Case Review: Post surgical management of 23 year old elite hockey player with a glenohumeral revision managed with Functional Range Release (F.R.)® techniques
Over the past few weeks I have been updating my twitter followers regarding a case of a 23 year old elite hockey player who had undergone a second revision of his glenohumeral joint in order to remedy his significant instability. The patient had first suffered from an anterior G/H dislocation back in 2009 when the decision was made (a correct one at that) to repair his capsule. Following this revision, the patient tore through the capsule yet again earlier in 2012. After careful consideration of the current state of the articulation, the decision was made to repair the now badly degenerating, highly unstable joint using an achilles allograft (cadaveric) procedure to tighten the capsule. This procedure took place April 5, 2012 and included a bankart repair in addition to the capsular shift and allograft.
Following the procedure, physical therapy commenced, and continued for a period of 1 1/2 months before the patient returned home (patient plays hockey for a college in the US) and presented at my clinic.
Side Note: In presenting this case I hope to accomplish a few goals. The first is to demonstrate the importance of selecting treatment modalities that are ACTUALLY based on the assessment findings (i.e. choosing the appropriate tools, and the appropriate time to implement said tools, for the job). While this first goal might seem an obvious one to the reader, it is far too common that the attempted depth and accuracy of the assessment performed is not mirrored in the resultant treatment plan generated by the therapist/doctor. Often the specificity is lost in place of implementing the ‘cookie-cutter’ approach which is most comfortable to the practitioner. The second goal is to outline the differences between the complete myofascial curriculum offered by Functional Anatomy Seminars vs. the other many treatment systems/seminars currently available – if you would rather not hear of our system, then I politely recommend that you skip this particular blog post and resume with next weeks post).
When the patient presented he had, as expected, a greatly reduced range of motion in all directions (as is shown on the case video 2). He also had the instructions, given to him by his surgeon, to have the treating therapist (me) contact him to discuss both the procedure, as well as the rehabilitative expectations. During our conversation the surgeon described the state of the shoulder pre surgery, the procedure itself, and the fact that the capsule had to be seriously tightened thus severely limiting his ROM. He also noted that therapy thus far has not improved his post surgical range, and that he would not expect much in this regards when the patient returns back to school in 2 months when he will have a follow up (especially in external rotation which he believed would be permanently hindered due to to the procedure).
Work with the previous therapist included soft tissue/massage techniques, modalities, mobilizations, and home stretching exercises. VIDEO 2 (0:24-1:25) below demonstrates the state of the articulation upon presentation on May 23, 2012
ASSESSMENT & TREATMENT — Confidence in the first, leads to improvements in the second.
When you assess your patients, do your findings affect your selection of treatment modalities? Does it alter your plan of action? Although many of you reading this post would answer yes, I am always surprised to learn that in many cases, the selection of treatment methods has little to do with assessment finding and more to do with routine. Many spend a long time on performing orthopaedic tests, functional movement screens, motion palpation, etc., only to employ the same tactics during each and every treatment….these often reflecting the techniques most recently learned at a seminar or conference. ”Because I am certified to perform Acupuncture….I will start with Acupuncture,” “Because I recently purchased a laser (and subsequently called my clinic the ‘ABC Laser’ clinic), I will use laser,” etc…
I believe that the treatment approaches can only effectively be altered if the practitioner has confidence in his or her assessment findings. The more detailed the assessment, the more specific the treatment plan that can be subsequently derived. In the Functional Anatomic Palpation Systems (F.A.P.) seminars, we strive to create confidence in the practitioners palpation technique, not only in specificity of structure, but also in the ability to utilize palpation to decipher the histological process afflicting the tissues in question. In VIDEO 1 I describe the reasoning behind my selection NOT to implement soft tissue release techniques at the start of this treatment plan….opting rather to utilize Progressive Angular Isometric Loading (P.A.I.L.s) & Regressive Angular Isometric Loading (R.A.I.L.s) techniques first to correct for the neurologically induced ‘tightness.’ –Note: both PAILs & RAILs rehab methods are taught as part of the Functional Range Release (F.R.)® system. These methods were utilized for the first 3 weeks (see video 2) of the treatment program in order to rapidly increase, and simultaneously expand the functional ranges of motion. We tackled GH flexion and extension first (Figure 1), and then began to work abduction, followed by internal rotation, and then external rotation (Figure 2 & 3).
NOTE: Although the surgeon was hesitant when I explained that I would be rehabilitating the patient INTO abduction and external rotation, with the explanation that I would be utilizing progressive loading techniques (PAILs & RAILs) which would simultaneously build strength and endurance whilst the ROM was increasing, he quickly changed his mind (as well as his future approach to prescribing rehab as per his claim).
As you can seen in VIDEO 2 below, rapid improvements were made in the patients ACTIVE ROM (Passive ROM improvements are of little benefit IMO). After the second week of PAILs & RAILs both in office, as well as with at home exercises, I began to prescribe ECCENTRIC NEURAL GROOVING (ENG) exercises for each GH motion — to examples are found on Video 2 (2:19-2:56). ENG training is part of both the Functional Range Release ® as well as the Functional Range Conditioning (FRC)systems. Using this method we are taking the newly acquired active ranges of motion and teaching the CNS & PNS how to control motions in these ranges whilst progressively loading soft tissue structures forcing beneficial progressive tissue adaptations to occur (e.g. increased protein synthesis).
After the 3rd week, I began to palpate the tissues for ‘mechanical tension’ (i.e. tension created by fibrosis/scarring/adhesion). When blocked motions were palpated, F.R. ® release procedures were utilized to break down fascial fibrosis while promoting relative motion between the fascial planes. When motion was restored, further PAILs/RAILs, followed by ENG exercises were utilized as needed…each time solidifying control in the ranges of motion acquired.
VIDEO 2: 4 week case review
As can be seen after the 4 week mark, there are still some mild restrictions in movement that should be expected following a GH capsular shift procedure. The patient has been instructed to resume his training and conditioning, as well as his hockey skills training in a slowly progressing manner. He has also been left with PAILs & RAILs techniques to practice on an ongoing basis both to maintaing his active ROM’s as well as to achieve slow improvements moving forward.
The above case demonstrates the importance of specifically defining your assessment findings in terms of the actual histological/pathological process occurring. By doing this, the selection of the treatment methods/plan can be better suited to the situation and thus will provide more efficient and effective results. The reason that no improvements in motion were achieved in the first 1.5 months in the above case was simply due to the fact that the treatment method selected did not appropriately match the process that was occurring (review video 1). At the 3 week mark, after the neural drive problems were removed, we were then able to properly palpate/assess the tissue for mechanical adhesion and reduced fascial motion. The FR release procedures that were then implemented were able to correct these problems very efficiently.
TAKE HOME POINT: Your treatments success depends on your confidence in assessment