Welcome to Hicksville Physical Therapy’s resource about shoulder dislocations.
A shoulder dislocation is defined as an uncomfortable and restricting injury to the glenohumeral joint. The majority of dislocations are in the forward direction, or anterior, but backward, or posterior, dislocations can also occur. While inferior and posterolateral dislocations can happen, they’re much less common. The type of dislocation is determined by the humeral head’s position in relation to the shoulder socket, or glenoid, when the patient is diagnosed.
This guide will explain:
The shoulder’s one-of-a-kind anatomy provides the coordination and range of motion we need for movements like throwing, lifting, and reaching. As you understand the anatomical structure, you’ll understand what caused your shoulder dislocation.
The shoulder consists of three bones: the upper arm bone, or humerus; the shoulder blade, or scapula; and the collar bone, or clavicle. The shoulder’s roof is formed by a portion of the scapula known as the acromion.
The shoulder is also made of four joints. The glenohumeral joint is the main joint in the shoulder and is formed where the humerus’s ball sits into a socket on the scapula called the glenoid.
The AC (acromioclavicular) joint is where the acromion and clavicle meet. The SC (sternoclavicular) joint supports the arms and shoulders where they connect to the main skeleton on the chest. Finally, the scapulothoracic joint is located where the shoulder blade meets the rib cage, or thorax. This joint helps the muscles around the shoulder blade to work properly and keep the socket aligned as you move your shoulder.
The shoulder is made of several important ligaments, which are soft tissue structures connecting bones to each other. The shoulder has a joint capsule (a watertight sac surrounding a joint) that is formed by several ligaments that connect the glenoid and the humerus. These ligaments hold the shoulder in place and prevent dislocation, serving as the shoulder’s primary source of stability.
The labrum is a unique structure of cartilage inside the shoulder, almost totally attached at the glenoid’s edge. The labrum has a wedge shape when viewed in cross-section. The shape and the manner in which the labrum is attached form a deep cup for the glenoid socket and provide more stability, helping to prevent dislocation. Since the glenoid socket is so shallow and quite flat, the humerus’s ball does not have a tight fit. The shape of these elements provides mobility in the shoulder, although stability can be lacking, leading to the commonality of shoulder dislocations.
The labrum also serves as the point where the glenoid and the long biceps tendon from the upper arm connect. Tendons connect bones and muscles, and muscles pull on tendons to move bones. The biceps tendon runs all the way from the biceps muscle through the upper arm to the glenoid. At the glenoid’s top, the biceps tendon becomes part of the labrum. When the biceps tendon is damaged, it can pull away from the glenoid, causing shoulder issues.
The rotator cuff’s tendons make up the next layer of the shoulder joint. There are four tendons in the rotator cuff connecting the humerus to the deepest layer of muscles. This layer of muscles attaches from the humerus to the shoulder blade and allows for the raising of the arm and rotation of the shoulder. These muscles are vital to the shoulder and are used in countless activities throughout the day. The tendons and muscles of the rotator cuff are crucial for assisting with stability in the glenohumeral joint, helping to hold the humeral head inside of the glenoid’s socket.
The outermost layer of shoulder muscle is called the deltoid, the biggest and strongest shoulder muscle. The deltoid muscle works to lift the arm higher when It’s already away from your side.
An anterior dislocation (sometimes called a subcoracoid dislocation) occurs when the humerus’s head is driven from within the glenoid cavity and is pushed under the coracoid process. Typically, the joint capsule is torn away (avulsed) from the margin of the glenoid cavity.
Anterior shoulder dislocation could also happen because of a detached labrum. When the labrum and the glenoid cavity’s capsule are avulsed, this injury is known as a Bankart lesion. When a shoulder dislocation causes the humeral head to hit the hard glenoid, resulting in a compression fracture, this injury is known as a Hill-Sach’s lesion. Three-quarters of all patients who develop a Bankart lesion will develop a Hill-Sach’s lesion as well.
Posterior and Inferior Dislocations
A shoulder dislocation in which the humerus’s head moves backward and is situated behind the glenoid is known as a posterior dislocation. Alternatively, if the humeral head is situated below the glenoid cavity, this injury is called an inferior dislocation. Only about five to 10 percent of all shoulder dislocations fall into one of these categories. The vast majority of shoulder dislocations are anterior.
What can cause a shoulder dislocation?
