Acute Shoulder Dislocation | Diagnosis and Treatment
The shoulder is an incredible joint. It is the most mobile joint in the human body, yet it can withstand enormous forces, allowing people to lift, hang, throw, tackle and even walk using them. Yet the amazing mobility this joint provides does have a downside - with a shallower socket than other similar joints, like the hip, it is the most commonly dislocated joint in the body. Acute shoulder dislocations account for around 45% of all dislocations in the human body.1
An acute shoulder dislocation can be a painful and traumatic experience, ranging from brief subluxation with a quick return to normal function, all the way to complete dislocation, requiring a trip to the local emergency department for pain relief so that the joint can be relocated. These injuries can lead to a loss of confidence in the shoulder and anxiety when returning to activity2. This blog is aimed at helping you understand shoulder dislocations and how your physiotherapist, and in some cases a surgeon, can help you recover from shoulder dislocation and return to activity with confidence.
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This blog will cover the following topics on Acute Shoulder Dislocation:
- Understanding the Shoulder
- What is Shoulder Dislocation?
- How is a Shoulder Dislocation Diagnosed?
- How are Shoulder Dislocations Treated?
- Non-Surgical Management of Acute Shoulder Dislocations
- Surgical Management of Shoulder Dislocations
- Post-Operative Recovery after Shoulder Reconstruction Surgery
Understanding the Shoulder
The shoulder joint is a synovial ball (head of the humerus) and socket (the shoulder blade glenoid) joint. The ball and socket of the shoulder are covered in hard hyaline cartilage, in a joint filled with synovial fluid. This thick fluid is important for cartilage nutrition and lubrication, reducing friction between the joint surfaces.4 It can move forwards/backwards, sideways, rotate, and any combination of all.
The glenoid socket is very shallow, like a golf ball on a wider golf tee, and thus the joint is reliant on soft tissue structures for stability. These include:
- the labrum, a type of fibrous cartilage that effectively deepens the socket and keeps the ball centred in the joint,
- the joint capsule, a thick connective tissue structure that surrounds the joint and much of the head of humerus, and
- the rotator cuff, important stabilising muscles with tendons that blend into the joint capsule to provide stability to the joint in all positions.
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What is a Shoulder Dislocation?
A shoulder dislocation occurs when the head of the humerus is forced out of the socket, most commonly with a fall onto the hand/forearm or during a direct trauma such as direct contact to the shoulder in sports/recreation activities.
In ~95% of acute shoulder dislocation cases, the dislocation is anterior (forward), with the remaining 5% of cases being posterior (backward) or, least commonly, inferior (downward)3.
In some cases, the ball will subluxate from the socket, escaping the glenoid before popping back into its place. In other cases, a complete dislocation occurs which creates an obvious defect, causing a complete loss of function of the shoulder, requiring manual relocation of the joint by a health professional.
Diagnosing An Acute Shoulder Dislocation
Shoulder dislocations are often dramatic and immediately apparent, causing pain and an associated sensation of instability in the shoulder. While this can lead to significant pain and loss of function in the shoulder, some people may experience very little pain with little to no loss of function in the shoulder after the injury.
If the head of the humerus does not relocate on its own, trained medical staff may assist a person to relocate the shoulder while minimising further damage to the shoulder.
Some people may injure surrounding soft tissue and neural structures during acute shoulder dislocation. Burning, pins and needles, numbness or weakness further down the arm may be a sign of nerve injury. Pain, tingling or numbness over the lower deltoid, also called the regimental badge area, is common sign of local nerve injury.
After the injury, a physiotherapist or medical doctor can help you determine the type of injury sustained, as well as the extent of injury to structures surrounding the shoulder. In many cases a CT or MRI scan will assist with this process to determine what structures may have been damaged when the dislocation occurred.
Some common concurrent injuries that may affect return to activity, or indicate an elevated risk of recurrence include:
- Bony injury to the socket, called a Bankart Lesion or Reverse Bankart Lesion
- Bony injury to the head of Humerus, called a Hills-Sach’s or Reverse Hills-Sachs Lesion
- Humeral Avulsion (complete tear) of the Glenohumeral ligament (HAGL)
- Glenolabral Articular Disruption (GLAD)
- Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA)
- Rotator Cuff Injury
- Axillary Nerve Injury
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Treatments for Acute Shoulder Dislocation
An acute shoulder dislocation might be managed with rehabilitation only (non-surgically) or surgically (with post-operative rehabilitation).5 This decision should be made on an individualised basis with evidence-based guidance from an experienced physiotherapist, doctor and/or surgeon. If any of the concurrent injuries mentioned above are found on scans, this will likely factor into the decision-making process.
