous shoulder dislocations cause microtrauma to the structures within the glenohumeral joint. This can lead to a tear or erosion in the glenoid labrum during the force of the movement of the humeral head. This weakens the glenoid labrum and therefore weakens its attachment to the humeral head (Olds et al, 2015; Mackenzie, 2013; Plaga et al 2010; Eshoj et al 2020; Gallabah et al 2017).

Anterior (1), inferior (2) and posterior (3) dislocations.

 

Previous shoulder dislocations can also lead to muscle weakness and ligament laxity. Muscle weakness can occur due to a lack of exercise, and as recovering from a shoulder dislocation requires a significant period of rest, this can be expected following a shoulder dislocation. Yes, you would also be performing rehabilitation exercises. However, ultimately, to get your muscles back to significant strength, this can take a long time. Especially, when you are at extreme risk of re-dislocating your shoulder whilst your muscles are still weak, causing another long rest period, and in turn, even weaker muscles. Ligament laxity can occur following a shoulder dislocation due to overstretching during the forceful movement of the humeral head anteriorly, posteriorly or inferiorly (Olds et al, 2015; Mackenzie, 2013; Plaga et al 2010; Eshoj et al 2020; Gallabah et al 2017). Muscles and ligaments of the glenohumeral joint play a huge role in the support and function of the shoulder. This includes: deltoids, pectoralis major and minor, biceps brachii, triceps brachii, coracobrachialis, latissimus dorsi, teres major and minor, supraspinatus, infraspinatus, and subscapularis, the capsular ligament and the glenohumeral ligaments (Biel, 2014). When these structures are weak or lax, it is harder for humeral head to sit in the joint, especially when subject to trauma (Olds et al, 2015; Mackenzie, 2013; Plaga et al 2010; Eshoj et al 2020; Gallabah et al 2017). This is especially supported for anterior shoulder dislocations as Eshoj et al (2020) and Gaballah et al (2017) both state the high risk of recurrent shoulder dislocations following their primary dislocation.

One of the greatest risk factors for inferior, posterior and anterior shoulder dislocations is collision sports. For instance, rugby and American football as well as combat sports, such as boxing, judo and karate (Jones et al 2019; Ahmed 2019). For anterior shoulder dislocations, collision or positions in these sports can force the humeral head to separate from the glenohumeral joint, rupturing its attachment to the glenoid fossa. Often this will occur when the collision or position forces too much extension, abduction or external rotation of the shoulder beyond its physiological limits (Olds et al, 2015; Ahmed 2019). For posterior shoulder dislocations, collision or positioning in these sports can force the humeral head to dislocate towards the back of the body. Often this will occur when the collision or position forces too much internal rotation with adduction beyond its physiological limits (Mackenzie, 2013; Ahmed 2019). For inferior shoulder dislocations, collision or positioning in these sports cause the humeral head against the acromion. Often this will occur when the collision or position forces too much abduction beyond its physiological limit (Plaga et al 2010; Ahmed 2019).

Racket based sports are a risk factor for anterior and posterior shoulder dislocations. For instance, badminton, squash and tennis (Jones et al 2019; Ahmed 2019). Racket based sports can result in your shoulder over stretching in a variety of movements beyond its physiological limits, particularly external rotation (creating a risk for anterior shoulder dislocations) as well as internal rotation with adduction (creating a risk for posterior shoulder dislocations) (Olds et al 2015; Mackenzie 2013; Ahmed 2019).

Board based sports such as surfing and snowboarding, equestrian sports such as jumping and polo, and extreme sports such as rock climbing and skydiving are all risk factors for anterior, posterior and inferior shoulder dislocations (Jones et al 2019; Ahmed 2019). For instance, falling off of these boards into a position of shoulder extension, abduction or external rotation beyond its physiological limits creates a risk of anterior shoulder dislocations (Olds et al 2015; Ahmed 2019). Falling off in a position of shoulder internal rotation and adduction beyond its physiological limits creates risk of posterior shoulder dislocations (Mackenzie 2013; Ahmed 2019). Or, falling off in a position of shoulder abduction beyond its physiological limits creates a risk of inferior shoulder dislocations (Plaga et al 2010; Ahmed 2019).

