The following information is provided as a general guide about shoulder dislocation. Shoulder dislocation is also referred to as shoulder instability, dislocated shoulder, shoulder out of socket, shoulder popped out and shoulder popped out and back in. It can also be referred to as anterior shoulder dislocation, posterior shoulder dislocation and recurrent shoulder dislocation. If you have any query about your shoulder, we recommend you see an experienced Orthopaedic surgeon. The surgeon will take a careful history, examine you, go through your imaging and then discuss your goals with you. For many people the goal is returning to contact sports. Returning to contact sports without advice carry’s a significant risk of further damage to your shoulder.
A few questions for you,
Do you wish to return to sport?
Do you understand the potential risks of returning to sport without advice?
Should you see a physio or surgeon first?
How quick can I get into see a specialist shoulder surgeon or Physio?
How can we help?
- Physiotherapy.
- Sports Medicine Doctors.
- Surgery.
Tim Neville is a physiotherapist with a special interest in treating shoulder conditions. He has nearly 40 years of experience and has made himself available to you to provide obligation free telephone advice if you call him on 9744 2201.
This conversation will help you to work out if our clinic is appropriate to you and if so, who you should see as a starting point. Tim will guide you through your journey back to optimal health and assist in arranging a prompt specialist appointment at your convenience. Learn more about our specialist shoulder surgeons.
What constitutes a shoulder dislocation?
A shoulder dislocation occurs when the head of the humerus (upper arm bone) comes out of the shoulder socket. The shoulder is a ball-and-socket joint, with the ball at the top of the humerus fitting into a shallow socket (the glenoid) in the shoulder blade.
The socket is held in place by a rim of soft tissue (the labrum) and a group of muscles and ligaments (the rotator cuff). The muscles and ligaments help to keep the head of the humerus in place while allowing a wide range of movement in the shoulder.
The shoulder can be dislocated forwards (anterior), backwards (posterior) or downwards (inferior). Anterior dislocation is the most common type, accounting for around 95% of all shoulder dislocations. Inferior and posterior dislocations are much less common.
A dislocated shoulder is a very painful injury. You will usually know if you have dislocated your shoulder as the pain is severe and the arm appears to be hanging awkwardly. The head of the humerus may appear to be visibly out of place.
These shoulder injuries are a medical emergency and you should seek medical attention as soon as possible.
The most common cause of a shoulder dislocation is a fall onto an outstretched arm or a direct blow to the shoulder. This type of injury is more common in young people.
What makes the shoulder more likely to dislocate?
It’s design.
The shoulder is a round ball on a flat socket, which makes it the most mobile joint in the body. Unfortunately, it is also the most likely to dislocate or go ‘out of joint’. Please note, when it half comes out and then goes back into place, it is called a subluxation. When it goes fully out of the joint, that is called a dislocation.
How you are born.
Genetics. If you are hypermobile, and play contact sport, the combination of a big hit to your shoulder and your loose ligament that you were born with, can make it more likely to dislocate.
Gender. Males are 3 times more likely to dislocate than females.
Age.
Nearly half of all shoulder dislocations happen in males in the 15-30-year age group usually due to lifestyle.
Why is it more likely to re dislocate?
Dislocation will usually damage the labrum, and sometimes the bone on the body side of the shoulder joint. Following dislocation, your pain will normally reduce as the inflammation reduces. This will make it feel better after a few months, but the damage to the labrum and any damage to the bone is permanent unless it repaired with surgery.
As such, following dislocation, the shoulders stability may be unreliable and particularly when playing sport, the re dislocation rate is very high.
How much more likely is it to re dislocate?
It depends on many factors, but unfortunately, once the shoulder has dislocated once it is quite likely to dislocate again. This is particularly true in young males playing contact sports. If you are under 18 when your first dislocation happens there is almost a 100% chance that your shoulder will dislocate again within 2 years if you continue to play contact sports. This percentage decreases with age but remains very high even until the age of 30.
What happens when you dislocate the first time?
The shoulder is a round ball on a flat bone socket. The socket part is deepened by a structure called the labrum and there are ligaments and muscles which help hold the joint in place.
When you dislocate your shoulder you typically damage one or more of these parts.
Most shoulder dislocations happen with ball shifting downwards and forwards. It usually very obvious when this happens as the shoulder is often stuck out of joint. This is very painful and usually a result of significant trauma like a rugby tackle.
Many times, a visit to the hospital emergency department will be required to put a first-time dislocation back in joint. There are times when the shoulder pops back in by itself but this does not necessarily mean that there has not been significant damage done.
What happens to the shoulder with repeated dislocation?
