Return to Play
Return to play in patients following a shoulder dislocation is determined when full ROM and strength have been regained. Return to play is usually sooner for older adults than for younger athletes, because the fear of redislocation is much lower in older adults. Usually, older adults can return to play within 3 months. With younger adults, conditioning can continue through shoulder rehabilitation; however, decisions about returning to play should be more conservative than those in older adults. Again, absolute criteria are full ROM and full strength.
When determining a patient's return to competitive sports, the author uses the following criteria:
- Scapular stability through full ROM
- Normal scapulohumeral rhythm
- Full active and passive ROM
- Rotator cuff strength at 80% of opposite side
- Pain-free activities of daily living (ADLs)
Complications
The most common complication of an acute shoulder dislocation is recurrence. This complication occurs because the capsule and surrounding ligaments are stretched and deformed during the dislocation. Age is the most important indicator for prognosis; dislocations recur in approximately 90% of teenagers.
Another common complication following dislocation is fracture. The most common type is a Hill-Sachs lesion or compression fracture of the posterior humeral head. Fractures of the proximal humerus, greater tuberosity, coracoid, and acromion have also been described.
Rotator cuff tears also commonly occur as a result of shoulder dislocations, and the frequency of this complication increases with age. This complication can be expected in 30-35% of patients aged 40 years or older. Slow progression in return to active function following shoulder dislocation in a middle-aged patient should warrant a workup for a rotator cuff tear.
Vascular injuries are rare, but they do occur, especially in older patients. Vascular injuries are more common with inferior dislocations and usually involve a branch of the axillary artery.
Nerve injuries are much more common than vascular injuries, especially with anterior or inferior dislocations. The axillary nerve is the nerve injured most often and may be crushed between the humeral head and the axillary border of the scapula or injured by traction from the humeral head. Axillary nerve injury has been reported in as many as 33% of acute anterior dislocations.
Prognosis
Age at dislocation is the most important prognostic indicator for recurrence of shoulder dislocations. Younger age at initial injury increases the likelihood for future dislocation. The recurrence rate is thought to be 90% if the initial episode occurs in the teen years. In patients aged 40 years or older, the recurrence rate is 10-15%. Most redislocations occur within 2 years of the primary injury. Persons with axillary nerve injuries can be expected to recover completely within 3-6 months.
Education
Educate the patient on the importance of strength training following shoulder dislocation. The patient must understand that recurrence is possible and therapy should be used to prevent recurrence.
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