Shoulder dislocation: Causes, Symptoms, and Treatment

A shoulder dislocation (also known as shoulder dislocation) is a displacement of the shoulder joint that is usually very painful.

The shoulder joint consists of the glenoid cavity of the shoulder blade (scapula) and the head of the humerus, which is only loosely placed on top of each other to allow maximum mobility and rotation. The joint is mainly held in place by an apparatus of ligaments and muscles.

If a large external force is applied, this may give way to the pressure, and the head of the humerus is displaced. In this case, the head of the humerus loses contact with the shoulder blade, and normal shoulder movement is no longer possible. A specialist should always reposition a shoulder dislocation.

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One can distinguish shoulder dislocations according to their mechanism of origin. According to this, there are:

  • Traumatic shoulder dislocations as a result of a direct accidental event…
  • One speaks of a post-traumatic recurrent dislocation if, after a primarily purely traumatic shoulder dislocation, frequent dislocations occur even with minor trauma.
  • Atraumatic shoulder joint luxation also called habitual shoulder luxation. Here, the shoulder joint repeatedly jumps out without any trauma, for example, when performing routine movements. The causes for the development of periodic shoulder dislocations are congenital. Congenital glenoid dysplasia or congenital flaccid ligaments, etc. can be mentioned as examples.
  • Conservative therapy – dislocation of the shoulder
  • A dislocated shoulder is always a hospital case. Under no circumstances should an attempt be made to re-insert the shoulder itself, as this could injure surrounding structures.

The conservative therapy of a shoulder dislocation can be carried out without an operation on the shoulder. Depending on the extent of the injury associated with shoulder dislocation, conservative treatment is sufficient to treat the shoulder and achieve an excellent result.

In principle, the shoulder must first be put back into place. Jerky movements must be avoided. It is also important to talk to the patient and explain the steps of the procedure to take away any fear. As a rule, the patient will have brief pain when the shoulder is put back into place. A subsequent absence of pain is a sign of successful reduction.

In the Hippocratic dislocation, the patient lies on his back; the doctor places his heel in the patient’s armpit and pulls on his arm. The doctor’s foot pushes the patient’s humeral head outwards, after which it slides back into the socket.

Arlt’s dislocation, on the other hand, is performed in a sitting position. Here, the patient’s arm is placed over a chair back upholstered with a cushion. The doctor then pulls on the patient’s arm, after which the chair is supposed to push the head of humerus upwards, causing it to slide back into the socket as well.

Before carrying out one of these procedures, the patient must always be given painkillers and muscle relaxants if necessary.

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Risks when adjusting the shoulder

The dislocation of a luxated shoulder must be carried out by qualified personnel, as persons without the necessary experience can harm the patient. On the one hand, there is a misconception that the dislocation should be performed with rough force and jerky movements. However, this is not the case at all, as the risk of injuring vessels and nerves is increased. On the other hand, it causes the patient avoidable pain. After repositioning the arm and immobilization for several days, intensive physiotherapeutic treatment is necessary. This can accelerate the healing of the soft tissue damage caused by the dislocation and counteract stiffening of the shoulder joint.

When does one need an operation?

An operation is useful in two constellations. If nerves, vessels, ligaments or bones, etc. have been damaged during the application of gross force, surgery is recommended to treat any damage. In the case of a conservative dislocation, bone fractures or vessel tears would be left untreated. The other necessity for surgery is in the case of recurrent dislocations. Frequent dislocations destabilize the shoulder joint, which is why the risk of further dislocations is constantly increasing. The operation restores stability to the joint.

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Procedure of the operation

With the advancement of medicine, it is now possible to operate on the shoulder with the smallest of operations. In a so-called arthroscopic procedure, the shoulder is provided with three holes through which a mini-camera and special instruments are passed. With these instruments, the injured structures can then be restored. Splintered bone parts are put back into their original place, and stretched ligaments are tightened to prevent a new dislocation.

