Acute Phase
Rehabilitation program
Physical therapy
In the acute phase of a dislocated shoulder, therapy should be limited. The arm should be immobilized in a sling and swathed for 1-3 weeks. The actual position of the arm in the sling has been debated and thought to be more beneficial to the torn soft tissues with the arm in external rotation. [10, 11, 12, 13] Recent literature has shown that having the arm in internal rotation while in the sling has no impact on the rate of recurrent dislocation when compared with patients immobilized in external rotation. [14] While the patient is in the sling, elbow, wrist, and hand range of motion should be encouraged. Working with the parascapular muscles is also important during this acute phase of rehabilitation since this can be initiated while the patient is still in the sling. These exercises should be continued when the patient comes out of the sling.
Active and passive flexion, extension, abduction, and internal/external rotation begin at about the third week, when the patient comes out of the sling. The authors encourage patients to get about 10 degrees of improvement in their motion per week. One will find that patients usually progress faster than 10 degrees per week. It is important to educate the patient and inform him or her that getting all of the motion back "right away" can be detrimental to the stability of their shoulder. Rehabilitation should be geared to gently restoring the range of motion over 6-8 weeks.
A good adage during the first 3 weeks after a shoulder dislocation is to "keep the hand in view." While looking forward, the patient should never let his or her hand be placed in a position outside the line of vision. This instruction assures a midrange position that does not compromise apposition of the torn or stretched anterior capsular structures to the glenoid.
Surgical intervention
The recurrence rate for shoulder instability is highly dependent on the age of the patient. Nonoperative care should be performed first before entertaining the thought of surgery. Most patients are able to rehabilitate their shoulder with rest and physical therapy. [1, 9]
A meta-analysis of 10 studies with 1324 patients analyzed the risk factors which predispose first-time traumatic anterior shoulder dislocations to events of recurrence. The study concluded that men, patients younger than 40 years at initial dislocation, shorter time from initial dislocation, hyperlaxity and lack of greater tuberosity fracture were key risk factors that increase the risk of recurrent instability after first-time traumatic anterior shoulder dislocations in adults. [15, 16]
In patients who have recurrent shoulder instability, operative care should be highly considered. [4, 2, 5] Numerous studies have shown the increased likelihood of traumatic glenohumeral arthritis in patients with multiple shoulder dislocations. Operative care may consist of both open or arthroscopic treatment of the cause of instability.
The goal of an operative repair is to reattach the torn tissue back to the place where it tore off of the bone. The most likely spot where the ligament tears is the glenoid. Recurrent shoulder dislocations also stretch out the ligaments. It is imperative to also address the tissue laxity during the operative procedure. The surgery can be done through small incisions (arthroscopy) or with an open incision.
A meta-analysis of 22 studies (n = 1633) comparing open versus arthroscopic surgical treatment of anterior shoulder dislocation found that either can produce reliable and reproducible results with satisfactory outcomes and recurrence rates between 10% and 15%. [17]
In a systematic review of 56 studies, Williams et al reported the following complication rates for different types of surgery for anterior glenohumeral joint dislocation [18] :
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Arthroscopic soft-tissue repair: 1.6%
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Arthroscopic repair combined with arthroscopic remplissage: 0.5%
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Open soft-tissue repair: 6.2%
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Open labral repair with remplissage: 2.3%
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Open bone-block procedure: 7.2%
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Arthroscopic bone-block procedure: 13.6%
Recovery Phase
Rehabilitation program
Physical therapy
After the initial period of immobilization, passive ROM exercises should begin. Older individuals should begin performing ROM of the shoulder after 1 week of immobilization, because these patients are prone to shoulder stiffness. Passive ROM exercises should include shoulder pendulum exercises and an overhead pulley system for the shoulder. Goals for passive ROM should be 30° of external rotation and 90° of flexion for the first 3 weeks, followed by 40° of external rotation and 140° of flexion for the second 3 weeks.
The rotator cuff may also have been injured during the dislocation, so the therapist should be cognizant of the status of the rotator cuff during the early phase of rehabilitation.
Surgical intervention
Athletes who demonstrate symptomatic instability during guarded physical therapy should be considered for an MRI evaluation and probable arthroscopic or open anterior shoulder tissue repair.
Maintenance Phase
Rehabilitation program
Physical therapy
More vigorous therapy can be initiated after full passive ROM has been regained, usually after 6 weeks. Rotator cuff strengthening exercises can be initiated with the use of rubber tubing or weights. Because the rate of shoulder redislocation is so much higher in young adults, vigorous training and strengthening should be delayed until approximately 3 months after the injury. Swimming is an ideal exercise to regain shoulder strength and should be encouraged once strengthening exercises have begun.
A literature review by McIntyre et al indicated that in patients with posterior glenohumeral instability, strengthening the rotator cuff and posterior deltoid may decrease pain, increase function, and reduce instability recurrence, particularly in those with nontraumatic instability who have not had surgery. [19]
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Anterior dislocation.
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Normal shoulder.
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Shoulder dislocation, Part 1.
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Shoulder dislocation, Part 2.
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Shoulder dislocation, Part 3.
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Shoulder dislocation, Part 4.
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Shoulder dislocation, Part 5.
