Ismayil Nebiyev

Dislocated Shoulder
Shoulder

dislocation is a very common traumatic injury across a wide range of sports and can cause severe shoulder pain. A dislocated shoulder can be either posterior or more commonly anterior where the head of the humerus pops out forwards.

Symptoms of a Dislocated Shoulder

The injury is usually acute, caused by direct or indirect trauma such as a fall or forced abduction and external rotation. There is a sudden onset of severe pain, and often a feeling of the shoulder 'popping out'. The shoulder will often look obviously different to the other side, usually loosing the smooth, rounded contour. The patient will usually hold the arm close into their body and resist abducting and externally rotating the shoulder. If there is any nerve or blood vessel damage there may also be pins and needles, numbness or discoloration through the arm to the hand. There is usually quite severe pain associated with dislocating a shoulder.

What is a Dislocated Shoulder?

Shoulder dislocation is a very common traumatic injury across a wide range of sports. In most cases, the head of the humerus (upper arm bone) is forced forwards when the arm is turned outwards (externally rotated) and held out to the side (abducted). This causes an anterior dislocation, which make up approximately 95% of all shoulder dislocations. Dislocations can also be posterior, inferior, superior or intra thoracic, although these are very rare and can cause a number of complications and extensive damage to surrounding structures such as muscles, tendons and nerves. Posterior are the second most common form of dislocation, although still only account for around 3% of shoulder dislocations. These can occur during epileptic seizures and when falling onto an outstretched hand.

The shoulder joint is particularly prone to dislocations due to its high mobility, which sacrifices stability. It is the most commonly dislocated joint, with elbow, knee, finger and wrist dislocations occurring far less regularly. Although some consider this to be a minor injury, most shoulder dislocations cause tears to the glenoid labrum. This is a ring of cartilage which deepens the glenoid fossa and acts as a cup, in which the humerus rests, forming the Glenohumeral (or shoulder) joint which can cause an injury known as a Bankart Lesion, and may even cause a fracture to the attached bone (a Bony Bankart Lesion). There may also be damage to the surrounding ligaments, tendons, nerves, blood vessels and fractures to other bones. Shoulder dislocations commonly become a reoccurring problem, with many people learning how to reduce (reposition) them on their own. This is only the case in those with highly unstable glenohumeral joints. A thorough rehabilitation program can help most individuals to prevent the shoulder repeatedly dislocating.

Although some consider this to be a minor injury, most shoulder dislocations cause tears to the Glenoid Labrum.

Treatment of a Dislocated Shoulder

What can the athlete do? Immediate treatment for a dislocated shoulder has two stages. Firstly to protect the shoulder joint and prevent further damage (e.g. rest in a a sling), and secondly to seek medical attention as soon as possible. The shoulder should be reduced (put back in) by a trained medical professional as soon as possible, never attempt to pop it back yourself as you may cause further damage! Ideally an X-Ray should be sought prior to reduction to rule out fractures. If this is not possible a post reduction X-Ray must always be sought.

If you sustain a dislocation, it is vitally important to seek medical attention.

If you sustain a dislocation, it is vitally important to seek medical attention, even if the shoulder pops straight back into position on its own. There is a strong likelihood that you will need some rehabilitation to help you regain both the function of the shoulder, and to prevent it from dislocating again. Some cases may even require surgery if the shoulder is regularly dislocating, or if there is an associated fracture. If the reduction is difficult it may be necessary to conduct the procedure under anesthetic. Following a reduction you will usually be advised to;

What can a sports therapist do?

Rest and immobilise the shoulder in a sling for 5-7 days. If there are complications such as fractures or soft tissue damage, immobilisation may be over a longer period. You may be prescribed NSAIDS such as ibuprofen to ease pain and inflammation. After the period of initial immobilisation you should be directed to gradually increase your range of pain free movement. You will also need to strengthen the rotator cuff muscles which support the shoulder joint to prevent reoccurrences. Exercises using resistance band are excellent for this in the early stages.

When is Surgery an option?

Surgery is sometimes necessary following a dislocated shoulder if there has been extensive damage to muscles, tendons, nerves, blood vessels or the labrum. Surgery is then usually performed as soon as possible after the injury. In cases of recurrent shoulder dislocations, surgery may be offered in an attempt to stabilise the joint. There are a number of procedures which can be performed. The decision over which procedure to use depends largely on the patients lifestyle and activity. Some procedures result in reduced shoulder external rotation and so are not suitable for athletes involved in throwing or racket sports as this would affect performance.

Rehabilitation - Shoulder Dislocation

The following guidelines regarding dislocated shoulder rehabilitation are for information purposes only. We recommend seeking professional advice before attempting rehabilitation. If the injury has caused a complete rupture of muscle or ligament then shoulder surgery may be required before attempting to rehabilitate the injury.

What is the best initial treatment?

Initially the treatment involves putting the joint 'back' known as reduction. This can be done without surgery (closed reduction) or in difficult cases, or those with associated fractures or damage to the area, during surgery (open reduction). It should NEVER be attempted by someone who is not appropriately trained as serious damage to nerves and other structures could occur, and should always be followed up with a postreduction X-Ray to check for any possible complications.

Immediate Treatment (0-24 hours)

Stop play immediately Seek medical attention Apply ice immediately for 15 minutes Do not attempt to pop the shoulder back in yourself If a reduction is not possible immediately, apply a sling to take the weight of the arm Go to hospital if there is not a medical professional available

What should I expect after the initial reduction?