Because the shoulder is so mobile, it is more vulnerable to becoming dislocated than many other joints. Compared to the humeral head, the glenoid cavity is quite small. The shoulder’s bony anatomy, along with its muscles and ligaments, helps maintain the stability of the shoulder and prevent dislocation. When these structures are altered or injured by a substantial force (a force that can overcome the structures’ abilities), dislocation can result.
Abductions (extending the arm sideways), external rotations (outward), and extensions can all lead to shoulder dislocations if done improperly. The joint capsule could potentially lift off of the bone, forcing the humeral head to become lodged between the bone and the capsule. If you fall on the back and side of your shoulder (also called the posterolateral aspect) or on your outstretched hand, an anterior dislocation could result. Shoulder dislocations can also result from intense and uncoordinated muscle contractions in the midst of a grand mal seizure.
Non-traumatic situations can also cause dislocations. Repetitive activities can cause the shoulder muscles to become imbalanced in their strength, which could lead to a dislocation. Dislocations can also occur from activities that steadily cause the shoulder’s ligaments to loosen. For instance, if a patient has rounded shoulders that are very forward, there could be an increased risk of dislocation. Over time, the shoulder’s front ligaments can become lax, providing insufficient support to the shoulder. Muscle imbalances can cause similar issues. Weight lifters who focus more on training their pectoral muscles in the chest and neglect their back muscles will often suffer from stress on the shoulder’s anterior structures, resulting in laxity in the shoulder.
Athletes like baseball pitchers, volleyball players, and swimmers have to perform powerful over-head actions over and over again. Since their shoulder ligaments are repeatedly stretched, the shoulders can become lax. At this stage, the shoulder ligaments don’t offer the proper stability, leading to a greater risk of dislocation, particularly during lateral (“wind-up”) and overhead movements. It is vital to ensure that the muscles of the rotator cuff and shoulder blade are coordinated and strong, allowing them to control the shoulder joint.
After an initial shoulder dislocation, a second dislocation is a distinct possibility, particularly in younger patients. When the first dislocation forces the humeral head forward, a pocket of sagging soft tissue is left behind, and the humeral head can slip back inside. Some patients are able to dislocate the shoulder and put it back in place themselves. When this happens repeatedly, it is known as habitual dislocation. Habitual dislocation should be discouraged.
Recurrence of shoulder dislocations largely happens in young patients under 20 years old. 60% of patients 20 to 40 years old will experience a recurrence, while only 10% of those 40 years old and older will experience one. Participating in contact sports can leave one at an increased risk of re-injury. Following a second dislocation, future dislocations can occur with even less force or stress.
What does a shoulder dislocation feel like?
The majority of patients with dislocated shoulders report severe and nearly instant pain following a fall or injury. The instinctive response is to use the opposite hand to support the arm.
Pain and anxiety surrounding movement are common in shoulder dislocations. Once the shoulder has been reduced (put back into place), some instability may still occur, bringing the initial pain and anxiety into everyday movements. Some patients are constantly aware of the risk of a second injury if the arm is moved in the wrong way.
In the event of an inferior dislocation, it can be hard or even impossible to lower the arm to your side. If this is the case, it likely indicates that the humeral head is stuck under the glenoid cavity.
How is a shoulder dislocation diagnosed?
Your medical history and a physical examination are the two most vital tools in diagnosing a dislocated shoulder. It’s particularly important to provide the full history of your injury. A diagnosis may be clear if the shoulder is still out of the joint. However, if the shoulder has been put back into place following the injury (which can happen spontaneously), it may be tougher to reach a diagnosis.
Your physical therapist at Hicksville Physical Therapy will ask you about how the injury happened, where you feel pain, what movements you can and cannot perform, and the stability of your shoulder. They will also ask if you’ve had a previous shoulder dislocation or other shoulder injuries.
Next, your physical therapist will perform a visual inspection of the shoulder. If the dislocation is still out of place, the typical rounded look of the upper arm and shoulder is hone. Instead, there is a square or flat appearance. The surface anatomy can also change in appearance; for instance, there could be a gap underneath the acromion, instead of the typical bony bump (or greater tuberosity) sticking out from the side. The humeral head could be felt as a bump behind or in front of the shoulder and is typically very tender when being examined.
If possible, your doctor will test the sensation, strength, and range of motion in your shoulder. Changes or loss of sensation could indicate nerve damage that has resulted from the dislocation. Your physical therapist might also check for vascular complications by taking the pulse in your arm.
