Avoiding Long-Term Problems with a Dislocated Shoulder

Avoiding Long-Term Problems with a Dislocated Shoulder

Shoulder dislocation is an all-too-common injury for many athletes.  Although possible in any direction, approximately 90% of these injuries occur in an anterior, or forward, direction.  With a shoulder dislocation, the head of the humerus (upper arm bone) is forced anterior from its shallow joint, and the glenohumeral (shoulder joint) is disrupted.

This injury typically occurs when the arm is raised away from the side (abduction) at an angle greater than 70 degrees and then externally rotated.  This is referred to as a “throwing position.”  If your arm or hand is forced past the normal range of motion in this position due to a fall, contact with an object or strike from another person, the humeral head dislocates from the joint and causes damage to the stabilizing structures.

Dislocated shoulders are more common than other joint injuries for two reasons:  First of all, the shoulder joint is very mobile and thereby not very stable.  As with any structure, the higher the mobility, the lower the stability.  Secondly, many sports require the athlete to employ the throwing position of shoulder abduction and external rotation described above.

What is a Shoulder Subluxation?

Less severe disruption of the shoulder joint can occur where the humeral head starts to dislocate but returns safely to the joint.  This is referred to as a shoulder subluxation or separation.  Some tissue damage can occur with this injury, which can predispose you to future shoulder dislocations.

What Happens When You Have a Dislocated Shoulder?

Tissue surrounding the shoulder girdle may become damaged when a shoulder dislocation takes place.  The capsule, which surrounds the joint and holds vital lubricating (synovial) fluid, is stretched and damaged as the humeral head relocates outside the joint.  Numerous ligaments reinforce the capsule, which gives stability to the shoulder joint.

Shoulder dislocations can also tear the glenoid labrum, a cartilage ring that surrounds the base of the shoulder joint and deepens the glenoid fossa. The now deeper bowl-like joint surface allows the humeral head to rest, forming the Glenohumeral (or shoulder) joint.  As expected, any joint disruption can injure surrounding ligaments, bones, blood vessels, nerves and tendons.

This injury can fester as a recurring problem, and damage to tissues surrounding the joint will result in instability. A well-balanced rehabilitation program may decrease the likelihood of a chronically unstable joint but cannot completely prevent additional shoulder dislocations.

Signs & Symptoms of a Shoulder Dislocation

• An acute or sudden dislocation usually results in significant pain encompassing the front half and top of the shoulder.
• A “pop” is often heard as the upper arm shifts, usually in an anterior and downward manner.
• It is difficult to move the arm due to pain and the inability to voluntarily contract the musculature surrounding the shoulder joint and upper arm.
• The arm (supported by the uninjured arm) is most comfortably held in a position slightly away from and in front of the body while leaning forward and toward that side.
• The shoulder takes on a flat and deformed-like appearance, unlike its typical, rounder shape.
• If blood vessel or nerve damage occurs, numbness and/or a pins-and- needles feeling may present in the shoulder, arm and hand.

Treating a Dislocated Shoulder

Trained medical specialists should attend to shoulder dislocations that require reduction (moving the joint back in place) in a hospital setting.  Serious secondary injuries to nerves and blood vessels can easily occur when reducing a dislocated joint.

• Lean on an X-ray and/or MRI to look for any fractures, labral tears or extensive soft tissue damage following a reduction.
• A thorough evaluation by a shoulder-oriented orthopedic surgeon is extremely important to confirm an exact diagnosis and solid rehab protocol. This is a crucial first step that ultimately sets the course toward either a full recovery or, in its absence, a chronic, life-long problem.
• Applying ice to the area helps decrease pain, spasms and swelling. Do this every hour for 15 minutes with ice bags covering the front, top and back of the shoulder.
• Wear a sling for the first three to seven days post-injury. This helps support the weight of the arm and allows it to rest while restricting motion of the injured tissue.
• If a fracture is ruled out, perform easy range-of-motion (ROM) activities, beginning with elbow motion and pendulum rotations.
• When the time is right, a physician can recommend and monitor a progressive strengthening program for the shoulder, arm and core.
• ROM exercises, strengthening programs and activities of daily living (ADLs) should not include any activities that place the arm in an “up and away” position, typically referred to as a throwing motion position.
• The specific protocol, including the timeframe for sling use, range of motion (ROM) progression, strengthening plan and return to play procedures, must be directed by a physician rather than this article, the purpose of which is to provide a general overview of this injury.

Surgical Options for a Shoulder Dislocation

Surgical shoulder repair is sometimes necessary after a dislocation.  The main objective for the surgery is typically to improve joint stability, hence improving the function of the entire upper extremity.

Parameters for surgery as well as the types of surgeries available for this injury are beyond the scope of this article.

Both the doctor and athlete will typically assess the following variables to determine the need for surgery:

1. Degree of shoulder instability and secondary injuries

2. Sport(s) of interest

3. Projected lifestyle and quality of life adjustments

4. Athlete’s ability to put forth the necessary effort with post-operative rehabilitation

5. Many shoulder-stabilizing surgical procedures result in a permanent reduction in some shoulder motion such as external rotation. Consider this important factor when determining the type of surgery and rehabilitation protocol.

Ask The Right Questions Like a Pro

To ensure you receive the best possible care for your injured shoulder, ask questions like smart professional athletes who seek help from their sports medicine specialist to quickly and safely return to their sport:

1. In which direction did my shoulder dislocate?

2. Do I have multidirectional instability?

3. How would you describe the extent of the damage to my shoulder joint surfaces, capsule, ligaments and muscles?

4. Do I need surgery, and if so, which type would you recommend and why?

5. When can I get out of my sling and start my ROM drills/strengthening exercises?

6. Is there a detailed rehab protocol I can follow during my recovery?

Sports Medicine Tips for a Quick Recovery

• The RC Rules – Shoulder joint stability is important, but the rotator cuff drives that train.  It’s crucial to strengthen the RC but in a smart manner to avoid chronic issues with both.
• Don’t Let the Labrum Scare You – Labral tears in the shoulder mimic small cartilage tears in the knee.  If your doctor finds a labral tear, don’t panic – many of us have them and do just fine.
• Honesty is the Best Policy – Be true to yourself and consider factors related to both your shoulder and lifestyle when considering surgery.  If your shoulder is unstable and activity level ambitious, stability is a must.
• Be Mindful of the Big A – You want to minimize arthritis, or it’s cooler name of Degenerative Joint Disease (DJD).  A combination of poor mechanics and a “sloppy” or loose shoulder is the easiest way to accelerate DJD in a very active athlete.
• Rehab With Passion – As with any injury, physical therapy is key to your recovery and beyond.  Put your heart into your one opportunity to gain back your range of motion and strength. Focus right now, kickstart a great maintenance program and get back in the game!