Shoulder dislocation is a painful injury. What is the pathway to recovery and how long does it take?
Australia’s Kim Michel ended her Olympic journey after dislocating her shoulder whilst trying to throw her javelin on her third attempt. It is the same injury suffered by Boomers basketballer Cameron Bairstow as he attempted a hook shoot in the paint with a seemingly innocuous incident.
So what exactly is a shoulder dislocation?
The shoulder is a ball and socket joint. It is the most flexible joint in the body, but the trade-off is that it is the most unstable. When the shoulder dislocates it means it the ball part (end of the humerus) comes completely out of the socket. A subluxation is a less severe situation where the humerus partially pops out, but does not fully come and therefore does not require being put ‘back in’.
If the shoulder fully dislocates, no matter whether it pops out the front (anterior dislocation) or the back of the joint (posterior dislocation), there is usually damage to a combination of structures around and inside the joint including the surrounding fibrous capsule (ball of ligament that surrounds the joint), the cartilage inside the joint (labrum) and sometimes bony damage like a fracture to the rim (acetabulum) or ball (humeral head fracture).
So does that mean surgery is required to fix it?
There is limited evidence comparing surgery versus conservative care (Padua et al 2007). And there is clearly not any convincing evidence at this stage favouring surgery.
And even though a diagnosis for two athletes or recreational warriors can be shoulder dislocation, they can have vastly different presentations and recoveries. So not surprisingly it is not a ‘one size fits all’, and each shoulder injury needs its own individual assessment.
It makes sense given that many shoulder injuries will do equally as well with conservative therapy, that a period of at least 6-12 weeks should be tried first, before surgery would be considered. At the very least this would likely improve, strength, function and pain and in the event of surgery still being required this ‘prehab’ would be beneficial and likely lead to better results post-surgery in terms of recovery.
So what exactly does conservative therapy entail?
The key is an initial assessment that helps identify what type of shoulder problem is present, and guides treatment based on the particular classification. Complicating matters is that imaging like MRI shows a high prevalence of labral tears in people without any pain (Schwartzberg et al 2016), and commonly used orthopaedic tests like the Hawkin’s Kennedy test (used to test for supposed labral tears) have been shown to have poor reliability and validity (May et al 2010), that is the same test will not produce the same result consistently, and it does not test the structure it is intended to isolate.
So we can’t rely on the scans or the orthopaedic tests. So where does that leave us?
Due to these difficulties it has been recommended that baseing assessment and treatment on specific patho-anatomic structures, that are thought to be causing the pain based on orthopaedic tests or imaging be abandoned, and another form of assessment based on signs and symptoms instead be adopted (Shellingerhout et al 2008, Lewis et al 2009, McKenzie and May 2002).
The McKenzie Method, or Mechanical Diagnosis & Therapy (MDT) is one such classification system that classifies patients, and assigns treatment based on their assessment into specific types of shoulder problems. Essentially in the MDT assessment the shoulder is repeatedly moved around (in directions based on the information in the history and physical exam) to identify if a specific direction of movement will eliminate pain and restore range of movement and function. This is called the patient’s direction preference, and studies show that around 40% of shoulder problems (May and Rosedale, 2012) will have a directional preference, meaning rapid improvement in pain and function will be achieved if they regularly perform these direction specific exercises.
The path to recovery- What is involved?
Firstly, this specific assessment is done to identify if there is a direction preference for your shoulder problem, given the excellent prognosis if one is identified.
If so, this direction specific exercise is done regularly (often every 2-3 hours) for a few weeks, which brings about rapid improvement. Then strengthening and sports specific graduated exercises are introduced. If there is no direction preference from the assessment, the recovery is less likely to be as rapid and favourable, but again graduated sports specific exercises are introduced to restore strength, mobility and control. The outcomes are still likely to be very good, but the timeframe is more likely months rather than weeks for return to sport and return to full pain free function.
So in the case of our injured athletes, we would be looking for that specific exercise that can rapidly restore pain and function (direction based), and otherwise we would aim to restore any lost mobility and strength specific to the assessment findings of that athlete.
Given the majority will do well with this, most would be able to return to their sport within 3-6 months successfully and have great outcomes.
So who might need surgery?
Should the athlete fail to do well with this conservative approach surgery may be required. This would be more likely if the athlete continues to dislocate or sublux despite being compliant with a rigorous strengthening program. Those with a past history of multiple dislocations or subluxations may be less successful, but many of these athletes may have had poor rehabilitation and so should not be written off until they have been put through an individualised program. Shoulders that continue to dislocated with even minor events like putting their arm in a sleeve are more likely to end up in surgery.
Given that surgery does not produce superior outcomes, and the timeframe for recovery after surgery is not faster (often the shoulder is in a sling for 4-6 post-surgery before rehabilitation even begins), all injured shoulders should be given a chance to improve with conservative treatment. Surgery should be reserved for those who truly need it, and not just given to anyone who has a labral tear based on imaging.
If you are struggling with recovery from a dislocation or any other shoulder problem, come on in to Absolute to see our McKenzie Specialist Physiotherapist to get your recovery back on track.
Written by Physiotherapist Joel Laing | Absolute Health & Performance- Physiotherapy Services Melbourne CBD.
References:
Padua, R., Bondì, R., Bondì, L. and Campi, A. (2007). Surgical versus conservative treatment for acute first-time anterior shoulder dislocation: the evidence. J Orthopaed Traumatol, 8(4), pp.207-213.
Schwartzberg, R., Reuss, B., Burkhart, B., Butterfield, M., Wu, J. and McLean, K. (2016). High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthopaedic Journal of Sports Medicine, 4(1).
May, S., Chance-Larsen, K., Littlewood, C., Lomas, D. and Saad, M. (2010). Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review. Physiotherapy, 96(3), pp.179-190.
Schellingerhout, J., Verhagen, A., Thomas, S. and Koes, B. (2008). Lack of uniformity in diagnostic labeling of shoulder pain: Time for a different approach. Manual Therapy, 13(6), pp.478-483.
Lewis, J. (2009). Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment?. British Journal of Sports Medicine, 43(4), pp.259-264.
McKenzie, R. and May, S. (2000). The human extremities. Waikanae, N.Z.: Spinal Publications (N.Z.) Ltd.
May, S. and Rosedale, R. (2012). A Survey of the McKenzie Classification System in the Extremities: Prevalence of Mechanical Syndromes and Preferred Loading Strategies. Physical Therapy, 92(9), pp.1175-1186.