Countless clinical tests can identify soft tissue structures that have ruptured or otherwise been damaged. A positive apprehension test very likely indicates an unstable shoulder at risk of another anterior dislocation in the future. During this test, your physical therapist will abduct and externally rotate your arm. You may become apprehensive as your arm is moved just before the point of dislocation, as it may feel like your shoulder will dislocate. At this point, the test will confirm shoulder instability.
X-rays can be used to display any bone fractures as well as the displaced humeral head. Several viewpoints may be necessary to reveal fracture lines (if present) and the direction of the dislocation. MRI (magnetic resonance imaging) is also used to diagnose lesions and determine their extent. MRIs can be helpful in finding Hill-Sach’s lesions.
What treatment options are available?
Often, the dislocated shoulder can be reduced (put back into place) without surgery; this practice is known as a closed reduction. Most health care providers (particularly those with emergency training) know how to put the shoulder back in its socket, though the procedure can be painful without a general anesthetic.
One easy technique for anterior shoulder reduction is done with the patient face down, also known as the prone position. The affected arm sits at the edge of the table and is then allowed to hang over the table’s edge as the patient holds a weight. Over several minutes, the shoulder muscles will relax, allowing the humeral head to naturally fall back into its original position.
If this technique doesn’t reduce an anterior dislocation, then the patient will be given a general anesthetic before the doctor applies traction to the upper limb. The doctor holds the arm in a position of sideways (lateral) shoulder abduction and applies a backward pressure to the humeral head. For a posterior shoulder dislocation, a similar technique can be used. The patient is given anesthesia before the shoulder is outwardly rotated and the humeral head receives forward pressure.
Some patients who experience recurrent dislocations may be able to pop their joint back into place with no assistance. When reduction is done by a health care professional, the process is generally quick and happens soon after the injury, preventing further discomfort or damage to the soft tissue.
If the dislocation is corrected quickly, the functional outcome can also be improved.
After a closed reduction, an X-ray can verify that the humeral head has been correctly placed into the glenoid cavity. Following reduction, it’s often recommended for the patient to wear a sling against the chest for a few weeks or a month. The arm is immobilized by the sling, allowing the soft tissues to heal.
Older adults may be at increased risk of frozen or stiff shoulders. For these patients, health care professionals may prescribe Codman’s or pendulum exercises. These gentle range of motion exercises should typically be performed once or twice daily with the sling off.
Particularly in young patients, recurrent dislocation is a common complication after an initial dislocation. Older patients are at an increased risk of chronic stiffness and pain. Surgical intervention could be necessary if conservative care fails to bring back normal shoulder stability and function.
Not every shoulder dislocation will need surgery. The majority of dislocations, particularly in middle- or older-aged patients, can be corrected without surgery. Physical Therapy at Hicksville Physical Therapy will help you regain function in your shoulder. Right after your dislocation, you’ll likely need to immobilize your shoulder with a sling for two to four weeks. The sling will relieve pain and let the soft tissue heal. In order patients, short immobilizations can prevent stiff shoulders. In younger patients, longer immobilizations can allow the tissues to scar, preventing a future recurrence.
The initial treatment you’ll receive from Hicksville Physical Therapy will focus on pain and inflammation relief caused by your shoulder dislocation and reduction. Ice, heat, ultrasound, or electrical current may be used to decrease swelling or pain. Since some muscles in the upper back and neck connect to the shoulder, you could also feel pain and need treatment in these places. Massage could be helpful to reduce pain. Additionally, taping the shoulder during early recovery can ease the tension on inflamed sections of the shoulder, relieving pain.
During immobilization, you should still perform simple movements of the fingers, neck, and elbow. If you’re at risk of developing a stiff shoulder, your doctor may recommend Codman (pendular) exercises without the sling. Codman exercises can relieve pain, maintain some range of motion, and prevent excess scar tissue from forming. You’ll perform these movements by leaning forward or sideways, dangling the arm without touching the chest, and moving from your truck, allowing your arm to gently swing. The glenohumeral joint will get some traction, helping to relieve pain and bring the shoulder into a slightly elevated motion. This activity should be as passive as possible; don’t initiate movement from the shoulder. This exercise mimics a weighted pendulum swinging from a string.
Hicksville Physical Therapy recommends continuing your regular fitness routine even while you’re immobilizing your shoulder. Lower extremity exercises like walking, using a stepper machine, or using a stationary bike can help maintain cardiovascular health. These activities should not hurt your shoulder. If they do, talk to your physical therapist about modifications.
