The shoulder joint is the most mobile joint in the human body, allowing large degrees of movement. This is due to the bony structures, their articulations and the fact that they are less restrained than other joints in the body.
The glenohumeral joint (shoulder joint) is comprised of the glenoid (shoulder blade) and humerus (upper arm) and is often thought of like a golf ball sitting on a golf tee due to its small articulation, which in turn increases its risk of injury. Shoulder dislocations are a common injury sustained by athletes with this area representing up to 50% of all major joint dislocations.
What is a shoulder dislocation?
A shoulder dislocation occurs when there is complete separation of the two bony surfaces (humerus and the glenoid). Athletes can also experience a partial dislocation or subluxation where the joint surfaces are only partially separated. Dislocations typically occur following an injury and these are termed traumatic dislocations.
With these types of dislocations, there is often associated damage to the fibrous capsule, bony surfaces and ligaments that surround the shoulder. A dislocation can also occur without an injury, and this is termed atraumatic instability/dislocation. These dislocations can occur with low force movements and often see high recurrence.
Types of Shoulder Dislocations:
There are three types of shoulder dislocations that athletes can suffer.
Anterior Dislocation: This is the most common type of shoulder dislocation and accounts for up to 97% of dislocations seen. This type of dislocation occurs when the humerus shifts anteriorly out of the glenoid, with the mechanism of injury of these types of dislocations being a fall onto an outstretched arm or arm overreached in an abducted and externally rotated position
Posterior Dislocation: Account for roughly 3% of all shoulder dislocations and are seen when players fall onto an outstretched arm that is flexed and adducted forcing the humerus posteriorly. They are often seen following patients who experience a seizure.
Inferior Dislocation: This rare type occurs when the humerus moves downward and is often seen when the arm is forced into a hyper-abducted position. These types of dislocations require significant force.
Symptoms of a Shoulder Dislocation
A dislocated shoulder is very painful and obvious, an anterior shoulder dislocation is generally diagnosed early, however posterior shoulder dislocations can be missed on imaging. The common symptoms include:
Deformity
Swelling
Numbness and weakness - this can be due to stretching of the neuromuscular bundle when dislocated or due to impingement when relocated.
Bruising
Pain
Muscle spasms
A complete shoulder dislocation is obvious to diagnose, but a partial dislocation or subluxation can be harder to detect with the bones often relocating on their own. The joint can appear relatively normal but there will still be associated pain. It is important to seek the advice of a healthcare professional if you suspect that you may have dislocated or partially dislocated your shoulder as you may continue to experience instability, pain and risk the ligaments of your shoulder not healing.
Immediate Treatment Steps
Acute management of a complete shoulder dislocation involves the reduction of the joint. This procedure will typically be performed in the emergency department or by a medial professional. You will then be placed in a sling and undergo further medical examination to rule out major damage to the bony, soft tissue and neurovascular structures. It is important to undergo investigative imaging to rule out any associated fractures and to determine the extent of soft tissue damage as this will guide us in your rehabilitation and determine the potential need for operative management.
X-rays are useful to rule out fractures which can occur with these types of injuries, due to the bones impacting each other on both separation and relocation. X-rays are also the best technique to confirm if the shoulder is still dislocated.
MRIs aren’t used to diagnose a shoulder dislocation but are used to determine damage to the soft tissue structures around the shoulder.
You may also be required to undergo a computed tomography (CT) scan if further information is needed regarding bony damage.
Treatment Options:
Once reduced, the discussion will then move to whether patients will undergo operative or non-operative management. This comes with controversy with some specialists recommending first line non-operative management for older patients and for younger athletes who don’t partake in overhead sporting activities.
Therefore, long-term treatment plans are varied based on the patients age, history, goals and activity levels. As age is the primary risk factor for re-dislocation, we generally see younger patients (less than 30 years old) who are shown to be more at risk of re-dislocation undergo surgical stabilisation. Factors that also impact decision making are around secondary lesions including a Hill Sach’s, Bankart and bony Bankart lesions.
