The image of someone presenting with an arm flailing at their side looking like a duck with a crook wing is not a pleasant one. Worse still is the image of someone being sat on the table and having their shoulder ‘relocated’ into the socket - effectively ‘popping it back in’. Its a huge manoeuver and doesn’t come without it’s risks. Its also a bit of a ‘glamour’ movement in that it is a quick fix and ultimately injury saving move. But not without it’s risks.
Relocating the shoulder when it has dislocated is fraught with issues that can create more damage than good. Due to the insecure nature of the glenohumeral joint (ball and socket joint of the shoulder) there is a great risk that other structures have become damaged or broken and this is a real concern before you begin trying to pop a shoulder back into place. Often there can be bone fractures in the humerus itself and this alone contraindicates any shoulder manipulation as there may indeed be bone fragments floating around in the compromised joint. It really is a medical professionals job to administer the techniques required to perform a ‘closed reduction’ of the shoulder.
Some people are more prone to a dislocated shoulder. And for these unfortunate people there can be a real risk involved in the continual manipulation of this joint space. Insecure shoulders require stability and those who have this issue should ultimately be addressing the muscular tension that helps to keep the glenohumeral joint in place.
In any shoulder dislocation, assessment should consider the possibility of a Hill Sachs Lesion. This is a condition that occurs in 40-90% of first time shoulder dislocations and is usually always present in those w ho suffer from multiple dislocations.
What Happens?
The bony head of the humerus sits in the shallow Glenoid Fossa (billiard ball on a teaspoon) and when the shoulder dislocates, in 90% of cases this occurs anteriorly. The head of the bony humerus is actually remarkably soft and when it is dislocated it impacts against the bony glenoid fossa and a depression in the humerus (arm bone) on the posterolateral aspect (back and outside edge) of the humeral head occurs. The ‘dent’ as such is usually due to the force of the arm being wrenched from the socket and hitting the bony glenoid cavity.
Essentially this bony depression can then create further problems as it makes the shoulder even more unstable, which results in further instances of shoulder dislocation. The degree of the lesion has something of a role to play in determining how much the shoulder is affected and prone to further issues. Lesions are graded according to the percentage of damage to the bone. With lesions <20% of deformity, there is usually no treatment recommended as this is not deemed sufficient enough to create instability in the joint. These are termed non engaging lesions. When the lesion is sufficiently impactive to change the way that the humeral head rotates within the socket, it is called an engaging lesion. This is the case where damage is >40% and surgery is a prescribed option to ensure functional operation of the arm.
Surgery
In the case of surgery, there are 3 options:
Capsular Shift - this involves surgery to tighten the labral surface area surrounding the capsule. Cutting the subscapular tendon the surgery pulls the articular tissue tighter around the articulation preventing excessive rotation. There are other techniques involving arthroscopic work with a camera that doesn’t involve cutting the subscapularis muscle. Capsular Plication is a less intrusive procedure.
Bone Grafting/Filling - involves taking bone tissue (commonly the pelvis) or other soft tissue structures and filling the depression on the humeral head. Disimpaction is another procedure that actually lifts the existing tissue from the depression in the arm to correct the abnormality.
Shoulder Replacement - usually reserved for more elderly patients or as a last resort for younger patients less than 25yo and those involved in throwing actions.
The other possible outcome of a dislocation can be the formation of a Bankart Lesion which is damage to the actual labrum of the shoulder sometimes termed the Glenoid Ligament) where a pocket forms in the labrum itself. This is an indicator for surgery and is usually always combined with a Hill Sachs lesion.
With any shoulder dislocation, whether surgical intervention is required or not, the recovery is always about strengthening and stabilising the shoulder joint. Ensuring that the rotator cuff tendons are in good condition (as they are usually impacted or torn during the dislocation) is primary. Ensuring adequate length and integrity involves the slow and laborious work of small, isolated exercises to get this vital combination of 4 muscles actively working to ensure structural integrity.
The next stage is increasing stability fo the glenohumeral joint. Looking at scapular stability and sufficient recruitment of larger muscles that help to stabilise the shoulder and prevent excessive rotation from pulling the shoulder out again. This involves moving the shoulder through all planes of motion, ESPECIALLY through lateral extension and rotation. In this way, the client may be very apprehensive to tempt fate by taking the arm into this position - understandably so. However the need for building strength in these positions is even more primary. This can involve biceps, triceps, pectoral, serratus (both posterior and anterior) as well as the all important scapula stabilisers.
Not only that but building stability in both straight and bent arm positions. Getting stability in a straight arm position is vital as so often a dislocation occurs when the arm is extended. Building up your movement patterns in those positions that are not accustomed such as lateral rotation with full extension fo the shoulder (hands behind the back - think full bridges), side planks (lateral rotation) inverted shoulder flexion (hands behind the shoulders) are all important movements to begin playing with and building familiarity and then strength in. Then we introduce bent arm strength like in a bench press position or dip position.
Ensuring structural integrity of all the shoulder muscles working in cohesion to support these ultimately challenging positions is vital and also a bit of a ‘holy grail’. This should be the primary focus before contemplating loading the shoulder with weights or resistance. Dare I say, I find this space is where most people fail. They yearn to return to those big power movements without necessarily doing the necessary small motor work that is necessary to build integrity from the base.
Exploring ALL the positions of the shoulder is vital. Getting the range of motion or addressing the range of motion issues that may be resulting in inadequate alignment is primary. Then building stability in these positions is secondary. Followed finally by strengthening these positions with increased load or resistance to ensure that the balance is there and keeping the integrity of the joint space when it is loaded or the extreme situation arises.
A shoulder dislocation is no small issue as it presents but it also poses a problem of recurrence and further weakness if you don’t address the issue of stability. Getting a plan in place of remedial movements to build full stability and the correct alignment is vital if you are going to use your shoulders in the future or have a movement capability. Its a complex joint and sometimes takea a long process to get right but is vital for ensuring you can move pain free and keep asking more of your body.
