MOBILISATION WITH MOVEMENT FOR PAIN AND STIFFNESS AFTER
BANKART REPAIR: A CASE REPORT
B. Burmeister
A Case Report submitted to the Orthopaedic Manipulative Therapists’ Group of the
South African Society of Physiotherapy, in partial fulfilment of the requirements for
the Continuing Education Course in Orthopaedic Manipulative Therapy (OMT
course).
Windhoek
September 2010.
MOBILISATION WITH MOVEMENT FOR PAIN AND STIFFNESS AFTER
BANKART REPAIR: A CASE REPORT
Coded Number: …………….
A Case Report submitted to the Orthopaedic Manipulative Therapists’ Group of the
South African Society of Physiotherapy, in partial fulfilment of the requirements for
the Continuing Education Course in Orthopaedic Manipulative Therapy (OMT
course).
Windhoek
September 2010.
TABLE OF CONTENTS
TABLE OF CONTENTS ..............................................................................................3
ABSTRACT .................................................................................................................1
INTRODUCTION .........................................................................................................2
CASE DESCRIPTION ................................................................................................4
DISCUSSION ........................................................................................................... 10
CONCLUSION .......................................................................................................... 15
REFERENCE LIST .................................................................................................... 16
ABSTRACT
Shoulder pain is a common phenomenon in the general population and
physiotherapists are often challenged by the complexity of shoulder conditions.
Manual therapy is known to be a useful tool in the management of shoulder
pathology. It was the objective of this study to assess the value of Mulligan’s MWM in
a painful and stiff shoulder after a Bankart repair. The treatment technique used was
a sustained anterior-posterior glide of the humerus, maintained by the therapist while
the patient performed a previously impaired active gleno-humeral movement. Pain
intensity, range of movement (ROM) and functional disability were used as
measurement outcomes and assess by means of the numeric pain scale, goniometer
and the SPADI questionnaire respectively. A significant initial impact on the pain
intensity was achieved after three treatment sessions. The active ROM for external
rotation increased by 30 degrees, abduction improved by 70 degrees and flexion by
35 degrees within four to five treatments. The functional disability changed
dramatically form a score of 48% prior physiotherapy intervention to 2.31% after the
sixth session. The amazing results indicate that this specific MWM technique had an
immediate effect on pain, ROM and function, and is certainly a useful technique in
manual therapy. Further research is required to evaluate the mechanism by which
this occurs and other areas of application, since only limited literature is available.
Key Words: Mobilisation with Movement, Bankart repair, Shoulder pain, Shoulder
stiffness
1
INTRODUCTION
Shoulder disorders are a common source of pain in the general population with
reports mentioning a prevalence of 30% of the population experiencing shoulder pain
at some stage in their lives (Lewis 2008). Shoulder dislocations were found to be a
frequent phenomenon affecting approximately 1,7% of the population of the United
States and Sweden. Anterior dislocations were the most frequent type of dislocation
(95%) and usually seen in individuals aged between 18 to 25 years with an incidence
ratio of 9:1 male-to-female. The mechanism of injury for anterior dislocation was
mostly traumatic in nature and recurrence rates were found to be approximately 80%
to 94% in people younger than 20 years at the time of initial dislocation. The major
pathology in the age group 18 to 25 years was believed to be a Bankart lesion
(Wilson and Price 2009).
The gleno-humeral joint, a so-called ball and socket joint, consists of the convex
humerus articulating on a very shallow glenoid fossa deepened by a cartilaginous
rim, the labrum. A tear to a specific part of the labrum, the inferior gleno-humeral
ligament, is called a Bankart lesion. This type of lesion can be managed
conservatively by immobilisation and physiotherapy, or surgically in case of recurrent
dislocations, where the torn labrum is reattached to the anterior margin of the glenoid
to restore its normal position. This procedure is referred to as a Bankart repair, and is
done by open or arthroscopic means or used in conjunction with a capsular shift
procedure where the anterior joint capsule is tightened selectively to optimise tension
in the anterior capsulo-ligamentous complex (Cluett 2009 and Millett et al 2005).
Although the results of the Bankart repair were usually good, post-surgical stiffness
2
often developed. Millett et al (2005) proposed that although stiffness after surgery for
the treatment of open anterior instability was seldom reported on in the literature, the
prevalence was probably underreported. Magit et al (2008) found in their study that
anterior-posterior gleno-humeral translation was decreased at three and six months
post surgery for anterior or posterior instability. Another possible predisposition to
joint stiffness was established in a study by Ko et al (2008) revealing that a higher
level of a pro-inflammatory cytokine, interleukin-1 beta, in the shoulder joint was
directly linked to a deficit in joint motion. A similar increased production of interleukin1 beta was found in the synovium of gleno-humeral joints with anterior instability
(Gotoh et al 2005).
