As usual, I will try to keep this somewhat generalized and avoid med-speak, but will also try to appease my fellow health care-practitioners with specificity. Also as usual, do not let my advice replace the opinion of a licensed health care practitioner who can attend to you personally.
Definition of shoulder dislocation
Displacement of the humerus (upper arm bone) from it’s socket (glenoid cavity of scapula) in the shoulder joint. Most commonly, this is an anterior (forward) and inferior (downward) displacement. For all intents and purposes this is the displacement I will be referring to.
This is most commonly the result of trauma, specifically a direct upward blow to the shoulder via humerus (hitting elbow on a rock) or backward force on an extended arm and/or flexed shoulder (rolling upstream on a high brace, hitting rock on high brace, etc).
Dislocations can also be the end result of severe shoulder strain/sprain, congenital anomaly (deformed joint surfaces) or soft tissue disease that pre-disposes Pt (patient) to dislocation, or powerful or violent contraction of shoulder mm (muscles), such a pitching or a clean and jerk lift.
Predisposition to shoulder dislocation: aside from forceful activities and contact sports, you are predisposed greatly if you have arthritis of any type, POOR MM (ed: muscular) CONDITIONING, or repeated shoulder injury of any sort (prior dislocations, strain/sprain, AC separation, fracture, etc.)
Signs and symptoms of shoulder dislocation:
- Immediate and excruciating pain at time of injury.
- Visible deformity at site; the Pts shoulder will be very obviously hanging down and forward. This is not always the case, and in my experience, usually not the case. Most dislocations I have seen have spontaneously repositioned themselves, and although the deformity is not observed, the damage is the same. To test for this, have the Pt try to externally rotate their humerus and flex their shoulder. If pain or apprehension are obvious, assume dislocation.
- Loss of function and/or severe pain and apprehension when trying to move arm.
- Tenderness, swelling, bruising at site of dislocation.
- Numbness or paralysis in arm, pallor (whiteness of skin), cold and clammy feeling skin, significant bruising and edema (swelling), or decreased brachial and radial pulses. THESE LAST SX (ed: symptoms) INDICATE VERY SEVERE CASES, and should be considered highest priority emergencies. This is indicative of vascular damage, nerve damage, internal bleeding, and may lead to shock, and/or permanent damage or loss of function in shoulder, arm etc.
If you have or suspect a dislocated shoulder, immobilize it (strap it to the body, supporting the elbow so gravity does not wreak havoc while bouncing or jostling around) and seek medical attention immediately. Do not try to reposition the shoulder unless you are trained to do so. This can lead to MAJOR problems with future instability, aggravate the injury even more, or worse, do irreparable damage to surrounding tissues (neural and vascular) which in worst case could lead to permanent impairment, shock, even death (from shock or loss of blood). Only in a life or death, extenuating circumstance should this be attempted-OR if you are 100% confident that it is NOT a severe dislocation (i.e. none of the nasty sx outlined above are present) and medical attention is not immediately available. If this is the case, here is how to do it:
- First of all, warn the Pt that this is going to hurt like nothing they have ever seen-this will prepare them mentally for it (it really isn’t that bad, but cover your butt in case it is).
- The goal is to return the hummers to the glen humeral joint.
- Assuming it is displaced inferior and anterior, we must move it superior and posteriorly.
- To do this, traction the arm lightly on the long axis of the humerus (i.e. at about 30degrees laterally from the body, straighten the arm, and apply light traction away from the shoulder-this is the opposite direction we will end up, but will make the Pt much comfier, and will require less force for the repositioning).
- Maintaining light traction, slowly and carefully externally rotate the humerus, adduct the humerus (move it medially, or inward towards mid-body), and gently push the arm back into the shoulder by cupping the elbow and pushing upward. Often times the shoulder will reposition itself before this last motion. If successful, you will feel it “suck” back into the joint, with a gentle clunking noise. Immediate relief of severe sx is usually attained.
- If the first attempt is unsuccessful, apply traction for about 10min to get the spasmed mm to relax and try again.
- AVOID any wrenching or quick motions. I have seen these maneuvers done many times in emergency rooms, sidelines, etc, and although they work, they are traumatic, and can lead to bigger trouble-no offense if this is the way you learned it, but remember: Primo No Cesere-first do no harm, and if you CAN do it a gentler way, then DO it a gentler way.
- If it is severe, and shock is setting in, keep Pt warm anyway you can, elevate lower extremities, keep them awake and hydrated while someone goes for help.
- If you are in transit to seek medical attention, basic rules apply to all injuries- RICE: Rest, Ice/immobilize, Compress, Elevate.
Care and feeding
After the joint is back in you want to sling it immediately to immobilize the shoulder and arm while the tissues heal. Soft tissue healing takes about 12 weeks. This does not mean you will be in pain or immobilized or even have to take it easy for this entire period, but that is when they will be fully recovered and at their “new” state of integrity. Follow your doc’s instructions, but here are mine:
- -In the Acute phase, ice every 2-3 hrs for 15-20min for the first 2-4 days. Also oral antinflammants-take what Rx your doc gave you, or use aspirin or ibuprofen.
