SHOULDER DISLOCATION

source: PhysioRoom.com

• A dislocated shoulder is common in contact sports.
• The shoulder is a ball-and-socket joint that has a large range of movement but not a lot of stability.
• It is particularly unstable when it is rotated outwards and the arm cocked back or 'abducted'. Any additional force in this position will cause the head of the humerus (arm) bone to come out of the joint in a forward direction. This is referred to as an anterior dislocation.
• The shoulder joint is enclosed by a fibrous capsule, and this is strengthened by ligaments that provide a reinforced thickening of the capsule.
• The joint also has a labrum, which is a fibrocartilage lip that increases the congruency of the joint. In the case of a traumatic dislocation, the joint capsule and ligaments are torn, and the labrum may also be damaged.

• The most obvious symptom is pain.
• A person with a dislocated shoulder will be unable to move the affected shoulder and will hold the arm protectively against the chest. 
• The normal rounded appearance of the shoulder will be replaced by a more squared-off edge because the head of the humerus bone drops downwards.
• If a dislocation is suspected, an x-ray should be taken to confirm the damage.

• It is important that a shoulder dislocation is seen quickly by a doctor who can put the joint back in place.
• This is because the position of the humerus in a dislocated shoulder joint can cause damage to the axillary nerve and the auxiliary artery. This can lead to a loss of sensation and muscle strength in the affected arm.
• Once the shoulder has been put back in place it is immobilized using a sling. The sling is kept on for about 2 to 3 weeks, during which time it is important that the elbow, wrist and fingers are kept moving to prevent them stiffening up.
• Rehabilitation is started as soon as possible but overhead arm movement and sporting activity should be avoided for at least 6 weeks.
• Because of the damage to the structures surrounding the shoulder, there is a high chance of recurrent dislocation. Surgery on an unstable shoulder is usually required after 4 dislocations.

• Once there has been a dislocation of the shoulder, the joint will have a degree of instability and will be more likely to dislocate again, or become subluxed (where it moves slightly but not fully out of joint). This is because the ligaments, capsule and labrum are damaged and cannot restrain the humeral head and prevent dislocation.
• In order to prevent dislocation, the muscles that surround the humeral head should be strengthened.

• The exercises that follow provide a rehabilitation program for an anterior dislocation shoulder injury.
• The information is intended as a guide and refers to those people who have dislocated their shoulder for the first time.
• The rate of progression is dependent upon the healing process, which is affected by the age of the patient.
• It is therefore not possible to be precise when indicating a prognostic timetable.

• In younger patients, the shoulder should be immobilized in a sling for 3 to 4 weeks. In patients over 40 years of age the sling should be discarded sooner to prevent secondary stiffening of the shoulder.
• No overhead arm movement or sporting activity should be undertaken for 6 weeks.
• Care should be taken at night, with some form of immobilizing device worn in bed.
• Some active exercises can be started immediately.
• However, the extent of shoulder movement should be guided by pain since over-stretching the healing tissues only delays the recovery.
• The exercises that follow should take place in the pain-free range.

Active exercises:

• Grip a sponge ball, making a fist, for 10 minutes every couple of hours.
• Wrist and elbow bending and straightening should be practiced at least twice daily.
• The arm can be raised forward to the level of the shoulder (90 degrees) and out to the side to the level of the ribs (60 degrees).
• Isometric exercises can be started once the arm is out of the sling
• The range of movement in the shoulder can be gradually increased over the course of 2-4 weeks.

	Isometric contraction of the lateral rotator muscles of the shoulder. This is achieved by pushing against a wall without any movement taking place.		Isometric contraction of the medial rotator muscles of the shoulder. This is achieved by pushing against a wall without any movement taking place.
	More advanced strengthening of the external rotator muscles using a weight and pulley device.		More advanced strengthening of the medial rotator muscles using a weight and pulley device.

• Continue with the strengthening program.
• Continue with range-of-movement exercises.

	Use of elastic cord resistance to strengthen the external rotator muscles of the shoulder.		Use of elastic cord resistance to strengthen the internal rotator muscles of the shoulder.
	Self-assisted range-of-movement exercises for the shoulder (this shows the advanced stage).		The patient balances with the affected shoulder on a medicine ball for 1 minute at a time, followed by a rest period.
	The medicine ball is replaced by a wobble board to make the exercise more difficult.		The difficulty is further increased by using a medicine ball and a wobble board!
	The balancing task, and therefore proprioceptive ability, is further taxed by resting the legs on a Swiss ball...		Another option