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THE UNSTABLE SHOULDER
MTS™ LEVEL 2
Develop your expertise in shoulder instabilities.
Complete management of glenohumeral & clavicular instabilities, together with a full day dedicated to solving scapular dyskinesis.
Level 2 syllabus - THE UNSTABLE SHOULDER
MTS™ Level 2 - Day I
TOPIC 3 - GLENOHUMERAL INSTABILITY
- Evaluating Instability
- Dislocations, Subluxations & MDI
- Defining labral, capsular and bony disorders
- Variations in SLAP tears
- Initial vs Recurrent Management
- MRI vs CT - What's the most important ?
- On-track vs Off-track lesions
- Bankart, Latarjet & Remplissage procedures
- Early - Mid - Late stage rehabilitation
Practical Session
TOPIC 4 -STERNOCLAVICULAR INSTABILITY
- Symptoms and mechanics of SCJ instability
- Diagnostic tests for SCJ instability
- Investigating & Managing SCJ disorders
Case Studies
TOPIC 5 -ACROMIOCLAVICULAR INSTABILITY
- Pediatric vs Adult Injuries
- How are AC separations are graded ?
- MTS™ GI - IV ACJ physio management
- Early - Mid - Late stage rehabilitation
- Key clinical concepts of treatment
Practical Session
MTS™ Level 2 - Day 2
TOPIC 6A - SCAPULAR DYSKINESIS
- Primary vs Secondary Scapular Dyskinesis
- Mal adaptive vs Adaptive changes
- Scapular flips, rhythms, tilts and wings
- Methods of measurement
- Current research directions
Case Studies
TOPIC 6B - TREATMENT RECOMMENDATIONS
- Critical force couples of the scapula
- Muscle separation vs faciliitation
- Early methods of correction
- Open vs closed kinetic chain movements
- Load, speed and eccentric considerations
Practical Session
TOPIC 6C - INTEGRATION OF MOVEMENT
- MTS™ 6 week rehabilitation program
- Muscle relaxation, activation and loading
- New exercises for integration
- Returning to resistance training
- Considerations for sport
Practical Session
Level 2 course questions / discussion points
Managing Shoulder Dislocations & Subluxations
Managing Shoulder Dislocations & Subluxations
Managing Shoulder Dislocations & Subluxations
- Is the apprehesion test the best for anterior instability ?
- What are the better tests for posterior instability ?
- Does an inferior sulcus matter ? adding ER ?
- Is the load and shift test or crank test helpful ?
- How would I adjust for an EDS patient ? Is MDI related to EDS ?
- How helpful are Bicep Load I/II and Shear Tests for SLAP lesions?
- How do you manage a reverse Bankart ?
- What are the key isometric movements for stability ?
- What are the recommended end points for cuff training ?
- What positions should be tested ?
- What bracing or taping strategies work ? Are they necessary or effective ?
- What are the differences for young athletes compared to older athletes ?
- When can a patient safely return to sport post initial dislocation ? recurrent ?
- What is an off track vs on track lesion ?
- What imaging is required prior to surgery ? Do we need MRIs ?
- When do you opt for a Latarjet procedure ? What is the difference in rehab to Bankart repairs ?
- What are the complications of Bankart vs Latarjet ?
- Do posterior labral tears require surgery ?
ACJ injuries & Instabilities
Managing Shoulder Dislocations & Subluxations
Managing Shoulder Dislocations & Subluxations
- How do you define a grade III vs grade IIIB vs grade V ACJ separation?
- When is an MRI necessary ?
- What's the difference between a grade II and III radiologically ?
- Can you image AP instability ?
- What x-ray views are necessary ?
- What are the starting exercises ?
- Should I offer bracing or taping ?
- Do I need to sling after a separation ?
- What are the considerations for return to sport ?
- What are the other pain sources to look for ?
- How do I return the patient to overhead movement ?
- What are the ideal stepping stones in rehab ?
- When is surgery necessary ?
- How should I manage the post op process ?
- How successful are ACJ reconstructions ?
- What should I protect the surgical site and for how long ?
- What are the risks and complications of surgery ?
SCJ Instability
Scapular Dyskinesis
Scapular Dyskinesis
- What are the key tests for SCJ instability ?
- What investigations are helpful ?
- Where can the SCJ refer to ?
- Are there any physiotherapy methods to stabilize the SCJ ?
- Does prolotherapy assist stability of the SCJ ?
- Should you reconstruct or resect an unstable SCJ ?
Scapular Dyskinesis
Scapular Dyskinesis
Scapular Dyskinesis
- What are the key force couples of the scapula ?
- Are scapular assistance and repositioning tests helpful ?
- Is there an ideal scapular position ?
- What pathologies lead to positive adpative changes in scapular motion ?
- How do primary vs secondary scapular dyskinesis differ ?
- Is the resting position of the scapula important ?
- What are the normal variations in scapular rhythm ?
- Does scapular flip need to be corrected ?
- How should scapular disorders be categorized ?
- Are facilitation technniques effective for scapular corrections ? Which ones ?
- What are the key muscles to facilitate ? Inhibit ?
- What are the key progressions for correcting primary scapular dyskinesis ?
- How important is lower trapezius activity ? Upper trapezius ? Serratus anterior ?
- Should you start with open or closed chain movements ?
- Does eccentric control require different muscle actions ?
- What are the recommended progressions and exercises to normalize scapular movement ?
- What changes are expected with load ? With speed ?
- How much asymmetry is acceptable ?
- Are subscapular / periscapular bursal injections effective ?
- Do scapular resections work ?
MTS™ CLINICAL CASE
25 y/o female snowboarder, traumatic fall with recurrent dislocations
A patient sees you for advice and rehabilitation options for a recurrent GHJ dislocation (*3), occurring on moderate overhead force. Current rehabilitation has consisted of rotator cuff exercise for the past month in various positions and range of motion drills. She does not feel confident with overhead movement, despite full range of motion and improvements in her exercises. She is unsure about whether her rehab is complete or if she should opt for surgery. The winter season is five months away, and she would prefer to avoid surgery if possible.
She is waiting on an MRA, and has an orthopedic consultation in 6 weeks time.
Examination of the shoulder demonstrates scapular flip with ER and abduction loading. Low shoulder girdle positioning in overhead positions, mild antalgic neck movements and comfort in 90/90 actively.
How would you address the following ?
- What advice would you begin with regarding rehabilitation effectiveness vs surgery ?
- What considerations and likely improvements in rehabilitation might be achievable ?
- Can you explain why the MRA might be less important ?
- What secondary effects from recurrent dislocation are there ?
- How would you counsel the patient on their discussion with the surgeon ?
- What is the shortest return to sport time, should the patient opt for surgery ?
