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The initial treatment of posterior subluxation is usually nonop-erative.8 Pain is treated with relative rest, avoidance of provocative activities and arm position, and anti-inflammatory medications. Physical therapy is initiated with an emphasis on strength and endurance of the parascapular musculature and rotator cuff. Improvement in the scapular muscles helps to create a stable platform for the humeral head. The rotator cuff is important in fine-tuning shoulder stability through a range of motion and also provides a compressive effect, helping to center the humeral head. In general, research has supported the belief that posterior subluxation responds better to rehabilitation than does its anterior counterpart. Clearly, patients with a history of a significant traumatic event are less likely to respond to nonoperative treatment.9,10 In these patients, surgery is considered earlier if response to conservative treatment is unsuccessful.

The indications for surgical treatment of patients with posterior shoulder instability are subjective and must be individualized. Many patients choose to live with occasional episodes of subluxation, and there are few data to support operative intervention to prevent future complications such as arthritis or rotator cuff injury. The patient who has undergone an appropriate period of rehabilitation and is not satisfied with his or her shoulder function is a candidate for surgery. This includes those who have pain with use of the shoulder or those who are unable to participate in desired activities due to episodes of instability. Football players, particularly offensive linemen, and weight lifters generally tolerate posterior instability poorly. In patients in whom a defined traumatic event has led to posterior instability, early surgery without a course of nonoperative treatment

Figure 19-2 A, Anteroposterior view of the shoulder in a 29-year-old patient with shoulder pain after a seizure. B, In the same patient, adequate axillary lateral view could not be obtained. Transthoracic lateral view remains inconclusive. C, Computed tomography scan done 1 month after injury shows the posterior dislocation with a large reverse Hill-Sachs lesion.

Figure 19-2 A, Anteroposterior view of the shoulder in a 29-year-old patient with shoulder pain after a seizure. B, In the same patient, adequate axillary lateral view could not be obtained. Transthoracic lateral view remains inconclusive. C, Computed tomography scan done 1 month after injury shows the posterior dislocation with a large reverse Hill-Sachs lesion.

is considered. This is particularly true if magnetic resonance imaging shows evidence of a posterior labral detachment.

There are several contraindications to surgical treatment of posterior glenohumeral instability. Patients who have not undergone an adequate course of rehabilitation are not surgical candidates, nor are those who are unable to complete an adequate postoperative rehabilitation program. Surgery is also contraindi-cated in the patient with a seizure disorder that has not been medically controlled because a seizure in the postoperative period will almost certainly result in failure of the repair. A documented period of 3 to 6 months without a seizure is required before elective surgical intervention.

As many as 50% of patients with posterior instability can voluntarily subluxate the shoulder.9,10 This is not an absolute contraindication to surgery, as this finding can be present despite the best intentions of the patient, after an aggressive rehabilitation program, and may occur with a pathologic lesion (posterior labral detachment). However, patients who voluntarily or habitually subluxate or dislocate the shoulder often have psychological problems or do so for issues involving secondary gain, whether it be attention, narcotic medication, or issues of compensation. These patients are very poor surgical candidates.

Posterior Dislocation

Initial management of acute posterior dislocation is attempted closed reduction. Adequate anesthesia and relaxation are required. The humeral head is often perched on the glenoid rim, impacted in the area of the reverse Hill-Sachs lesion. For reduction, the arm is adducted and gently flexed to 90 degrees as lateral distraction is applied to disimpact the humeral head. Once this is accomplished, the humeral head is translated anteriorly and gradually externally rotated, and the arm is brought down to the side. The arm is generally held in a brace in neutral rotation for about a month before initiating physical therapy. In the presence of a lesser tuberosity fracture or a reverse HillSachs lesion involving more than 30% to 40% of the humeral head, early surgery is indicated. In cases of chronic locked posterior dislocation, generally present for more than 1 to 2 weeks, surgical open reduction is necessary.

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Cure Tennis Elbow Without Surgery

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