Case 1

A 30-year-old Mixed Martial Arts (MMA) athlete presented one day following a traumatic, LEFT
anterior shoulder dislocation. Prior to injury, the athlete was participating in Jiu Jitsu training with his
training partner. The opponent forcefully pulled the patient’s left arm into a position of horizontal
adduction causing dislocation. The patient described utilizing a self reduction technique to relocate
the articulation. The patient had no prior shoulder injuries and this was his first episode of
dislocation. The patient indicated that post-reduction he had immediately begun a program of
cryotherapy (10/10/10 protocol several times per day) and was currently taking Ibuprofen. On
examination the patient’s left glenohumeral joint range of motion was globally restricted by
approximately 20 degrees (external rotation was not attempted) and painful.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2796945/
http://www.vmh.org/sites/default/files/ANTERIORSHOULDERDISLOCATIONPROTOCOL.pdf
*KIV:
 Bankart lesion 80-97%
 Hill sachs lesion 80%
 Axillary n. dmg 5-35%
 Brachial plexus, radial n. dmg.
o Check radial pulse to assess for vascular injury.
o Check sensation in the regimental badge area on the lateral
aspect of the shoulder over the deltoid muscle. This tests for
axillary nerve damage. Contraction of the deltoid during
attempted abduction can also be palpated.
o Assess radial nerve function: test for thumb, wrist and elbow
weakness on extension as well as reduced sensation on the
dorsum of the hand.
 Rotator cuff injury.

Demographic data:
Name: Mr Anthony
Age: 30 y/o
Gender: Male
Occupation: Mixed Martial Arts (MMA) athlete
Dominant hand: Right
Dr’s Dx: Anterior shoulder dislocation.
Dr ‘s Mx:
 Conservative mx:
o Painkillers (Ibuprofen 400mg)
o Immobilization of shoulder in sling in 10 degrees of external rotation and mid-
pronation.
o Refer to PT.
Date of Ax: 31st March 2020
C/O:
 Pt. c/o of persistent pain in L. shoulder.

Subjective assessment:
Present Hx:
Pt. dislocated his left shoulder anteriorly 3 days ago on 28th March 2020 when he was participating
in Jiu Jitsu training. He mentioned that his opponent forcefully pulled his left arm into a position of
horizontal adduction, which caused the dislocation. Pt. had described using a self-reduction
technique to relocate the articulation. Post-reduction, pt. indicated that he had immediately begun a
program of cryotherapy with 10/10/10 protocol several times per day. Due to persistent pain, pt.
had visited a doctor on 30th March 2020. He had MR arthrography of his left shoulder but the
radiographs were unremarkable. Afterwards, the Dr. prescribed the use of a sling and Ibuprofen.
Past Hx:
 Nil.
Medical Hx:
 Ibuprofen for pain relief.
Surgical Hx: Nil
Investigation:
 MR arthrography ( 30th March 2020):
o Axial and sagittal view of left shoulder.
o NAD.
Family Hx:
 Nil.
Personal Hx:
 Smoking: Nil
 Alcohol: Occasionally.
 Lifestyle: Active.
 Mixed martial arts training 3 days per week.
Socioeconomic Hx:
 Married, with 1 child.
 Financially stable. Pt. and his wife are working. Wife is working as an accountant.
Environmental Hx:
 High cabinets in kitchen.
 High hanging rail in wardrobe.
Pain Hx:
 Site: around left shoulder.
 Onset: Sudden.
 Characteristics: Aching pain.
 Radiating: Nil.
 Associated symptoms: Nil.
 Time: No specific timing. Pain is persistent throughout day and night.
 Exacerbating factors: Movement of L. shoulder, side lying on L. side.
 Relieving factors: Cryotherapy, ibuprofen.
 Severity:
o On movement: 6/10
o At rest: 4/10
Objective assessment:
General observation:
 Body type: mesomorph.
 Deformities: Nil.
 Shoulder immobilized in external rotation and mid-pronation with sling.
Local observation:
 Redness: Nil
 Swelling: mild swelling around left shoulder.
 Bruising: Nil
 Scar: Nil.
Palpation:
 Tenderness: Grade 2 over left shoulder.
 Mm spasm: Present over rotator cuff muscles, biceps, deltoid.
 Skin temperature: mild warmth over left shoulder.
 Edema: Nil.
 Crepitus: Present at anterior aspect of L. shoulder.
Postural assessment:
 Anterior view:
o Left shoulder appears lower than right shoulder.
 Lateral view:
o Rounded shoulders.
 Posterior view:
o Left shoulder appears lower than right shoulder.
Gait assessment:
 Reduced left arm swing.
ROM:
Joints Action AROM(°) PROM(°) End feel
Neck Flexion FROM - Firm
Extension FROM - Firm
Lateral flexion FROM - Firm
Rotation FROM - Firm

Joints Action AROM(°) PROM(°) End feel

Shoulder Left Right Left Right Left Right
Flexion 0-160 FROM 0-160 Empty Firm
Extension 0-40 FROM 0-42 - Empty Firm
Abduction 0-157 FROM 0-160 - Empty Firm
Internal 0-51 FROM 0-53 - Empty Firm
rotation
External kiv FROM kiv - kiv Firm
rotation
Elbow Flexion FROM FROM - - Soft Soft
Extension FROM FROM - - Hard Hard
Supinatio FROM FROM - - Firm Firm
 n
Pronation FROM FROM - - Hard Hard

 Interpretation:
o Pt. has normal ROM in elbows, and right shoulder.
o Pt. has reduced ROM for left shoulder.
o Left shoulder external rotation ROM was not measured d/t combined external
rotation and abduction being a contraindication.
MMT:
Location Muscles Grade (MRC
Grading)
Neck Flexors 5/5
Extensors 5/5
Lateral flexors 5/5
Rotators 5/5

Location Muscles Grade (MRC Grading)

Shoulder Left Right
Flexors 3-/5 5/5
Extensors 3-/5 5/5
Abductors 3-/5 5/5
Internal 3-/5 5/5
rotators
External kiv 5/5
rotators
Elbow Flexors 5/5 5/5
Extensors 5/5 5/5
Supinator 5/5 5/5
Pronator 5/5 5/5

 Interpretation:
o Pt. has good muscle strength in neck, elbows, and right shoulder.
o Pt. has reduced mm. strength for left shoulder which is generally 3-/5.
o Mm. strength for left shoulder external rotation was not tested d/t combined
external rotation and abduction being a contraindication.

