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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.

The length of time someone should spend in a sling is not a matter of agreement and a typical time of 3-4 weeks for young people with a shorter time for an older patient is common. The rate of having a second dislocation was indicated to reduce in one study by having a longer time in a sling, but another study, tracking patients over ten years, showed no difference in re-dislocation rates whatever times of immobilisation were used. The physiotherapist will normally review a patient at the three to four week mark and begin rehabilitation.

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.

Thirty percent is the overall re-dislocation rate for those of us who are not athletic, and this rises very steeply to 82 percent in sports people and athletes. How old the patient is has a strong influence on how likely they are to dislocate again, with under ten years having a 100 percent likelihood of re-dislocation. Older people in their forties have a much reduced chance between nought and twenty four percent. Repetitive re-dislocation may mean that a patient requires surgical intervention to prevent further episodes of joint problems.

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 Physiotherapy, back pain, orthopaedic conditions, neck pain, injury management and physiotherapist in hartlepool. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.

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