Shoulder Dislocation

The primary cause of shoulder joint instability is a shoulder dislocation, colloquially called "shoulder popping out" by patients. This is often followed by inadequate treatment, such as a lack of immobilization, insufficient rehabilitation, or premature return to normal activities involving the limb. However, a significant number of people suffer from shoulder instability without ever experiencing a dislocation.

Shoulder Dislocation - Typical Symptoms of Shoulder Instability

• Reduced mobility – limited range of motion in the shoulder joint.
• Severe pain in the shoulder joint felt during movements.
• Joint snapping during certain activities involving raised arms.
• Visible depression under the acromion process caused by the displacement of the humeral head within the joint.
• The humeral head can be felt in the armpit area.

Causes of Shoulder Instability

• Injury to the joint capsule (capsuloligamentous apparatus of the joint).
• Damage to the glenoid labrum.
• Injury to the articular surface of the humeral head.
• Abnormal development of joint surface structures.
• Subscapularis muscle injury.
• Excessive joint mobility.
• Overuse from occupational or sports activities.

Diagnosis of Shoulder Dislocation

The diagnosis of acute shoulder dislocation primarily relies on clinical and radiological examinations. The doctor evaluates the shoulder joint, its appearance, the position of the upper limb, the gap below the acromion, and the range of motion. Assessing nerve function and blood supply to the limb is also crucial. Shoulder dislocation may, for example, cause injury to the axillary nerve, leading to sensory loss in the skin area laterally and below the acromion process.

Among imaging studies, X-rays play a key role in diagnosing shoulder dislocation, typically performed in two projections (most commonly AP and "Y" view). Unfortunately, there are still cases where patients treated in Emergency Rooms or Hospital Departments receive only one AP projection image. This can result in missed posterior shoulder dislocations, which may be difficult to detect for the inexperienced eye. In cases of uncertainty or when fractures are detected in the proximal humerus or glenoid, Computed Tomography (CT) may be necessary.

In cases of chronic shoulder instability, the labrum, which acts as a "seal" deepening and stabilizing the shoulder joint, is often damaged. Suspected labrum injuries may require Magnetic Resonance Imaging (MRI) with contrast injected into the joint (Arthro-MRI). This is the most precise method for assessing intra-articular structures. For such injuries, ultrasound plays a limited role and is insufficient for a definitive diagnosis.

Shoulder Dislocation - Treatment of Shoulder Instability

In cases of acute shoulder dislocation (commonly referred to as "shoulder popping out" or "shoulder slipping out"), it is necessary to reposition the joint as soon as possible. Patients often ask how to realign a dislocated shoulder. While it may seem complex, repositioning the shoulder is not difficult. Typically, joint reduction is performed under local (intra-articular) or general anesthesia. Repositioning techniques include methods such as Hippocrates, Kocher, Stimson, and FARES. Generally, reduction involves pulling the upper limb while the humeral head moves back into its correct position in the glenoid cavity. After reduction, it is essential to reassess blood supply and nerve function in the limb, perform a follow-up X-ray, and immobilize the limb. Unfortunately, shoulder dislocation often accompanies other injuries, such as Hill-Sachs deformities, fractures of the greater tuberosity, rotator cuff injuries, or Bankart lesions. Occasionally, there may be a bony fragment detached from the glenoid rim, known as bony Bankart injury. These factors, along with the patient's age, sports activity level, and expectations, influence further treatment decisions.

For first-time shoulder dislocations in middle-aged and older individuals who are not professional athletes and have no significant accompanying injuries, conservative treatment is implemented. This involves immobilizing the upper limb using a Dessault-type orthosis for 3–4 weeks, followed by gradual rehabilitation. Full recovery is typically achieved within 4–6 months. However, it is important to remember that the first shoulder dislocation increases the risk of subsequent dislocations. This risk is higher in younger, physically active patients.

Surgical treatment is considered in cases of:

Recurrent (habitual) shoulder dislocation.

First-time dislocations in young individuals (under 25 years of age) who are professional athletes or lead active lifestyles with high physical demands.
Displaced fractures of the greater tuberosity causing subacromial impingement.
Fractures involving >20% of the glenoid rim surface.
Accompanying injuries such as rotator cuff tears.
Surgical Techniques for Shoulder Instability and Dislocation
Arthroscopic Labral Repair Using the Bankart Technique
The procedure is performed under general anesthesia, meaning the patient "sleeps" throughout the operation and does not recall the procedure. The orthopedic surgeon makes 3–4 small skin incisions around the shoulder to introduce a camera and surgical instruments into the shoulder joint. Initially, diagnostic arthroscopy is performed to evaluate all joint injuries. Then, the detached labrum is mobilized and reattached to the anterior glenoid rim using specialized anchors. The anchors are inserted into the bone, and the labrum is sutured to the bony rim using threads attached to the anchors. The surgery takes approximately one hour. Postoperatively, the patient must use an orthosis for 4–6 weeks. Rehabilitation begins gradually during this period. Returning to office work is possible within 1–2 weeks after surgery, while a full return to sports activities usually takes about 6–7 months.

Remplissage

This procedure is often performed during a Bankart repair surgery. The indication for this procedure is a large Hill-Sachs lesion (indentation of the humeral head), which increases anterior instability of the shoulder joint. Due to this injury, the indented portion of the humeral head may catch on the bony edge of the glenoid during rotational movements, causing the humeral head to "slip out" of the joint. In such cases, a Bankart procedure alone may be insufficient, and remplissage is necessary.