If a shoulder dislocation needs to be operated on, a joint endoscopy (arthroscopy) is usually performed first. In this minimally invasive surgical method, the shoulder is provided with three holes through which a mini-camera and special instruments are passed. Using these instruments, the injured structures can then be restored. Splintered bone parts are placed in their original position, and stretched ligaments are tightened to prevent further dislocation. In this way, any damage that may have been caused by the dislocation in the joint can be assessed. Depending on how extensive the damage to the joint is, different surgical methods are used. Recently, the minimally invasive method of performing shoulder dislocation surgery has become more and more popular. A shoulder dislocation often causes damage to the ligamentous apparatus of the shoulder joint and the joint capsule. The treating surgeon fixes the ligamentous apparatus back to the edge of the glenoid cavity and will attempt to tighten a loosened capsule.

Whether surgery is appropriate in an individual case depends on the extent of the injuries to the joint and the surrounding ligaments and tendons. If no structures have been injured and if it was a one-time luxation, surgery can often be avoided.

The advantages of an operation are that damage to the joint and the ligamentous apparatus can be reliably repaired, and a new dislocation of the shoulder can be avoided.

Disadvantages of an operation can arise if complications occur. For this reason, the shoulder should only be operated on if the orthopedic surgeon or trauma surgeon in charge of the surgery has indicated to do so. One risk of the operation is an infection of the joint, which may result in a new surgery or long-term treatment. Since the surgery is usually performed using minimally invasive techniques, there is usually no major blood loss or injury to nerves. A stiffened shoulder often occurs after the operation, which can be prevented by intensive physiotherapy and active training during post-operative care.

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Aftercare

The therapy mustn’t end after surgery for a shoulder dislocation. The follow-up treatment is at least as relevant as the operation itself to achieve good function of the shoulder joint and mobility in the shoulder. The shoulder is usually first immobilized with a sling. Even slight movements may, and should, be carried out without stress, but intensive physiotherapy usually begins about three weeks after the operation. This is essential to regain full mobility in the joint and prevent stiffness of the shoulder. The time until the disease has healed should, therefore, include follow-up treatment. Depending on the extent of the injury, it can often take 6-8 weeks, including follow-up treatment, until the function of the shoulder is fully restored.

To a certain extent, pain that occurs during post-operative treatment of a shoulder dislocation can be considered normal. Pain that occurs after a longer period of immobilization may be caused by a stiff shoulder. The treatment of pain occurring after a shoulder dislocation should be discussed with the attending doctor. Often the intake of so-called NSAIDs such as ibuprofen or diclofenac is sufficient to relieve the pain significantly.

Physiotherapy

Physiotherapy primarily serves to keep the shoulder in shape after a treated dislocation to prevent functional limitations. A distinction is made between exercises that strengthen the muscles and those that make the shoulder more mobile. A typical strengthening exercise is the forearm support. Here you take the push-up position, with the difference that you support your forearms on the floor instead of your hands. One exercise that promotes mobility is circling the arms in alternate directions. In physiotherapy, these and similar exercises are performed under supervision.

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Exercises

After the reduction of the dislocation, it is important to perform exercises for the shoulder joint, since immobilization of the joint can quickly lead to its stiffening. The type of exercise depends on the extent of the damage to the joint and the therapy performed.

If only a conservative therapy were necessary, the shoulder is reduced, and the musculoskeletal system of the shoulder is intact, physiotherapy can be started immediately. Strength-building training therapy on machines, as known from the gym, but also free movements with dumbbells or elastic bands are possibilities to increase the strength of the shoulder. Especially exercises with bands or dumbbells can also be done at home if the treating physiotherapist has explained how to perform the exercise.

Once the shoulder has been stabilized with surgery, no intensive exercises should be performed initially. While only light pendulum exercises of the arm should be performed for the first three weeks, the intensity should be increased afterward. The physiotherapist should discuss with the treating orthopedic surgeon how much load the joint may be subjected to. It is also recommended that you carry out exercises on your own to prevent stiffness of the shoulder.