The next aspect of treatment involves regaining the coordination, strength, and range of motion in the shoulder. The hope is that you will fully regain your shoulder function. For athletes, the goal is to return to full participation in your sport. Depending on the length of your immobilization, your age, and the severity of your injury, you could experience weakness and reduced range of motion in your arm after the sling is removed. Shoulders that don’t lose any range of movement after being immobilized may be at risk for future recurrence.
Your physical therapist at Hicksville Physical Therapy will prescribe exercises to perform both at home and in the clinic to help bring back your function, strength, and range of motion. You may use equipment like poles and pulleys, light weights, or Therabands throughout your exercises. As previously discussed, the shoulder joint is quite mobile but lacks stability and relies on the neighboring muscles to maintain stability and prevent dislocation. Rotator cuff muscles in particular are important to hold the shoulder joint inside the socket. These muscles will be targeted with rotational resistance activities. To ensure your shoulder can fully function, you’ll need to build strength and endurance in the rotator cuff muscles. You may find an upper body bike helpful at the beginning of rehabilitation to increase your range of motion and coordination.
In needed, your physical therapist can mobilize your shoulder joint. This technique helps your shoulder slowly regain its range of motion. Luckily, it doesn’t usually take long to regain your range of motion and strength after immobilization. After a few treatments at Hicksville Physical Therapy, you should start seeing results.
Any injury can cause your joint and ligament receptors to worsen in proprioception (the ability to realize the location of your body in space without looking at it). However, this issue is especially prominent if joint stability has been impacted. Immobility can cause these receptors to decline even faster. The arm and shoulder aren’t usually considered weight-bearing, but tasks like pushing yourself up out of a chair or getting a dish from a cabinet require some weight-bearing and proprioception. Athletes find that proprioception of the upper limbs is vital to returning to sports after a dislocation. Swimming, volleyball, and other overhead sports need an even greater amount of shoulder control.
When using your arm above shoulder height or performing quick movements like throwing, controlled scapulothoracic motion is vital. Scapulothoracic motion refers to proprioceptive control of the scapula, located on the rib cage. Proper scapulothoracic motion helps decrease the risk of further injury or future dislocations. Your physical therapist will help you control your scapula during rehabilitation and in your everyday life. As you can better control your shoulder girdle, your physical therapist will recommend harder exercises, like those that mimic everyday activities or, for athletes, those that mimic motions in your sport. You may roll a ball with your hand, hold a weight overhead, or do pushups to start. More advanced exercises could include throwing and catching a ball overhead or reaching and lowering a weight. Your physical therapist will customize your exercises based on your ability level, direction of instability, and goals for function.
Regardless of the direction of your dislocation, you must gain glenohumeral and scapulothoracic control, especially during weight-bearing tasks and overhead movements. If you can’t do advanced exercises without pain or anxiety, surgical intervention may be considered. Your physical therapist will speak with your surgeon in this case. Sadly, getting proprioception back in the upper limb and shoulder girdle usually requires a lot of work, and most patients haven’t had to work the shoulder blade and arm so intently before. A concentrated effort can lead to a great reward, though, as you’ll work toward maximum shoulder function and can prevent future dislocations and secondary pain. Scapulothoracic control is an important part of both surgical and non-surgical rehabilitation.
Finally, during rehabilitation, your physical therapist will help you work on proper posture at all times, whether sitting or standing. If you round your shoulders or slump over, the shoulder joint can become crowded, possibly leading to pain and shoulder impingement during recovery.
Rehabilitation after a dislocation can bring positive results at Hicksville Physical Therapy. In general, you can return to sports as long as you have no swelling or pain, your muscles are almost back to their prior control and strength, and you have no problem with your shoulder popping out of its joint.
Surgery may be required to treat a dislocated shoulder if the shoulder doesn’t respond to manual reduction attempts or non-surgical treatment methods as outlined above. Surgery could also be necessary if instability symptoms aren’t controlled by other methods. The primary goal of surgery is shoulder reduction and/or stabilization. Long-term goals of surgery include the restoration of typical function and motion and the prevention of future dislocations.
Even if your doctor determines surgery is necessary as a first intervention, you may still see a physical therapist for a few sessions before surgery. Physical therapy can reduce swelling, increase strength, and begin to slowly stabilize the shoulder before surgery. Your exercises can also speed up your recovery and reduce the risk of scarring in the joint.
