RECOVERY THROUGH KINETOTHERAPY AFTER A LATARJET PROCEDURE

The Latarjet procedure provides excellent long-term outcomes in the treatment of recurrent anterior glenohumeral instability. Twenty years after the Latarjet procedure, arthritis may develop or progress in 23.5% of cases, but the majority of arthritis is mild. [9] This paper had as object of study the importance of kinetotherapy in the recovery of the shoulder after a Latarjet procedure. The research also aims upon the importance of a well-developed program, using individualized and rationalized exercises in order to bring a rapid and efficient recovery of the


Introduction
The shoulder joint has the largest range of motion in the body. Anatomically, it consists of a shallow articular fovea, which can easily cause instability between the acromion and the humeral head. Due to this instability, pain in the shoulder joints is the second most frequent type of complaint, surpassed only by lumbar pain [2].
The treatment of recurrent glenohumeral dislocation is surgical; the type of procedure depends on the characteristics of the instability, type of underlying lesion, number of dislocations until surgery, age, and level of physical activity practiced and expected [11,12], [15].
Coracoid process transfer, also known as the Latarjet procedure, was first described by Dr Michel Latarjet in 1954. [8] The procedure, which involves the transplantation of a section of the coracoid process flush with or slightly medial to the anterior aspect of the glenoid, continues to be popular for anterior shoulder stabilization with associated glenoid bone loss [14]. More recently, the arthroscopic Latarjet technique has been described, with promising early results [4], [7]. The Latarjet procedure, particularly when performed arthroscopically, is a technically difficult procedure [6].
Recovery of internal and external rotator muscle strength after surgical stabilization by the Bristow-Latarjet procedure seems important in order to allow patients to truly benefit from the surgical therapy and resume normal daily activity [1], [3], [5], [13], [16].

Objectives and hypothesis
The aim of this research is to select the best kinetotherapeutic means and methods for the recovery of the shoulder joint and to create a personalized program so that the patient who has undergone the Latarjet procedure to recover as much as possible regarding the anatomical function.
General objectives of the research: -Evaluating the effectiveness of the recovery methods using different testing.

Research hypothesis:
If a kinetotherapeutic program, optimally conceived and appropriate to the particularities of the subject helps to recover and restore the functionality of the affected member, increase muscle activity within a time frame as well as to regain self-confidence.

Material and Methods
The clinical trial was performed on a 21year-old subject and took place between November 2017 and April 2018.
The athlete presented left anterior shoulder dislocation (recent injury after a relapse). It is worth mentioning that the subject after the surgery had immobilized the abduction arm at 90º in a orthosis with immobilization support for 2 weeks. After these 2 weeks of immobilization, the kinetotherapeutic plan was started.
This research began with first patient assessments and completing medical records.
The recovery programs that have been developed and used were structured in five phases.
In addition to these exercises, the recovery of the subject included massage, kinetic bands, psychotherapy, hydrokinetotherapy, physiotherapy, medical treatment and to the end of kinesitherapy, the subject gradually began to practice swimming.
The kinetotherapeutic plan was composed of five phases as follows: • Passive and active exercises for wrist, elbow and cervical area were performed in the first phase (the first 1-3 weeks) after the orthosis was abandoned for the use of movement, abduction, adduction, flexion, extension, exercises with the cane, submaximal isometry in all planes, cure for the reduction of pain inflammation and posture exercises. • The second phase (weeks 4-9), was divided into 2 stages, all passive and active exercises: In the first stage (weeks 4-6), in which shoulder pivotal exercises, initiation in joint mobilization, flexion, extension, abduction, 45° external rotation, 45° internal rotation, isometry, isotonicity, proprioceptive exercises, neuroproprioceptive facilitation techniques for scapula. During the second stage (weeks 7-9), flexing, extension, adhesion to tolerance, external rotation 50-60°, internal rotation 50-60°, articulation mobilization, different isometric angles, isotonic exercises for shoulder muscles, proprioceptive exercises. • In the third phase (weeks 10-15) passive, active-passive, passive-active exercises for joint mobilization, stretching exercises, neuromuscular control means, neuroproprioceptive facilitation techniques, isotonicity, abduction, flexion, extension , internal rotation, external rotation. • In the fourth phase (weeks 15-20), proprioceptive active exercises were performed and increased functional activity. Exercises specific to practiced sport and further exercises performed in the previous phase. • In the fifth phase (after week 20), the following month, the patient performed exercise on the affected limb, practiced swimming and all of them coincided with the strenght.
The clinical evaluation included some of the following tests: range motion of the shoulder, muscular testing, Apley test, Hawkins test, Job test, Lift-Off Gerber test.

Results and Discussions
The results obtained after the application of the kinetotherapeutic programs show that the objectives of the recovery were fulfilled:    figure 2 shows the results registered by the patient in the three evaluations made during his recovery process. There is a good evolution in muscle strength, especially in flexor muscles, arm abductors and scapula descenders, which show that the exercises used in the kinesitherapeutic programs aimed at increasing muscle strength, have been well-selected and properly executed.
Regarding the muscular balance in the movements of flexion, extension, abduction, adduction, internal rotation and external rotation made by the scapula-humeral joint, the patient returned to normal force but immediately after the surgery he had a muscle mass deficiency. During the three trials (initial, intermediate and final), the patient recorded values of the force from F2 to F4, which means that he was close to the normal force value, namely F5, for the representative muscles of each movement

Conclusions
Following the study of the patient and the results obtained at the data interpretation we can draw the following conclusions: In the three tests performed, the degree of flexion was progressively improved with the exercises staged in five phases, the flexion movement reaching its normal value (180°).
The degree of extension, due to the use of the exercises in the five phases, approximated the normal value, namely (60°).
The abduction movement recorded a major increase to almost normal (180°).
The adduction movement, with the help of the exercises, came close to the normal value 45°, not showing any pain after the three evaluations.
The degree of amplitude of the internal rotation movement achieved a 30° increase without pain, the recovery program exercises contributing decisively to this increase.
The degree of amplitude of the external rotation movement increased by a total of 30° reaching almost normal values.
There were recorded values with progressive relief, so the patient continued the exercise program under the guidance of the physical therapist. It is very important for the recovery program to be done by a skilled and wellknown physical therapist who will leave a mark on the way he / she works with the patient, on the improvement of each movement, but also on the patient's psyche.
The communication and the relationship between patient-physiotherapistphysician have resulted in improved recovery results to the limit of each patient's exercise.
The recovery program was created specifically for this patient, and the positive results made it return to regular day-to-day activities.