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 scientific studies have given new ideas on why these injuries should be immobilised in particular ways. One study done via MRI scanning showed that the socket and the fibro-cartilage rim, which is often damaged, were kept in most intimate contact with the arm by the side and the shoulder externally rotated at thirty-five degrees. A second study performed with dead bodies showed a reasonable range of movement where the two important structures are closely applied if the arm is in slight adduction. Bringing the arm forwards (flexion) or out sideways (abduction) tended to disrupt the joint rim.

How long a person should be in a sling is not clear and wearing a sling for three to four weeks is common in younger people with perhaps a bit shorter for older patients. One study indicated that the chances of the shoulder dislocating again was reduced by having a longer period of immobilisation. However, another long study following patients over 10 years did not find any effect on the recurrence rate by the period they were immobilised. At the three or four week point the patient is usually reviewed by a physiotherapist and rehabilitation started.

Pendular exercises begin rehabilitation and due to the patient bending over and the arm hanging dependent there is less force through the shoulder, allowing the maintenance of shoulder range without inappropriate joint stresses on the capsule. Early practising of scapular movements is also taught to maintain shoulder girdle mobility and function. The physiotherapist will then progress the patient onto active assisted exercises which promote range of movement and muscle activity with the unaffected arm providing significant effort to reduce the stresses through the injured side.

External rotation will initially be limited due to the re-dislocation risk and gradually allowed to increase as the weeks go on, but it is never pushed strongly and there may be an advantage to the patient if they lose some range of this movement. This may protect them from easily going into the risky and vulnerable dislocating position again. At six weeks much of the soft tissue healing will be well advanced and patients can start doing full active range of movement and strengthening exercises for the shoulder and shoulder girdle.

Stronger rehabilitation can be pursued if the patient needs high performance from their shoulder but four months should typically elapse before overhead sports practise will be wise. Older patients or those with greater tuberosity fractures (a bit of the upper arm bone where tendons attach) have a somewhat better prognosis. Modification of a patient’s typical activities may be required by limiting arduous work, controlling overhead activities and deciding not to indulge in sporting activities which carry increased risks.

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.

When a problem shoulder should be surgically managed is not generally agreed but surgery early after the dislocation may be helpful. Scientific studies vary but in one there was only a four percent re-dislocation after arthroscopic shoulder stabilisation compared to a 94 percent re-dislocation rate in those managed non-operatively. Conservative treatment may have higher recurrence rates than those managed surgically. Open surgery used to provide better stability results but newer techniques with the arthroscope have meant that this technique is now as good.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, 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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