We know that if your shoulder dislocates more than twice you are more likely to develop arthritis in the shoulder when you are older. The exact age depends on how heavily you use the shoulder and how many dislocations occur but it is generally present within 20 years. Each time it dislocates it tends to damage more bone in the process. This damage is usually permanent and increases the risk of arthritis developing in the shoulder later in life.
If enough bone is damaged then treatment may shift from simply repairing and tightening the tissues around the shoulder to having to take bone from another part of your body to put in the shoulder. In addition, the likelihood of a nerve injury increases with each dislocation and this is not always reversible.
What can you do to stop it from happening again?
Avoid.
You can stop activities such as contact sports or other activities where your arm is working at shoulder height or above.
Physio.
A physiotherapy programme to strengthen up the shoulder and restore range of motion is very helpful and this usually takes about 6 weeks to happen. This may help generally but is unlikely to get you safely back to sports that require contact or above shoulder height activity.
Surgery.
Have an operation to repair the soft tissues that have torn or stretched. In addition, a bone transfer operation may be performed if the bone on the body side of the joint is damaged. See below.
Initial Dislocation Treatment.
On the day of dislocation, we strongly recommend you attend your local hospital’s Emergency Department for review. Even if you shoulder pops back in after a dislocation, we still recommend attending for review.
If your shoulder does not go back into place, the hospital will put it back in place for you.
Following discharge from Hospital, we recommend that you arrange a referral from your GP to see an Orthopaedic Surgeon. Learn more about our specialist shoulder surgeons.
Otherwise, the initial care is often as follows.
Wear a sling.
Once the shoulder is back in joint a sling is worn for at least one week to rest the shoulder. When the pain subsides, the shoulder can be used for simple daily activities. There is no advantage to wearing the sling for more than one week in terms of likelihood of the shoulder dislocating again.
Physiotherapy.
A physiotherapy programme to strengthen up the shoulder and restore range of motion is very helpful and this usually takes about 6 weeks to happen.
Return to sport.
Return to sport before 6 weeks is more likely to result in another dislocation than if the shoulder is strong with a full range of motion having completed at least a 6-week programme.
Treatment Recommendations
Included here are general recommendations and they may not apply in your situation. We suggest you see an experienced Orthopaedic surgeon who will take a careful history, examine you, go through your imaging and then discuss your goals with you.
Imaging. Xray – MRI – CT scanning.
All shoulders that are dislocated for the first time should be x-rayed. This is because a segment of the socket can be broken off (Boney Bankart Lesion) and a segment of the ball can be crushed (Hill Sachs Lesion) and these 2 injuries make further dislocations much more likely. In these situations, early surgery gives the best long terms results.
We advise all patients following a dislocated shoulder to have an MRI arthrogram (with dye injection) performed. This will show the extent of the damage to the tissues in the shoulder. If there is any evidence of bone damage then a CT scan is advisable as well (special views need to be requested with a 3-dimensional reconstruction of the bone at a particular angle being most useful).
Most patients will require surgery to stop their shoulder dislocating again. In broad terms the surgery can be performed arthroscopically (Keyhole) or open. There are advantages and disadvantages to both approaches.
Arthroscopic stabilisation of the shoulder has a very low complication rate with a very high level of return to sport (close to 90%). It is the operation of choice for most people who dislocate their shoulder.
The results of arthroscopic surgery are much worse in contact athletes so my treatment paradigm is broadly divided into patients who participate in contact sports (Rugby, AFL, Boxing, Basketball, Ice Hockey etc) and those who do not. This is also true of teenagers who dislocate their shoulder.
Open Surgery
If the patient is likely to re-dislocate with an arthroscopic operation, we then change to performing open surgery for them. This can be a soft tissue repair and tightening operation or a bone transfer operation.
Recovery from Surgery
The recovery is very similar regardless of which operation you have. Typically, you will stay overnight in hospital and wear a sling for 6 weeks. A physiotherapy programme is then commenced which continues until 6 months after the surgery. Only at that point is a return to sport allowed.
Summary
Ongoing dislocations of the shoulder are very common after you have dislocated it for the first time. These days early surgery is being used to prevent further damage to the shoulder and while the recovery is quite long the surgery is usually very successful at restoring strength, confidence and stability to your shoulder.
Tim Neville is a physiotherapist with a special interest in treating shoulder conditions. He has nearly 40 years of experience and has made himself available to you to provide obligation free telephone advice if you call him on 9744 2201. This conversation will help you to work out if our clinic is appropriate to you and if so, who you should see as a starting point. Tim will guide you through your journey back to optimal health.
Shoulder Specialist consultation is available at Randwick, Hurstville, Bella Vista, Penrith and Concord.
