Lauren’s Shoulder Focus- “Anterior Dislocations”

During the winter I see plenty of traumatic shoulder injuries with it being contact sport season (rugby union and league, skiing, wet roads and cycling). Anterior shoulder dislocations make up a large proportion of these injuries and unfortunately are very painful and carry a high rate of recurrence in certain individuals. An anterior shoulder dislocation typically occurs in a contact sport when the arm is forced into an elevated and externally rotated position. An impact to the outstretched arm or the back of the shoulder are also common mechanisms. 

During the winter I see plenty of traumatic shoulder injuries with it being contact sport season (rugby union and league, skiing, wet roads and cycling). Anterior shoulder dislocations make up a large proportion of these injuries and unfortunately are very painful and carry a high rate of recurrence in certain individuals. An anterior shoulder dislocation typically occurs in a contact sport when the arm is forced into an elevated and externally rotated position. An impact to the outstretched arm or the back of the shoulder are also common mechanisms. 

What actually happens?
A number of structures may be damaged in the shoulder during a dislocation. The glenohumeral ligaments which are responsible for maintaining the humeral head in the socket may have torn or been severely stretched not only at the front but also at the back. The cartilage that sits around the socket (called the labrum) acts like a plunger to hold the humeral head in place. This structure may or may not tear also. And lastly if you dislocate your shoulder you will usually be advised to get an X-ray to make sure that there is no fracture of the bones as well.
               
Will it happen again?
After a shoulder dislocation the joint can become much more “loose” and this will make subsequent dislocations much easier. The risks are increased further if you wish to return to sports (especially contact sports).
  • Generally the risk of you having another dislocation should a patient return to contact sport is as high as 85-95% even after rehabilitation.
  • The risks of dislocation after surgical repair and rehabilitation is much lower around 10-15% depending upon the sport the patient returns to.
 
What are the options for rehabilitation?
Management after dislocation will usually be conservative initially. This is to return strength and movement to the shoulder in a graded fashion and will allow the maximum amount of natural healing to take place. After this a graded strengthening and stability program would be tailored specifically to the patients shoulder and goals. 
 
Surgical Repair
Surgical repair is not always needed. It will depend on what sport the patient is wanting to go back to, their age, their general health, ligamentous laxity and the severity of damage. Most techniques to repair the damage are now performed arthroscopically. The primary aim is to tighten up the front of the shoulder to prevent future dislocations. The technique shown below is a capsular shift. A “T” shaped cut is made into the front of the shoulder capsule. The two flaps of capsule that are now made are overlapped and stitched together. This will result in a tighter anterior capsule and should shoulder stop the shoulder from dislocating at the front of the joint again.
 
 
Conservative Management
This involves a period of rest and sometimes immobilisation which will allow the joint capsule to stiffen and recover. After this a graded strengthening and stability program would be tailored specifically to the patients shoulder and goals.
A typical progression may look something like this;
1)        1-3 weeks: Gentle elbow wrist exercises
2)        2-4 weeks: Light bicep and triceps exercises and gentle rotator cuff exercises.
3)        4-6 weeks:  Work into full range of movement, rotator cuff exercises working into elevated positions
4)        6 weeks+ : Elevated rotator cuff strengthening (above 90 degrees), speed and strength retraining.
5)        Return to work/sport when no pain, full movement, and strength at least 90% of opposite side
 
Things to think about:
–          Every patient is slightly different and will have different degrees of damage with a shoulder dislocation
–          The best line of defence would be prevention of the injury in the first place!
–          Having strong muscles to support the joint, good stability and good technique in your chosen sport will go a long way to protecting your shoulders however accidents will still occur.
Next month we will talk more about how to prevent injuries in the shoulder from occurring.