This procedure is performed arthroscopically. It involves suturing the posterior capsule and infraspinatus tendon to the humeral head at the site of the Hill-Sachs defect using anchors and sutures. This effectively reduces the joint volume, increases its stability, and decreases the risk of re-dislocation. Postoperative management is similar to that following standard Bankart repair. A slight reduction in external rotation (approximately 10°) in the shoulder joint is a consequence of this procedure, though it does not interfere with daily activities. Return to sports activities is typically possible after 6–7 months.

Latarjet Procedure

This technique is used when a Bankart repair fails or as a primary procedure (e.g., in cases where there is a large bony fragment of the glenoid rim >20%). The surgery is performed under general anesthesia. The surgeon makes a longitudinal skin incision (approximately 5–10 cm) on the anterior surface of the shoulder joint. The coracoid process is then detached along with the attached tendons, known as the conjoined tendon (including the short head of the biceps brachii and the coracobrachialis muscle tendon).

The coracoid process is passed through the subscapularis tendon and fixed to the anterior rim of the glenoid cavity using two screws. This results in a triple effect:

Increases the surface area of the glenoid cavity.
The transposed conjoined tendons act as a "hammock" for the humeral head, enhancing stability.
Restores the joint capsule by transferring the coracoacromial ligament attached to the coracoid process.
The surgery takes approximately one hour. After surgery, the patient uses an orthosis for 4–6 weeks and gradually begins rehabilitation. This procedure carries a higher risk of complications, such as nonunion of the bone fragment, migration of the hardware, and nerve damage. Return to office work is possible within 2–3 weeks, while full return to sports activities may take 6–9 months.

Tricortical Iliac Crest Bone Graft Procedure

This surgery is typically performed following a failure (re-dislocation) after a classic Latarjet procedure. The difference lies in using a bone graft harvested from the patient’s iliac crest instead of the coracoid process.

The anesthesia and access to the shoulder joint are similar to the classic Latarjet procedure. However, an additional skin incision is made at the level of the iliac crest (right or left). A tricortical bone fragment is cut from the iliac crest using an oscillating saw and attached to the anterior glenoid rim with screws. Postoperative management is similar to that of the classic Latarjet procedure.

Patients may experience discomfort in the hip area where the graft was taken. However, this pain typically subsides over time. The missing fragment of the iliac crest does not cause any deficits in future life or sports activities. Return to office work often depends on the severity of the hip pain but is usually possible after 2–3 weeks. Full return to sports activities can be achieved 6–9 months postoperatively.

Shoulder Dislocation - Rehabilitation

Rehabilitation is a crucial part of the treatment process and should be guided by an experienced physical therapist. After hospital discharge, the patient performs certain exercises at home until the first rehabilitation visit. During this period, the arm is immobilized in a sling to limit movement.

Proper posture is essential during this phase, ensuring the upper limb is correctly positioned in the sling to prevent the shoulder from being raised too high. While sitting, attention should also be paid to posture, avoiding rounded shoulders.

Breathing exercises are performed on the first day after surgery, once the orthosis is removed. The patient inhales through the nose, expanding the abdomen, and exhales through the mouth, lowering the shoulders. These exercises can also be done while lying down and should be alternated with anti-thrombotic exercises, such as squeezing and releasing the hand or pressing a small ball.

Codman Shoulder Stretching Exercises

Start with 1 set of 10 repetitions, gradually increasing to 3 sets of 20 repetitions.

Starting Position: Sit on the edge of a chair with legs spread wide for better balance. The operated arm (forearm) is supported from underneath by the healthy hand. The torso leans forward deeply.

Flexion (towards the forehead) and extension (towards the stomach) of both arms. The healthy arm performs the movement, while the operated arm passively follows and remains relaxed (keep the back straight). Move only to the limit of pain.
Circular motions of both arms in both directions (e.g., figure eights, clockwise and counterclockwise). The healthy arm leads the motion, while the operated arm passively follows and stays relaxed.

Exercises to Improve Range of Motion (with the use of a stick)

Flexion (forward movement): The operated arm holds the stick from above (overhand grip). The healthy arm guides the motion from below. Avoid raising the shoulder.
Intermediate motion (forward and sideways): The operated arm holds the stick from above. The healthy arm guides the motion from below.
Abduction (sideways movement): The operated arm holds the stick from above. The healthy arm guides the motion from below.
While standing, holding the gym stick with both hands, raise the arms upward from the front.

Strengthening Exercises While Standing at a Wall (Performed from the 4th day after surgery)

• Isometric tension of shoulder muscles for abduction (pressing the arm sideways against the wall without movement) – hold for 3 seconds.
• Isometric tension of shoulder muscles for flexion (pressing the arm forward against the wall without movement) – hold for 3 seconds.
• Isometric tension of shoulder muscles for extension (pressing the arm backward against the wall without movement) – hold for 3 seconds.
• Isometric tension of shoulder muscles for adduction (pressing the arm toward the body without movement) – hold for 3 seconds.

Related Articles:
Explore other possible shoulder injuries and conditions.

References:

• National Library of Medicine - "Shoulder Dislocations Overview" - Rachel Abrams; Halleh Akbarnia - 2022
• Radiopedia - "Shoulder dislocation" - Dr Pir Abdul Ahad Aziz Qureshi - 2022
• Royal College of Surgeons of England - "Anterior Shoulder Dislocation" - Steven Cutts, Mark Prempeh, and Steven Drew
• "Complications of shoulder dislocation" - Michael S, Beeson MD, MBA - The American Journal of Emergency Medicine Volume 17, Issue 3, May 1999, Pages 288-295