- In the subacute phase, apply heat locally to initiate hyperemia that helps with healing, but follow with ice to prevent inflammation. My basic rule is 15min heat/15min ice, (always end with ice) do this at least 4xdaily. You may also start passive range of motion (PROM) at this time. Have someone put your shoulder through any and all tolerable ranges of motion. YOU DO NOT DO ANY OF THE WORK!! TOTAL relaxation is required of you. Listen to the pain-if it hurts or you have severe apprehension, wait another day. Unless you are doing your PROM, keep immobilized with sling.
- When you can do relatively pain free PROM, start to do active ROM (AROM), where you do all of the work. Wall walking, circumduction, flexion, extension, internal and external rotation, etc. Add very little resistance as strength and ability improve. Start with a can of beer or something :-), and work up to wherever you are comfy with weights. Cross friction massage, local massage and very gentle manipulation are beneficial at this time. Keep with heat/ice, especially after AROM.
- Rehab phase. When you have your ROM back and relatively pain free, you are ready for rehab. Ultrasound helps, as does interferential muscle stimulation, Russian mm stimulation, stretch and exercise, resistance training. Any shoulder exercises should be done with minimal pain or apprehension. Avoid incline, flat, or decline flys. Avoid straight bar incline bench, straight bar military press, do these with dumbbells. Avoid heavy shrugs. Go for high reps, light weights. Stretch thoroughly before and after workouts, and perform ice massage to shoulder and surrounding area-Styrofoam cup with frozen water is best, peel back as needed.
- Drink TONS of water.
- Supplement with any joint raw materials such as chondroitin, glucosamine, MSM, also antioxidants and B-vitamins, Calcium, Magnesium, and Zinc. As you all know, I am anal when it comes to water and supplements, but just to give you a baseline of what I find optimal, the following is my daily supplementation schedule: I am a very active and muscular, 6’1, 225# male. Daily I drink 2.5-3+gal water, 4x500mgC, 2xBComplex tab, 2×1,000IU E, 2×25,000IU Beta-carotene, 3x400mg Ca, 2xMg with Zn tab, 2xZn lozenges, 3x500mg Glucosamine, 3x500mg Chondroitin, 3x500mg MSM, 2xOmega3@6FishOil/fatty acids, 3x20g Psyllium fiber, 1xaspirin. Supplements have kept me very healthy, and my injury recovery time is next to nothing. Also-no kidding-I have not had a cold-even a sniffle-for 8 years. (I am now knocking on wood).
- You don’t have to take as much as I do to get major benefits, and if you are smaller and not as active, this would be overkill. There are basically 3 levels of supplementation: RDA=bare minimum to get by and thrive.
Maintenance= what your tissues/body needs to work optimally. Preventative/prophylactive (what I do) = disease prevention, immunity bolstering, disease combating, injury healing, and high oxidative stress status requirements (i.e. being an extremely active and relatively large person). Talk to a Nutritionist or email me-we can figure something out.
Post-reduction Complications: -call the Dr. ASAP if you have any of the following:
- persistent difficulty with shoulder motion.
- coldness, numbness, pallor (paleness), weakness, reduced pulses in arm, hand, or shoulder-emergency.
- signs of infection.
Real life adventures-prepare for this by:
- Looking at an anatomy book to get a general feel for the shoulder and it’s components.
- Always have a method of slinging, or immobilizing joints with you.
- Practice SEVERAL times the outlined reduction technique, just in case it comes to this. If you have done it several times before you will not be scratching your head wondering just which way to pull-push-rotate.
- No matter how bad it is, remain calm whether you are the victim or helper. This cannot be stressed enough.
- If this happens on a local run, immobilize and transport.
- Several hours walk out-immobilize and walk out if possible, otherwise send for help or reduce. Reduce ONLY if 100% candidate for non-skilled reduction.
- several days out-reduce if necessary, immobilize, walk AND send for help if you have enough in your party.
- If it is a severe case as outlined above-do anything. Keep them out of shock, awake, and hydrated, do not leave them alone. Send help out, but have at least one person stay with the patient. Start a signal fire, whatever it takes.
I hope this helps, and if you have any questions, etc, please feel free contact me through the comments below.
For those who have dislocated their shoulder or have other injuries-don’t despair. You will get better and back at it even if you need surgery. I personally have dislocated my L shoulder 3x, R shoulder 1x, L thumb 3x, and have a torn ACL and MCL in my R knee, and still am able to do (just about) anything I want to physically-and I have never had surgery for any of these…yet.
It is all about PREVENTION. STRETCH, EXERCISE, LIFT WEIGHTS, STAY ACTIVE AND EAT RIGHT. It’s as simple? as that.
See you all on the water!!