Bandage and braces

Depending on the extent of the injury, it may be useful to wear a bandage or a brace for some time to relieve and stabilize the shoulder joint. A brace has an enormous healing effect in the therapy of a shoulder dislocation. There are several different products from different manufacturers. Most of the available braces have in common that the affected arm is fixed to the trunk while the elbow is bent. Although the shoulder joint is restricted in its movement by the brace, some movement is usually still possible. Braces are generally comfortable to wear.

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Kinesio tapes

One way to fix the shoulder joint and increase the stability and strength in the joint is to apply a Kinesio tape. Kinesiotape is an elastically stable band that can hold the head of the humerus in the socket during post-treatment of a shoulder dislocation and support the muscles that stabilize the shoulder. To ensure the correct application of the Kinesio tape, an experienced physiotherapist or the treating orthopaedist or trauma surgeon should apply the bandage.

Complications of a shoulder dislocation

A shoulder dislocation can lead to several unwanted complications. A frequent event that can result in a shoulder dislocation is a renewed dislocation of the shoulder. Since the ligaments and muscles have become virtually worn out or weakened, they can no longer keep the bone stable and cannot secure it in its basic position. The effects of force or movements that previously caused no problems can already lead to a dislocation. The great danger here is that the risk of a new dislocation increases with the increasing number of dislocations, with the consequence that the patient is in a downward spiral that becomes almost deeper and deeper unless something is done about it. A shoulder dislocation can also damage the surrounding tissue. Cartilage or bone damage are known complications that can occur. Since nerves and vessels also run in the shoulder area, they can be damaged during dislocation. This results in movement and sensitivity disorders in the shoulder and upper arm.

Labrum tear

The joint lip, the so-called “labrum glenoidale,” are bulge-like ligaments around the joint socket. They serve to hold the head of the humerus in the socket mechanically. The labrum tear is a possible complication that can occur in the case of a shoulder luxation. The ligaments are not torn but detach from the edge of the socket. Of course, this only happens when a very strong force is applied. Because the labrum is detached, it loses its stabilizing effect. The treatment of a labrum tear involves an operation to reattach it to the edge of the glenoid cavity, thereby restoring the shoulder joint to its original stability.

Total healing time

A shoulder dislocation does not usually heal on its own and should, therefore, always be repositioned by a doctor. As a rule, the shoulder must be protected for 4-6 weeks. From this period onwards, a slow mobilization begins. It is estimated that after seven weeks, the shoulder can be used again without complaints and fully functional. It should be noted, however, that heavy loads on the shoulder, such as those that occur during sport, must not be performed after seven weeks, as there is an increased risk of dislocation.

However, the time required for healing is highly dependent on the severity of the dislocation. During this time, careful exercise and physiotherapy can already be started to prevent the dislocation of the musculature and to minimize the risk of a renewed dislocation. After a surgical dislocation, regeneration can take much longer.

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How long should I not do sports?

After a shoulder dislocation, it is strongly recommended not to do any sport for up to six months after the event. To ensure a complete recovery, it is essential to follow this guideline, as the risk of a renewed dislocation is far too high. Since every shoulder dislocation is individual, the doctor has the final say in each case. He may allow you to be active in sports earlier. Of course, it also depends on the type of sport you are doing.

Prognosis of shoulder dislocation

The probability of recurrent (= renewed) dislocation is the higher, the younger the patient, and the greater the level of sporting activity.

The limitations caused by the individually varying extent of joint involvement of luxation and the associated different type and duration of the therapy measures carried outplay a significant role in the risk of a further luxation so that only the treating physician can make an individual prognosis.

The likelihood of a recurrence is significantly increased since the repositioning and the subsequent treatment – if not surgically performed – did not cause any changes about the partially congenital cause.

Prevention of shoulder dislocation

Adequate immobilization and consistent physiotherapy after the initial luxation. Adjustment of physical/sporting activities, if necessary, avoidance of strains on the shoulder.