Physiotherapists often use manual therapy to treat post surgical stiffness. Mulligan’s
mobilisation with movement (MWM) treatment techniques were used in many
musculoskeletal conditions to decrease pain and improve range of motion and
function (Collins et al 2003, Teys et al 2006, and Vicenzino et al 2006). A technique
that De Santis and Hasson (2006) found to be useful involved the application of a
sustained anterior-posterior (AP) glide that is maintained by the therapist, while the
patient actively performs a painful and/or restricted movement.
It was the purpose of this study to investigate the effect of manual therapy using
Mulligan’s MWM in the treatment of pain and stiffness after surgery for anterior
instability.
3
CASE DESCRIPTION
ASSESSMENT
The patient was a twenty-eight year old female, who fell off a horse and injured her
right shoulder eleven years ago. At the time it was diagnosed as a biceps tear. The
right shoulder being her dominant side remained troublesome and she received an
injection into the joint a month later .She dislocated her right shoulder for the first
time while lifting up a blanket onto her horses’ back about six months after the initial
injury. Since then frequent dislocations had occurred over the past ten years.
Approximately one month before surgery, she fell down the stairs at work, where she
was employed as personal secretary, and dislocated her shoulder yet again. After
this incident she was unable to continue with her daily horse-riding programme due
to pain and the risk of further trauma. She was concerned that she would not be able
to ride again or participate in her other sporting activities- cycling and running. This
led her to the decision to have a surgical repair done. An open Bankart- repair and a
capsular shift were done on her right shoulder. Physiotherapy treatment started two
weeks after surgery and she was treated using active and passive physiological
movements. At a follow-up consultation with the surgeon, he found her progress to
be unsatisfactory and she was referred to our practice for further management. She
arrived eleven weeks after surgery and on assessment, her main complaint was very
limited active range of movement (ROM) of the gleno-humeral joint, accompanied by
pain at the end of ROM. Functionally, she was unable to wash her back and
experienced great difficulties opening a car door, washing her hair, placing an object
4
onto a high shelf, reaching her back pocket and carrying heavy objects of about 4 kg.
In her work environment she struggled to maintain the expected performance level
due to her abovementioned main complaints. Her social life was only affected to a
minor extent, but she had not been back to riding yet, fearing dislocation or re-injury.
Observation revealed that her right scapular was elevated and retracted. Muscular
atrophy on the right side was noted when compared to the other side. On
assessment of the active physiological movements of the right gleno-humeral joint,
flexion was limited to 120 degrees due to stiffness and abduction was measured at
60 degrees causing pain of an intensity of 6/10 at the subacromial area (pain area 2).
External rotation and extension were limited to 0 degrees and 30 degrees
respectively due to an anterior joint pain (area 1) of an intensity of 6/10. The right
hand behind back movement could reach to the middle of her right buttock. The
evaluation of the passive physiological movements resulted in the same clinical
findings as for the active movements. The muscle power in the right upper arm was
established at a grade 3 to grade 4+ using the Oxford Scale.
For the purpose of the above assessment the goniometer was use to measure ROM
and the numeric pain scale to determine the intensity of the perceived pain. Both of
these are acceptable means in the clinical setting (Riddle et al 1986; Williamson and
Hoggart 2005).
At the first visit the patient completed the Shoulder Pain and Disability Index
questionnaire and scored a total SPADI score of 48%. This questionnaire was found
to be useful in patients where movement of the shoulder is encouraged (Heald et al
1997).
There was no indication of any neural sensitivity. The patient’s general health was
good. She used an anti-inflammatory drug for a week after surgery.
5
Considering the history and examination findings it was hypothesised that glenohumeral joint, ligament and capsular dysfunction were the major components of her
shoulder pathology. The anterior capsular tightness was the intended result of the
surgery, but could according to Werner et al (2006) affect humeral translation during
movement and hence alter the joint kinematics. David et al (2008) found glenohumeral translation to be restricted at three months post surgery for shoulder
instability, which corresponds with this study.
Body Chart 1
Area 1
Ant gl-h jt
Intermittent
Intensity 6/10
Sharp - deep
Area 2
Lat gl-h jt (subacromial)
Intermittent
Intensity 6/10
Ache – superficial
6
MANAGEMENT
The patient was treated twice a week for three weeks for the duration of about thirty
to forty-five minutes each session. The individual session consisted of an
assessment of active ROM and pain intensity of specific active physiological
movements, the application of the manual therapy technique, the re-assessment of
each movement and home exercises.
