Reverse Hill-Sachs Lesion 1

Reverse Hill-Sachs Lesion Repair

Julia Villani

Carrie Meyer/ Jeb Davis

November 22 2014
 Reverse Hill-Sachs Lesion 2

Background Information

Anatomy/Physiology

The glenohumeral joint is the largest joint in the shoulder complex. This joint has three

degrees of freedom, making it a very mobile joint. However, this level mobility also means there
1-3
is compromised stability. There are static and dynamic stabilizers that work together to allow

necessary movement while also providing adequate support. The static stabilizers include the bony

anatomy, as well as several soft tissue static structures, the labrum, ligaments and joint capsule.

For the shoulder to have adequate mobility these structures need to be relatively lax, therefore the

dynamic stabilizes which include but are not limited to the rotator cuff muscles, deltoid and long

head of the biceps provide most the shoulders stability.3

The round humeral head is attached to the diaphysis of the bone with the anatomical neck.

Just below the neck, the bicipital groove runs between greater and lesser tubercles. The scapula is

roughly triangular shaped with a medial, lateral and superior boarder and inferior apex. The spine

of the scapular separates the posterior rotator cuff muscles; supraspinatus superiorly and

infraspinatus and teres minor inferiorly. The lateral spine becomes the acromial process which

hooks medially to connect with the clavicle forming the acromioclavicular joint. The last

projection of the scapula is the coracoid process which originates anteriorly just lateral to the

glenoid fossa.2 The head of the humerus and the glenoid fossa of the scapula form a ball and socket

joint. However, this ball and socket is not as stable as the ball and socket joint of the hip. This is

due to the fact that the concave surface of the glenoid fossa is relatively flat. Another factor that

can cause instability is the presents of anteversion or retroversion.

 Reverse Hill-Sachs Lesion 3

Due to the relative instability of the bony anatomy, soft tissues are needed to help support

the joint. The joint capsule encases the entire glenohumeral joint from the neck of the humerus to

the scapula. Dense, white, fibrous connective tissue forms the outer layer of the capsule while the

inner layer secretes synovial fluid in the joint to provide lubrication for joint movements. In certain

areas of the capsule, the connective tissue thicken, these areas are the superior, middle and inferior

glenohumeral ligaments. The location of these ligaments can be seen in figure 1. Another very

important soft tissue structure is the glenohumeral labrum, a fibrocartilage ring around the glenoid

cavity. The labrum deepens the glenoid fossa and creates a larger surface for the humeral head to

articulate with the scapula. All of these soft tissue structures are relatively lax in order to allow for

a large range of motion. This means that typically the static soft tissue structures are injured and

extreme end ranges of motion.

The glenohumeral joint relies largely on musculature to provide the necessary stability for

proper shoulder function. The rotator cuff muscles are the primary glenohumeral joint stabilizers

as the tendons adhere to the joint capsule.2 The rotator cuff is comprised of four muscles that assist

with shoulder motion. The supraspinatus abducts, the infraspinatus and teres minor externally

rotate, and the subscapularis internally rotates the shoulder. The rotator cuff along with the deltoid

and long head of the biceps compress the humeral head into the glenoid fossa providing stability.

The contraction of these muscles before movement helps to stabilize the joint. The level of

muscular endurance can have an effect on the level of stablity.3 Due to the shoulders complexity,

there are muscle that effect the glenohumeral joint that do not actually cross the joint. The

latissimus dorsi, trapezius, serratus anterior levator scapulae and rhomboids all act on the scapula.

They help to allow the scapula and humerus to move together, maintaining normal joint

articulation.3
 Reverse Hill-Sachs Lesion 4

Mechanism of Injury

The Reverse Hill-Sachs Lesion is a depression fracture of the anteriomedial portion of the

humeral head that occurs in up to 86% of all posterior should dislocations.4,5 Posterior dislocations

are very uncommon, in fact, they account for less than 5% of all shoulder dislocations.6,7 The

mechanism for a posterior dislocation is an axial force applied to the humerus with or without

internal rotation. This can happen from straight-arm blocking where the arm is in 90 degrees of

flexion and internally rotated. It can also occur from a fall on an elbow with the shoulder in a

flexed postion.1 As the humerus pushes thought the posterior joint capsule and rotator cuff muscles

the anteriomedial portion of the humeral head approximates with the posterior rim of the glenoid.

