eMedicine Specialties > Sports Medicine > Shoulder
Shoulder Dislocation: Treatment & Medication
Updated: Dec 8, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
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. Active or passive shoulder abduction with shoulder internal rotation is permissible, and removing the arm from the sling to work in a neutral internal-external rotation position is desirable, because a neutral position may actually improve positioning of the torn anterior capsule to the glenoid. During this time, the patient should perform elbow, wrist, and hand ROM exercises.
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
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.
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.
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.
Medication
Shoulder dislocations are extremely painful events. If relocation is not accomplished within an hour, anesthesia via conscious sedation is necessary in the emergency department setting. Medications for this technique are not discussed in this article.
Oral narcotic analgesics are reasonable for a period of days, but prolonged use is categorically inappropriate.
Related Medscape topics:
Resource Center Adverse Drug Events Reporting
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma. A 3- or 4-day supply of hydrocodone or similar schedule III narcotic should be provided following shoulder relocation.
Related eMedicine topic:
Toxicity, Narcotics
Hydrocodone and acetaminophen (Lortab, Norcet, Vicodin)
Drug combination for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/d
Coadministration with phenothiazines may decrease the analgesic effects; the toxicity increases with CNS depressants or TCAs
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates, because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction
Hydrocodone and ibuprofen (Vicoprofen)
Drug combination for short-term (<10 d) relief of moderate to severe acute pain.
Adult
1-2 tab PO q4-6h prn; not to exceed 5 tab/d
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; third trimester of pregnancy
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased ICP, and erosive gastritis; duration of action may increase in elderly persons
Acetaminophen and codeine (Tylenol With Codeine [# 3])
Indicated for mild to moderate pain.
Adult
30-60 mg/dose based on codeine PO q4-6h or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen
Pediatric
0.5-1 mg/kg/dose PO based on codeine q4-6h; 10-15 mg/kg/dose based on acetaminophen; not to exceed 2.6 g/d of acetaminophen
The toxicity of codeine increases with CNS depressants, TCAs, MAOIs, neuromuscular blockers, phenothiazines, and narcotic analgesics.
Rifampin can reduce the analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase the hepatotoxicity of acetaminophen.
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who are dependent on opiates, because this substitution may result in acute opiate-withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction.
Hepatotoxicity with acetaminophen is possible in individuals with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses and exceed recommended the maximum dose.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may also exist, such as leukotriene synthesis inhibition, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions. During rehabilitation, shoulder discomfort may interfere with sleep or basic ADLs. Oral NSAIDs should decrease the discomfort. NSAIDs do not speed recovery and should not be used to accelerate physical therapy goals.
Related eMedicine topic:
Toxicity, Nonsteroidal Anti-inflammatory Agents
Ibuprofen (Motrin, Ibuprin)
DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults.
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Anaprox, Naprelan, Aleve)
For mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing the activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
Ketoprofen (Orudis, Oruvail, Actron)
For mild to moderate pain and inflammation. Small initial doses are indicated in small and elderly patients and in those with renal or liver disease.
Doses >75 mg do not increase the therapeutic effects. Administer high doses with caution and closely observe the patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults.
Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of coagulation abnormalities or during anticoagulant therapy
More on Shoulder Dislocation |
| Overview: Shoulder Dislocation |
| Differential Diagnoses & Workup: Shoulder Dislocation |
 Treatment & Medication: Shoulder Dislocation |
| Follow-up: Shoulder Dislocation |
| References |
| « Previous Page | Next Page » |
References
Matsen FA III, Thomas SC, Rockwood CA Jr. Anterior glenohumeral instability. In: Rockwood CA Jr, Matsen FA III, eds. The Shoulder. Vol 1. Philadelphia, Pa: WB Saunders Co; 1990:526-622.
Dodson CC, Cordasco FA. Anterior glenohumeral joint dislocations. Orthop Clin North Am. Oct 2008;39(4):507-18, vii. [Medline].
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.
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. Nov 1996;78(11):1677-84. [Medline].
Burkhead WZ Jr, Rockwood CA Jr. Treatment of instability of the shoulder with an exercise program. J Bone Joint Surg Am. Jul 1992;74(6):890-6. [Medline]. [Full Text].
Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: pathophysiology, diagnosis, and management. J Am Acad Orthop Surg. Jan-Feb 1998;6(1):65-72. [Medline].
Cox CL, Kuhn JE. Operative versus nonoperative treatment of acute shoulder dislocation in the athlete. Curr Sports Med Rep. Sep-Oct 2008;7(5):263-8. [Medline].
Cofield RH, Kavanagh BF, Frassica FJ. Anterior shoulder instability. Instr Course Lect. 1985;34:210-27. [Medline].
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. Nov 2008;94(7):659-69. [Medline].
Pouliart N, Gagey O. Consequences of a Perthes-Bankart lesion in twenty cadaver shoulders. J Shoulder Elbow Surg. Nov-Dec 2008;17(6):981-5. [Medline].
Reeves B. Acute anterior dislocation of the shoulder. Clinical and experimental studies. Ann R Coll Surg Engl. May 1969;44(5):255-73. [Medline]. [Full Text].
Further Reading
Keywords
shoulder dislocation, dislocated shoulder, shoulder pain, rotator cuff muscles, shoulder injury, anterior shoulder dislocation, dislocation of the glenohumeral joint, glenohumeral dislocation, glenohumeral subluxation, glenohumeral joint dislocation, posterior shoulder dislocation, acromioclavicular joint injury, humerus, glenoid, glenohumeral ligaments, glenoid labrum, negative intra-articular pressure
