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Shoulder Dislocation Treatment & Management

  • Author: L Edward Seade, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Aug 27, 2015
 

Acute Phase

Rehabilitation Program

Physical Therapy

In the acute phase of a dislocated shoulder, therapy should be limited. The arm should be immobilized in a sling and swathed for 1-3 weeks. The actual position of the arm in the sling has been debated and thought to be more beneficial to the torn soft tissues with the arm in external rotation.[9, 10, 11, 12] Recent literature has shown that having the arm in internal rotation while in the sling has no impact on the rate of recurrent dislocation when compared with patients immobilized in external rotation.[13] While the patient is in the sling, elbow, wrist, and hand range of motion should be encouraged. Working with the parascapular muscles is also important during this acute phase of rehabilitation since these can be initiated while the patient is still in the sling. These exercises should be continued when the patient comes out of the sling.

Active and passive flexion, extension, abduction and internal/external rotation begin at about the third week, when the patient comes out of the sling. The authors encourage patients to get about 10 degrees of improvement in their motion per week. One will find that patients usually progress faster than 10 degrees per week. It is important to educate the patient and inform him or her that getting all of the motion back "right away" can be detrimental to the stability of their shoulder. Rehabilitation should be geared to gently restoring the range of motion over 6-8 weeks.

A good adage during the first 3 weeks after a shoulder dislocation is to "keep the hand in view." While looking forward, the patient should never let his or her hand be placed in a position outside the line of vision. This instruction assures a midrange position that does not compromise apposition of the torn or stretched anterior capsular structures to the glenoid.

Surgical Intervention

The recurrence rate for shoulder instability is highly dependent on the age of the patient. Nonoperative care should be performed first before entertaining the thought of surgery. Most patients are able to rehabilitate their shoulder with rest and physical therapy.[1, 5]

A meta-analysis of 10 studies with 1324 patients analyzed the risk factors which predispose first-time traumatic anterior shoulder dislocations to events of recurrence. The study concluded that men, patients younger than 40 years at initial dislocation, shorter time from initial dislocation, hyperlaxity and lack of greater tuberosity fracture were key risk factors that increase the risk of recurrent instability after first-time traumatic anterior shoulder dislocations in adults.[14, 15]

In patients who have recurrent shoulder instability, operative care should be highly considered.[2, 6, 7] Numerous studies have shown the increased likelihood of traumatic glenohumeral arthritis in patients with multiple shoulder dislocations. Operative care may consist of both open or arthroscopic treatment of the cause of instability.

The goal of an operative repair is to reattach the torn tissue back to the place where it tore off of the bone. The most likely spot where the ligament tears is the glenoid. Recurrent shoulder dislocations also stretch out the ligaments. It is imperative to also address the tissue laxity during the operative procedure. The surgery can be done through small incisions (arthroscopy) or with an open incision.

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Recovery Phase

Rehabilitation Program

Physical Therapy

After the initial period of immobilization, passive ROM exercises should begin. Older individuals should begin performing ROM of the shoulder after 1 week of immobilization, because these patients are prone to shoulder stiffness. Passive ROM exercises should include shoulder pendulum exercises and an overhead pulley system for the shoulder. Goals for passive ROM should be 30° of external rotation and 90° of flexion for the first 3 weeks, followed by 40° of external rotation and 140° of flexion for the second 3 weeks.

The rotator cuff may also have been injured during the dislocation, so the therapist should be cognizant of the status of the rotator cuff during the early phase of rehabilitation.

Surgical Intervention

Athletes who demonstrate symptomatic instability during guarded physical therapy should be considered for an MRI evaluation and probable arthroscopic or open anterior shoulder tissue repair.

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Maintenance Phase

Rehabilitation Program

Physical Therapy

More vigorous therapy can be initiated after full passive ROM has been regained, usually after 6 weeks. Rotator cuff strengthening exercises can be initiated with the use of rubber tubing or weights. Because the rate of shoulder redislocation is so much higher in young adults, vigorous training and strengthening should be delayed until approximately 3 months after the injury. Swimming is an ideal exercise to regain shoulder strength and should be encouraged once strengthening exercises have begun.

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Contributor Information and Disclosures
Author

L Edward Seade, MD Chief of Shoulder Service, Orthopaedic Specialists of Austin

Disclosure: Nothing to disclose.