This causes a defect in the humeral head from traumatic impact.7 A reverse hill-sachs lesion may

go undetected as posterior shoulder dislocations often spontaneously reduce.1 While a missed

diagnosis is problematic, it is advantageous that the humerus relocates on its own, as the longer

the joint remains dislocated the more the anteriomedial humeral head is forced into the posterior

rim of the glenoid causing a deeper compression fracture.7 If the humerus does not relocate on its

own the patient will present with their shoulder adducted and internally rotated.2

Surgical intervention

There are several types of surgical procedures used to treat a reverse hill-sachs lesion; this

includes the McLaughlins repair, bone graft repair, and arthroplasty. Orthopedic surgeons will

use clinical evaluation and imaging to choose the most appropriate surgical intervention. There are

three key determinates for determining the type of surgical intervention; the size of the humeral

head compression fracture, the time passed from initial injury and the length of time the shoulder

has been dislocated.4, 7, 8 Figure 2 showed a simple chart of how to determine which surgical
 Reverse Hill-Sachs Lesion 5

intervention should be used. This image is generalized however, and cannot be used under all

circumstances.

The McLaughlin reconstruction is a commonly used procedure for a reverse hill-sachs

deformity that is 20% to 30% 8-10

of the humeral head. While a McLaughlins repair can be

effective for a deformity up to 50% of the humeral head, other surgical techniques are advised for

deformities larger than this or injuries that are more than three weeks old.8 The McLaughlins

procedure is the placement of the subscapularis tendon into the humeral head defect. When the

defect is less than 25% of the humeral head this can be done without the lesser tubercle attachment

of the subscapularis tendon. However, depending on the extent of the humeral head defect and the

condition of the articular cartilage the lesser tubercle will be used in the reconstruction, known as

the Hawkins and Neer modification.4,8-10

The McLaughlin repair is performed by creating a posterior and anterior portal in which

an arthroscope can be inserted to get a visualization of both sides of the glenohumeral joint. The

posterior arthroscopic view is used to observe any injury to the posterior labrum from the contact

with the anteriomedial humeral head in posterior dislocation. Posterior capsule and labral tears are

often present with Reverse Hill-Sachs lesions. Before addressing the humeral defect, the labrum

will be repaired with suture anchors and the posterior capsule with suture application.10 Once the

posterior joint injury is repair the humeral head deformity can be reconstructed. First, the humeral

head is revitalized by using a shaver or rasp to create a bleeding bone and any damage cartilage is

removed.9,10,12 When using the subscapularis tendon without the lesser tubercle the tendon is

separated from the fascia and sutures are threaded through the mobilized end. Depending on the

orthopedic surgeon these sutures will either be attached to the defect using titanium cork
 Reverse Hill-Sachs Lesion 6

screws10,13 or directly into the defect using a technique known a mattress configuration.9 The

Hawkins and Neer modification involves using the lesser tubercle as a bone graft in the humeral

head defect.6 This modified procedure is recommended when there 20% to 45% humeral head

defect and poor bone stock.8

An allograft is utilized in younger patients when the defect is 20% to 50% of the humeral

head.8 The humeral head is carefully reached by separating the anterior deltoid and the pectoralis

major. The surgeon will use great caution to protect the axillary nerve throughout the procedure,

as well as attempt to keep the superior glenohumeral ligament and the coracohumeral ligament

intact. The allograft can be harvested from a humeral or femoral head to keep the spherical shape

of the humeral head intact. The allograft is shaped to fit the defect and then secured using

cancellous-bone screws.14 It will take 6-8 weeks for the bone graft to significantly heal, this should

be considered when progressing a patient through rehabilitation.

An arthroplasty is recommended when more than 50% of the humeral head is deformed.8,11

This condition is typically seen in older patients or patients with chronic posterior shoulder

dislocation. The patient discussed below do not fall into this category, therefore arthroplasty

procedure will not be discussed in detail.

Initial injury and evaluation

A 17 year old male football player presented with posterior instability after a posterior

shoulder dislocation. He was performing a stiff arm block with his left arm at approximately 90

degrees of shoulder flexion and internal rotation. This produced an axial load through the arm that

pushed the humeral head through the posterior joint capsule. The humeral head spontaneously

reduced after the dislocation, however, the patient reported instability even after relocation. A
 Reverse Hill-Sachs Lesion 7

clinical assessment was performed one week post injury when the athlete came into the athletic

training room with complaints of pain, instability, and decreased range of motion. Upon

observation, the athletic trainer found moderate swelling and bruising over the anterior humeral

head, but there was no obvious deformity. The athlete had moderate to severe limited range of

motion with 90 degrees of abduction, 45 degrees of flexion, 45 degrees of extension, 60 degrees

of external rotation and 0 degrees of internal rotation with severe pain. Due to the limited range of

motion and mechanism of injury strength was not assessed to limit chance of re-dislocation.

Posterior instability was confirmed with a positive posterior drawer test with significant pain and

apprehension. Both anterior and inferior drawer tests were negative.

