Very Early Rehabilitation of the Shoulder
Posted on March 10, 2009
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Shoulder problems are a significant part of the workload of a physiotherapist and an orthopaedic surgeon, with various injuries and conditions affecting this joint. The shoulder has the greatest range of motion of any body joint and this requirement leads to risks of injury and the development of pathologies. As the shoulder is a very unstable joint it is vulnerable to dislocation in falls or vigorous activities at the end of its range. Its structure and the repetitive movements we perform predispose the shoulder to cuff tears and its function as an emergency support when we fall makes fractures a common occurrence.
The precise diagnosis of the condition and a clear agreed treatment plan are essential in shoulder conditions as there is a very large number of different fractures, operations and injuries to the shoulder complex. Post-trauma and post-operative shoulder conditions are part of the core work of orthopaedic physiotherapists and they follow the agreed trauma and elective surgery protocols, referring patients for further treatment once they are discharged. Going over the case quickly from the beginning once we meet the patient is useful as this can throw up errors and missing facts which need addressing. Patients also appreciate an opportunity to tell their story.
As the arm hangs from the shoulder and needs effort to keep it in place, after operation or injury it may be useful to relieve this load by using a sling. The typical triangular bandage broad arm slings are not comfortable, difficult to apply, pull at the back of the neck and are not easily adjusted to the physiotherapist’s requirements. Foam padding around the knot at the back of the neck can help but the Seton type sling with Velcro straps is much better tolerated by patients and is much more adjustable and comfortable.
To get the best fitting and most comfortable fit for the sling the physiotherapist needs to take a few actions for success. The gutter for the arm should have the elbow placed back as far as it will go and the hand can be kept out of the sling by folding back the cuff part. The small Velcro strap to close the forearm gutter should not be tightly fixed as it may cut in to the upper arm, particularly if there is a lot of oedema as swelling can occur after fractures of the upper arm. Tightening up the main strap which runs across the back and upwards over the shoulder is a little more difficult to achieve a good result.
Due to the materials from which the slings are made there is a degree both of elasticity and friction against surfaces when they are adjusted. As the sling is adjusted and tightened up the elbow is often not well supported by the sling at all and patients are usually aware that the support is not that good. The physiotherapist can easily feel that the sling is not giving the correct support and if they just tighten up the strap it solely tightens up at the front but does not improve the support of the arm. This needs another strategy.
Adjusting the sling correctly needs the cooperation of the patient and one other person. The patient allows the arm to relax while the assistant lifts the elbow up gently, taking care of any pain. Then assistant pulls the rear part of the strap up towards the opposite shoulder and then fixes it there with their rear facing hand. The assistant then uses their front hand to undo the strap and re-fix it further round on the back part of the strap, when it is easy to see the improvement in the support of the arm.
General advice to patients about sling management should be given to cope with daily activities, the sling only being off for dressing and washing. To wash the armpit the patient should hold their arm in a position as if the sling was on and then bend forward, allowing the arm to bend forward with gravity. To put clothes on the affected arm should be placed on first and with no significant movement of the arm involved.
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