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Arthroscopic Rotator Cuff Repair with Allograft Augmentation--Examples

Shoulder Dislocation-Part 2

The management of dislocated shoulders is a matter of controversy in the orthopaedic field, with the usual management being confined to a sling for between one and six weeks, with or without a strap around the waist to prevent external rotation. The arm is maintained close to the body with the forearm across the belly, a position known as medial rotation and adduction. This avoids the stresses which would be applied to the joint if it were moved to the side or outwards, known as lateral rotation and abduction.

Scientific work has given a better indication of how or why these problems should be immobilised. An MRI scanning study indicated that the shoulder socket and the rim, made of fibrocartilage, are kept in the closest correct relationship by having the arm by the side and laterally rotated 35 degrees. Another study on cadavers showed that if the arm was kept in slight adduction there was a reasonable range of motion during which the two vital structures maintained close alignment. Allowing the arm to flex forward or to abduct outwards was disruptive for the rim or labrum of the socket.

The time of immobilisation is not one of general agreement with three or four weeks in a sling typically prescribed for younger people and shorter periods for older people. A longer period of immobilisation was shown in one study to significantly lower the rates of recurrent dislocation. Another study followed patient with shoulder dislocation for ten years and found no influence of the period of immobilisation on the rate of recurrent dislocation. After the patient is reviewed at the three week period they start their rehabilitation with the physiotherapists.

Rehabilitation starts with pendular exercises which allow range of motion of the shoulder joint without high levels of stress through the area. The patient bends at the waist and permits the arm to hang vertically, making movement easy. Physiotherapists will teach scapular movements to maintain range of this area and progress the patient towards active assisted exercises next. Muscle function and range of movement can be facilitated by using the unaffected arm to participate, thereby allowing increased but controlled forces to be applied.

Re-dislocation risk determines that external rotation should be limited and only increased as the healing process proceeds. Pushing this movement may not be wise and a loss of end range may be acceptable as it prevents the joint from going into one of its vulnerable positions, reducing the chances of a dislocation occurring again. Soft tissue healing time is around six weeks and at this time the physiotherapist will progress to muscle strengthening and full range of motion shoulder exercises.

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.

The surgical management of dislocated shoulder is not wholly clear but some indications are that early surgery may be a helpful technique. There is variation amongst scientific papers but one showed a 94 percent re-dislocation after conservative management and only a 4 percent recurrence after stabilisation of the shoulder with arthroscopic surgery. Overall there may be higher rates of recurrence in conservatively managed patients. Surgical results were better with open surgery but advances in arthroscopic technique have brought this up to the same level.

About the Author

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapist, back pain, orthopaedic conditions, neck pain, injury management and physiotherapists in Newcastle. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.