The athlete was referred to a sports medicine physician to confirm the presence of a reverse

hill-sachs lesion and to assess for addition injury to the posterior glenoid and capsule. An x-ray

confirmed a reverse hill-sachs lesion, approximately 25% of the humeral head. An MRI revealed

no damage to the posterior glenoid and labrum and only minimal damage to the posterior capsule.

After discussion with an orthopedic surgeon it was determined that surgical intervention was the

best option as the lesion was larger enough to cause posterior instability. This instability could lead

to the degeneration of the posterior soft tissues and predispose the athlete to osteoarthritis in the

future. An allograft from a humeral head was deemed the best option for that patient for several

reasons. First, as he is still in adolescents the bone graft will heal faster than it would in older

patients, thus leading to a potentially faster rehabilitation. Also, because of the early diagnosis and

spontaneous relocation there is little damage to the articular cartilage which is crucial in an

allograft repair. Lastly, the deformity is 25% of the humeral head, this is the upper limits for a

McLaughlin reconstruction and could decrease its chances of success, where as an allograft can be

used for up an 50% humeral defect.8

 Reverse Hill-Sachs Lesion 8

The patient was put in a sling until he underwent surgery the following week (2 weeks after

injury). This was to minimize further damage to the posterior labrum and anteriomedial humeral

head. No prehabilitation was performed because the sooner the reconstruction was performed the

less secondary injury the athlete sustained to the humeral head and posterior glenoid. After the

reconstruction, the athlete was placed in a shoulder immobilizer at 20 degrees abduction, 20

degrees external rotation, and slight extension (elbow behind plane of body) tted preoperatively

for 4-6 weeks to allow the repair to heal without unnecessary tension.

Rehabilitation Program

Phase I: Acute Motion Phase (0-4 weeks)

Goals, Indications/Contraindication

For the first 72 hours of the rehabilitation program the patient should came in for treatment

twice a day to control pain and swelling and begin therapeutic exercises; after this time period he

can come in once a day. The patient will remain in the immobilization brace at all times expect

during their rehabilitation program and bathing for the first two weeks. From weeks two to four

the patient can begin discontinuing use of the brace as he becomes comfortable, and only wear it

when vulnerable in an uncontrolled environment. The main focus for rehabilitative exercises in

phase I should be on early range of motion (ROM) while carefully protecting the newly healing

allograft. This early ROM will help prevent muscle atrophy and establish voluntary muscle

contraction, however, stress of the joint capsule should be avoided until dynamic stabilization is

restored. This can be accomplished by avoiding active internal rotation, shoulder elevation, and

cross body adduction as these positions put pressure on the anteriomedial humeral head. Lastly,

therapeutic interventions should be used to decrease pain, inflammation and muscle spasm.
 Reverse Hill-Sachs Lesion 9

Therapeutic Exercise

The first movements the athlete will perform are passive range of motion (PROM)

exercises. This includes flexion to 90 degrees, abduction to 90 degrees, external rotation to 30

degrees and internal rotation as tolerated. Restoring range of motion (ROM) is vital to begin

isometric strengthening exercises. Until full or nearly full ROM is restored this type of strengthen

should be limited. PROM will initially be performed for 2 sets of 30 seconds in each direction and

can be increased to 2 sets of 1 minute in the second week if tolerated. This exercise should remain

non-painful throughout, therefore the degree of movement should be decreased if the patient

experiences any pain. As range of motion improves in the first two weeks, the patients can progress

to very light active-assisted ROM (using 10-20% of muscle ability). This will help to limit muscle

atrophy while still protecting the healing tissues. This progression will also prevent muscle

contracture, which is also addressed by the at home exercises (appendix e) after they are

demonstrated/taught during the rehabilitation appointment.

In addition to ROM exercises gentle joint mobilizations will be performed anteriorly and

posteriorly. The clinician will begin with grade I movement, making very little oscillations for 3-

5 minutes. This technique is to help decrease pain using neuromodulation to block pain signals.

This type of nerve transmission is not as fast as neurotransmission15, and therefore takes longer to

reduce pain. The clinician can progress to grade II mobilization with the tolerance of the patient

and consideration to not stretch the posterior joint capsule. These mobilizations not only help with

pain, but also can facilitate the movement of nutrients to the area in order to speed up the healing

process15, but again caution needs to be taken not to stretch the joint capsule so as to not cause

further injury.
 Reverse Hill-Sachs Lesion 10

Therapeutic Modalities

During the first two weeks the allograft is still in the acute phase of healing, therefore

continuous ultrasound (US) should not be used as it would increase the process of inflammation.