Another risk factor for anterior and posterior shoulder dislocations is seizures and electric shocks (Olds et al, 2015; Mackenzie, 2013). During this, tiny muscle contractions can cause the humeral head to pull away from the glenohumeral joint, whether its anteriorly or posteriorly. Anterior shoulder dislocations are more likely to occur than posterior shoulder dislocations during a seizure or electric shock. However, without significant trauma, it is unlikely that a posterior shoulder dislocation will occur (Olds et al, 2015; Mackenzie, 2013).

Age and sex has been depicted by Olds et al (2015) to be a risk factor for anterior shoulder dislocations. This research suggests that people between the ages of 15-40 are at a higher risk of shoulder dislocations than those who are 40 and above, and that men are at a higher risk than women of shoulder dislocations.

Ultimately, research suggests that there are a multitude of different risk factors that can contribute to anterior, posterior and inferior shoulder dislocations. Previous shoulder dislocations, collision sports, combat sports, racket sports, board based sports, seizures, electric shocks, age and sex are all significant factors to be considered when determining risk factors for shoulder dislocations.

 

 

References

Gaballah, A., Zeyada, M., Elgeidi, A., & Bressel, E. (2017). Six-week physical rehabilitation protocol for anterior shoulder dislocation in athletes. Journal of Exercise Rehabilitation, 13(3), 353-358.

Ahmed, H. (2019). A Rehabilitation Protocol For Athletes Diagnosed With Shoulder Dislocation. Physical Education, Sport and Kinetotherapy Journal, 56 (2), 32-37.

Jones, G., Wilson, E., Hardy, M., Summers, D., Edwards, J., & Munro, M. (2019). BMA Guide to Sport Injuries: The Essential Step-by-Step Guide to Prevention, Diagnosis and Treatment. London: Dorling Kindersley Limited.

Plaga, B., Looby, P., Fledhaus, S., Kreutzmann, K & Babb, A. (2010). Axillary Artery Injury Secondary to Inferior Shoulder Dislocation. The Journal of Emergency Medicine, (39) 5, 599-601.

Olds, M., Ellis, R., Donaldson, K., Parmar, P & Kersten, P. (2015). Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis. Br J Sports Med, (49), 913-923.

Mackenzie, D. (2013). Point-of-care Ultrasound Facilitates Diagnosing a Posterior Shoulder Dislocation. The Journal of Emergency Medicine, (44) 5, 976-978.

Biel, A. (2014). Trail Guide to the Body: a hands on guide to locating muscles, bones and more. USA: Books of Discovery.

Eshoj, H., Rasmussen, S., Frich, L., Hvass, I., Christensen, R., & Boyle, E. et al. (2020). Neuromuscular Exercises Improve Shoulder Function More Than Standard Care Exercises in Patients With a Traumatic Anterior Shoulder Dislocation: A Randomized Controlled Trial. Orthopaedic Journal Of Sports Medicine8(1), 1-12.

11/03/2020 2 hours

This session took place in the Sports Therapy and Rehabilitation clinic.

In this session, I gave one player a lower back massage and a soft tissue release on their glutes to help decrease their pain whilst they continue to strengthen their glute maximus and glute medius. It is a real confidence boost to see some big improvements in this player. In the next session, I gave another player mobilisations on their spine for their ongoing back pain whilst under supervision by the clinic supervisor. This time, the supervisor didn’t have to show me what to do first, I felt confident going ahead straight away. This time, I was still using my thumbs instead of the side of my hands, but the clinic supervisor said that this will come with time.

11/03/2020 2.5 hours

This session took place court side to the Plymouth Raiders practise session. The final hour took place at their strength and conditioning session.

To begin, I conducted the warm-up. Following this, one player explained that their hamstrings still felt tight, so, pitch side, I stretched them before the player went onto the court. At the end of practise, one player asked me to get them some ice for their knees, and said he was going to discuss his problems with the head sports therapist. In the final hour in strength and conditioning, I helped deliver the session through demonstrating exercises and giving coaching tips. As well as this, I also observed the assessment the head sports therapist carried out with the player who had knee pain. I always find it useful to watch the head sports therapist conduct assessments and treatments, as he always offered the newest way of doing things/the newest information due to the fact he always stays on top of the literature.