Coauthor(s)

Robert Josey, MD Consulting Staff, Department of Orthopedic Surgery, Orthopaedic Specialist of Austin

Robert Josey, MD is a member of the following medical societies: American Medical Association, Phi Beta Kappa, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, Minnesota Medical Association, American College of Sports Medicine

Disclosure: Nothing to disclose.

References
  1. Matsen FA III, Thomas SC, Rockwood CA Jr. Anterior glenohumeral instability. Rockwood CA Jr, Matsen FA III, eds. The Shoulder. Philadelphia, Pa: WB Saunders Co; 1990. Vol 1: 526-622.

  2. Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthop Clin North Am. 2008 Oct. 39(4):507-18, vii. [Medline].

  3. Blasier RB, Guldberg RE, Rothman ED. Anterior shoulder stability: Contributions of rotator cuff forces and the capsular ligaments in a cadaver model. J Shoulder Elbow Surg. 1992. 1:140-50.

  4. Hovelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996 Nov. 78(11):1677-84. [Medline].

  5. Burkhead WZ Jr, Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am. 1992 Jul. 74(6):890-6. [Medline]. [Full Text].

  6. Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management. J Am Acad Orthop Surg. 1998 Jan-Feb. 6(1):65-72. [Medline].

  7. Cox CL, Kuhn JE. Operative versus nonoperative treatment of acute shoulder dislocation in the athlete. Curr Sports Med Rep. 2008 Sep-Oct. 7(5):263-8. [Medline].

  8. Cofield RH, Kavanagh BF, Frassica FJ. Anterior shoulder instability. Instr Course Lect. 1985. 34:210-27. [Medline].

  9. Itoi E, Hatakeyama Y, Urayama M, Pradhan RL, Kido T, Sato K. Position of immobilization after dislocation of the shoulder. A cadaveric study. J Bone Joint Surg Am. 1999 Mar. 81(3):385-90. [Medline].

  10. Itoi E, Sashi R, Minagawa H, Shimizu T, Wakabayashi I, Sato K. Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging. J Bone Joint Surg Am. 2001 May. 83-A(5):661-7. [Medline].

  11. Itoi E, Hatakeyama Y, Kido T, Sato T, Minagawa H, Wakabayashi I, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg. 2003 Sep-Oct. 12(5):413-5. [Medline].

  12. Itoi E, Hatakeyama Y, Sato T, Kido T, Minagawa H, Yamamoto N, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial. J Bone Joint Surg Am. 2007 Oct. 89(10):2124-31. [Medline].

  13. Liavaag S, Brox JI, Pripp AH, Enger M, Soldal LA, Svenningsen S. Immobilization in external rotation after primary shoulder dislocation did not reduce the risk of recurrence: a randomized controlled trial. J Bone Joint Surg Am. 2011 May. 93(10):897-904. [Medline].

  14. Olds M, Ellis R, Donaldson K, Parmar P, Kersten P. Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis. Br J Sports Med. 2015 Jul. 49 (14):913-22. [Medline].

  15. Boggs W. Several Risk Factors Predict Instability After Anterior Shoulder Dislocation. Reuters Health Information. Available at http://www.medscape.com/viewarticle/844400. May 11, 2015; Accessed: August 28, 2015.

  16. Jouve F, Graveleau N, Nove-Josserand L, Walch G. [Recurrent anterior instability of the shoulder associated with full thickness rotator cuff tear: results of surgical treatment] [French]. Rev Chir Orthop Reparatrice Appar Mot. 2008 Nov. 94(7):659-69. [Medline].

  17. Orloski J, Eskin B, Allegra PC, Allegra JR. Do all patients with shoulder dislocations need prereduction x-rays?. Am J Emerg Med. 2011 Jul. 29(6):609-12. [Medline].

  18. Pouliart N, Gagey O. Consequences of a Perthes-Bankart lesion in twenty cadaver shoulders. J Shoulder Elbow Surg. 2008 Nov-Dec. 17(6):981-5. [Medline].

  19. Reeves B. Acute anterior dislocation of the shoulder. Clinical and experimental studies. Ann R Coll Surg Engl. 1969 May. 44(5):255-73. [Medline]. [Full Text].

 
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Anterior dislocation.
Normal shoulder.
Shoulder dislocation, Part 1.
Shoulder dislocation, Part 2.
Shoulder dislocation, Part 3.
Shoulder dislocation, Part 4.
Shoulder dislocation, Part 5.
 
 
 
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