However, low intensity pulsed ultrasound (LIPUS) only has mechanical effects, and has been

shown to facilitate bone healing. While the research is still uncertain, it is thought that the

mechanical wave can help to stimulate bone growth. This technique is typically used in stress or

non-union fractures, however the same application can be applied to this allograft reconstruction.

The parameters for LIPUS include a 20% duty cycle, a frequency of 1.5 MHz, at an intensity of

30mW/cm2 for 20 minutes. During the treatment the clinician needs to continually ask the patient

how they are feeling, and keep in mind the precaution that they are applying US over metal screws

that could potentially heat up if US is done incorrectly.15

To reduce effusion, swelling and pain, a gameready unit can be used after the daily

rehabilitation program for 20 minutes at medium to high pressure depending on the level of

swelling and effusion in the anterior shoulder joint. The gameready combines the use of

intermittent compression and cryotherapy to provide an effective treatment. The compression of

the sleeve as the cold water flows through it acts as a pump providing pressure to the joint

intermittently. This change in sleeve pressure forces lymphatic and venous drainage which in turn

reduces edema. The cold water flowing through the sleeve decrease tissue temperature and

metabolism. This puts the affected cells in a hibernation like state in which they required less

energy to function. With less energy demand, less blood and nutrient dense fluid flows to the cells

which in turn prevent further swelling. Furthermore, decreasing metabolic need decreases the rate

at which cellular acidosis occur. This limits secondary injury and further swelling and edema.15
 Reverse Hill-Sachs Lesion 11

Throughout the day and ice bag can be applied for 20 minutes with an hour break in between to

have continual cryotherapy effects.

Phase II: Intermediate Phase (4-8 weeks)

Progression Criteria, Goals, Indications/Contraindication (Precautions)

In order to progress into phase II of the rehabilitation program the patient needs to have

nearly full (90%) if not full PROM. This criteria ensures that they are ready to progress into more

active range of motion (AROM) exercises. In addition, the patient should have minimal pain and

tenderness both when the area is palpated and when the joint is moving. Once it is confirmed that

these criteria are met the athlete can focus on regaining AROM. Along with AROM, the athlete

will begin regaining muscular strength in order to enhance proprioception and kinesthesia, as well

as improve their arthrokinematics and neuromuscular control. During therapeutic exercise he

should continue to avoid excessive adduction and internal rotation, but can discontinue the use of

the brace except in uncontrolled environments. The patient is a high school student, so he should

be caution of other students as they can be unaware of their surrounding and potentially put him

in a dangerous position.

Therapeutic Exercise

To begin strengthening exercises the patient will perform isometric contractions lying

prone or supine with his arm comfortably at his side. This exercise begins with a simple

strengthening activity and will have a long progression to achieve full AROM against resistance.

He will isometrically contract the muscles needed for shoulder flexion, extension, adduction,

abduction, internal rotation, external rotation and horizontal adduction. This exercise can be

performed for 2 sets of 45 seconds, the patient will contract and hold for 3 seconds, then relax.
 Reverse Hill-Sachs Lesion 12

These parameters are meant to cause slight fatigue, but should remain non-painful; they can be

adjusted as needed based off of the patients feedback. As long as this exercise is pain free after

the first two days performing this exercise the patient can progress to first a sitting position, and

then by the end of the week have his arm at 90 degrees of abduction and standing. Once the patient

is able to perform these without excessive fatigue he has established enough strength, dynamic

stability, and neuromuscular control to progress to isokinetics.

As with isometics, for isokinetics, the patient will begin prone or supine, moving their arm

through the different shoulder ROMs for 2 sets of 45 seconds. The patient will limit adduction and

horizontal adduction to 0 degrees and internal rotation to 45 degrees to prevent unnecessary stress

on the healing graft. Again, once these can be performed easily the patient will progress to sitting

then 90 degrees of abduction and standing. The progression up to this point should take

approximately 2 weeks depends on the athletes ability. From here manual resistance can slowly

be added as tolerated, performing all shoulder motions concentrically and eccentrically against the

clinicians force. Manual resistance is preferred over bands or weights not only because the

resistance can be immediately adjusted, but also because it gives the clinician feedback as to how

the patient is progressing. In conjunction with manual resistance, aquatic therapy can be used as it

provides resistance as well as pressure on the cutaneous receptors. This pressure can assist

proprioception by sending information to the CNS about the position of the joint in its surrounding

while the joint and ligament receptors are still being retrained after being damaged during

surgery.16

At this stage of rehabilitation core strength needs to be improved before progressing to

more functional shoulder exercises. The trunk and hips need to have the stability and strength to
 Reverse Hill-Sachs Lesion 13

provide a stable base for the upper body. The forces generated from the lower body are transferred

through the shoulder and into the arms and hands through the bodys kinetic chain. Therefore,

without a stable core, the shoulders have to work harder to stabilize the body while performing

functional exercises.16 This strengthening will include abdominals, low back, and gluteal

strengthening. As these muscles and joints are not injured, a high intensity low duration circuit

came be utilized to improve core strength and power needed to provide adequate stabilization to

the upper body. The circuit will include: flutter kicks, wall sits, bosu ball squats, and crutches. The

circuit will performed five times, increasing and then decrease in time from 30 seconds to 45 to 1

minute, back to 45, and then finishing with 30 seconds. These intervals are to help gain the

muscular endurance needed to provide a stable base for the upper body.