Special tests:
 Apprehension test: +ve.
 Jobes relocation test: +ve.
Interpretation: Pt. has anterior glenohumeral instability.

ICF:
 Structural impairment:
o Pain at left shoulder.
 o Limited left shoulder ROM.
o Reduced left shoulder strength.
 Activity limitation:
o Unable to perform overhead activities.
o Unable to dress self without difficulties.
o Unable to carry heavy weights.
o Unable to drive.
 Participation Restriction:
o Unable to participate in mixed martial arts training and competitions.
 Personal factors:
o Age (+)
o Motivation (+)
o Athlete: competitive background (-)
 Environmental factors:
o Emotional support (+)
o Financial support (+)
o High cabinets in kitchen (-).
o High hanging rail in wardrobe (-).
Analysis
PT impression:
 Pain around left shoulder d/t muscle spasm.
 Mild swelling and warmth around left shoulder and shiny skin d/t inflammation.
 Reduced ROM for left shoulder d/t pain and mm. spasm.
 Reduced mm. strength for left shoulder d/t mm. weakness.
 Abnormal posture and gait d/t left shoulder pain.
 Crepitus at anterior left shoulder and +ve findings for special tests d/t anterior glenohumeral
instability.

Goals:
 STG (< 2 months):
o Reduce pain and inflammation from VAS 6/10 to 3/10 on activity and 4/10 to 1/10
on rest within 1/52.
o Immobilization of left shoulder in sling for 3/52.
o Regain FROM left shoulder within 6/52.
o Improve scapular stability within 6/52.
o Improve posture within 6/52.
o Maintain mm. strength of unaffected UE.
o Maintain mm. strength of left elbow, wrist, and hand.
o Maintain aerobic endurance.
 LTG:
o Regain full mm. strength of left shoulder within 8/52.
o Improve left shoulder proprioception within 8/52.
o Perform ADL independently without pain and difficulties in 9/52.
o Return to mixed martial arts training in 9/52.
o Prevent recurrence of shoulder dislocation.
Plan of Tx:
 Pain management.
 Isometric exercises for left shoulder.
 Scapular exercises.
 Strengthening exercise for unaffected UE.
 Strengthening exercises for elbow, wrist, and hand of affected UE.
 Aerobic exercise.
 Pt. education
 HEP
Intervention:
1. Reduce pain:
a. IFC
i. P: high sitting on chair with back and arms supported.
ii. Placement of electrodes: quadripole placement around left shoulder.
iii. Intensity: As tolerated by pt.
iv. Frequency: 120 Hz
v. Frequency modulation: 10Hz.
vi. Sweep modulation: 6/6s.
vii. Duration: 10mins.
 2. Isometric exercises for left shoulder:
a. P: high sitting on chair with back supported.
b. I: Pt. instructed to perform isometric shoulder movements in all planes while
maintaining shoulder in neutral position against torso. Pt. instructed to hold
contractions for 10s.
c. R: 10 reps, 3 sets.
3. Scapular exercises:
a. P: high sitting on chair with back supported.
b. I: Pt. instructed to elevate, depress, and retract shoulders and to hold contraction
for 10s.
c. R: 10 reps, 3 sets.
4. Strengthening exercise for unaffected UE:
a. P: standing
b. E: 3kg dumbbell
c. I: Pt. instructed to perform shoulder and elbow movements in all planes up to FROM
with dumbbell.
d. R: 10 reps, 3 sets.
5. Strengthening exercises for elbow, wrist, and hand of affected UE:
a. Elbow and wrist exercise
i. P: high sitting on chair with back supported.
ii. E: 1kg dumbbell.
iii. I: Pt. instructed to flex and extend elbow and wrist slowly up to FROM.
iv. R: 10 reps, 3 sets.
b. Hand exercise:
i. P: high sitting on chair with back supported.
ii. E: putty.
iii. I: Pt. instructed to perform finger grip, pinch, spread, abd, add, and
extension with putty.
iv. R: 10 reps, 3 sets.
6. Maintain aerobic endurance:
a. Foot pedal cycling:
i. P: high sitting on chair with back and arms supported.
ii. I: Pt. cycle at moderate intensity for 30 mins.
iii. R: Once per day.
7. Pt. education:
a. Advise pt. to keep the sling on at all times except during shower and performing
exercises.
b. Advise pt. to sleep on unaffected side with a pillow placed below affected arm for
support.
c. Advise pt. to avoid combined movements of ext rotation & abd.
d. Advise pt. to avoid lifting weights with affected arm.
e. Advise pt. to avoid sports involving shoulder movements.
f. Advise pt. to continue with cryotherapy at home for 5 days.
8. HEP:
a. Pt. instructed to perform the exercises taught at home according to frequency and
repetitions given.
Evaluation:
1. Pain around shoulder reduced from 6/10 to 4/10 after IFT.
2. Tenderness reduced to Grade 1.
 3. Pt. is cooperative throughout session and is able to complete the exercises taught with
minimal fatigue.
Review:
 Pain severity
 ROM
 MMT
 Posture