Pain

The pain of a dislocation of the shoulder that has just occurred is severe and usually almost unbearable. The pain continues until the shoulder dislocation has been treated. This includes the reduction of the joint or the administration of painkillers. If the reduction is successful, there should be no more pain, as the cause of the pain has been eliminated. During an acute dislocation, it is almost impossible to move the upper arm without pain. For this reason, the arm is placed in a kind of gentle position, which usually looks bizarre to outsiders. If pain persists despite treatment, it should be checked whether there are any accompanying symptoms, such as damage to nerves, vessels, or ligaments.

To a certain extent, pain that occurs during the post-operative treatment of an operation after a shoulder dislocation should be considered normal. Pain that occurs after a longer period of immobilization may be caused by a stiff shoulder. The treatment of pain occurring after a shoulder dislocation should be discussed with the attending doctor. Often the intake of so-called NSAIDs such as Ibruprofen or Diclofenac is sufficient to relieve the pain significantly.

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Duration of the pain

The pain of dislocation of the shoulder is strongest as long as the shoulder is in a dislocated state. The intensity of the pain is relatively strong, which is why a dislocation is immediately noticeable. As soon as the shoulder is repositioned, the pain subsides, unless structures such as vessels or bones have been affected by the dislocation. Persistent pain in the shoulder may indicate that this is the case and a sign that further diagnostic measures are required. The pain of an acute dislocation can be minimized with the administration of painkillers. If the treatment is successful, there should be no more pain.

Further accompanying symptoms

Another symptomatology that can occur with a shoulder dislocation is nerve irritation. This causes a tingling sensation and possibly numbness in the affected area.

Besides, the shoulder is severely restricted in its movement because the head of the humerus and the socket of the shoulder blade no longer interlock. In most cases, bruising and swelling are visible on the shoulder, and a dent in the bone contour is palpable or sometimes visible.

In the case of a shoulder dislocation, there is a risk of injury to surrounding structures. The muscles and tendons of the supporting apparatus are particularly at risk, and a surgical intervention may be necessary. The biceps tendon also runs near the shoulder joint and can be damaged. Also, nearby blood vessels and nerves are at risk.

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How does a shoulder dislocation occur?

As briefly described above, there are various causes for the occurrence of a shoulder dislocation.

The most common, however, is a levering movement of the upper arm with simultaneous external rotation, in which the arm moves away from the body. The head of the humerus usually jumps forward (luxatio axillaris) or downward (luxatio subcoracoidea) in a shoulder dislocation. Dislocations to the back are rather untypical. Only very rarely does a shoulder dislocate when the arm is extended upwards. As a rule, shoulder luxations have traumatic causes: falls, sports, bicycles, or other traffic accidents should be mentioned in this context.

The more rarely occurring habitual shoulder dislocations (see above) lead to dislocation without adequate trauma (minor trauma) due to individual events (e.g., congenital glenoid dysplasia).

Diagnosis of a shoulder dislocation

The diagnosis of shoulder dislocation is primarily a clinical examination. However, depending on the severity of the dislocation, this can be difficult under certain circumstances. In particular, in the case of distortions (twisting) and subluxations (incomplete dislocation), the medical history is, therefore, also very important in distinguishing between the various forms of severity.

During the clinical examination, the doctor palpates the shoulder and can feel the empty socket, the protruding bony acromion, and the dislocated head of the humerus in case of dislocation. If an attempt is made to reposition the dislocated arm carefully, it jumps back into the wrong position, which is known as “spring fixation.” The examination should also cover possible concomitant injuries, such as damage to a nerve.

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Necessary instrumental investigations

  • X-ray of the shoulder in 2 planes to define the type and to determine any accompanying bony injuries. X-rays can also be used to determine whether there are causes for the dislocation (e.g., dysplasia, etc.).
  • Apparative examinations useful in individual cases
  • Sonography (especially to exclude a rotator cuff lesion)
  • Special x-rays, for example, Velpeau image (positional relationship between humeral head and socket), ventrodorsal 60° internal rotation image (Hill-Sachs view), socket profile image
  • MRI of the shoulder joint
  • CT (if necessary air-arthro-CT)

What do you see on an MRI?