Non-Surgical Management of Acute Shoulder Dislocations
After discussion with an experienced physiotherapist, sports physician and/or surgeon, the decision may be made to manage the dislocation non-surgically. This is more common:
- following a first-time dislocation,
- in instances where there is minimal concurrent damage to the structures of the joint, or
- in cases where the person is not aiming to return to high-risk sport/activity.
Non-surgical management should be guided by an experienced physiotherapist, in consultation with medical specialists, and typically involves the following stages of rehabilitation:
- Immobilisation
- The arm may be placed in a sling until symptoms reside.
- This may be recommended for the first week, or in some cases longer, to help symptoms settle and to potentially reduce the risk of recurrence.
- Early Rehabilitation
- Regain active range of motion
- Restoration normal shoulder kinematics
- Rotator Cuff strengthening
- Advanced Rehabilitation
- Upper limb strength development
- Upper limb power development
- Reintroduction to functional/sports related activities
- Return to Sport/Activity
- Return to sport/ activity, usually while braced/strapped to restrict movement of the arm into vulnerable positions
Surgical Management of Shoulder Dislocations
After consultation with an orthopaedic surgeon, it may be determined that surgical repair of damaged structures in the shoulder may be in your best interests. This decision is more common when:
- there have been multiple dislocations,
- there is extensive bony and ligamentous damage raising the risk of recurrence, or
- if the person is returning to contact sport at a high level/high risk activity.
The most common approaches to this operation are:
- Bankart Repair
- Multiple sutures to repair the labrum and joint capsule
- Typically done through arthroscopic approach
- Less disruptive procedure that is commonly associated with good outcomes
- Latarjet Repair
- An open procedure where the insertion of the short head of biceps tendon and corocoid process are grafted to the anterior glenoid in order to provide additional stability to the shoulder
- An open procedure does have increased risks, though the Latarjet is often preferred for those returning to contact sports/high risk activity
- Remplissage
- A procedure to fill in a Hills-Sachs lesion on the head of the humerus, often done in conjunction with a Bankart repair
Post-Operative Recovery after Shoulder Reconstruction Surgery
The recovery period following surgery to restabilise the shoulder after dislocation ranges from 5-8 months, depending on the procedure, the surgeon’s protocol post-op, the person’s goals and what sports activities the person aims to return to.
Post-operative rehabilitation after shoulder reconstructive surgery typically includes the following components:
- Recovery/healing
- Up to 6 weeks in a sling to allow repaired/grafted tissue to heal
- Protected early mobilisation is often permitted under the direction of your surgeon and physiotherapist
- Early Rehabilitation
- Restoration of shoulder range and control
- Development of rotator cuff strength
- Reintroduction of load through safe ranges
- Intermediate Rehabilitation
- Rebuilding strength in the shoulder and surrounding musculature
- Restoration of strength and control through the core/trunk and arm
- Development of upper limb power
- Advanced rehabilitation
- Development of high-level power/control in challenging positions
- Gradual re-introduction to contact/higher risk activity
- Return to Sport/Activity
- Return to desired activity/sport, often with bracing/taping to restrict movement into vulnerable ranges
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Author
This blog was written by Andrew Vetter, one of our sports physiotherapists. Andrew has a special interest in treating hip, knee, ankle and shoulder injuries and has had much experience with rehabilitation after joint injury including dislocation and reconstructive surgery, during many years working with elite football athletes, including the Qld Reds. Andrew aims to provide high quality care to his patients, help them perform better, recover from injuries, and get back to doing the things they love.
You can read more about Andrew here.
References:
- McCausland C, Sawyer E, Eovaldi BJ, Varacallo M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 8, 2023. Anatomy, Shoulder and Upper Limb, Shoulder Muscles
- Olds, M., & Webster, K. E. (2021). Factor Structure of the Shoulder Instability Return to Sport After Injury Scale: Performance Confidence, Reinjury Fear and Risk, Emotions, Rehabilitation and Surgery. The American Journal of Sports Medicine, 49(10), 2737–2742. doi:10.1177/03635465211024924
- KhiamiF, GéromettaA, LoriautP Management of recent first-time anterior shoulder dislocations. Orthop Traumatol Surg Res (2015) 101: S51–57
- Chang LR, Anand P, Varacallo M. Anatomy, Shoulder and Upper Limb, Glenohumeral Joint. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL)
- Kavaja L, Lähdeoja T, Malmivaara A, et al. Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis Br J Sports Med (2018) ;52:1498–1506.