Therapeutic Modalities

Before starting rehab exercises for the day the athlete can use a moist heat pack to heat the

superficial tissue around the shoulder joint. While this superficial heat has little effect on deeper

tissues it can help to decrease pain from muscle soreness, as well as decrease muscle spasm by

promoting relaxation in chronic or post-acute injury such as the reverse hill-sachs lesion

reconstruction. Superficial heat can also help to decrease tissue stiffness that has developed from

prolonged immobilization.15 It is vital to eliminate joint stiffness from prolonged immobilization

as it can lead to adhesive capsulitis which will delay recovery time.1

Neuromuscular electrical stimulation (NMES) should be used during the isometric

contraction exercise. The use of NMES can be used to help re-establish muscle contraction after

surgery when the muscle is inhibited using the following parameters: 2500 Hz, 50-70

pulses/second, electrical pads placed on motor points and muscle belly, increase intensity until
 Reverse Hill-Sachs Lesion 14

visual muscle contraction is seen, a duty cycle of 10seconds on to 50 seconds off, and a treatment

time of 20 minutes daily. For the shoulder complex, the targeted muscles for re-establishing

contraction is the deltoid, long head of the biceps and rotator cuff muscles. These muscles are

responsible for the dynamic stabilization needed for proper proprioception and arthrokinematics

while the static structures like the posterior capsule and anteriomedial humeral head are

compromised.

Phase III: Strengthening Phase (8-12 weeks)

Criteria to Progress to Phase III:

By approximately week 8 the athlete should obtain full non-painful range of motion, with

only little limitation in adduction and internal rotation. There should be no palpable tenderness of

the glenohumeral joint as well as good muscular strength, dynamic stability and neuromuscular

control. By this time the bone graft has heal significantly, as adolescences have faster bone growth

than adults. By the end of phase III it will be healed completely and remodeling will begin.16 Now

that good basic function has been restored the rehabilitation goals will be targeted towards

preparing the athlete for return to activity, this includes continuing to improve muscular strength,

power, endurance and neuromuscular control. To do this the athlete will start basic conditioning

and advanced proprioceptive activities to prepare for functional exercise. The clinician must still

be cautious of excessive stress in internal rotation and adduction as well as it end ranges of motion.

Therapeutic Exercise

The athlete will begin each day using the upper body ergometer (UBE) active exercise with

little resistance and comfortable pace. This will not only be more effective to warm up the shoulder

than a heat pack, but it also introduces functional movement in a safe and controlled environment.
 Reverse Hill-Sachs Lesion 15

The athlete will use the UBE for 15 minutes before starting other rehabilitation exercise. As he

begins to regain upper extremity endurance he will be allowed to use the UBE at home twice a day

for 10-20 minutes. This will help the patient spend more time performing functional exercises

during rehabilitation as his shoulder will take longer to fatigue.

At this stage of rehabilitation the athlete can begin advanced neuromuscular control and

proprioception drills with the precaution that he doesnt put stress on the joint at the end ranges of

motion. He will begin with wall perturbation activities by placing his hand on a ball against the

wall. With his eye closed the athlete will move the ball side to side, up and down, and then in

circles both directions, performing each task for 2 sets of 1 minute and 30 seconds. This is a stable

exercise as it is close kinetic chain, but to progress the exercise it will become open chain, and the

athlete will have to keep his arm still as the clinician applies resistance in a multidirectional faction.

This again will be perform with the athletes eyes closed for 2 sets of 1 minutes and 30 seconds.

To ensure the athlete is getting the most out of the exercise the clinician should make sure that the

athlete is in scapular protraction as it is a more unstable, but also sports specific position.

The athlete will then begin a functional push-up progression, to increase dynamic strength

and stability. He will start the progression with simple wall push-up for 3 sets of 15. As these

become easy, he will progress to table push-ups with his body at approximately 45 degrees and

then regular floor push-ups. To test the patients core stability he will then be placed on a wobble

board or bosu ball while perform his push-up sets in order to ensure full body, dynamic stability.

