The Recurrent Anterior Dislocating Shoulder

First Aid Management:

• Seek medical attention ASAP to reduce the dislocation (put back into place)
• DO NOT attempt to reduce without a trained medical professional as this may result in irreparable damage to surrounding structures such as nerves, blood vessels, bone, ligaments or cartilage.
• The arm should be protected from further injury by placing in a splint and held close to the body in a comfortable position to stop any unnecessary movement
• Avoid lifting or rotating the arm
• Apply ice (until numb or up to 20 minutes per hour to aid with pain and swelling)  

External Rotation Method 

 Scapular Manipulation Method

Reduction (putting back in place):

Follwoing medical examination several techniques may be used to relocate the arm to its normal allignment. Two common methods used include: 

• External Rotation Method: Patient lies on back with elbow bent and arm by side. The arm is then brought upward and then turned outward until reduction is achieved (Marinelli & de Palma, 2008). 

• Scapular Manipulation Method: The patient is lying on their stomach with the arm hanging off the table while a traction (pulling) force is applied to the arm. The lower portion of the shoulder blade (inferior scapula) is pushed towards the spine until reduction is achieved (Baykal et al, 2009).  

In the rare event that the dislocation cannot be reduced surgery may be required. 

Conservative Management (non-surgical):

Conservative management often involves a period of immobilisation (limiting movement) of the affected arm in a sling for 3-6 weeks. Current research suggests placing the arm in a position were it is turned out (external rotation) 30 degrees day and night reduces the rate of recurrent dislocation (Itoi et al, 2003). The goals of conservative management are:

• Activity restriction to prevent further injury and promote healing of damaged tissues (brace/sling) 
• Muscle (rotator cuff) strengthening exercise to increase the stabilising structures of the shoulder (exercise protocol below) 
• Avoid aggravating activities or positions such arm raised above head or exessive rotation (e.g.throwing position)
• Isometric exercise invoving contraction of the muscle with no movement of the limb
• Range of motion exercises
• Shoulder blade (scapula) retraining
• Proprioceptive exercise (regaining coordination)

Neutral and External Rotation sling / brace

• Anterior shoulder reconstruction - procedure involving large incisions enabling the surgeon to look insde the joint (Bankart repair)
• Arthroscopic shoulder reconstruction - microtelescope entered into shoulder joint used to view the structures within the shoulder (Magee, 2008) 

 Acute phase (immediately post reduction):

• Promote tissue healing by rest, short term immobilisation, avoid aggravating positions to allow damaged structures to mend 
• Minimise pain and inflammation with medication such as anti-inflammatories, panadol, ice (cooling), bandaging (compression) and raising (elevation) of the limb to limit swelling 
• Re-establish partial pain-free movement below the height of the shoulder. (e.g. pendulum exercises below)
• Limit muscle wasting with exercise (example protocol below) 
• Optimise shoulder blade control (e.g. scapular holds)
• Maintain fitness and movement of surrounding structures such as the elbow, hand, fingers and legs

 Recovery Phase:   

• Achieve normal movement of the shoulder that the patient had prior to injury
• Improve shoulder blade control to promote the proper movement of the shoulder joint
• Improve strength of the muscles that enable movement of the shoulder (rotator cuff)

 Day 1-3 weeks (Acute)

• Sling (20-30 degrerees) for 3 weeks
• Finger, wrist and forearm movements
• Elbow bending and straightening in standing
• Maintain hygiene around wound
• Teach postural awareness and shoulder blade position
• Leaning forward and allowing the arm to hang to 90 degrees
• Turning of the arm outward (external rotation) with the help of the other arm until fingers point forward (neutral)
• Core stability exercises to maintain balance 
• No combined raisng and turning out of the arm (abduction & external rotation) e.g.throwing position
• Typical exercises for this stage may include: pendulums, passive ROM, pulleys 

Pendular exercise (left shoulder at 45 degrees): Patient will allow arm to hang and move arm in pain free directions. Aggravating positions as mentioned should be avoided. 

 3-6 weeks (Recovery)

4 point kneel: Patient allows some weight to be taken through the shoulder joint. If reproduction of symptoms or pain occurs the exercise should be stopped. 

 6-12 weeks (Functional)

• Regain shoulder blade stability. Aiming for shoulder joint control rather than range
• Gradually increase range of movement
• Strengthen muscles around shoulder (rotator cuff) 
• Increase coordination through progression to more challenging exercises 
• Progress core stability (balance) exercises
• Be sure to address tightness at the back of the shoulder joint
• Typical exercises for this stage may include functionallly specific exercises for return to sport, work or previous level of activity

 Coordination (Proprioceptive) exercise: Pain free rolling of ball in a figure of 8 against the wall to aid in regaining coordination of the shoulder.