The choice of intervention was Mulligan’s (MWM) using a sustained AP glide of the
humeral head maintained by the therapist while the patient performed active glenohumeral external rotation in neutral, abduction or flexion. The treatment procedure
and quantity of repetitions were followed as described by Mulligan (1999) for
peripheral joint treatment .The individual active movements used were purposefully
selected to represent movements that were impaired by one of the three variables,
namely, pain in area 1 or pain in area 2 or stiffness only.
During all treatment sessions a specific management sequence was followed to
ensure consistency. The patient was seated on the edge of the plinth and the active
ROM for external rotation (in neutral) was measured and the pain intensity was
recorded. Then the MWM technique was applied using external rotation as active
movement, followed by measurement and documentation of ROM and pain intensity
again. The same procedure was repeated for abduction and flexion.
The session was concluded by firstly, teaching the patient home exercises involving
active gleno-humeral joint movements using a stick / wall to maintain the gained pain
free active ROM and to facilitate joint proprioception and secondly, scapular mobility
exercises to assist with the correct scapular position as illustrated in appendix 2.
7
At the end of the sixth session the patient completed a SPADI questionnaire again,
and was discharged with an exercise programme, since MWM did not have any
effect anymore. (See appendix 2 for programme and questionnaire).
OUTCOME
The patient responded very well to the Mulligan MWM technique. At each treatment
session an increase in active ROM and/or decrease in pain intensity could be
achieved. The pain intensity decreased rapidly, while the ROM improved more slowly
as illustrated in Table 1 below.
Table 1: TREATMENT RESULTS
Day 1
Assessment
Day 1
Treatment
Day 7
Treatment
Day 12
Treatment
Day 16
Treatment
Day 19
Treatment
Day 22
Treatment
Active Movement
Intensity
Pain
Area
Range of Movement
Intensity
Pain
Area
Range of Movement
Intensity
Pain
Area
Range of Movement
Intensity
Pain
Area
Range of Movement
Intensity
Pain
Area
Range of Movement
Intensity
Pain
Area
Range of Movement
Intensity
Pain
Area
Range of Movement
Ext Rot
6/10
A1
0º
4/10
A1
10º P2
0/10
Abduction
6/10
A2
60º
2/10
A2
70º P2
0/10
15º P2
0/10
30º P2
0/10
90º P2
1/10
A2
110º P2
2/10
A2
110º P2
0/10
30º P2
0/10
130º P2
0/10
155º S2
0/10
30º P2
130º P2
155º S2
20º P2
0/10
Table 1 Legend:
Ext Rot = External Rotation
P = Pain
S = Stiffness
8
Flexion
0/10
120º
0/10
130º S2
2/10
A1
150º S2
3/10
A1
155º S2
0/10
155º S2
0/10
After six treatment sessions she had overcome her previously experienced functional
limitations, the SPADI questionnaire score had changed from 48% to only 2.31% and
she had returned to horse riding for an hour per day.
A follow-up session at 70 days after the initial visit revealed that she had regained full
pain free ROM in all active physiological movements apart from external rotation in
90 degrees of abduction, which was limited by 20 degrees.
9
DISCUSSION
The treatment of musculo-skeletal dysfunction often involves the use of manual
therapy techniques such as Mulligan’s MWM where a sustained accessory glide to a
joint is maintained while a pain provoking movement is performed. The effect of this
technique is based on the concept of restoring a’ positional fault’ occurring secondary
to injury and resulting in symptoms like pain, stiffness or weakness. It has been
suggested that changes in the shape of the articular surface, cartilage thickness and
soft tissue alignment or direction of pull could be the cause of a positional fault (Hing
et al 2008).
Numerous studies indicated that MWM techniques have a beneficial effect on the
specific outcome measures used, such as pain levels, ROM, strength or pain
pressure threshold (PPT), to mention a few. In this case study the pain intensity,
ROM and function were used to evaluate the effect of MWM. An immediate
improvement in the pain intensity was found during the initial two treatment sessions.
Similar results emphasising the immediate effect were obtained by Teys et al (2006)
in a repeated measures, double-blinded randomised–controlled trial with a crossover
design, where the initial effects of a MWM technique on ROM and PPT in individuals
with anterior shoulder pain were investigated. In osteoarthritic knee joints it was
found that accessory knee joint mobilisation caused both an immediate local and
widespread hypoalgesic effect (Moss et al 2007).
The actual extent of the hypoalgesic effect of MWM in this study was reflected in the
vast reduction of the pain intensity decreasing from 6/10 to 0/10 for external rotation
and abduction movements within the first two treatment sessions as seen in chart 1.
