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shoulder injuries management in Ayurveda



Introduction:

Normal shoulder rhythm is highly essential for many popularsports and shoulder dysfunction causes significant impairment of performanceand quality of the athlete. There are somany abnormalities underpinning toshoulder pain and shoulder region remains one of the most challenging regionfor all sports medicine practitioners. Functional and structural anatomybiomechanics, kinesiology, dyanamic forces on shoulder on each sports should beunderstood.

Glenohumeral joint is ball and socket joint with shallowsocket and inherently unstable.  Thereare static stablisers and dynamic stabilisers in shoulder joint.  Glenohumeral ligament, glenoid labrum andcapsule are static stabilizers and Rotator cuff and scapular stabilizingmuscles.

Scapulohumeral rhythm: The scapular stablisers also play animportant role in shoulder joint movement. Glenohumeral movement requires thescapulothoracic, acromioclavicular, and sternoclavicular joints to alsomove.  Normal shoulder function requiressmooth integration of movements of these joints; This integrated movement isreferred as scapulohumeral rhythm.  An abnormality of scapulohumeral rhythmare most common cause for shoulder injury. It may be due to weakness ofscapular stabilizers with or without weakness of rotator cuff muscles,tightness of scapulohumeral muscles (infraspinatus, teres minor, andsubscapularis)  OR involuntary adaptationto avoid a painful arc..

An imbalance between the deltoid and the rotator cuffmuscles strength may result in excessive superior movement of the humeral head,causing impingment of subacromialstructures.

 

Injury to shoulder:

Shoulder injuries are common in sports like volleyball,handball, basket ball, cricket, tennis, badminton and throwing activities likehammer throw, javelin, shot put etc…There are few occasions in which shoulderinjuries occur in Soccer, Kabbadi due to heavy fall on shoulder or stretchforce of the shoulder muscles due to pull.

Pain on shoulder maybe due:

Rotator cuff injury or strain – mainly supraspinatusinjury, strain, tear

Instability-  labral lesions, dislocation,

Stiffness- (secondary to trauma,surgery, injury to cervical nerve root and brachial plexus, adhesive   capsulitis), A C join (Acromio clavicularjoint)

Referred pain- cervical pain, upper thoracicpain, trapezius, lavator scapulae,

 

Symptoms of rotator cuff tear

  • Pain at rest and at night, particularly if lying on the affected shoulder
  • Pain when lifting and lowering your arm or with specific movements
  • Weakness when lifting or rotating your arm
  • Crepitus or crackling sensation when moving your shoulder in certain positions

 

 

Correct predisposing factors:

 

Rounded Rectangle: Over head serve or smash during game Is unnatural and highly dynamic, oftenexceeding the physiological limits of the joint.Optimal shoulder function requires goodkinetic chain function, optimal stability, andcoordination of the scapula in the overhead action.Kinetic chain allows generation andtransfer of forces from the leg to the hand.50% of total kinetic energy and totalforces of the serve are developed inthe leg, hip, trunk linkShoulder has 13% contribution to total energy and 21% contribution to total force                                         Poor throwing technique, faultyswimming style, stiffness of lower cervical or upper thoracic  spines, or muscles imbalance and weakness ofscapular stabilizing muscles. It is essential to consider the whole kineticchain, as any deficiency in the chain (eg stiff lumbar spine) put additionalstress on distal part of the chain (eg rotator cuff).

 

 

Over head serve or smash during game

Isunnatural and highly dynamic, often

exceedingthe physiological limits of the joint.

Optimalshoulder function requires good

kineticchain function, optimal stability, and

coordinationof the scapula in the overhead action.

Kinetic chain allows generation and

transfer of forces from the leg to the hand.

50% oftotal kinetic energy and total

forcesof the serve are developed in

theleg, hip, trunk link

Shoulderhas 13% contribution to total energy and 21% contribution to total force

Force distribution chain graph of shoulder

 

 

 

We have donetreatment for 32 cases of rotator cuff injuries in sports so far, among themmany National players including volley ball, handball and badminton. 2 caseswere National volley ball players and underwent surgery from Mumbai by Expertshoulder Arthroscopic specialist.

 

CASE STUDY:

 

Name of thepatient: R. Rajeeve

Working atBPCL (Former National Volleyball team)

Player) with rotator cuff injury- lostcareer due to surgery-  18 months back

Condition of the patient after surgerywas not promising even after rehabilitation phase.  Patient cannot abduct right shoulder morethan 45 degree. ROM was limited on external rotation and forward flexioncompared to left shoulder joint. 

