SHOULDER INJURY IN A PROFESSIONAL FIGURE SKATER

1. SHOULDER INJURY IN A PROFESSIONAL FIGURE SKATER Jennifer Flug, PT, DPT Orthopedic Resident University of Delaware

2. Patient 31 year-old male figure skater from Spain Injured while performing a lift in a professional skating show Show’s Performance Director present for evaluation

3. WHAT ELSE DO YOU WANT TO KNOW FOR YOUR SUBJECTIVE REPORT AND WHY?

4. SUBJECTIVE • Mechanism of Injury • Pairs figure skater • Skater was lifting his partner overhead • While turning the corner her body shifted backwards • Had to keep her head from hitting the ice- shoulder subluxed • Occurred during a live performance • No medical staff on site • Shoulder subluxed two times during performance • Patient self-reduced his shoulder both times • Incident occurred 1 week ago • Has not skated/performed since incident

5. SUBJECTIVE • Skates for Disney On Ice • Principle pairs skater • Travels internationally • Referred for: • Posterior shoulder instability • Muscle weakness

6. SUBJECTIVE • No prior history of shoulder problems • Right hand dominant • Current pain • 0/10 • Medications • none • Imaging • x-rays and MRI unremarkable

7. KNOWING HIS UNIQUE SITUATION, WHAT OTHER SPECIFICS MAY YOU WANT TO KNOW?

8. SPORT SPECIFIC INFORMATION • Performs 10-13 shows per week • As a principle performer he is allowed one show off per week • May have to skate ensemble numbers during his “off” show • Contracted to skate 2 solo pairs routines each show • Approx. 5 minutes each • Includes jumps, spins, overhead lifts, connecting steps • Currently staying 1 hour away from UDPT • Willing to come daily for treatment • Leaving town in 1 week • Traveling to Virginia for next set of shows • Touring for another 6 months without a break

9. ADDITIONAL FACTORS TO CONSIDER • Skater does about 6 lifts per routine, totaling around 12 each show • Without warming up this could be 156 lifts per week • Skater’s contract requires him to skate both routines to keep his job • Most elements are one-handed using his injured arm • This is NOT reversible • Skaters live in hotel rooms and travel weekly • Limited consistency in plan of care and little equipment • The show travels basic weights and exercise mats only • Performance Director supportive of therapy and willing to make temporary changes to the show programs

10. WHAT TESTS AND MEASURES WOULD YOU LIKE TO PERFORM?

11. OBJECTIVE INFORMATION • Shoulder AROM • Limited and painful right abduction and flexion • All others full and pain free • Shoulder PROM • Right ER/IR at 90°: 87°/56° • Left ER/IR at 90°: 114°/65° • (-) Thumb to forearm • Quick screen for ligamentous laxity

12. QUESTION #1What measure can you use to assess general body hypermobility? • O’Briens • Apprehension tests • Beighton scale • Active range of motion measures

13. QUESTION #2Which of the following IS NOT measured in the Beighton scale? • Knee extension • Fifth digit extension • Elbow extension • Lumbar extension

14. OBJECTIVE INFORMATION • Shoulder resisted isometrics • Strong and painful right abduction, ER • All others strong and pain free • Handheld Dynamometry Strength Testing

15. QUESTION #3Finding of strong and painful in resisted testingis indicative of injury to what? • Contractile (muscle/tendon) • Peripheral Nerve • Spinal Cord • Joint Capsule

16. OBJECTIVE INFORMATION • Scapulohumeral rhythm • Early initiation of movement on the right • Increased scapular elevation • Palpation • 8/10 long head biceps tendon • 6/10 supraspinatus • Special Tests • (+) Neer’s, anterior & posterior apprehension, Jobe relocation, Kim’s test • (-) Biceps load II, O’Brien’s, sulcus sign • DASH ADL: 26%, Sport: 50%, Work: 62.5% • Note: He has not tried anything since injury

17. WHAT IS A PROBABLE IMPAIRMENT LIST? WHAT IS WRONG WITH THIS PATIENT?

18. IMPAIRMENT LIST • Painful shoulder motion in his functional range • Decreased strength in dominant arm • ER • Point tenderness • Supraspinatus > LHBT • Poor scapulohumeral rhythm

19. DIFFERENTIAL DIAGNOSIS Impingement Instability Rotator cuff, biceps tendonitis Labral tear

20. HYPOTHESIS Tenderness to rotator cuff and biceps and associated shoulder weakness and painful range of motion due to traumatic subluxations Positive apprehension tests due to instability following traumatic subluxations Compensatory motion due to weakness in scapular stabilizers and to avoid provocative positions NEED TO INITIATE REHAB TODAY!!!!!!!!