10
Chart 1: Treatment Results
Pain Intensity
10
8
External rotation
6
Abduction
4
Flexion
2
0
0
1
2
3
4
5
6
Treatment Session
In an attempt to find an explanation for the actual pain control mechanism involved in
the hypoalgesic effect of MWM, Paungmali et al (2004) conducted a randomised,
controlled trial to evaluate the effect of naloxone injection on the MWM-induced
hypoalgesia. The interesting finding demonstrated that naloxone did not antagonize
the initial hypoalgesic effect of MWM, indicating that non-opioid pain inhibiting
pathways were involved in the pain control mechanism. It was mentioned that these
findings correlated with similar studies involving spinal manual therapy techniques.
Further research is required to investigate the precise neuro-physiology behind this
pain control mechanism.
A study conducted by Collins et al (2003) assessed the initial effects of a MWM
technique in sub-acute lateral ankle sprains using dorsiflexion ROM, PPT and
thermal pain threshold (TPT) as comparable sign. From the results it could be
derived that the MWM technique had a significant immediate positive effect on
dorsiflexion ROM only. In this case study it was found that the ROM increased
gradually, but consistently during treatment sessions one to five, to the effect of 0 to
11
30 degrees for external rotation, 60 to 130 degrees for abduction and 120 to 155
degrees for flexion, indicating a less dramatic response as shown in chart 2.
Chart 2: Treatment Results
Degrees of Movement
180
150
120
External rotation
90
Abduction
60
Flexion
30
0
0
1
2
3
4
5
6
Treatment Session
Interestingly, a clear difference in the effect of treatment on pain intensity compared
to ROM could be seen. The slower, gradual improvement of ROM compared to the
fast change in pain could possibly be attributed to the prolonged period of inadequate
movement in the gleno-humeral joint prior to the treatment with MWM. Alternatively it
could be suggested that the limited ROM could be due to soft tissue tightness rather
than a positional fault causing joint dysfunction. Unfortunately, the severely limited
ROM in this patient did not allow a proper assessment of possible posterior capsule
tightness, which could have thrown light on this issue. It was realized as a shortfall in
this case study.
The functional impairment of the patient in this case study improved significantly
according to the results of the SPADI questionnaire, which changed from 48% to
2.31% after six sessions. A case study by De Santis and Scott (2006) where the
same MWM technique was used to treat a patient with subacromial impingement, a
12
similar major impact on function was experienced. Paungmali et al (2003) in a study
using MWM for lateral epicondylalgia had the same outcome indicating a positive
responds favouring the improvement of function as in pain-free grip force over
changes in PPT and sympathoexcitation.
From the available literature it was evident that the effect of Mulligan’s MWM
techniques was assessed in a variety of spinal and peripheral applications using a
wide range of outcome measures. Amazingly, only the case study conducted by
Virtuoso et al (2008) was found, where the same MWM technique was used for the
same condition as in this case study. The outcome of that study indicated that
exercises combined with Mulligan’s MWM had a beneficial effect on ROM and
strength. Unfortunately it was not mentioned how soon after surgery the treatment
started, which compromises the value of a comparison of the two studies.
A different treatment technique that could possibly have a similar effect as Mulligan’s
MWM is a technique described by Lewis (2008) called the humeral head procedure.
It is part the shoulder symptom modification procedure (SSMP) that he introduced in
an attempt to propose an alternative clinical examination method for shoulder
impingement syndrome/ rotator cuff tendinopathy. It is based on the same principal
as MWM by applying a glide to the head of the humerus. In Lewis’ technique
however, the pressure could be applied in one or more directions to the humeral
head while the patient performs the activity or movement that most closely
reproduces the symptoms. Since only little evidence exits to support this treatment
model, further research could reveal interesting information with regard to the effect
of MWM compared to SSMP in the treatment of pain and/or stiffness.
In other literature describing the common treatment regimes used after shoulder
surgery, it was noticed that only Maitland’s mobilizations were mentioned in addition
13
to exercises and other modalities (Turner et al 2000). The value of Mulligan’s MWM
and SSMP as part of the post surgery treatment regime for a Bankart repair and
other conditions should be assessed in further research.
14
CONCLUSION
This study highlights the value of Mulligan’s MWM technique using an A-P glide of
the humerus in a painful and stiff shoulder after a Bankart repair. The immediate
hypoalgesic effect, and the positive impact on the functional disability and the ROM
obtained, supports this. In addition it was found to be useful even in the late stage of
rehabilitation where soft tissue tightness was thought to be the cause of glenohumeral dysfunction. Limited literature is currently available, leaving a vast scope for
research that could throw more light on the mechanism by which Mulligan’s MWM
work, and the value of it in other conditions or in conjunction with other treatment
modalities
15
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