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    Shoulder Dislocation

    What is a shoulder dislocation?

    • This is an injury in which your upper arm bone pops out of the cup-shaped socket that’s part of your shoulder blade.

    How common is a shoulder dislocation?

    • Shoulder dislocation normally occurs following a high force impact or fall and involves the humerus (arm bone) coming out of its socket.
    • Not very common in the general population.
    • Around 1.7% of the population may dislocate their shoulder in their lifetime (1).

    Should I worry?

    • Moderately.
    • A dislocation of the shoulder can be painful and may often require a hospital visit to relocate the shoulder and check for further damage.
    • If you suspect you have a shoulder dislocation, getting immediate assessment and treatment are vital to recovery.
    • Despite the need to get it checked immediately, most people recover well from the injury.

    Who is most likely to suffer from a shoulder dislocation?

    • More common in males than females.
    • Typically occurs in people aged 20-30.
    • Commonly involving sporting trauma.
    • Elderly people fall onto an outstretched hand (1).

    What are the common symptoms?

    • Inability to move the arm.
    • Pain into shoulder joint region.
    • The shoulder may look square rather than round.
    • A feeling of instability in the shoulder.

    What can I do?

    • Do not try to relocate the shoulder back in as you may cause further damage to the nerves, tissues and blood vessels. A medical professional should do this.
    • Seek medical help at A&E immediately as the shoulder may need to be relocated.
    • Following the dislocation being relocated, conducting a rehabilitation programme under the aid of a physiotherapist is recommended (2).

    How long will it take to recover?

    • This depends on the type of dislocation and if any further injury has occurred in the shoulder itself.
    • On average recovery takes from 6 weeks – 6 months dependant on your long-term functional goals (4).
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    1. Introduction

    Traumatic shoulder dislocation is the most common large joint dislocation in the human body (1). As these injuries commonly occur in sport, it is typically a condition that affects a younger population. As a result, it is important that early intervention is carried out to avoid chronic shoulder instability in the future for patients (1).

    There are two types of traumatic dislocation, anterior being the most common with up to 97% of cases (2). Posterior dislocations are rare and account for 3% which can be most complex given that there is usually an associated injury to the rotator cuff muscles as well (2).

    Patients can also have non-traumatic shoulder dislocations where repeated shoulder movements may gradually stretch out the soft tissue cover around the joint (the joint capsule) (3). This can happen with athletes such as throwers and swimmers. Following capsular stretching, the rotator cuff muscles can become weak, affecting how the muscles around the shoulder interact with each other and, in turn, leading to an imbalance of the shoulder.

    As traumatic anterior dislocation is the most common, this will be the focus of the following information.

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    2. Signs & Symptoms

    A traumatic anterior shoulder dislocation is a very distributive injury and severe pain is felt in the upper arm, axilla region and shoulder joint region (2). Normally the arm will be held into medial rotation (across your body) as any movement away from the body evokes more pain. There will be a visible change of shoulder position, often with it being held forwards (2).

    3. Causes

    • Fall onto an outstretched hand.
    • Sporting injury, such as direct trauma on the shoulder through a rugby tackle.
    • People who have seizures as excessive muscle contractions force the shoulder joint to move more than normal.
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    4. Risk Factors

    This is not an exhaustive list. These factors could increase the likelihood of someone developing a dislocated shoulder. It does not mean everyone with these risk factors will develop symptoms.

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    5. Prevalence

    It is rare but up to 1.7% of people may have a shoulder dislocation in their life (1). There are many factors that come into play but it is more common in sporting males due to the increased risk of contact in sport and traumatic situations that can arise in sport.

    6. Assessment & Diagnosis

    If a traumatic dislocation has occurred, a medical doctor will assess you in A&E. An assessment will be carried out and then once the shoulder has been relocated, the doctors may then send you for further imaging or a specialist review. This is to ascertain if there is any further injury that has occurred to the shoulder. The extent of that damage will often determine whether surgery is required, or rehabilitation will be able to provide a full recovery.

    Most commonly a rehabilitation programme will be conducted with a physiotherapist. Your physiotherapist will want to know how your condition affects your day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and will allow appropriate adjustments to your treatment to be made.

    7. Self-Management

    As with all injuries, it is important that short and long term you have strategies in place to self-manage your condition. Your physiotherapist will help you understand the condition and what needs to be implemented to effectively manage your shoulder dislocation. This will include activity modification strategies, as well as other useful treatments aimed at reducing discomfort. Regular adherence to a condition-specific rehabilitation programme is important in the management of this condition. It should be noted that rehabilitation exercises are not always a quick fix but if adhered to on a consistent basis (weeks to months), over time they have been shown to yield positive outcomes.

