Sports Medicine
Sports Injury Prevention & Rehabilitation

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Dislocated Shoulder

(Also known as Shoulder Dislocation, Anterior Shoulder Dislocation, Dislocation of the Shoulder Joint)
What is a dislocated shoulder?
A dislocated shoulder is a common traumatic sporting injury characterized by tearing of the connective tissue surrounding the shoulder joint with subsequent displacement of the bones forming the joint so they are no longer situated next to each other (i.e. the upper arm bone comes out of the socket).
The shoulder joint is a ball and socket joint. The shoulder blade gives rise to the socket of the shoulder, whilst the ball of the shoulder arises from the top of the humerus (upper arm bone). Surrounding the ball and socket joint is strong connective tissue holding the bones together known as the shoulder joint capsule. In addition, a group of muscles known as the rotator cuff cross the shoulder joint and collectively help to hold the shoulder joint in position increasing the shoulder's stability.
During certain movements of the arm stretching forces are applied to the shoulder joint capsule. When these forces are excessive and beyond what the shoulder can withstand, tearing of the connective tissue may occur. This may allow the upper arm bone (humerus) to move out of the socket if the forces involved are too great and beyond what the connective tissue and supporting muscles can withstand. When this occurs, the condition is known as a dislocated shoulder.

Causes of a dislocated shoulder

A dislocated shoulder typically occurs traumatically due to forces pushing the ball shaped aspect of the upper arm bone out of the socket. This may occur due to a direct impact or more commonly, due to a fall on the outstretched arm (seen frequently with cyclists and horseback riders). Shoulder dislocations are commonly seen in contact sports such as rugby and football. The usual movements involved in this injury are a combination of shoulder abduction (side elevation) and excessive external rotation (outer rotation of the humerus).

Signs and symptoms of a dislocated shoulder
Patients with a dislocated shoulder usually experience sudden severe pain at the time of injury. The pain is usually so intense that the patient can not continue activity and will often cradle the arm against their body. Pain is usually felt in the shoulder region, however can occasionally radiate down the arm.
Patients with this condition will often experience a sensation of the shoulder 'popping out' at the time of injury. Visible deformity of the shoulder joint may be detected when compared to the other side. Occasionally, patients may experience pins and needles or numbness in the shoulder, arm or hand.
Once a dislocated shoulder has been 'relocated' (i.e. the ball positioned back in the socket by a sports medicine professional), patients may experience a feeling of weakness in the shoulder and an ache that may increase to a sharper pain with certain movements. These symptoms generally resolve over time with appropriate rehabilitation. However patients with this condition may be left with a feeling of impending dislocation when the shoulder is placed in certain positions, particularly the combination of abduction and external rotation.

Diagnosis of a dislocated shoulder

A thorough subjective and objective examination from a physical therapist is usually sufficient to diagnose a dislocated shoulder. X-ray investigation is usually required to determine if there are any fractures associated with the dislocation and to confirm diagnosis. Further investigations such as a CT scan, Ultrasound or MRI may be required to assist diagnosis and determine involvement of other structures.

Treatment for a dislocated shoulder

Before commencing treatment for a dislocated shoulder, patients with this condition should have shoulder X-rays to determine if there are any fractures associated with the dislocation. This is particularly important in the case of traumatic shoulder dislocation where large forces are involved and should ideally occur before attempting to 'relocate' the upper arm bone (humerus) back into the socket. Following X-ray an experienced sports medicine professional can assist with safely 'relocating' the humerus back into the socket. This should not be attempted alone, as serious long term damage may occur to other structures around the shoulder such as nerves, bones, ligaments and cartilage if the shoulder relocation is performed incorrectly.
Following relocation of the shoulder, most patients heal well with appropriate physical therapy treatment. The success rate of treatment is largely dictated by patient compliance. Treatment for a dislocated shoulder usually entails an initial period of approximately 3 weeks immobilization in a sling (less time for older patients) to allow the damaged connective tissue to heal and form a 'scar'. During this period of immobilization, gentle pendular exercises are allowed as guided by a physical therapist.
Following this, patients should perform pain-free flexibility and strengthening exercises as part of their rehabilitation to ensure an optimal outcome. However, movements placing the shoulder at risk of further dislocation (combined abduction and external rotation) should be avoided for at least 6 weeks. The treating physical therapist can advise which exercises are most appropriate and when they should be commenced. Particular emphasis needs to be placed on strengthening the rotator cuff muscles to improve stability of the shoulder joint. Exercises to improve posture and shoulder blade stability are also important.
Patients with a dislocated shoulder usually benefit from following RICE. RICE is beneficial in the initial phase of the injury (first 72 hours) or when inflammatory signs are present (i.e. morning pain or pain with rest). This should primarily involve resting from aggravating activities (i.e. use of a sling), regular icing, and sleeping on the opposite side (to keep the arm slightly elevated). Heat, alcohol and massage should also be avoided in the initial 72 hour period following injury or when inflammatory signs are present. Anti-inflammatory medication may also benefit those with a dislocated shoulder by reducing the pain and swelling associated with inflammation.
In the final stages of rehabilitation for dislocation of the shoulder, a gradual return to activity program is indicated as guided by a physical therapist.

Prognosis of a dislocated shoulder
Many patients with a dislocated shoulder heal well with appropriate physical therapy and return to normal function. This may take weeks to months to achieve an optimal outcome. However, due to the severity of injury and widespread connective tissue damage associated with this condition, patients may experience long term effects. The most common long term effect of a dislocated shoulder is an increased likelihood of future dislocation with relatively minor trauma. In cases of recurrent shoulder dislocation, surgical repair of the shoulder joint capsule may be indicated. This is usually followed by an extensive rehabilitation program lasting many months.
Patients with a dislocated shoulder who also have damage to other structures such as cartilage, bone or nerves are likely to have a significantly extended rehabilitation period to gain optimum function.

Contributing factors to the development of a dislocated shoulder
There are several factors which can predispose patients to dislocating their shoulder. These need to be assessed and where possible, corrected with direction from a physical therapist. Some of these factors may include:
  • history of previous shoulder dislocation or shoulder instability
  • inadequate rehabilitation following a shoulder dislocation
  • participation in sports or activities placing the shoulder at risk of dislocation
  • shoulder weakness
  • shoulder joint hypermobility
Physical therapy for a dislocated shoulder
Physical therapy treatment for a dislocated shoulder is vital to hasten the healing process and ensure an optimal outcome. Treatment may comprise:
  • use of a sling (for approximately 3 weeks)
  • soft tissue massage
  • electrotherapy (e.g. ultrasound, TENS)
  • protective taping
  • joint mobilization
  • dry needling
  • ice or heat treatment
  • exercises to improve flexibility, strength, shoulder blade stability and posture
  • hydrotherapy
  • education
  • activity modification advice
  • postural correction
  • anti-inflammatory advice
  • devising and monitoring a return to activity plan
Other intervention for a dislocated shoulder
Despite appropriate physical therapy management, some patients with this condition require other intervention to ensure an optimal outcome. The treating physical therapist or doctor can advise on the best course of management when this is the case. This may include further investigations such as X-rays, ultrasound, CT scan or MRI, pharmaceutical intervention, corticosteroid injection, or referral to appropriate medical authorities who can advise on any intervention that may be appropriate to improve the condition. Occasionally, patients may require surgery to repair the torn connective tissue or to correct other abnormalities associated with the dislocated shoulder (such as fractures).