21. Goals • Return to performing in 8 days • Return to skating his show track • This will include pairs lifts • Feel confident in his activities • Be comfortable with a home program that can be completed while touring • Allow for continued success throughout the remainder of his contract

22. PROGNOSIS • Fair to excellent • Patient is young, physically fit • No prior history of shoulder injury • However, demanding job/sport that will require end range shoulder positioning • Patient will have to be willing to follow PT recommendations on positions to avoid

23. What positions would we want to have this patient avoid? How can we cue him to protect his shoulder while lifting his partner?

24. Patient Guidelines • Patient will be managing his care independently in 8 days, HE MUST: • Know when he can progress his exercise program • Know when he can try specific lifts and a safe environment to do this in • Be compliant with the mentioned positions to avoid UNTIL healing can occur

25. QUESTION #4What guidelines can this patient follow to determine when it is appropriate to progress his strengthening exercises? • Full range of motion • Pain scales • DASH score (disabilities of the arm, shoulder and hand) • Soreness rules

26. WHAT WOULD YOUR INTERVENTION OR PLAN OF CARE BE…STARTING RIGHT NOW?!

27. FOLLOWING EVALUATION • Treatment that day • NMES to supraspinatus & infraspinatus • Right arm held isometrically in place with a belt, with patient seated • Parameters: 400 µsec, 12 on/50 off, 2 sec ramp, 15 min treatment time, amplitude to patient tolerance and visible, palpable muscle contraction • Noxious stim to long head biceps and superior to lesser tuberosity • Parameters: 400 µsec, 12 on/8 off, 2 sec ramp, 15 min treatment time, amplitude to patient tolerance • Patient given home EMPI unit for noxious and NMES

28. REMAINING VISITSProgressions of the following • Treatments • Rhythmic stabilizations • PNF exercises to fatigue • Perturbations on BOSU ball • Sleeper stretch • Manually resisted ER to fatigue • Ball on the wall, ball taps • Scap walks • Pushup plus • Plyometrics (ball toss with plyoback) • Inertial machine IR/ER • NMES, noxious with ice

29. Education • Particularly important to educate the skater and performance director • Determined moves he must avoid • Educated on stretching- avoid end ranges • Soreness rules • Danger in a future subluxation

30. HOW DID WE MAKE THESE EXERCISES MORE SPORT SPECIFIC?

31. Sport Specific • Weighted medicine balls • Will have to lift his partner • Stable  Unstable surfaces • Standing on foam, rockerboard, BOSU ball • Functional positions • Arm in elevation (lifting position) • Avoiding excessive motion

32. Push-up plus Scap walks Exercises

33. On BOSU Weighted rhythmic stabs Manual Perturbations

34. QUESTION #5In order to allow the capsule to recover from the subluxation, after what time frame should the patient be cleared to return to all lifts? • 4-6 weeks • 6-8 weeks • 8-12 weeks • > 6 months

35. Shoulder Brace • Script given by MD for brace • DonJoy Sully Shoulder Stabilizer • Company representative went to Wachovia Center • Skater, partner, performance director demonstrated/described all necessary positions • Typical brace only allows 90° flexion, abduction • Wear brace for at least 12 weeks • Costumes will accommodate/hide shoulder brace

36. How would you determine return to sport?

37. Return to Sport Reevaluate initial evaluation findings • Must have pain free range of motion • Adequate strength • Confidence in overhead lifting positions

38. Discharge Findings 1 week later: Shoulder AROM: Flexion and abduction full, functional range, pain free Scapulohumeral rhythm: No movement deficiencies Resisted Isometric Testing: All motions strong and pain free Handheld dynamometry values: decreased deficit in flexion, abduction and ER Palpation: 3/10 tenderness of bilateral LHBT only DASH ADL 19% Sport 25% Work 44%

39. Special Tests • (+) Neer’s • (-) Anterior Apprehension • (-) Jobe Relocation • (-) Posterior Apprehension • (-) Kim Test • Functionally able to demonstrate safety and confidence with overhead lifts in “safe zone”

40. Additionally… • Performed all necessary lifts with PT • Extensive background in skating • Performance director and another PT there for safety • On grass- safer surface • Began with non-overhead and progressed • WEARING SHOULDER BRACE!!!

41. Home Program • Prior to discharge: • Skater and performance director independent in a home program identical to PT treatment • Performance director able to assist with home program and providing manual resistance • Performance director willing to buy a BOSU ball for the company to assist with treatment • Pictures taken of all exercises and given to skater with explicit directions

42. Key Points • Treatment must be a team effort • Enabling the patient to participate in their rehab and continue care independently • Basic understanding of his sport/work requirements

43. Thank youQUESTIONS?