10/03/2020 1 hour

This session took place in the Sports Therapy and Rehabilitation clinic.

In this session, I was treating the player who I had recently given glute rehabilitation to alleviate some pain he is experiencing in his back (that is occurring due to him using his back instead of his glutes, because his glutes are in pain). So, I gave the player a soft tissue massage to his lower back. Following this, I did soft tissue release on his glutes to again, relieve some pain. As I have been working with this client quite consistently, we have built up quite a rapport and I feel very comfortable working with him. This player is very interested in why certain pain has occurred, as he keeps getting referred pain, he is very confused. So, during this session I was able to explain to him what exactly was happening, explaining what referred pain is referencing the kinetic chain. This seemed to calm his anxiety about his injuries. This session taught me that especially in non-linear injuries, like this one, it is best to keep the client knowledgeable of what is going on their body, rather than just giving them their rehabilitation and giving them treatment. If you don’t give the players the knowledge, this could cause the player to loose confident in your abilities as a therapist, as you keep changing where and how you treat the player.

10/03/2020 1 hour

This session took place in the Sports Therapy and Rehabilitation clinic.

Within this session I was treating one of the Raider’s for their tight neck muscles. So, I performed a soft tissue massage to their upper fibres of trapezius. Following this, I performed soft tissue release again, on their upper fibres of trapezius. I ensured I got all angles of this through slighting moving the head forward/backward when in side flexion. Following this session, I got some very positive feedback from the player, who said that I was the best student the head therapist had taken on. This made me feel very confident, as I feel as though this could increase my chance of getting a placement with the Raiders next year.

10/03/2020 2.5 hours

This session took place court side to the Plymouth Raiders practise session. In the last hour, this took place at their strength and conditioning session.

To begin, I conducted the warm-up whilst being observed by the head sports therapist. He explained that following my formative assessment feedback I had become more assertive which was a predominant aim of mine. Following this, a player came in late to practise, so I observed the head sports therapist deliver a quick but effective warm up to this player. I found this extremely useful and will be using this whenever a player comes in late. Following their mini warm up, the player was complaining of tightness in their hip flexor, so I observed the head sports therapist release this. To begin, he did some eccentric lengthening of the players hip flexor using a muscular energy technique. After this, he made it more dynamic, making the player do slow and controlled banded ‘a skips’. Following this, he made the player do explosive ‘a skips’. I found this extremely useful as there is a player in the Marjon basketball team who has trouble with their hip flexor, so before practises/games I can go through this process with him. During practise, the head therapist went through the difference between strength and hypertrophy training to help me with my new module, and to aid my knowledge when writing rehabilitation plans. Following this in the strength and conditioning session, it was only the head sports therapist and I running this. Due to this, I was able to get more involved in running the session. I demonstrated some of the exercises, as well as giving coaching tips throughout, encouraging progressions and regressions depending on the player. At the end of the strength and conditioning session, one player came forth complaining of neck pain. The head therapist allowed me to asses this player under his supervision, to which I came to the conclusion that the issue was tight muscles. So, the head therapist invited me to treat this player in the clinic following this session, whilst under supervision by himself.

09/03/2020 1 hour

This session took place in the Sports Therapy and Rehabilitation clinic.

Within this session, I gave a player a rehabilitation programme I had written (that had been verified by the head sports therapist). Considering this was the second time giving someone rehabilitation, this time round I felt a lot more confident delivering the exercises. I feel as though the delivery ran a lot smoother and I was more articulate in my description. Considering the player had trouble remembering the exercises last time, this time, upon delivery, we came up with new names for every exercise so the player would remember them.

06/03/2020 1 hour

This session took place in the Sports Therapy and Rehabilitation Clinic.

Within this session, I assessed the player who came to me at practise complaining of glute/back pain. To begin, I did a neurological assessment, which this time round I feel a lot more confident doing since we have now begun the spinal module. The player wasn’t experiencing any neurological symptoms, however upon assessment it was decided that the issue was muscular. It seemed that the player had an overactive piriformis and had a weak glute maximus and glute medius. I took this information to the head sports therapist to ask if it was ok for me to write a rehabilitation plan for this player (but would get this reviewed before giving this to the player).

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