Conservative management of shoulder dislocations is not a matter of universal agreement in the field of orthopaedics, typical treatment being immobilisation in a sling from 1-6 weeks. A waist strap to keep the arm immobile in by the abdomen may be used but is often not. The arm is held by the side and in across the abdomen (known as shoulder adduction and medial rotation) to prevent joint stresses, in order to prevent moving the arm out from the side and rotating it outwards (known as shoulder abduction and lateral rotation).
Recent studies of dislocation in the scientific literature have shown some clues as to how these injuries should be managed. One study involved MRI scanning to show that the relationship between the rim of the socket and the socket itself is best maintained by placing the arm by the side and rotating it laterally 35 degrees. A cadaveric study of shoulders showed that keeping the arm in slight adduction close to the body allowed a reasonable range of motion without disrupting the close approximation of the structures. Lifting the arm up forwards or out to the side (flexion and abduction) disturbed this relationship.
The time of immobilisation is not one of general agreement with three or four weeks in a sling typically prescribed for younger people and shorter periods for older people. A longer period of immobilisation was shown in one study to significantly lower the rates of recurrent dislocation. Another study followed patient with shoulder dislocation for ten years and found no influence of the period of immobilisation on the rate of recurrent dislocation. After the patient is reviewed at the three week period they start their rehabilitation with the physiotherapists.
Initial exercises will include pendular exercises, chosen for their reduced joint stresses due to the patient being bent over and the arm hanging in a relaxed position. This keeps the shoulder joint moving without fear of overstressing the joint capsule. Scapular movements are also performed early so that the shoulder girdle remains mobile and functional. Active assisted movements are the next progression taught by the physiotherapist, allowing the range of movement to be increased whilst reducing joint stresses as the other shoulder contributes much of the force needed.
The risk of dislocating again means that lateral rotation of the joint will be restricted and the range gradually progresses as healing occurs, without ever being strongly stressed as a loss of the end range of this movement may help this joint prevent further dislocations. Restricting the joint from attaining the risk position may reduce the likelihood of it dislocating again. Six weeks is typical soft tissue healing time and patients are then progressed onto performing full active range of motion exercises and also muscle strengthening.
More vigorous rehabilitation can follow if the patient has particular requirements for their shoulder function, but overhead sports are unlikely to be sensible for at least four months. If the patient is older or the greater tuberosity, a part of the humeral head which bears muscular insertions, is fractured then the prognosis is better overall. In some cases the person may have to modify their activity to avoid the risk of dislocating again, limiting overhead work, avoiding high risk sporting activities and modifying heavy work.
Recurrence of dislocation is 30% overall for non-athletic individuals and 82% in those who are athletes, if they are not surgically managed. However, re-dislocation rates after the first dislocation event vary greatly depending on the age of the individual. Very young people, under ten years old, have a 100% likelihood of dislocating again whilst people between 41 and 50 years old have a probability of recurrence between 0 and 24%. If patients suffer from recurrent dislocation or subluxation (partial dislocation) they may need surgical management.
The timing of surgical management is not clear although early surgery after the initial dislocation may be advantageous. Studies vary but one showed that after stabilisation surgery via the arthroscope there was a four percent dislocation rate but a 94 percent repeat dislocation rate after conservative treatment. Overall it looks like the recurrence rate is higher for those patients managed by non-operative immobilisation. The level of stability given in operation was better with open surgery but arthroscopic techniques have advanced considerably and this distinction has disappeared.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, Physiotherapists in Exeter, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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