Ask a sports medicine doc: shoulder dislocations
April 15, 2014
I almost made it through the season without injury, but I fell snowboarding over the weekend and dislocated my shoulder. Does this mean I need surgery?
Shoulders are inherently unstable joints. Unlike a hip joint, for instance, which rarely dislocates given its deep socket, the shoulder socket is very shallow and quite small. This allows for a joint that has excellent range of motion, but is also more prone to dislocate. In most shoulder dislocations, the ball or humeral head comes out the front of the shoulder. When this occurs, ligaments, or the so-called labrum, are torn off of the front of the socket. Orthopedists call this a labral tear or a Bankart lesion. In addition, the backside of the humeral head impacts the front of the socket when the head dislocates, and this leaves a depression in the backside of the humeral head. Orthopedists call this impression fracture in the head a Hill-Sachs defect.
Following a shoulder dislocation, patients usually present in severe pain with their arm held across their stomach. In a thinner person, one can appreciate a fullness in the front of the shoulder and often a depression in the back of the shoulder when the shoulder is dislocated anteriorly. In some cases, patients have numbness along the side of their shoulder and possibly down their arm into their hand due to nerves that have been stretched. In our active mountain communities, our ER docs do a large number of shoulder reductions and are great at getting the shoulder joint reduced. There are a number of different reduction maneuvers to get the shoulder back in place. If you are ever alone and dislocate your shoulder, you can try to get it back in by doing the following: Sit down, bend your opposite knee and interlock your fingers from both hands around your opposite knee. Then push away with your opposite knee thus applying traction to your arm. In effect, you are trying to pull the humeral head even farther out of the joint. This should in turn release the ball and allow it to fall back into the socket. X-rays are usually done to confirm that the shoulder is reduced and that there are no associated fractures.
In the office, treatment of a shoulder dislocation depends largely on the patient's age and activity level, as this gives orthopedists a good idea of whether the patient will have future dislocations. For instance, in someone in their 40s, studies have shown that the risk of the shoulder dislocating a second time is around 30 percent. In a high school age student who is participating in high impact sports, the chances of a second dislocation is greater than 90 percent. Thus, this latter population is more likely to have future dislocation and ultimately require surgery to stabilize the shoulder.
Following a first-time shoulder dislocation, I would recommend immobilizing the shoulder in a sling for three to 10 days, icing it, taking pain medications if needed, and doing early physical therapy to restore full, painless shoulder range of motion followed by strengthening. When the patient achieves full motion and good strength, they can then return to sport. Be aware that there are some risks with returning to sport too soon. If the shoulder dislocates again, one could do further damage to the ligaments or cartilage or bone in the shoulder, which might have long-term, deleterious effects.
An MRI will show if there is a labral tear, and any associated bone or cartilage injury. In patients who come to surgery, the torn and retracted labrum is arthroscopically sutured back onto the edge of the shoulder socket where it belongs. In patients who have sustained multiple dislocations in the past, the ligaments of the shoulder are also stretched out, and these are shortened in surgery in addition to repairing the torn labrum.
Dr. Rick Cunningham is a Knee and Shoulder Sports Medicine Specialist with Vail-Summit Orthopaedics. He is a Physician for the US Ski Team and Chief of Surgery at Vail Valley Medical Center. Do you have a sports medicine question you'd like him to answer in this column? Visit his website at http://www.vailknee.com to submit your topic idea. For more information about Vail-Summit Orthopaedics, visit http://www.vsortho.com.
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