Dislocated Shoulder

The shoulder is a very mobile joint in comparison to the hip or the knee. It has to be in order to do its job of positioning the hand around the body to wherever you want it to be. However it pays the price for being mobile by running the risk of becoming unstable and dislocating – the ball (humeral head) of the ball and socket joint comes completely out of the socket (glenoid).

A footballer with a dislocated shoulder

Usually it takes a lot of force to dislocate the shoulder the first time but each subsequent dislocation occurs more easily. There are also people who have naturally loose ligaments (double-jointed) and their shoulders can dislocate with minimal effort and there are even some people who can dislocate their own shoulder at will.

The problem is that the ball is very big in comparison to the socket – it is a bit like a golf ball sitting on a golf tee. To make the socket a bit deeper and a bit wider there is a lip of cartilage (the labrum) attached around the rim that converts the socket from a saucer into a shallow bowl.

When you dislocate the shoulder the ball is forced out of the front of the socket and tears the labrum off the bone. The ball gets put back into the socket and the labrum may or may not drop back into the right place and may or may not reattach itself there.

Anterior dislocation of the right shoulder

An x-ray showing the humeral head dislocated from the glenoid.

My shoulder came out when I came off my mountain-bike. Do you think I need an operation?

There are quite a few factors to be considered before we decide if you need surgery.

Such as?

The most important ones are your age, whether you have had any previous dislocations and how active you normally are.

If you have had a previous dislocation – especially if that was fairly recent – then the statistics are that you will dislocate again (and more easily) so an operation is probably a good idea.

If it is your first dislocation and it happened after a big fall and you are over 40 then it’s better to wait and see because, again based on the stats, this should be a one off event.

If you are under 40 and sporty then we should at least discuss doing an operation after one dislocation.

It was about 3 week ago now and my shoulder is recovering quite well already. According to your blurb though, as a young active sportsman, I should be considering surgery but my shoulder is feeling ok.

There are no hard and fast rules and what you describe is quite common – a few weeks down the line and everything seems to be sorting itself out. So why operate? In this case it is absolutely fine to wait and see: get some good rehab on the shoulder; get back to your normal sports and see how things pan out. No more problems? Great. But a second dislocation or if it feels painful or unstable so that you don’t really trust it, then that’s the time for an operation.

So although the research tells us that a first time, traumatic dislocation in a young, active person has an 80% chance of dislocating again, many people do seem to make a good initial recovery and it does seem a bit harsh to force an operation on them. If your shoulder is feeling ok then let’s give it a chance.

My shoulder comes out very easily. I haven’t fallen down or anything but it’s becoming a problem because it comes out just turning over at night or reaching for things.

Are you double-jointed? Were you good at gymnastics as a child? Could you pop your own shoulder out as a party-piece? If so then it’s not so much a structural problem – as with the guy who dislocated falling down a ski slope – but a control problem.

You mean my shoulder is normal? Why does it come out then?

In your shoulder there is no damage to the labrum – it hasn’t been torn off. But everything is a little bit too stretchy so the ball can ride up and over the labrum and then you can clunk it back in yourself. Your brain has started to accept that behaviour as normal and doesn’t act properly to hold the ball in the socket.

I imagine it this way. Up in the brain there are little brain cells sitting in front of TV screens – one for each joint. Normally the signals coming from the shoulder are really high quality – 3D, HD – but when the shoulder is damaged the signal quality degrades. The picture the brain cell is seeing goes black and white and 2D and lots of pixels are missing so the brain cell isn’t sure where the ball is in relation to the socket. That means it allows the ball to get into dangerous positions without realising it and without sending the right messages back to the muscles to tighten up here or loosen up there to keep the ball centered on the socket.

You mean I have a software problem rather than a hardware problem?

That’s exactly it. The traumatic dislocaters have a structural (hardware) issues with normal control pathways (software) and you are the other way round.

Do I need an operation?

No. At least not at first. What we need to do is reboot your software and the way to do that is with physiotherapy.

Done that. Made no difference.

Well there are physiotherapists and there are physiotherapists. And what you need is a very specific set of skills that not many physiotherapists are actually expert at.

What were they doing with you?

Rotator cuff exercises, ultra-sound – that sort of stuff.

Do the words patterning, proprioception or biofeedback ring any bells?

If not then, I’m afraid, what you have been doing has been a bit of a waste of time.

I would send you to see someone who deals with this sort of thing on a regular basis and you will see and feel the difference straight away. 3 months of hard work should get you sorted out and give you back confidence in your shoulder. They will reboot your software.

And if that doesn’t work what then?

There is an operation that will stabilize your shoulder and that is discussed in the next section.

And getting back to my ‘hardware’ problem – what about my shoulder?

We will discuss your shoulder in some detail focusing on what you did, when you did it, have you done it before, how you are getting on and whether you want to have an operation now and whether you are able to have an operation now. As I said before, if you are recovering quite quickly, the shoulder function is returning, it’s your first time and you can’t afford to be stuck in a sling for 4 weeks then its rehabilitation and see how you go.

If those factors don’t apply then it is time for surgery.

The A&E people put me in a sling after they put my shoulder back – can I come out of it now?

There is no evidence that being in a sling for more than 2 weeks makes any difference so if you’ve done your time then out you come.

And physiotherapy? A good one please!

Very important. You won’t need so much of the software rebooting exercise used for the double-jointed dislocaters – or not as much anyway thoug that depends on how many dislocations you’ve had and how much confidence you had lost. Your rehabilitation is more based on recovering movement and strengthening up the important muscle groups around the joint.

I can do that myself in the gym.

The problem with the gym –  particularly in regards to the shoulder – is that there is a tendency to do the same old group of exercises that you have always done and often done badly. I know you may have a personal trainer as well but even they aren’t always clued up on what should be done to maximally improve the shoulder. A lot of people focus on what we call the ‘ mirror muscles’ – the ones that make you look good in front of the mirror! – at the expense of the ones you really need to keep the shoulder solidly in joint.

So you need to work on rotator cuff strengthening exercises and scapular stabilisation exercises guided by your therapist.

And when can I get back to my sports?

Take it slowly. There is no rush. Use the first 4 – 6 weeks to work on regaining movement, good control of that movement and strength in those specific muscle groups mentioned above.

Avoid the risky sports for the longest – so keep away from rugby until you are 100% sure of the shoulder. You can keep up your cardio-vascular fitness on an exercise bike. In fact you can even do that in the sling if you want to.

Swimming is a great exercise because the water supports the shoulder and you can do exercises in the pool after the first couple of weeks (guided by your therapist) before you start swimming properly. And you start with the breast-stroke, then back-stroke and finally front-crawl.

If you dislocated your non-dominant shoulder then you can think about returning to racquet sports relatively early – when you can move the arm around comfortably – but it will be longer if it was the dominant shoulder.

Impact sports are the last thing to get back to and it will probably be 4 to 5 months before you are safe to play rugby.

When can I drive?

As soon as you are out of your sling.

And back to work?

That depends a lot on what you do. It it’s a desk job then really as soon as you feel you can then back you go. Even with your arm in a sling you can use a keyboard. The more physical the job the longer it takes to feel confident enough but most people are feeling up to it after 4 weeks.

So, you’ve had your first traumatic dislocation and things seem to be going well; you are out of your sling, back at work and working with your therapist.

With a bit of luck you will make a complete recovery but if your shoulder dislocates again or feels unstable or painful then it is time for an operation.