There are multiple methods of repairing a consistently unstable shoulder after an initial dislocation or recurrent dislocations. The best reconstructive technique will be determined based on the direction of the dislocation (inferior, posterior, anterior, or a combination). Your surgeon will also base their approach on the extent of the damage, the site of the injury, and your goals for returning to activity.
Shoulder reconstruction surgery can be done arthroscopically or using an open incision. An arthroscope is a tiny camera placed inside the shoulder joint to help the surgeon see throughout the procedure. Your surgeon will make other small incisions to allow instruments to be inserted, but the joint does not have to be fully opened, leading to smaller surgical scares. The technique your surgeon uses will be based on the risk of infection, the surgeon’s preference, and the repair needed. In some cases, arthroscopic surgery cannot address the issue, calling for an open repair instead.
The Bankart operation is one of the most commonplace procedures for correcting an anterior dislocation. During this process, the capsule and labrum and reattached to the glenoid cavity’s anterior margin. The desired result is restored stability and anatomy of the shoulder as well as repair of the Bankart lesion, as outlined above.
Older patients with fractures and shoulder dislocations may need a full replacement (as opposed to reconstruction) to repair the fracture and reduce the dislocation.
Most shoulder reconstructive surgeries can be performed as outpatient procedures, allowing patients to go home the same day. Some patients may experience a one- or two-night hospital stay.
Your shoulder will be immobilized after surgery. You’ll likely need to wear a hard brace or sling for three to six weeks. Your surgeon will decide on your immobilization period based on your rehabilitation goals, the surgeon’s experience, the type of procedure, and your anatomy. The arm is held in place by an abduction wedge placed under the armpit. The soft tissues need ample time to heal and make scar tissue to stabilize and support the shoulder joint.
Studies are being performed to learn more about early motion (within two or three days) after surgery. Benefits include a quicker return to activity and a decreased level of post-op pain. Not all surgeons have adopted this technique, as some argue that moving too early can lead to stretching in the scar tissue, letting the joint become too loose. Still, recovery with little or no immobilization has been seen in several cases. Athletes may be interested in this technique to return to their sport as quickly as they can.
You will begin physical therapy after your immobilizer is removed. During immobilization, your only exercise will be simple movements of the neck, elbow, and fingers. As explained above, some surgeons will allow pendular exercises without your immobilizer to reduce pain. Surgeons may also provide simple range of motion exercises almost immediately after surgery. In general, each surgeon has their own rehabilitation protocol, which they will share with your physical therapist. Your physical therapist will then help you through the personalized exercises.
Rehabilitation after surgery is quite similar to rehabilitation performed in non-surgical treatment. Surgery can cause increased stiffness and pain, however, because of the surgery as well as the longer immobilization period. In this case, your physical therapy sessions will be more regular (especially in the first few weeks) and modalities like heat and ice may be used more often. Remember that the goal of surgery is to stabilize your shoulder. It is common for the shoulder to be stiff when the immobilizer is removed, but the stiffness will decrease over time as you continue physical therapy and at-home exercises. If your shoulder remains stiff and doesn’t gain the desired range of motion, your physical therapist will speak with your surgeon. In general, rehabilitation after shoulder stabilization surgery lasts approximately three to six months.
After the initial stage of treatment, pain should decrease and your range of motion should increase, allowing you to perform more functional exercises. This typically happens around three to six weeks after beginning physical therapy. At this time, your physical therapist will help you gain the rest of your motion and increase your strength and control.
For an additional six to 12 weeks after this period, your exercises will become even more advanced as your shoulder moves into late recovery. These exercises will help increase muscle endurance and test your scapulothoracic motion and control. You’ll notice that you need a well-controlled shoulder girdle throughout everyday activities. You won’t need to attend sessions at Hicksville Physical Therapy quite as often, but you’ll need to continue an intense at-home rehab exercise regimen.
Athletes can expect to enter the full-to-sport phase approximately three to four months following surgery. Your physical therapist will give you drills specific to your sport to improve agility, speed, and coordination. You must have at least 90% of your normal strength, as well as your normal flexibility and range of motion, to begin these drills. Additionally, you must have no other symptoms during daily activities or sports drills.
Rehabilitation after shoulder stabilization surgery usually brings significant results thanks to the physical therapy provided by Hicksville Physical Therapy. Patients can return to normal activities after rehabilitation. However, if you notice that your pain is prolonged during rehabilitation or your physical therapist is not seeing the results they’d like, you’ll be asked to follow up with your doctor or surgeon. They can then confirm that the shoulder is responding to the rehabilitation and ensure you have no hardware issues impacting your recovery.