The diagnosis using an MRI is of central importance for many injuries. The importance is based on the fact that the extent of the injury can best be determined with an MRI, as an MRI image shows joints and soft tissues very well. As a result, treatment planning can be optimally determined. In an MRI, bony injuries can be identified, such as a notch in the back surface of the head of the humerus. A special eye mark is located on the joint lip. This is a ring of ligaments that lies around the joint socket. The MRI clearly shows a detachment of this joint lip. An important criterion is also the assessment of the condition of the biceps tendon and the nerves running there.

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What causes shoulder dislocation?

The distinction between a traumatic and an atraumatic shoulder dislocation has already been mentioned. The respective causes for the development of both forms of shoulder dislocation are described in more detail below.

The post-traumatic recurrent shoulder dislocation presupposes an initial traumatic dislocation and can, therefore, be considered a partial form of traumatic shoulder dislocation.

Traumatic (accident-related) shoulder dislocation

When trying to restrain the arm, the shoulder joint is suddenly subjected to great pressure and maybe unfavorably rotated. For this reason, the supporting apparatus of ligaments and muscles can no longer hold the joint, and it becomes dislocated.

The same can happen in some sports, such as tennis, skiing, and handball.

Depending on the direction in which the force is applied and thus the dislocation, a distinction is made between anterior, posterior and lower shoulder dislocation, with the anterior shoulder dislocation being by far the most common. The classic cause of a front shoulder dislocation is a fall to the rear, in which the arm falls unhappily on the ground.

While sports accidents are the most common cause of shoulder dislocations in young people, the risk of falling is a major risk in older people. Also, the stability of ligaments and muscles in the body often decreases over the years. Previous dislocations also represent a risk factor, as the ligament apparatus lends itself out over time.

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Post-traumatic recurrent shoulder dislocation

The causes and injury mechanisms of post-traumatic recurrent shoulder dislocation are considered to be largely understood. They are considered to be “recurrent” because of their name so that a traumatic (accident-related) initial dislocation must already have occurred, which may not have healed as planned.

Remaining damage after initial traumatic dislocation, which usually occurs for the first time in adulthood.

  • Cartilaginous/bony Bankart lesion (= tearing of the labrum glenoidale in the context of an anterior shoulder joint luxation)
  • Hill-Sachs lesion (= impression on the dorsolateral (towards the back, lateral) edge of the humeral head; in habitual dislocation)
  • Weakness of the capsule-band apparatus
  • Loss of proprioception (= loss of perception and control of the position of the body in space; sensory disorder)
  • Muscle weakness despite adequate rehabilitation
  • Habitual (multidirectional) shoulder dislocation

In the area of permanent shoulder dislocation, both the etiology and the origin of the disease have not yet been sufficiently clarified. Classically, a first dislocation is present in this subgroup, which is usually directed anteriorly downward to the processus coracoidia (= coracoid process). A first permanent dislocation occurs mainly in childhood and adolescence. Usually, an instability remains, which is usually very painless. Also, certain factors are assumed to have a favorable effect on the development of a permanent shoulder dislocation:

  • Anomalies in the area of the capsular ligament apparatus
  • Modified collagen cross-linking or composition of the capsule
  • Dysplasia of the glenoid cavity (reduced socket capacity)
  • The increased inclination of the socket to the reduced front rotation of the humeral head to the rear
  • inborn connective tissue weakness
  • Ehlers-Danlos syndrome (hyperelasticity, increased vulnerability and wound healing disorder of the skin, hyperextension of the joints with a tendency to dislocation; hereditary clinical picture)
  • Marfan syndrome (hereditary clinical picture, special connective tissue disease: changes in the eyes, habitus and cardiovascular system)
  • Muscular misalignment

Perspective

An expansion or improvement of the arthroscopic techniques can be expected.

Medium and long-term results of arthroscopic operations and laser techniques remain to be seen. Whether early reconstruction after initial luxation influences, the recurrence rate has yet to be proven by studies.

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