What is a shoulder dislocation?
A shoulder dislocation occurs when the upper arm bone (humerus) is forced out of the shoulder socket (glenoid). The shoulder joint is a very shallow joint, and this makes it more susceptible to being dislocated. Shoulders can dislocate for a couple of reasons, such as trauma (football tackle, car accident etc) or due to an injury that happens over time (repetitive overuse of the shoulder, genetic factors etc). A dislocated shoulder can be relocated by a medical professional at the time of the injury in most cases. A shoulder subluxation is when the joint only moves slightly out of the joint and then moves back in.
Typically your shoulder will dislocate one of two ways: anteriorly (front of the socket) or posteriorly (back of the socket). Anterior dislocations are much more common, and usually happen due to a direct blow, or when we have our arm out to the side and it takes a sudden high speed impact, such as tackling someone in football with your arm out straight and getting it caught on their jumper. Posterior dislocations also happen, and typically these are from a trauma that forces the shoulder out the back of the socket such as falling onto an outstretched arm.
How can I tell if my shoulder is dislocated/unstable?
A shoulder dislocation has a few symptoms that you may feel or see. In a traumatic incident, such as during a football tackle or fall, you will more often than not experience a sudden onset of shoulder pain and an inability to move your arm. Your arm may also feel ‘dead’ and you could have some pins & needles, numbness or arm weakness. These are serious symptoms and make sure you tell whoever the medical professional is that is caring for you of these symptoms.
If your shoulder is dislocating due to a more chronic issue, such as genetic laxity of your ligaments of long term traumatic injury, you may often feel that your shoulder ‘gives out’, it may feel like your shoulder ‘hangs loose’ and you can also have apprehension putting your arm in certain positions such as behind you head or behind your back. Your physiotherapist will take a detailed history to fully understand your symptoms to let you know if your shoulder is unstable.
Further investigations, such as X-ray and MRI can also be used to determine the level of injury after a traumatic injury.
How can physiotherapy help after a shoulder dislocation?
The first thing you need to do after a shoulder dislocation is make sure that the joint has relocated properly, or if it is still out of the socket, seek immediate medical advice. Your doctor should also check that the nerves and blood vessels of your arm have not been compromised either when the popped out or popped back in. Usually, you will get an X-ray of your shoulder to make sure it has been relocated and to clear you of any fractures to the joint.
Once your shoulder has been cleared to be back in the socket and your nerve and blood vessels are intact, your physiotherapist will help fit you with a sling for immobilisation and comfort. The sling is used to prevent your arm from moving, which will allow the initially injured structures in your shoulder to start to heal. You should remain in your sling, even at night, for at least the first 1-3 weeks, based on the guidance of your physiotherapist. Your physiotherapist may also use manual therapy techniques for pain relief, and if your pain is severe encourage you to seek further advice about pain relief or anti-inflammatory medications. Most movements of the shoulder will be painful in this early stage, so it is important you listen to your body and let the injury heal.
After you have been cleared to come out of the sling, it is paramount that you safely begin to restore range of motion and strength to the shoulder. It is especially important to return strength to the rotator cuff muscles, as these will help stabilise your shoulder. Range of motion will not be pushed early as to reduce the risk of re-injury and stressing the healing structures. Early strength exercises will include static hold and arm movements close to your body to get your muscles working again.
As your shoulder starts to feel and move better, your physiotherapist will start to push your exercises further into vulnerable positions for the shoulder. These exercises will start to load your shoulder up a lot more and place you in positions where you might not feel comfortable. It is important that you gradually expose yourself to these positions to get your body used to them. Your physiotherapist will also start to gradually re-introduce sport specific movements through this phase to help speed up your return to sport.
The final stage is formulating a program to help minimise the risk of you dislocating your shoulder again. Your physiotherapist will help structure an ongoing program that focuses on strength and control of the rotator cuff muscles, strength and coordination of the shoulder blade muscles and proprioception (awareness of your shoulder position). They will help work this into your weekly training schedule. It is paramount you continue this program as unfortunately you are always at risk of redislocation after your initial injury.
Will my shoulder be the same after a shoulder dislocation?
You should regain most but not all of the function you had in your shoulder previously. If you manage your shoulder conservatively, you should regain most of your range of motion you had previously. If you have surgery, your shoulder will be a lot stiffer than the non-operated side as this decreases your risk of re-injury and allows the surgery to heal better. You can expect these differences to be noticeable in the first 9-12 months post surgery, with small differences in range of motion lasting longer than that. Some arm positions, like putting your hand behind your head or back, will feel very stiff as these are vulnerable positions for the shoulder.
When can I return to sport after a shoulder dislocation?
This is highly individual and is based on a lot of variables that your doctor and physiotherapist will discuss with you. As mentioned above, you will need at least 1-3 weeks in a sling post shoulder dislocation, and this will increase to 4-6 weeks after surgical repair. As soon as you are out of the sling more intensive strength and range of motion exercises can be begun. As your strength and range of motion improves, you can begin a graded return to training program as guided by your physiotherapist. It is very rare that you will be back to sport before 12 weeks post injury, with most people taking around 3-6 months to return to sport post shoulder dislocation.
Will I need surgery for my shoulder dislocation?
Not all shoulder dislocation injuries need to be surgically managed. Most cases can be managed conservatively with a period of immobilisation and physiotherapy, although some will need to be surgically stabilised. It is recommended that all people undertake a course of conservative exercise based physiotherapy before thinking about surgery. The key factors in determining whether or not your need surgical repair are:
- Your age: the younger you are, the more likely you are to re-dislocate and hence shoulder stabilisations are usually needed
- Your level of sport/activity: higher level athletes who play a contact sport are more likely to re-dislocate if they return to the same level of sport
- A bankart lesion or bony bankart lesion is shown on MRI: these are injuries to the capsule or bone at the front of your shoulder. If you have these, they create a pocket for the shoulder to easily dislocate into and often need to be surgically fixated.
- Repeated dislocation in spite of 12 weeks of progressive strengthening.
Am I at risk of my shoulder dislocating again?
Unfortunately, there is quite a high risk you will dislocate your shoulder again after an initial dislocation. Young patients under the age of 25 have a re-dislocation rate of about 80%, but this rate decreases as your age at first dislocation increases. To manage this risk, it is paramount you seek early advice from a physiotherapist to help begin a rehabilitation program early. You should have your arm immobilised in a sling for 1-3 weeks to minimise the risk of early re-dislocation. Surgical repair if indicated can reduce your risk to about 5-10%.
When can I drive again after a shoulder dislocation?
This will depend on the severity of your injury and whether or not you have surgery. If you have surgery, you can expect to not be able to drive for at least the first 6 weeks until cleared by your surgeon. If you manage without surgery, it will depend on how your shoulder is functioning. As a general rule of thumb, expect to not be driving for 4-6 weeks post any shoulder dislocation injury.