Therapeutic Modalities

While the humeral head allograft is healing and the athlete is participating in therapeutic

exercises there will potentially be some pain from joint stiffness as well as from muscular fatigue
 Reverse Hill-Sachs Lesion 16

and delayed on-set muscle soreness. The most effective electrical stimulation for this situation is

interferential current therapy (IFC). It can cover a large area and is also thought to penetrate tissues

deeper than transcutaneous electrical nerve stimulation (TENS).

The interference between the two sinusoidal waves are thought to create a large area in

which the nerves are being stimulated from. This non-painful stimulus travels along type A nerve

fibers which are larger and more myelinated than the type C fibers which makes them faster. The

faster, non-painful stimulus reaches the CNS faster than the painful stimulus through the afferent

nerves and therefore blocks out the pain signals according to the gate-control pain theory. By

placing the 4 electrical pads in a crisscross fashion around the glenohumeral joint for 20 minutes

at a tolerable but not painful intensity, the use of ICF will decrease the athletes level of pain after

performing therapeutic rehabilitation exercises.15

In conjunction with the ICF treatment, an ice bag can be place directly on the skin over the

electrical pads as an effective treatment for pain and muscle spasm. The ice creates an analgesic

effect that can work with the IFC to decrease pain. The ice also helped to increase tissue stiffness

which is advantageous for the posterior joint capsule. By increasing stiffness there is an increased

stability while the soft tissue heals.15

Phase IV Return to Sport (12-24 weeks)

Phase IV is that last phase of rehabilitation, as the athlete prepares to return to sport. For

the patient to progress to phase IV they must have full ROM, no pain or palpable tenderness,

along with satisfactory isokinetic test strengthen test and clinical exam which can be seen in the

12 week progress note in appendix C. The goal of the athlete to return to play is obtained by

maintaining optimal levels of strength, power, and endurance in order to have proper
 Reverse Hill-Sachs Lesion 17

biomechanics when performing functional exercises. He will progressively increase activity level

to prepare patient/athlete for full functional return to activity/sport. However, before performing

these exercises the patient needs to be cleared by the physician, follow any activity restrictions

he may give. The physician will also determine if the patient can return to a normal weight lifting

routine, and certain exercise he should or should not perform. The athlete return to a weight

lifting program will meet the goal to maintain optimal muscular function which will allow the

athlete to progression to plyometric and return to sport exercises.

Therapeutic Exercise

Now that optimal muscular performance has been reached and is being sustained, the

athlete may initiate plyometric training. Plyometric exercises use the Golgi tendon organ and

muscle spindle to obtain optimal results from the neuromuscular system. Plyometrics are

essential to the explosiveness and rapid speed and directional changes, such as the deceleration

the athlete will need during a baseball pitch or football throw.16 2-hand drills such as the chest

pass throw, side to side throw and overhead soccer throw will be used for beginning plyometric

exercises. The athlete can start with a light ball, a soccer ball, and progression to using a

medicine ball. These exercises should be performed not only to fatigue, but past fatigue so as to

train the plyometric mechanisms how to function correctly every when the muscles are tired.

This will help during sport activity to prevent not only re-injury, but new injuries from occurring.

After progressing through two-handed plyometrics the athlete can progress to 1-hand

drills such as 90/90 baseball throws, wall dribbles and 90/90 baseball throws against different

targets on the wall. These multi-plane exercises are sport specific and maximizes the use of all

the necessary components of a successful rehabilitation including ROM, strength,

 Reverse Hill-Sachs Lesion 18

proprioception, plyometrics, dynamic neuromuscular control. They should be performed without

instability, pain or swelling with good biomechanics and posture.

Therapeutic Modalities

During this stage in the rehabilitation program there is not much requires for the use of

modalities. The most important effect to limit at this stage is muscle soreness. In the case of this

high school athlete who is heading into baseball season as a pitcher, the use of a cold whirlpool

could be effective in treating muscle soreness. Cold whirlpool is effective in treating areas like

the shoulder where an ice bag cannot easily conform to the entire area. The movement of the

water helps to reduce the heat of the skin through conduction.16 It also acts as a massage to help

decrease muscle spasm and pain.

Once athlete has demonstrated dynamic neuromuscular control with multi-plane

activities, without pain and with full ROM, then he is allowed to return to play. See appedix D

for discharge notes. It need to be a slow progression back to sport, meaning the athlete should

ease into practice and not go all out right away. It is important for that athletic trainer to monitor

this as the athlete in this case study will most likely be very eager to return. During baseball

season the athlete should be fine without a brace, however next football season he shoulder

strongly consider using a glenohumeral joint stabilizing brace as it is a contact sport.

