The human shoulder is a wonderful machine. The unique shoulder anatomy allows the greatest range of motion of every joint in the body. The arms allow overhead activities such as attaching a light bulb, doing a handstand or throw a ball 95 miles.
Under normal circumstances, we rarely stop thinking about our shoulders. However, when a shoulder injury does occur, it’s often impossible to ignore it. The dislocated shoulder is one of those injuries. This article discusses important aspects of a dislocated shoulder, including normal and shoulder dislocation anatomy, diagnosis, treatment, and future considerations after treatment.
Dr Chandra Sekhar’s article gives information about Dislocated Shoulder Care: An Orthopaedic Guide to Shoulder Dislocation and Repair.
Normal shoulder anatomy
When most people think of the shoulder joint, “ball and socket” comes to mind. However, the “shoulder” actually consists of three separate joints.
- Glenohumeral Joint: The joint where the “ball” of the humerus (arm bone) meets the “socket” of the glenoid (part of the shoulder blades).
- Acromioclavicular Joint: The “AC” joint where the collarbone meets the scapula or “scapula”.
- Scapular Joint: When the shoulder blades meet the chest.
The scapulothoracic and glenohumeral joints account for the shoulder’s range of motion mostly. In contrast, the AC joints provide a stable connection between the arm and the rest of the skeleton.
Much of the stability of the shoulder comes from the soft tissue surrounding the ball and socket. Three layers contribute to this stability:
- Outer Layer: The large, strong muscles, including the deltoid, trapezoid, and chest are the outer layers and provide most of the shoulder’s strength.
- Middle layer: The middle layer consists of a rotator cuff, that is a group of four small muscles that surround the glenohumeral joint and help keep the “ball” in the place “socket.”
- Inner layer: The strong connection between the humerus (ball) and glenoid (socket) prevents joint dislocation. The labrum, the hard tissue that surrounds the glenoid, is another important structure. In case of injury, can damage these ligaments and labrum, and the shoulder sprains.
What is a shoulder dislocation?
A shoulder dislocation is a painful and dangerous injury to the glenohumeral joint, the primary shoulder joint. It appears where the ball of the humerus fits into the flat socket in the scapula. Because the shoulder joint is the most flexible in the body, it is easily movable.
Types of shoulder dislocation
Most dislocations occur in the front (front), but the shoulder can also be moved posteriorly (back). Smaller dislocations are possible, but they occur less frequently.
Shoulder dislocation can be either a partial dislocation (subluxation), in which the humeral head (humerus) is partially outside the socket (glenoid), or a complete dislocation, where it originates entirely from the socket. Partial and complete sprains can cause pain and instability in the shoulder.
- Anterior shoulders dislocation: With an anterior dislocation, the humeral head slides forward and rests in front of the glenoid. This type of dislocation is the most common type of shoulder dislocation.
- Posterior shoulders dislocation (back): When the shoulder is shifted from behind, the humeral head moves backwards behind the glenoid. Posterior and inferior shoulder dislocations account for only about 5 to 10 per cent of all shoulder dislocations.
What causes a shoulder dislocation?
Causes and risk factors for shoulder dislocation are:
- Traumatic injuries such as falls, sports injuries, or car accidents
- Frequent/repetitive stress: From sports such as tennis, golf, swimming, volleyball
- Loose capsule ligament: The connective tissue in the shoulder that holds the humeral head in the shoulder fossa loosens due to injury or previous overuse or sprain
- Multidirectional instability: This is a genetic predisposition causing the shoulder to become unstable or feel loose. People with this instability often have similar loose connections in their bodies and can be described as “double-jointed”.
How to diagnose a shoulder dislocation?
If you suspect you have a dislocated shoulder, it’s important to see a shoulder surgeon. Medical management of shoulder dislocations is important because X-rays are required before and after the shoulder reset. With imaging, your doctor can look for fractures and other joint injuries.
The diagnostic process begins by talking with you about your symptoms and doing a detailed physical exam. Diagnostic images, including X-rays and magnetic resonance imaging, are used to confirm the diagnosis and check for other shoulder injuries.
How to treat shoulder instability?
Several non-surgical and surgical treatments are available to relieve symptoms of shoulder instability. Non-surgical treatments include:
- lifestyle Changes: It is advisable to avoid activities that aggravate your symptoms
- Physical Therapy: A physical therapist may recommend an exercise program to strengthen the shoulder muscles to increase stability.
- Anti-inflammatory drugs: These can help reduce swelling and relieve pain
A dislocated shoulder is usually painful and often requires the shoulder muscles’ complete relaxation to put the shoulder back in place. For this reason, sedation or anaesthetic injection into the shoulder joint is often done while putting the shoulder back in place.
Placing the joint into its location is called “reduction” by pulling the arm in a specific direction based on the type of dislocation. Once the joint is back in place, comfort increases. Once your shoulder joint has healed, your pain should subside, and you only need a simple pain reliever and a sling for 1-2 weeks for comfort. You will then be sent to physical therapy to restore movement and strength to your shoulder. If you experience symptoms of instability, additional testing may be needed.
It is an orthopaedic emergency. The longer the joint is dislocated, the greater the risk of injury to the bones, tendons, nerves, and blood vessels when the shoulder is reinserted into the joint.
