Shoulder dislocation Background

Shoulder dislocations may occur from a traumatic injury or from loose capsular ligaments. Different conditions may affect the stabilizing structures of the shoulder and, thus, negatively affect patients with shoulder dislocations.[1] Note the images below.
Anterior dislocation.

This article focuses on glenohumeral joint dislocation. Although acromioclavicular (AC) joint separations are sometimes called shoulder dislocations by nonmedical persons, these are not true shoulder dislocations. Shoulder dislocations occur when the head of the humerus comes out of its socket, the glenoid. For patient education resources, see the Breaks, Fractures, and Dislocations Center and Sports Injury Center, as well as Shoulder Dislocation and Shoulder Separation.

Epidemiology
Frequency United States The shoulder is the most commonly dislocated joint in the body.[1, 2, 3] Although most shoulder dislocations occur anteriorly, they may also occur posteriorly, inferiorly, or anterior-superiorly. Patients with a previous shoulder dislocation are more prone to redislocation. Other factors that show a clear correlation to redislocation are the age of the patient and concomitant rotator cuff tears and fractures of the glenoid. Younger patients (teenagers and those aged 20 years) have a much higher frequency of redislocation than patients in their 50s and 60s.[4] Many physicians believe that age is less of a predisposing risk factor for redislocation than activity level. Patients who tear their rotator cuffs or fracture the glenoid during their shoulder dislocation have a higher incidence of redislocation than patients without these problems.

Functional Anatomy

Shoulder stability is maintained by the glenohumeral ligaments, the joint capsule, the rotator cuff muscles, the negative intra-articular pressure, and the bony/cartilaginous anatomy. The main stabilizers of the shoulder joint are the ligaments and the capsule complex. Multiple ligaments are present, but the inferior glenohumeral ligament is the most important and the one most commonly injured during an anterior shoulder dislocation. The injury may be a tear of the ligament/capsule off one of its bony attachments, and/or it may cause a stretch injury to these structures. Tears in the rotator cuff muscles may also lead to shoulder instability. Four rotator cuff muscles are present in the shoulder. They are found superficial to the glenohumeral ligaments and the bones. Large tears may lead to shoulder instability, even with intact glenohumeral ligaments. Instability of the shoulder can also occur from injury to the nerves that control the shoulder muscles, specifically the axillary nerve.

Sport-Specific Biomechanics
The shoulder is a very mobile joint; therefore, it is often placed in awkward positions during sports. Thus, the force from a fall or a blow may be sufficient to cause shoulder damage. If the force is strong enough, the athlete tears the ligaments/tendons, fractures the glenoid or humerus, and dislocates the shoulder.

History
Patients with a dislocated shoulder report a myriad of symptoms to their physician. Because most dislocations happen from trauma, patients report feeling the shoulder pop out during the incident. Different shoulder positions during the dislocation tear different ligaments. Thus, trying to determine the shoulder position at the time of the injury is important. The most common dislocation is anterior. In an anterior dislocation, the patients report having their arm abducted and externally rotated. Ask the patient if they had to go to the emergency department to have the shoulder reduced. If they did, they should have a radiograph of the dislocated shoulder. If they did not go to the emergency department, did the patient pop the shoulder back in or did it just go back in by itself? Patients with very loose joints (hyperlaxity) report feeling like their joint rolls out of the socket. These patients can usually "roll" the shoulder back in. Remember that patients with previous shoulder dislocations are more

apt to redislocate, so ask about any previous dislocations. Some patients feel stingers or numbness run down their arm at the time of the dislocation.

Physical
The physical examination in a patient suspected of having a dislocated shoulder should confirm what the clinician picked up from the history of the injury. If the patient has a dislocated shoulder, range of motion (ROM) is poor and the patient is in a lot of pain. If the shoulder is anteriorly dislocated, the arm is in slight abduction and external rotation. In patients who are thin, the prominent humeral head can be felt anteriorly and the void can be seen posteriorly in the shoulder. Posterior shoulder dislocations can be easy to miss, because the patient usually keeps his or her arm in internal rotation and adduction (ie, the patient holds the arm up against his or her abdomen). In patients who are thin, the prominent head can be seen and palpated posteriorly. Poster shoulder dislocations can be missed, because the patient appears to only be guarding the extremity. If the proper radiographs are not obtained, the diagnosis will be missed (see Imaging Studies). Performing a detailed neurovascular examination before and after the shoulder has been reduced is imperative. Injury to the axillary nerve during shoulder dislocation has been reported to be as high as 40%.

Causes
Approximately 95% of shoulder dislocations result from a major traumatic event, and 5% result from atraumatic causes. Distinguishing the type and severity of the event is important to determine the true etiology of the dislocation. This distinction is necessary to determine the treatment.[1, 2, 5, 6, 7] With a traumatic dislocation, the cause is obvious; however, atraumatic dislocations can result for different reasons. Ligamentous lax shoulders may dislocate with little or no trauma. Patients with lax ligaments may have 2 loose shoulders, but only 1 may be symptomatic. Congenital causes, such as excessive retroversion of the humeral head or malformation of the glenoid, can lead to instability. Neuromuscular causes, such as injury to the axillary nerve or cerebral palsy, have also been associated with shoulder instability.