 Reverse Hill-Sachs Lesion 19

Appendix
A: Initial Evaluation SOAP Note
August 10th
S: The athlete is a 17-year-old high school football quarterback on the varsity team. He entered
ATR 4 hours after undergoing allograft surgery for a reverse hill-sachs lesion of his left humeral
head. He states he is feeling pretty stiff and sore, but does feel more stable. His pain level is at a
constant 6-7/10 but that is to be except after surgery. He has some general drowsiness and nausea
from the use of the anesthesia and took 300mg of Vicodin upon arriving at the ATR and has a
14-day prescription directed to take 300mg twice a day, in the morning and at night.
While he will be unable to return for football season, the athlete also plays baseball in the spring
which begins 7 months from now. Baseball is very important to him, so his ultimate goal is to be
back for the start of the season in March. He was placed in a shoulder immobilizer at 20 degrees
abduction, 20 degrees external rotation, and slight extension (elbow behind plane of body) tted
preoperatively for 4-6 weeks to allow the repair to heal without unnecessary tension. He seems
worried about his current immobilizes state, but seems eager to begin moving it. I informed him
that if he is to return to baseball on time he will need to be very diligent about following
rehabilitation and treatment instructions.
The athlete lives at home with his parents, his mother works from home so she will be able to
help him throughout the course of his rehabilitation. He does not have a job to worry about so he
will be able to focus on his shoulder.
O: Athlete appears in good condition considering the circumstances. There is moderate swelling
and heat over the left glenohumeral joint, has well as severe discoloration/bruising over the
anterior portion of the joint where the fracture occurred. He is TTP over all aspects of his left
shoulder, especially the posterior capsule, and anterior deltoid. Elbow and wrist ROM are full
bilaterally. His shoulder ROM or strength was not assessed and doing so could cause damage to
the joint. Today the athlete received grades I joint mobilizations for pain before using the
gameready at medium pressure and IFC at an intensity of 30 for 20 minutes.
A: Post-operative allograft repair for a reverse hill-sachs lesion of the L shoulder. Prognosis for
this athlete looks good; he is a dedicated and smart athlete and seems to be committed to the
rehabilitation process. His short term goals are to gain nearly full passive ROM and discontinue
the use of the immobilizer in 4 weeks. Long-term goals are to return to baseball season on time
with full shoulder function and strength.
P: Athlete will come into the ART twice a day for the next 72 hours, 12:00 p.m. and 6:30 p.m.
appointment times. Will complete same treatment in todays session; joint mobilizations, and
IFC, as well as begin will PROM and LIPUS. PROM measurements of the shoulder will be
taken every day with a goniometer and documented. After the first 72 hours post-op, athlete will
be seen once a day at 3:15 p.m. when school is over. Will be diligent about icing 4-5 times a day
and elevating at home
 Reverse Hill-Sachs Lesion 20

B: 4-week progress note

S: Athlete is 4 weeks post reverse hill-sachs allograft for his left shoulder. He has been seen
every weekday for rehabilitation sessions. States that he is happy with his PROM progress and
feels ready for AROM. Swelling and pain have decrease significantly. Only has slight p! during
shoulder strength and motion exercises. His injury has not interfered with his classroom learn,
and his peers have been considerate of his braced shoulder to avoid accidental injury.
O: Athlete is doing very well with nearly full PROM loss and ready to begin AAROM exercises
and beginning strengthen exercises. Strength was not assessed as he does not have AROM, but
PROM is as follows:
L shoulder R shoulder
Internal rotation 50 degrees Internal rotation 60 degrees
External rotation 90 degrees External rotation 90 degrees
Flexion 180 degrees Flexion 180 degrees
Extension 60 degrees Extension 60 degrees
Horizontal abduction - ~42 degrees Horizontal abduction - ~42 degrees
Horizontal adduction - ~100 degrees Horizontal adduction - ~130 degrees
He is doing very well with at home exercises, and is more than ready to start AROM and
strengthening. Athlete no uses braces except when in the halls, as fellow classmates can be
unpredictable. No observation of adhesive capsulitis forming.
A: Post-operative allograft repair for a reverse hill-sachs lesion of the L shoulder. Athlete is right
on schedule and is ready to be pushed a little harder during rehabilitation. He has remained fully
committed to his rehabilitation process and has met his short term goal of full PROM.
P: Continue to see athlete on a daily basis, transition to AROM exercises and begin strengthen.
By week 12 the bone graft will be fully healed at which time he can do more functional
exercises. Until then he will continue to progress through AROM and strengthen programs
 Reverse Hill-Sachs Lesion 21