Surgical techniques can vary depending on the factors listed above but the common surgeries we see are:
Bankart Repair - A Bankart lesion occurs when the ring that surrounds the glenoid is damaged. This is an arthroscopic procedure done to repair the damaged labrum and reattach it to the socket.
Latarjet Procedure - Often used when there is extensive bony damage, athletes with recurrent dislocations or a failed rehab following a stabilisation surgery. This procedure involves moving the coracoid process onto the front edge of the shoulder socket, along with the biceps tendon.
Remplissage Procedure - This is done when there is a Hill Sach’s lesion but minimal damage to the glenoid. It is an arthroscopic technique which is often done alongside a bankart repair
Return to play times following a shoulder surgery will vary depending on your age, sport and previous history but generally fall within the 6-8 month range.
Recovery and Rehabilitation
As mentioned above, recovery from a shoulder dislocation can vary depending on whether it is managed operatively or non-operatively. For athletes that undergo a non-operative approach, rehabilitation timelines vary from 4-6 months. The structure of the rehabilitation will look similar to that of an operatively managed injury, but timelines will change.
A structured rehab plan is essential for recovery, to minimise the risk of re-dislocation or surgical failure and ensure a safe return to sport. Here at Rehab Advantage, a shoulder rehab will progress through the following phases:
Acute Repair:
This phase will differ dependent on whether you have undergone surgery or if your injury is managed conservatively. Surgical repairs are typically managed in a sling for the first 6 weeks post op before slowly weaning from the sling. For non-surgical patients, the timeline of a sling will vary and will be dependent on whether you have suffered a complete or partial dislocation.
Our main goals for this phase are to:
Reduction of pain and swelling.
Re-activation of the muscles around the shoulder.
Graded exposure of range of motion exercises.
Shoulder, neck and back range of motion exercises.
Modification of lower body strength training to maintain loading.
Opposite limb strengthening to reduce atrophy.
Reload Phase:
Once cleared to wean from your sling, patients will transition into the reload phase where we will look to regain function of your shoulder. The main focus in this phase is to normalise your shoulder range of motion while progressively loading your rotator cuff and scapular muscles. Patients will also begin their preparation to return to run through gym-based drilling exercises.
Our main goals for this phase are to:
Normalise your shoulder, scapular, neck and mid back range of motion.
Progress your shoulder activation and strength through both open and closed chain exercises.
Maintain lower body strength and conditioning.
Run preparatory drilling exercises to return to field.
Rebuild Phase:
During the rebuild phase our emphasis moves towards global upper body strengthening as we looking to build strength and muscle bulk in the muscles around the shoulder joint. Patients will also begin exposure back into controlled gym-based contact and skills work under the guidance of our physiotherapists.
At Rehab Advantage we have a structured contact and skills model to ensure you safely progress through this stage. Our main goals for this phase are to:
Normalise all shoulder strength and range tests - progressing from inner to outer range.
Progression to higher stress exercises.
Return to contact and skills drilling in a controlled environment.
Introduction of running loads.
Maintain lower body strength, power and plyometric profiling.
Return to Training + Sport
Our final two phases are aimed at a staged return to training, building from controlled to chaos, before a return to competition and full functional participation. Our goal during these phases is to get you back performing in your sport. Our main goals for this phase are to:
Progress team training loads from controlled to chaos.
Maintain strength, power and plyometric loading.
Educate on ongoing resilience exercises to help prevent reinjury.
Conclusion
Shoulder dislocations are the most common joint dislocation, and we see high injury rates in young active patients, especially those involved in contact and overhead sports. It is important following a shoulder dislocation to undergo the necessary imaging and seek professional opinion on appropriate management.
Whether you have been recommended for operative or non-operative management, a structured rehabilitation protocol is key for a successful return to play and reduction of re-injury risk. Here at Rehab Advantage, our sports physiotherapists are trained and experienced in returning athletes to sport following both acute and recurrent shoulder dislocations.