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Physiotherapists and orthopaedic surgeons spend significant amounts of time and effort treating shoulder injuries and conditions, of which there are many. The shoulder, an unstable joint with a very large range of movement, the greatest in the body, is vulnerable in many situations to injury or mechanical stresses. Its instability means it can be relatively easily dislocated in a fall or activity at end range. We use the arm to save ourselves if we fall, making fractures common and heavy or overhead work over time leads to rotator cuff tears.
Due to the very large number of potential injuries, fractures and operations which can affect the shoulder it is very important to know the exact diagnosis and plan of treatment. Physiotherapists specialise in managing post-operative and post-trauma shoulder problems, following the surgical and trauma protocols agreed with the shoulder surgeons. On meeting the patient initially a good strategy is to review the progress of their case so far, as this can occasionally throw up unexpected anomalies which need exploring. The patient should have a short time to tell their story or they may not feel they have been heard.
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.
When fitting the Seton sling the elbow should fit right back into the gutter with the sleeve folded back slightly if necessary to allow the hand to be clear of the sling. There may be a small Velcro strap to place across the upper forearm to keep the gutter closed but this should not be tight or it can cut in to the tissues, especially if there is a lot of thick swelling such as after humeral fracture. The long strap is then taken from the elbow side of the sling over the opposite shoulder and down to the wrist. Tightening this up is where it gets trickier.
The straps of the sling are made from a material which has some elasticity and tends not to slide that well on skin or clothes when it is adjusted in situ. When the sling is applied and all tightened up it can usually be observed that there is actually little support under the elbow so the sling is not doing its support job well. Feeling under the elbow it is easy to notice the looseness of the elbow part of the gutter and tightening up the strap at the front just leads to increased tension in the front section of the strap. This needs a different type of approach.
To get the sling right needs two people, the patient and a helper. The helper lifts the elbow of the affected arm in the sling while the patient tries to let the shoulder relax. Then the helper gets hold of the part of the strap along the back and pulls it up towards the shoulder, holding it there. The helper lets go of the elbow and adjusts the strap whilst still holding the back part of the strap under tension with the other hand. Having completed this manoeuvre the elbow should now feel heavy and supported in the sling and the patient feel it is quite comfortable.
The physiotherapist will give general advice to the patient about managing in the sling and how to do day to day activities. The sling should only be taken off for washing and dressing initially. If the clothes are put on normally the affected arm must be put in first without lifting or rotating it significantly. Washing under the arm can be achieved by holding the arm in the position it usually is in the sling and bending forward, allowing access to the armpit without lifting the arm up actively.