Avoiding Long-Term Problems with a Dislocated Shoulder

SHOULDER DISLOCATION - "HERE COMES THE PAIN"

Shoulder dislocation is an all too common an injury for many sports with both men and women.  Although it can happen in any direction, approximately 90% of these dislocations are in an anterior or forward direction.  With a shoulder dislocation, the head of the humerus (upper arm bone) is forced anterior from it’s shallow joint and the glenohumeral or shoulder joint is disrupted.

Typically this injury occurs when the arm is raised away from the side (abduction) at an angle greater than 70 degrees and externally rotated.  This is what is referred to as a throwing position.  When in this position, if your arm or hand is forced past the normal range of motion with a fall or comes in contact with an object or is struck by another person, the humeral head is dislocated from the joint and the stabilizing structures are damaged.

Dislocated shoulders are more common than similar injuries with other joints for two reasons.  First of all, the shoulder joint is very mobile which means it is not very stable.  As with any structure, the higher the mobility the lower the stability.  Secondly, a large percentage of sports require the athlete to put their arms in the throwing position of shoulder abduction and external rotation.

What is a Shoulder Subluxation?

A less severe disruption of the shoulder joint can occur where the humeral head starts to dislocate but it returns to the safety of the joint.  This is referred to as a shoulder subluxation or separation.  Some tissue damage can occur with this injury and it can predispose you to dislocating your shoulder in the future.

What Happens When You Have a Dislocated Shoulder?

When a shoulder dislocation takes place, tissue surrounding the shoulder girdle can be damaged.  The capsule, which surrounds the joint and holds the vital lubricating fluid known as synovial fluid, is stretched and damaged as the humeral head is relocated outside the joint.  Numerous ligaments reinforce the capsule, which gives stability to the shoulder joint.

Shoulder dislocations can also tear the glenoid labrum, which is 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 disruption of a joint can injure surrounding ligaments, bones, blood vessels, nerves and tendons.

This injury can often become a recurring problem. Due to the many stabilizing tissues surrounding the joint, damaged tissues will result in a highly unstable shoulder joint. A well-balanced rehabilitation program may decrease the likelihood of a chronically unstable glenohumeral joint but it cannot eliminate the change of additional shoulder dislocations.

Signs & Symptoms of a Shoulder Dislocation

  • An acute or sudden dislocation of the shoulder usually results in significant pain encompassing the front half and top of your shoulder.
  • A “pop” is often heard and a shifting of the upper arm, usually in an anterior and downward manner.
  • Difficulty in moving the arm due to pain and the inability to voluntarily contract the musculature surrounding the shoulder joint and upper arm.
  • Arm is most comfortably held slightly away from and in front of your body while you lean forward and towards that side with the arm supported by the uninjured arm.
  • The typical rounded appearance of your shoulder is replaced with a flatter and deformed-like appearance.
  • If blood vessel or nerve damage occurs, numbness and/or pins and needles may be present in your shoulder, arm and hand.

Treating a Dislocated Shoulder

Shoulder dislocations which require reduction (putting the joint back in place) is best when done by a trained medical specialist in a hospital setting.  Serious secondary injuries to nerves and blood vessels can easily occur when reducing a dislocated joint.

  • Once the shoulder is reduced, an x-ray and or MRI should be done to determine if there are any fractures, labral tears or extensive soft tissue damage.
  • A thorough evaluation by a shoulder-oriented orthopedic surgeon is extremely important.  Determining an exact diagnosis and a solid rehab protocol may very well be the most important initial steps that will determine if you fully recover from this injury or if you have a chronically unstable and painful shoulder for the rest of your life!
  • The application of ice helps decrease pain, spasms and swelling to the area.  Ideally ice should be applied every hour for 15 minutes with ice bags covering the front, top and back of your shoulder.
  • A sling is most often needed and helpful for the first 3 – 7 days after a dislocated shoulder. This helps to support the weight of the arm allowing for the arm to rest while restricting the motion of the injured tissue.
  • The specific protocol, which will include the timeframe for use of the sling, the range of motion (ROM) progression, the strengthening plan and the return to play procedures, must be directed by your physician and not by this article.  The purpose of the article is to inform you and to give a general overview of this injury.
  • If a fracture has been ruled out, easy range of motion (ROM) is initiated beginning with elbow motion and pendulum rotations.
  • A progressive strengthening program for the shoulder, arm and core is extremely important and should be started and monitored with the advice of your physician.
  • With your ROM exercises, strengthening program and activities of daily living, avoid any activities that place your arm in an “up and away” position, which is typically referred to as a throwing motion position.

Surgical Options for a Shoulder Dislocation

It is sometimes necessary to surgically repair a shoulder after dislocation.  The main objective for the surgery is usually to improve the stability of the joint and, hence, improve the function of the entire upper extremity.

The parameters for surgery and the types of surgeries for this type of injury are beyond the scope of this article.

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

  1. Amount of shoulder instability and secondary injuries.
  2. The sport(s) of interest.
  3. The projected lifestyle and quality of life.
  4. The ability of the athlete to put forth the necessary effort with the post-operative rehabilitation.

Many shoulder-stabilizing surgical procedures result in a permanent reduction in some shoulder motion such as external rotation.  This is an important factor that needs to be considered when determining the type of surgery and the rehabilitation protocol.

Asking The Right Questions

To ensure you receive the best possible care for your injured shoulder, ask questions like a smart professional athlete who wants to safely return to his/her sport as quickly as possible.  Here’s what a pro athlete would ask his sports medicine specialist:

  1. 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 I do, which type of surgery would you recommend and why?
  5. When can I get out of my sling, start my ROM drills and when can I start my strengthening exercises?
  6. Do you have a detailed rehab protocol for me to follow during my recovery?

Sports Medicine Tips for a Quick Recovery

  • The RC Rules – The shoulder joint stability is important but the rotator cuff drives that train.  You need to get that RC strong but in a smart manner so you avoid chronic issues with both.
  • Don’t Let the Labrum Scare You – Labral tears in the shoulder are much like small cartilage tears in the knee.  If your doctor finds a labral tear, don’t let it scare you because many of us have them and do just fine.
  • Be Honest With Yourself – Look at all the factors related to your shoulder and your lifestyle when considering surgery.  If your shoulder is unstable and your activity level is ambitious, having stability is a must.
  • The Big A Word – You want to minimize Arthritis or it’s cooler name of Degenerative Joint Disease (DJD).  Poor mechanics and a “sloppy” or loose shoulder for a very active athlete is the easiest way to accelerate DJD.
  • Rehab With Passion – As with any injury, physical therapy is key to your recovery and beyond.  Put your heart into getting your range of motion and your strength because you only have this opportunity one time.  Get it right now, get on a great maintenance program and get back into the game!
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