Differential Diagnoses
Acromioclavicular Joint Injury Bicipital Tendonitis Clavicular Injuries Rotator Cuff Injury Shoulder Dislocation Swimmer's Shoulder

Imaging Studies
Radiographs When dealing with shoulder instability, obtaining 2 orthogonal views of the shoulder is imperative. The author suggests routinely ordering an anteroposterior (AP) view of the shoulder and an axillary lateral view. If an axillary lateral radiography cannot be obtained, then a scapular Y view may be taken in its place. If good radiographs cannot be obtained, order a computed tomography (CT) scan. This study can be performed quickly and is not expensive. Posterior shoulder dislocations can look like a normal shoulder on the AP view. If an orthogonal view radiograph is not obtained, the diagnosis may be missed. The findings of one study show that younger patients (< 30 y) with mechanisms that are low risk for fractures are probably safe to reduce without prereduction radiography.[8] Magnetic resonance imaging (MRI) Glenohumeral ligament tears can be visualized with an MRI. They are better seen with the injection of contrast into the joint before the MRI evaluation. The bony architecture on these studies can also be appreciated. Patients older than 45 years tend to tear the rotator cuff tendons when the shoulder is dislocated. The tendons are less elastic and do not stretch out during the incident and thus tear. Proper diagnosis is necessary to get these patients back to their preinjury status. If the patient is older than 45 years and has marked weakness in the strength testing of the rotator cuff muscles, an MRI is a great tool to assess for tears.

Acute Phase
Rehabilitation Program

Physical Therapy In the acute phase of a dislocated shoulder, therapy should be limited. The arm should be immobilized in a sling and swathed for 1-3 weeks. The actual position of the arm in the sling has been debated and thought to be more beneficial to the torn soft tissues with the arm in external rotation.[10, 11, 12, 13] Recent literature has shown that having the arm in internal rotation while in the sling has no impact on the rate of recurrent dislocation when compared with patients immobilized in external rotation.[14] While the patient is in the sling, elbow, wrist, and hand range of motion should be encouraged. Working with the parascapular muscles is also important during this acute phase of rehabilitation since these can be initiated while the patient is still in the sling. These exercises should be continued when the patient comes out of the sling. Active and passive flexion, extension, abduction and internal/external rotation begin at about the third week, when the patient comes out of the sling. The authors encourage patients to get about 10 degrees of improvement in their motion per week. One will find that patients usually progress faster than 10 degrees per week. It is important to educate the patient and inform him or her that getting all of the motion back "right away" can be detrimental to the stability of their shoulder. Rehabilitation should be geared to gently restoring the range of motion over 6-8 weeks. A good adage during the first 3 weeks after a shoulder dislocation is to "keep the hand in view." While looking forward, the patient should never let his or her hand be placed in a position outside the line of vision. This instruction assures a midrange position that does not compromise apposition of the torn or stretched anterior capsular structures to the glenoid.

Recovery Phase
Rehabilitation Program Physical Therapy After the initial period of immobilization, passive ROM exercises should begin. Older individuals should begin performing ROM of the shoulder after 1 week of immobilization, because these patients are prone to shoulder stiffness. Passive ROM exercises should include shoulder pendulum exercises and an overhead pulley system for the shoulder. Goals for passive ROM should be 30 of external rotation and 90 of flexion for the first 3 weeks, followed by 40 of external rotation and 140 of flexion for the second 3 weeks. The rotator cuff may also have been injured during the dislocation, so the therapist should be cognizant of the status of the rotator cuff during

the early phase of rehabilitation..

Maintenance Phase
Rehabilitation Program Physical Therapy More vigorous therapy can be initiated after full passive ROM has been regained, usually after 6 weeks. Rotator cuff strengthening exercises can be initiated with the use of rubber tubing or weights. Because the rate of shoulder redislocation is so much higher in young adults, vigorous training and strengthening should be delayed until approximately 3 months after the injury. Swimming is an ideal exercise to regain shoulder strength and should be encouraged once strengthening exercises have begun.

Return to Play
Return to play in patients following a shoulder dislocation is determined when full ROM and strength have been regained. Return to play is usually sooner for older adults than for younger athletes, because the fear of redislocation is much lower in older adults. Usually, older adults can return to play within 3 months. With younger adults, conditioning can continue through shoulder rehabilitation; however, decisions about returning to play should be more conservative than those in older adults. Again, absolute criteria are full ROM and full strength. When determining a patient's return to competitive sports, the author uses the following criteria: Scapular stability through full ROM Normal scapulohumeral rhythm Full active and passive ROM Rotator cuff strength at 80% of opposite side Pain-free activities of daily living (ADLs)

Complications
The most common complication of an acute shoulder dislocation is recurrence. This complication occurs because the capsule and surrounding ligaments are stretched and deformed during the dislocation. Age is the most important indicator for prognosis; dislocations recur in approximately 90% of teenagers. Another common complication following dislocation is fracture. The most common type is a Hill-Sachs lesion or compression fracture of the posterior humeral head. Fractures of the proximal humerus, greater tuberosity, coracoid, and acromion have also been described. Rotator cuff tears also commonly occur as a result of shoulder

dislocations, and the frequency of this complication increases with age. This complication can be expected in 30-35% of patients aged 40 years or older. Slow progression in return to active function following shoulder dislocation in a middle-aged patient should warrant a workup for a rotator cuff tear. Vascular injuries are rare, but they do occur, especially in older patients. Vascular injuries are more common with inferior dislocations and usually involve a branch of the axillary artery. Nerve injuries are much more common than vascular injuries, especially with anterior or inferior dislocations. The axillary nerve is the nerve injured most often and may be crushed between the humeral head and the axillary border of the scapula or injured by traction from the humeral head. Axillary nerve injury has been reported in as many as 33% of acute anterior dislocations.

Prognosis
Age at dislocation is the most important prognostic indicator for recurrence of shoulder dislocations. Younger age at initial injury increases the likelihood for future dislocation. The recurrence rate is thought to be 90% if the initial episode occurs in the teen years. In patients aged 40 years or older, the recurrence rate is 10-15%. Most redislocations occur within 2 years of the primary injury. Persons with axillary nerve injuries can be expected to recover completely within 3-6 months.