The management of dislocated shoulders is a matter of controversy in the orthopaedic field, with the usual management being confined to a sling for between one and six weeks, with or without a strap around the waist to prevent external rotation. The arm is maintained close to the body with the forearm across the belly, a position known as medial rotation and adduction. This avoids the stresses which would be applied to the joint if it were moved to the side or outwards, known as lateral rotation and abduction.
Recent studies of dislocation in the scientific literature have shown some clues as to how these injuries should be managed. One study involved MRI scanning to show that the relationship between the rim of the socket and the socket itself is best maintained by placing the arm by the side and rotating it laterally 35 degrees. A cadaveric study of shoulders showed that keeping the arm in slight adduction close to the body allowed a reasonable range of motion without disrupting the close approximation of the structures. Lifting the arm up forwards or out to the side (flexion and abduction) disturbed this relationship.
The time of immobilisation is not one of general agreement with three or four weeks in a sling typically prescribed for younger people and shorter periods for older people. A longer period of immobilisation was shown in one study to significantly lower the rates of recurrent dislocation. Another study followed patient with shoulder dislocation for ten years and found no influence of the period of immobilisation on the rate of recurrent dislocation. After the patient is reviewed at the three week period they start their rehabilitation with the physiotherapists.
Initial exercises will include pendular exercises, chosen for their reduced joint stresses due to the patient being bent over and the arm hanging in a relaxed position. This keeps the shoulder joint moving without fear of overstressing the joint capsule. Scapular movements are also performed early so that the shoulder girdle remains mobile and functional. Active assisted movements are the next progression taught by the physiotherapist, allowing the range of movement to be increased whilst reducing joint stresses as the other shoulder contributes much of the force needed.
The risk of dislocating again means that lateral rotation of the joint will be restricted and the range gradually progresses as healing occurs, without ever being strongly stressed as a loss of the end range of this movement may help this joint prevent further dislocations. Restricting the joint from attaining the risk position may reduce the likelihood of it dislocating again. Six weeks is typical soft tissue healing time and patients are then progressed onto performing full active range of motion exercises and also muscle strengthening.
Some patients demand high performance from their joint and need ongoing advanced rehabilitation but should be prevented from pursuing overhead sports for about four months. If the patient has a greater tuberosity fracture (a small bony upper arm area with tendinous insertions) or is an older person then their outcome is somewhat better. Patients may be required to modify their typical activities by limiting overhead actions, avoiding sports which demonstrate high risks and change to lighter physical work.
Overall the incidence of re-dislocation of the shoulder is around 30 percent in non-sporting people but rises to eighty-two percent in those in athletic sports. The age of the patient is however very important in determining the recurrence rate. There is a one hundred percent chance of dislocation recurrence in patients under 10 years old and only zero to 24 percent likelihood in patients who are in their forties. Surgical management may be required should a patient suffer from recurrent dislocation of the shoulder.
The timing of surgical management is not clear although early surgery after the initial dislocation may be advantageous. Studies vary but one showed that after stabilisation surgery via the arthroscope there was a four percent dislocation rate but a 94 percent repeat dislocation rate after conservative treatment. Overall it looks like the recurrence rate is higher for those patients managed by non-operative immobilisation. The level of stability given in operation was better with open surgery but arthroscopic techniques have advanced considerably and this distinction has disappeared.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and physiotherapist in hartlepool. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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