Drop arm test found to be negative, apprehensiontest  positive, Active forward flexionlimited to 90 degree (passive pain limiting 120 degree), patient cannot lift 1kg dumbbell above 90 degree, unable to use level 1 theraband in full extension.

 

General Stability and ROM examination ofaffected shoulder was as follow

 

?  Patientwas unable to lift his right hand full range of motion

?  Cannotlift weight more than 1 kg forward flexion.

?  Canotuse theratube level 2 for shoulder exercseise.

?  Forwardflexion was restricted to 65 degree

?  Severemuscle wasting noted on the subscapular, deltoid, supraspinatus muscles.

?  Feelingof pain on shoulder movements

?  Cannothold the shoulder for forcible abduction and external rotation.

 

Patient was advised for active sportsafter 1 year after surgery

 

Treatment protocol:

 

First phase of treatment was to improvethe range of motion and flexibility of the shoulder, so given stretching andactive passive ROM exercises for shoulder,

Second phase strengthening the dynamicstabilizers and then static stabilizers of the shoulder

Third Phase muscle training,stabilization programme and finally core strengthening programme of shoulderback hip and trunk muslces

 

Treatment modalities implemented

?  Physicaltherapy

?  Isolatedmuscle stretching

?  Rangeof motion exercises

?  Musclestrengthening with thera tubes level 1 & 2

?  Dumbbellexercises for Rotator cuff particularly supraspinatus, infraspinatus, deltoids,subscapularis, teres minor and ultimately to serratus anterior and trapezius.

?  Strengtheningof lower leg muscles of calf and hamstring and thigh

?  Strengtheningof lumbar muscles and trunk muscles

 

 

Ayurvedic treatment modalities

(Internalmedication)

?  Panchatikthakamgritham 10 gm at night

?  Aswabala  1 tablespoon at night

?  OMCcapsules 1-1-1 bef food

?  Gandhathailam10 drops with milk

?  Musthadimarma kashayam + Nadi kashayam

 

 

External applications;

?  Karpasasthyadi+ostalgin+ kethakeemooladi 1st  week

?  Mahamasham+ karpasasthyadi+ Rasathailam 2nd  week

?  Shashtikathailam + mahamasha tailam= 3rd week.

 

 

 

Treatment modalities:

Dhanyamladhara 5 days (day 1 – 5 days)

Patrapodalaswetha 7 days

Shashtikamamsa pinda swetha  days (11-17 days)

Lepanam(External application)  ayursports powder+ honey+ Ghee on affected muscle and shoulder

Nasyam: ksheerabala101. : 7 days.

 

 

?  Patientcan only do treatment for 17 days, inbetween the treatment period he wasrequired at the office frequently, so treatment was stopped for 2 days inbetween.

 

After the treatment condition of thepatient was as follows:

 

Muscles strength improved to greatextend.

Wasting was still there but reduced itsseverity.

He was able to use theraband level 4without any discomfort 25 Rep x 3 sets, Level 5 theratube with 15rep x 2 sets.

Can raise dumbbell of weight 4 kg forthe same repetitions

Over head throwing with medicine ballwas excellent

Bend over raise with weight, lat pullexercise without resistance

External rotation against resistancewas Grade 5.

Forward flexion was full Rom withoutany pain

Joint movements were pain free exceptforward flexion.(mild pain on supraspinatus on slow forward flexion with slightover sliding of muscles noted)

 

Patient wason preparation to play for Kerala in National Games at Ranchi after thetreatment, Since he was unable to play for the Country for the last 2 years, heurged to join the team and started to Ranchi from our hospital without waitingfor further rehabilitation and resting period.

And finallyhe played for Kerala and performed well, and was success for the Kerala teamwith his performance.

 

?  This study proves that Ayurvedic integratedapproaches can be successfully employed in sports injury rehabilitation fasterthan modern treatment and make their performance as before or evenbetter than before.

?  We can speed up the recovery and earlypropioception without further resting period up to certain extend.

 

Next issue: Spondylolisthesisgrade 2 patient Advised to quit sports and surgery -Achieved National Recordfor Polevault after integrated treatment approach.

 

Dr. Arshad.P

P. G. DipSPSN

CSM(international Olympic Committee)

TPDC (AsianFederation of Sports medicine)

DAISMANSPORTS MEDICINE CENTE, KONDOTTY

E-mail: ayursports@yahoo.co.uk

Mob: 09895265312/0483-6415898
















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