Treatment following a closed reduction is often referred to as conservative treatment (non-surgical), and usually involves a period of rest in a sling or other immobilising device, followed by a shoulder rehabilitation programme prescribed by a physiotherapist. The purpose of immobilising the arm for a period of time is to allow the structures which may have been injured to have adequate time to heal in the position which is most likely to facilitate this.

Rehabilitation Program Stage 1 - Following Reduction should be immobilised in a sling The shoulder

for at least a week depending on the severity of any associated damage Perform wrist and hand exercises such as moving each finger through its range of motion and clenching the fist to prevent stiffness and keep the blood flowing to the area Continue icing the injury regularly to reduce pain and swelling. If prescribed, take anti-inflammatories You can try taping the shoulder for extra support

Stage 2 Aim: Start to mobilise the shoulder Duration: Week 2-4

When pain allows start mobility exercises for the shoulder Avoid the combined movements of abduction (taking the arm out to the side) and external rotation (turning the shoulder outwards) as this is often the position the injury occurred. Only exercise if pain free Continue to wear a sling when not performing exercises if you feel it necessary Ice after exercise if swelling occurs

Stage 3 Aim: Achieve full range of motion and begin strengthening Duration: Weeks 4-6

Begin isometric (without movement) strengthening exercisesproviding there is no pain Begin to move the shoulder into abduction and external rotation if comfortable to do so, but do not perform strengthening exercises in this position. Continue with mobility exercises Try to achieve a full pain free range of movement Try to avoid wearing a sling

Stage 4 Aim: Achieve strength equal to uninjured side and maintain mobility.Duration: Weeks 6-10
Progress strengthening to resisted exercises if pain free Progress to perform external rotation strengthening in the abducted position if comfortable. Continue with mobility exercises to maintain full range of motion Introduce proprioception exercises

Stage 5 Aim: Return to sport Duration: Weeks 10-16

Increase resistance used for strengthening, progress to dumbells and body weight exercises Start functional activities such as throwing (start underarm and progress) and catching Begin a gradual return to sport, starting with training drills, non-contact and slowly increase the demand on the shoulder

Mobility - Shoulder Dislocation

The following guidelines regarding dislocated shoulder mobility exercises are for information purposes only. We recommend seeking professional advice before beginning rehabilitation.

Pendulum exercises
Gently swing the arm forwards, backwards and sideways whilst leaning forwards. Gradually increase the range of motion All exercises should be pain free Aim to reach 90 degrees of motion in any direction

Active assisted range of motion

Once the shoulder has started to heal, your therapist may start you doing active assisted exercises. This involves you using your good arm to assist the injured arm through the range of movement. Some good examples of this include:

Abduction/Adduction
Holding onto a broomstick with both hands shoulder width apart Using the good arm, push the injured arm out to the side, and back towards the body. This should be performed in both directions, taking the injured arm across the body and away from the body (adduction/abduction)

Flexion/Extension
Lying on your back or seated in a chair, grip the hand of your injured side with the good side Slowly and gently bring the arms up and towards your head, and if you feel comfortable, over the head If at any time you feel like the shoulder is going to pop out, stop and return to the resting position

Rotation
Using the broomstick, this time keep your elbows into your side Allow the stick to move to the left and right in front of you, rotating the shoulder joint

Active unassisted exercises

These involve you using your muscles against gravity, and are working towards you gaining full use of the shoulder again. These involve you practicing all the movements you would expect from the shoulder: Flexion - Lift the arm in front of you & above the head Extension - Move the arm out behind out Abduction - Take the arm away from the body to the side and up above the head Adduction - Move the arm across the body Internal Rotation - Keep the elbow bent by your side, turn the forearm in so that your wrist touches your stomach External Rotation - Keep the elbow bent by your side, turn the forearm outwards so that your hand points away from you

Strengthening - Shoulder Dislocation

Isometric Exercises Isometric means 'without movement, also known as static contractions these are exercises where the muscles are being worked without moving the joint, and are often quite useful if the joint itself is still healing. Isometric Extension Standing with your back against a wall, with your arms by your side. While keeping your elbows and wrists straight, push back into the wall and hold for 5 seconds (work to increase to 10). Repeat this 5 times (work to increase to 10)

Isometric Adduction With a small pillow or a rolled up newspaper between your injured arm and your torso, squeeze inwards and try to hold it in position. Start with a small item and gradually move to larger sizes to work through a larger range of movement. Hold for 5 seconds (work to increase to 10). Repeat this 5 times (work to increase to 10) Isometric Abduction Stand side-on to a wall, with the arm to be worked next to it. Place the back of the wrist against the wall and push outwards as if trying to raise the arm to the side (see picture). Hold for 5 seconds (work to increase to 10). Repeat this 5 times (work to increase to 10)

External Rotation Stand facing a door frame. Keep the elbow bent to 90 degrees and place the back of the hand against the frame (see picture). Push against the it. Hold for 5 seconds (work to increase to 10) and repeat 5 times (work to increase to 10) Internal Rotation Stand facing a door frame. Bend the elbow to 90 degrees, and place the palm of the hand on the side of the door frame and push against it (see picture). Hold for 5 seconds (work to increase to 10) and repeat 5 times (work to increase to 10)