Article by John Miller
What is a Shoulder Dislocation?
A shoulder dislocation occurs when the ball of your upper arm bone (humerus) is forced fully out of its normal position on the shoulder socket (glenoid labrum).
What Causes a Shoulder Dislocation?
Your shoulder is the most mobile joint in your body. It has an amazing range of motion. Your shoulder allows you to lift your arm overhead, out to the side, rotate it behind your head and your back and reach in multiple directions. However this huge range of motion comes at the cost of its stability.
Shoulder dislocation and subluxation can occur as a result of a sudden trauma or from underlying shoulder joint instability.
Most Common Causes of Shoulder Dislocation
1. Traumatic Shoulder Dislocation
High speed or traumatic shoulder dislocation occurs when your shoulder is in a vulnerable position and is popped out at speed. Commonly this is with your arm out to the side. This injury description is common when dislocating in a football tackle or during a fall.
2. Repetitive Shoulder Ligament OverstrainOccasionally, people with looser ligaments in their shoulders can dislocate their shoulders with relative ease. This increased passive shoulder instability is sometimes just your normal anatomy. Sometimes, it is the result of repetitive overstretching of the shoulder joint.
Some sports such as swimming, tennis, throwing sports (cricket, baseball etc) and volleyball that require repetitive overhead motion can overstretch your shoulder ligaments and joint capsule.
Looser shoulder ligaments make it harder for your shoulder’s rotator cuff muscles to maintain your shoulder stability. If you have an unstable shoulder, the best thing that you can do to prevent or help rehabilitate your shoulder dislocation is to undertake a specific shoulder rotator cuff strengthening program.
Please ask your physiotherapist for their professional advice.
3. Multi-Directional Instability
In a small number of patients, your shoulder is unstable in multiple directions due to your genetic disposition. In these patients, the shoulder may feel loose or dislocate repeatedly in multiple directions. This is called multi-directional instability.
These patients have naturally loose ligaments throughout the body and may be "double-jointed" or hypermobile.
Due to their genetically elastic collagen fibres in their ligaments, these patients typically do not respond with much success to surgical stabilisation. They are best managed with a thorough shoulder stabilisation strengthening program.
Please ask your physiotherapist for their professional advice.
What are the Symptoms of a Shoulder Dislocation?
The history of a shoulder that is traumatically “popped out” of joint is the classic sign of a shoulder dislocation.
Shoulders that do not stay out of joint are more likely to have partially subluxed before self-relocating.
A shoulder that is dislocated will look deformed. The arrow indicates a dislocated shoulder.
How is a Shoulder Dislocation Diagnosed?
After discussing your shoulder symptoms and injury history, your physiotherapist will examine your shoulder for dislocation or signs of instability. They can normally confirm your diagnosis within the clinic or on the field of play.
Your physiotherapist or doctor may order imaging tests to help confirm your diagnosis and identify any other problems. These may include: X-rays. Magnetic Resonance Imaging (MRI). Magnetic Resonance Arthrogram (MRA). Radiological findings may identify fractures, Bankart lesions or labral tears.
How is a Shoulder Dislocation Treated?
Both acute and repeated shoulder dislocations are normally treated initially with non-operative rehabilitation guided by your physiotherapist.
Stabilisation surgery may be considered should your exercise-based treatment fail.
PHASE I - Joint Reduction. Check Neurovascular Integrity
The most urgent matter for a recently dislocated shoulder is to ensure that your nerves or blood supply are not compromised.
If your shoulder did not relocate itself naturally, it important to promptly head to hospital for an emergency X-ray to exclude fractures. You will then have your shoulder reduced to its normal position by the emergency doctors.
PHASE II - Pain Relief. Minimise Swelling & Injury Protection
Managing your pain. Pain will accompany shoulder movement in the early days. Overstretching the injured tissues should be avoided for between two to six weeks. You will usually be prescribed a shoulder sling to support and immobilise your shoulder.
Manage your inflammation via ice therapy and rest to deload the inflammed structures.
Your physiotherapist will use an array of treatment tools to reduce your pain and inflammation. These may include: ice, electrotherapy, acupuncture, deloading taping techniques, soft tissue massage and temporary use of a sling to off-load the injured shoulder ligaments.
PHASE III - Maintain & Restore Muscle Control & Strength
It is important to maintain the strength of your shoulder’s rotator cuff muscles and scapular (shoulder blade) stabilisers.
Researchers have discovered the importance of your rotator cuff muscles to dynamically stabilise your shoulder joint.
It is also vital to address your shoulder blade stability, since your scapular is the stable platform that attaches your arm to your chest wall. It is an important base that if it is not functioning correctly, will allow your shoulder blade to slide into a position that could predispose you to future dislocations.
Your physiotherapist will assess your muscle recruitment pattern and prescribe the best exercises for you specific to your needs.
PhysioWorks has developed both a “Rotator Cuff Strengthening” and a “Scapular Stabilisation Program” to assist their patients to regain normal shoulder muscle control. Please ask your physio for their advice.