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    8. Rehabilitation

    An evidence-based treatment rehabilitation programme allows your shoulder to regain movement and become stronger and more robust following a shoulder dislocation. Research suggests that improving the strength and conditioning of the shoulder will give more stability, reduce pain and, most importantly, prevent any further dislocations.

    9. Shoulder Dislocation Rehabilitation Plans

    Early Plan

    Phase 1 (up to 6 weeks) – goal is to maintain anterior-inferior stability and ensure a safe progressive range of movement. Early isometric exercises are introduced. Pain should not exceed 3/10 on your self-perceived pain scale whilst completing this exercise programme.

    Early Plan - Rating

    Intermediate Plan

    Phase 2 (6-12 weeks) – goal is to restore adequate motion, specifically in external rotation, and an early strengthening programme for your upper limbs. This should not exceed 4/10 on your perceived pain scale.

    Intermediate Plan - Rating

    Advanced Plan

    Phase 3 (12-16 weeks) – in this phase expect the exercises to be more challenging and involving weights and functional movement patterns specific to your long-term return to sport/work. There is some debate as to what timescale a patient can return to sport, with shoulder surgeons tending to favour a longer timescale of 6-8 months post-injury, rather than shoulder physiotherapists 3-4 months (4). This should not exceed 4/10 on your perceived pain scale.

    Advanced Plan - Rating
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    10. Return to Sport/Normal Life

    For patients wanting to achieve a high level of function or return to sport, an assessment will be made by the physiotherapist to check your strength, range of movement, stability and general functional capacity to be safe enough for a return to sport. Before returning to the sport, a rehabilitation programme should incorporate some contact drills and exercises that mimic the sport you participate in ideally (5).

    As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain reliving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and establish appropriate progression of treatment.  Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.

    11. Other Treatment Options

    In some cases when conservative management fails to impact the patient’s presentation, surgery is the next step. It is often the case that surgical stabilisation may be indicated after the first dislocation, particularly for younger adults under 25 (6).

    The aim of the operation is to repair the damage to the structural stabilisers of the shoulder. This involves repair of the damaged rim of cartilage and tightening, or repair, of the over-stretched and damaged ligaments (1, 6). This operation may be done either as an open procedure, where a cut is made over the shoulder or with a keyhole (arthroscopic) technique where smaller cuts are made. The operation is often performed under a light anaesthetic with a regional nerve block as a day case.

    12. Links for Further Reading

    https://www.shoulderdoc.co.uk/article/1650

    https://www.bmj.com/content/bmj/371/bmj.m4485.full.pdf

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    Book an Appointment

    Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.

    We have Pure Physiotherapy clinics across the country including Norwich, Ipswich, Manchester, Bolton, Wakefield and Sheffield. Please view our clinics to find the closest physiotherapy clinic for you.

    References

    1. Kavaja, L., Lähdeoja, T., Malmivaara A. & Paavola, M. (2018). Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis. British Journal of Sports Medicine, 52. 1498-1506.
    2.  Verweji, L. P.E., Baden, D. N., van der Zande, J. M. J. & van der Bekerom, M. P. J. (2020). Assessment and Management of Shoulder dislocation. British Medical Journal, 371. doi: https://doi.org/10.1136/bmj.m4485.
    3. Barrett C. (2015). The clinical physiotherapy assessment of non-traumatic shoulder instability. Shoulder & elbow, 7 (1). 60–71. https://doi.org/10.1177/1758573214548934.
    4. Lennard, Funk. (2012). Arthroscopic shoulder surgery has progressed, has the rehabilitation? International Musculoskeletal Medicine, 34 (11). 141-145.
    5. Watson, S., Allen, B., & Grant, J. A. (2016). A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation. Sports health, 8 (4). 336–341. https://doi.org/10.1177/1941738116651956.
    6.  Terra, B. B., Enjisman, B. & Belango, P. S. (2019). Arthroscopic Treatment of First-Time Shoulder Dislocations in Younger Athletes. Orthopaedic Journal of Sports Medicine, 7 (5).
    Other Conditions in Shoulders

    Whiplash Disorders

    An injury which typically occurs following a road traffic collision, often affecting the soft tissues of the neck.

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    Rotator Cuff Tendinopathy

    Pain and weakness affecting the shoulder and limiting function.

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    Frozen Shoulder

    An insidious (no clear cause), painful/stiff condition of the shoulder persisting for more than 3 months.

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    Shoulder Impingement

    Shoulder impingement is an umbrella term used to describe a variety of conditions that can cause pain in the shoulder.

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