Recovery from non-surgical treatment
Sometimes there is a tingling sensation in the shoulder for several days to weeks. This is common and usually temporary. However, this tingling sensation should always be reported to a doctor. Once the shoulder is attached, the risk of dislocation is high, so to prevent this from happening must take precautions. Shoulder dislocations can be associated with additional injuries such as tendon ruptures or fractures. For this reason, follow-up appointments should be made with a shoulder surgeon.
Once the dislocated shoulder is put back in its place, one needs to use the sling for 4-6 weeks. It is important to get out of the sling during this time and then to move the elbows, wrists, and fingers as these joints tend to be stiff. Your doctor may recommend physical therapy to restore your shoulder circumference while protecting ligament tears during treatment. In most situations, the healing process is advanced enough to start careful shoulder treatment at 4-6 weeks after the injury under a physical therapist’s supervision. People can use their shoulders for most of their normal activities a few months after the injury. Contact sports or activities in which the shoulder is at high risk of re-dislocation are usually stopped for 4–6 months after injury.
A doctor can treat most first-time shoulder dislocations successfully without surgery. People who have been successfully treated without surgery can use their hands for most of the normal activities they enjoyed before the dislocation. The decision to have surgery often depends on the risk of moving and other associated injuries. Repeated shoulder sprains can cause cartilage damage and bone loss, which in turn can lead to pain, weakness, chronic instability, and osteoarthritis, if the risk of re-sprain is higher than the risk of surgery, shoulder stabilization surgery maybe your best option. It may also need surgery if the rotator cuff, bone around the shoulder, or labrum has been injured.
Shoulder stabilization surgery to stabilize the shoulder can be performed in two ways:
Arthroscopic Surgery: This is a surgical procedure using an arthroscope, a tubular instrument with a camera on one end. A small incision is made in the shoulder, and an arthroscope is placed so that the orthopaedic surgeon can see inside the shoulder joint. The saline solution is delivered to the shoulder for better visibility, and the damaged tissue and ligaments are repaired with the help of small surgical instruments. The incision is closed with sutures, and this procedure helps prevent further instability and dislocation symptoms. You must wear the sling while your shoulder is healing.
Open Operations: In some cases, keyhole operations may not be possible. In this case, a larger incision will be made in your shoulder, and the repair will be done using an open surgical technique. Your advisor will discuss this with you in more detail during the consultation.
One of the most common surgical procedures for shoulder dislocation is Bankart surgery. In Bankart’s procedure, the torn labrum and capsule are reconnected to the glenoid cavity’s front edge. This operation is mainly performed in arthroscopic procedures.
Some patients with multiple shoulder dislocations may experience changes in the shoulder joint’s soft tissues and bones that require more in-depth and complex surgical reconstruction. Some severe injury cases can discuss techniques such as repositioning, bone grafting, and anterior subscapular enlargement.
After the surgery, you will hold your shoulder in the sling for up to 6 weeks. After initial healing, return to physical therapy to strengthen the shoulder for the next 4 to 6 months. This will reduce the chance of returning sprains and improve your mobility. Even though surgery is necessary, you will likely visit the physical therapy team before surgery. This happened to:
- Reduce swelling
- Strengthen muscles
- Stabilize the shoulders
- Reduce the chance of scarring to the joints
- Can speed up recovery after surgery
Depending on the extent of the damage, this operation usually takes 1-3 hours, and the patient usually goes home the same day.
Recovery after surgery:-
The sling is usually used four to six weeks after surgery. Since it is difficult to control our movements while we sleep, you may need to wear this sling at night. You will need to confirm specific limitations with your surgeon. During this time, some people find it easier to sleep in a recliner.
Surgery for shoulder instability is usually followed by a period of discomfort and stiffness, which can vary from patient to patient. Some people experience pain or stiffness, while others experience pain and stiffness that can last for months. Your surgeon will likely prescribe medication for pain relief for a limited amount of time after surgery. These medications will help you relieve pain and tolerate physical therapy sessions. Since opioid pain relief can be a powerful habit, it is important to speak with your surgeon to determine what postoperative pain control you can expect.
You may also start physical therapy within a few weeks of surgery. Physiotherapy can be important after surgery for several reasons. A licensed physical therapist will help you restore and maintain freedom of movement of your shoulder, and protect your repair during the first few weeks and months after surgery when repairs are most prone to rupture. The therapist will improve your shoulder’s range of motion and condition based on the postoperative plan established by your surgeon. Depending on the procedure performed and the level of pain and stiffness in the shoulder, multiple therapy sessions may be required. Most patients who undergo shoulder stabilization surgery achieve a good range of motion and pain improves within three or four months after surgery. Shoulder conditioning will likely take four to six months after surgery. People usually have the right to return to sports about six months after surgery.
A dislocated shoulder is a painful injury that can happen to anyone. Fortunately, the doctor can treat most of these dislocated shoulders without surgery. Younger and more active people have a higher risk of redislocation. Repeated shoulder sprains can lead to chronic instability, additional shoulder injuries, and shoulder arthritis. As a preventive measure, surgery can be performed on patients who are at higher risk. Consulting with a qualified shoulder surgeon like Dr Chandra Sekhar can help you make the best decisions about treating shoulder injuries. For more information on the best treatment, contact Dr Chandra Sekhar. B at 91 9959588389.