PHASE IV - Restoring Normal ROM & Posture
As your pain and inflammation settles and your ligaments start to heal, your physiotherapist will turn their attention to restoring your normal joint range of motion, muscle length, neural tissue mobility and resting muscle tension.
Regaining full shoulder motion in the early phase is not a priority to avoid overstretching the healing shoulder ligaments and capsule.
Treatment may include joint mobilisation and alignment techniques, massage, muscle stretches and neurodynamic exercises, plus acupuncture, trigger point therapy or dry needling. Your physiotherapist is an expert in the techniques that will work best for you and avoid predisposing you to a future dislocation.
PHASE V - Restoring Full Function
During this stage of your rehabilitation is aimed at returning you to your desired activities. Everyone has different demands for their shoulders that will determine what specific treatment goals you need to achieve. For some it be simply to carry the shopping. Others may wish to throw or pitch a ball, serve or bowl with high speed or return to a labour-intensive activity.
Your physiotherapist will tailor your shoulder rehabilitation to help you achieve your own functional goals.
PHASE VI - Preventing a Recurrent Shoulder Dislocation
Shoulder dislocation and subluxation have a tendency to return in poorly rehabilitated shoulders.
In addition to your muscle control, your physiotherapist will assess your shoulder biomechanics and start correcting any deficiencies. It may be as simple as providing your will rotator cuff exercises or some scapular or posture exercises to address any biomechanical faults in your upper limb. Your physiotherapist will guide you.
Fine tuning your shoulder stability can be further enhanced by proprioception, co-contraction, speed and agility drills with the ultimate goal of safely returning to your previous sporting or leisure activities!
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What Results Can You Expect Post-Dislocation?
After the first time you dislocate or sublux your shoulder, recurrence is very likely, especially in younger patients. The recurrence rate in patients under 25 years old is about 80%. The recurrence rate decreases as your age advances.
Because of the high recurrence rate, the goal of any treatment is to reduce the possibility of a recurrent dislocation. The minimum treatment for the first time dislocation should be immobilisation in a sling for 2 to 3 weeks to take advantage of the off-chance that it will reduce the recurrence rate.
Resumption of athletic activities can be taken up on an individual basis, but 6 to 8 weeks after injury is minimum and three months is probably safer to avoid redislocation.
Despite immobilisation treatment, the recurrence range is still fairly high. If your shoulder is not immobilised after a dislocation, the chances of redislocation are extremely high with unrestricted activity in the first three weeks.
Once your shoulder dislocates a second time, it will almost always continue to re-dislocate with the arm in certain positions and often with less and less trauma on each occasion.
Your best chance to avoid re-dislocation is to immobilise your shoulder in a sling and undertake a physiotherapist prescribed exercise program specific to your shoulder.
What is a Bankart Lesion or Hills-Sach Fracture?
When the head of your shoulder dislocates, the capsular ligaments are overstretched. If the glenoid labrum, which attaches your capsule to the rim of the shoulder socket is torn, it is known as a Bankart lesion. If a Bankart lesion exist, you are more likely to require surgical stabilisation.
A Hills-Sach Fracture occurs when the humeral head impacts against the rim of the shoulder socket resulting in a depression fracture in the humeral head. The fracture will normally increase your pain but does not normally require surgery as it is stable. It can however, increase your likelihood of future shoulder dislocation.
These injuries will normally rehabilitate successfully with a supervised shoulder exercise program. A small percentage require surgical stabilisation if there are repeat dislocations.
Surgical Stabilisation Post-Dislocation
Surgical shoulder stabilisation is sometimes necessary to repair torn or overstretched ligaments, repair Bankart lesions etc and prevent a future shoulder dislocation.
With surgery, the chances of recurrent dislocation for all patients overall are about 5%. As a group, footballers have a slightly higher recurrence, but this is generally 10% or less.
You will advised whether this option is suitable for you after discussions between your doctor and physiotherapist have assessed your shoulder and analysed your response to non-operative treatment.
You can feel confident that your PhysioWorks physiotherapist will look after your shoulder dislocation or instability issue. They work with leading shoulder specialists to provide assessment and diagnosis, non-operative and post-operative shoulder rehabilitation programs.
If you have any questions about your shoulder please ask your physiotherapist.
Shoulder Dislocation Treatments
A shoulder sling is the initial treatment of choice during the first few weeks post-dislocation.
Kinesio tape may be helpful to add to the stability of your shoulder in the early stages of your rehabilitation.
A shoulder brace can provide mild to moderate support. Unfortunately even the best braces will not guarantee 100% protection from a future dislocation.
Some typical braces that will assit your shoulder dislocation can be found here: http://bit.ly/RCMbUS
More Advice about Shoulder Dislocation
If you have any concerns or have some specific questions regarding your condition, please ask your physiotherapist.
FAQs about Shoulder Dislocation
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