C: 12-week progress note

S: Athlete is 3 months post reverse hill-sachs allograft for his left shoulder. Have been seeing
athlete every weekday for rehabilitation sessions. Athlete has improve drastically and states that
he is doing awesome. No complaints about any p! or instability at any time. He has not used
the brace at all for 6 weeks now and feels totally comfortable without it. He states that now that
he has pain free full AROM and is using the UBE he feels much more functional and is eager to
start sport specific exercises. The bone graft is almost fully healed at this time and is now in the
remodeling stage. With improved static stability he can progress quickly to return to play.
O: Athlete is doing fantastic with full PROM and AROM. We are still limiting the amount of
stress on the joint when in internal rotation or adduction until at least 4 months. He is completing
exercises everyday almost effortlessly and has been quickly gaining strength, with MMT grades
all 4 or above. AROM measurements as follows:
L shoulder R shoulder
Internal rotation 55 degrees Internal rotation 60 degrees
External rotation 90 degrees External rotation 90 degrees
Flexion 180 degrees Flexion 180 degrees
Extension 60 degrees Extension 60 degrees
Horizontal abduction - ~42 degrees Horizontal abduction - ~42 degrees
Horizontal adduction - ~125 degrees Horizontal adduction - ~130 degrees
He is doing very well with UE functional exercises, with the progression from wall push-ups to
unstable ground push-ups from week 8-12. No observation of any abnormal scapula-humeral
rhythm while doing any of his exercises.
A: Post-operative allograft repair for a reverse hill-sachs lesion of the L shoulder. Athlete
remains on schedule, and should be ready to return to play 2 weeks before baseball season start,
giving him time to participate in preseason workouts. In order to be discharged he must be able
to perform functional activities properly, perform sport and activity-specific exercises at least to
pre-surgery levels, and return to full participation without pain, with full ROM, with normal
strength, mobility and execution of activities.
P: Continue to see athlete on a daily basis and include more agility and sports specific drills.
Increase plyometric and strengthening exercises using ball toss exercises. Allow last 5-10
degrees of ROM to return on its own.
 Reverse Hill-Sachs Lesion 22

D: Discharge Note
This athlete has completed 6 months of rehabilitation after an allograft repair of the
anteriomedial humeral head from a reverse hill-sachs lesion of the L shoulder. Long-term
treatment goals were to gain normal range of motion and function as well as enabling the patient
to return to baseball season on time. Patient has been through many ROM exercises, including
joint mobilizations, PROM, AAROM exercises and AROM. He has also completed several
strengthening exercises as well as UE plyometric and functional progression which he performed
without pain or discomfort. Subjectively athlete has expressed extreme improvement in his
shoulder/left upper extremity from the time of initial evaluation. Objective Findings:
AROM has returned and continue to be normal;
Internal rotation 60 degrees
External rotation 90 degrees
Flexion 180 degrees
Extension 60 degrees
Horizontal abduction - ~42 degrees
Horizontal adduction - ~130 degrees
Muscle strength: Athlete continues to display -5/5 to 5/5 muscle strength in all shoulder and UE
muscles during MMT and specific strength muscle testing techniques. Athlete has begun to pitch
with proper mechanics with no dysfunction or pain. At this time, the athlete will be discharged
to a simple pre-practice/meet schedule for RTC strengthening activities. At this time I feel he is a
candidate for discharge to return to play without fear of re-dislocation or injury to anteriomedial
humeral head. Posterior stability and shoulder strength will be checked every month to ensure
proper static and dynamic stabilize continues.
 Reverse Hill-Sachs Lesion 23

E: Home exercise program

Given to the athlete 24 hours after surgery to perform two times daily for the first four weeks
Pendulum exercise: 1 set of 5 minutes
Bend from the waist, letting your arms hang down
Keep your arm and shoulder muscles relaxed
Allow arm to swing forward to back, side to side, then in small circles in each direction
Only use hips to create shoulder/arm momentum

Range of motion exercise: 2 sets of 1 minute

Wrist and elbow active range of motion: to prevent muscle atrophy and contracture
Remove brace and use caution not to elevate glenohumeral joint
Move elbow or wrist from flexion to extension at a moderate pace (120bpm)
Can brace shoulder by resting elbow on table with shoulder in neutral position if needed

Rope & Pulley: 2 set of 1 minute

Elevation in scapular plane to tolerance

Slow and controls
Relax shoulder completely
 Reverse Hill-Sachs Lesion 24

Figure 1

Drake RL, Vogl W, Mitchell AW et al. Gray's Anatomy for Students. Elsevier Brasil; 2010.
 Reverse Hill-Sachs Lesion 25

Figure 2

Cvetanovich G, Bhatia S, Provencher M, Cole B. Treatment of Bone Defects in Posterior

Instability. Operative Techniques In Sports Medicine [serial online]. March 2014;22(1):10-
17. Available from: SPORTDiscus with Full Text, Ipswich, MA.
 Reverse Hill-Sachs Lesion 26

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