Shoulder dislocations are injuries that occur when the ball of the ball-and-socket shoulder joint comes out of position. Usually a shoulder dislocation occurs after a sports injury or trauma, such as a fall. Shoulder dislocations are painful, and immediate treatment is necessary. Once the shoulder is back in proper position, management options can be considered.
Determining the appropriate treatment depends on a number of factors including exactly what was damaged in the shoulder, how many dislocations have occurred, age of the patient, activities or sports performed, and other factors. You will need to discuss with your doctor the most appropriate treatment for your situation.
Repositioning the Dislocation:
Repositioning a shoulder into proper position is a procedure called "reducing the shoulder." There are several maneuvers that can be used to reposition a shoulder dislocation--usually each physician has a favored reduction maneuver. In general, the goal is to manipulate the joint to allow ball to slide back into position without causing further damage to the shoulder joint.
Once the should dislocation is back in place, repeat x-rays are performed to ensure it is indeed in the correct position, and to evaluate for other injuries such as fractures. Patients are placed in a sling to rest the shoulder and referred to their orthopedic surgeon for further management.
The immediate treatment of a shoulder dislocation is to place the patient in a sling to allow the swelling and inflammation around the shoulder to subside. Thereafter, progressive exercises are started until the patient is able to resume their normal activities. There have been no studies to demonstrate using the sling for any specific period of time is best.
The sling that is used to treat most shoulder dislocations holds the shoulder in internal rotation. This means that the shoulder is turned inwards, and the forearm is held against the body. When the shoulder is held in internal rotation, the ligament that is commonly torn (the Bankart tear) when the shoulder dislocates, is held in an abnormal position. When the ligament heals, it tends to heal in this improper position. In some patients, especially younger athletes, healing of the ligament in this position may lead to repeat shoulder dislocations.
Immobilization in External Rotation:
Research out of Japan has investigated the treatment of shoulder dislocations with the shoulder held in external rotation. When the shoulder is held in external rotation the torn ligament is brought into a more normal position, and may heal in this proper alignment. The idea behind immobilization in external rotation is that if the ligament heals in the proper position, then repeat shoulder dislocations may be less likely.
Immobilization in external rotation is cumbersome and difficult to perform. It is important that the external rotation brace be properly configured--the upper arm should be held tightly against the side, and the forearm should be pointing away from the body. Many patients (and some doctors) confuse abduction immobilizers (shoulder immobilizers with a pillow in the armpit) with an external rotation immobilizer. These are not the same, and similar results of treatment should not be expected. While this treatment is exciting in concept, most patients cannot comply with the brace, and therefore this treatment is seldom used.
Physical therapy can help an injured person regain their strength and mobility after a shoulder dislocation. When the dislocation occurs, damage can lead to a tendency to have repeat dislocations. Therapy can be used to strengthen the muscles that help to hold the shoulder in position to compensate for damaged ligaments from the dislocation injury.
Again, while physical therapy is often used, and extremely helpful in regaining strength and mobility, this has not been shown to lower the chance of having a second dislocation. The most common treatment recommendation is to try therapy after a first dislocation, and if a second dislocation occurs, to proceed with surgery.
Bracing is sometimes considered for patients who sustain a shoulder dislocation. A brace is most commonly used for an in-season athlete who sustains this injury. In this scenario, surgery for treatment of the shoulder dislocation would be season-ending. Therefore, a brace may be used to help prevent a shoulder dislocation.
Braces can help to prevent the shoulder from being placed into a position in which a dislocation is possible. While they cannot prevent all shoulder dislocations, these braces can reduce the overall chance of shoulder dislocations in athletes.
The major problem with bracing, is that athletes who participate in sports often have difficulty wearing the brace and competing effectively. Braces are especially cumbersome in athletes who overhead function (such as throwing) is critical for their effectiveness. Therefore, most athletes are unable to return to their sport while wearing a shoulder dislocation brace.
Surgical treatment of a shoulder dislocation is most often recommended for patients who have recurrent, or repeat, shoulder dislocations. In some patients, surgery may be recommended after a first shoulder dislocation. Surgery is being more commonly considered as an initial treatment, especially in young athletes who participate in contact sports. Because these athletes have such a high change of repeat dislocation, surgery is often used as a first-line treatment.
Surgery is performed to repair the structures that normally hold the shoulder in position. The most common damage is to the ligaments in the front of the shoulder joint. Surgery to repair these ligaments is called a Bankart repair.
Itoi, E, et al. "A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study." J Shoulder Elbow Surg. 2003 Sep-Oct;12(5):413-5.
Owens BD, et al. "Management of Mid-season Traumatic Anterior Shoulder Instability in Athletes J Am Acad Orthop Surg August 2012 ; 20:518-526.