Shoulder Dislocation

One of the most common injuries in contact sports, such as football and rugby, is shoulder dislocation, due to the shoulder being the most mobile joint in the body, which means it can also be at risk of instability during traumatic collisions.The shoulder can dislocate forwards,

 backwards

 or downwards

 but anterior dislocation is the most common. Contact sports involve tackles, falls onto an outstretched arm, overhead possession and collisions, all of which increase the risk of injury. 

Dislocation of the shoulder means that the ball of the arm bone comes out of the socket in the shoulder, not only putting the shoulder at higher risk for repeat dislocations,(up to 29% in contact sports),and negatively impacting on performance, but can mean a recovery of 6 months, although some athletes may take less time. It also increases the risk of injury in the other shoulder. 

The shoulder is stabilised by ligaments, muscles, the labrum and the capsule, and dislocation can damage these structures, causing a SLAP tear (see previous post on SLAP). The rotator cuff muscles also play an important role in shoulder stabilisation, counterbalancing the power of the deltoids, pectorals and lats, so any weakness can also increase the risk of injury.

COMMON SHOULDER INJURIES IN CONTACT SPORTS:-

• SHOULDER DISLOCATION – the ball and socket of the joint separate, often due to strenuous arm movements or traumatic collisions with another player or the ground

 • SHOULDER SEPARATION – tearing of the ligaments which stabilise the collarbone (more severe than dislocations)

 • ANTERIOR SHOULDER INSTABILITY – the ball slips in and out of the socket often due to long distance and repetitive throwing 

• SHOULDER TENDONITIS – repetitive throwing can cause inflammation of the tendons in the shoulder, usually the biceps tendon

 • SLAP TEARS – damage to the top of the labrum (see previous post on SLAP)

 • ROTATOR CUFF INJURIES – inflammation and tearing due to repetitive/excessive throwing motions

 • INTERNAL SHOULDER IMPINGEMENT – pinching of the rotator cuff muscles due to repetitive overhead throwing and loose shoulder joints 

RISK FACTORS:-

 • males in their teens or 20s

 • athletes with excessive range of motion due to shoulder instability ie.‘loose’ ligament/capsule complex

 • contact sport athletes with poor isokinetic strength (the ability of a muscle to contract at a constant speed) of the shoulder may be at risk of injury 

• athletes with asymmetrical rotational movement of the shoulders 

• impaired performance and/or trunk/leg injury – research shows that tackling fatigue may decrease the sense of shoulder joint position thus increasing risk of injury 

• common in contact sports, eg.football, hockey,rugby and sports with potential for falls, eg. downhill skiing, gymnastics, volleyball 

CAUSES:-

• collisions or sudden blow to the shoulder, pulling the bones out of place 

• excessive rotation of the shoulder can push the ball of the upper arm bone out of the socket 

• falling onto an outstretched arm

SYMPTOMS:-

 (will vary according to type of dislocation)

 • a visibly deformed shoulder

• local inflammation and heat

 • bruising

 • intense pain

 • inability to move the shoulder

 • shoulder instability

 • loss of shoulder proprioception

 • numbness/weakness/tingling in the neck or down the arm

 • muscles spasms in shoulder 

• popping sound heard at time of injury 

• hypertonicity and overcompensation of muscles crossing the joint

 • tissue may be cool due to ischaemia in chronic dislocations

 • additional complications eg.contusion, muscle strain,nerve and blood vessel injury,haematoma, development of adhesions around the joint 

COMPLICATIONS:-

 • tearing of muscles, ligaments and tendons that stabilise the shoulder joint

 • Bankart lesion – damage to the bone socket, ligaments and labrum (see previous SLAP tear post)

 • nerve or blood vessel damage around the shoulder joint 

• shoulder instability, especially if you have a severe dislocation or repeated dislocations, which makes you more prone to re-injury. 

PREVENTION:-

 • ensure any protective equipment eg. shoulder pads are fitted properly 

• undertake football-specific strength training to adequately prepare muscles and ligaments 

• use correct techniques when throwing, tackling and blocking 

• stretch and strengthen the back and torso to maintain function of the shoulder girdle

 • maintain fitness programme throughout the year rather than just in season 

TREATMENT:-

IMMEDIATELY FOLLOWING INJURY:-

 • place the shoulder in a sling to maintain its current position 

• don't try to move the shoulder or force it back into position as the muscles, ligaments, nerves and blood vessels could be damaged further

 • ice to the shoulder can reduce internal bleeding and fluid build up and therefore control pain and inflammation 

MEDICAL TREATMENT:- 

• closed reduction - gentle manoeuvres to reset the shoulder back into place 

• surgery - may be required if the shoulder joint is weak, shoulder dislocations are recurrent or if there is ligament/nerve/blood vessel damage 

• immobilization - a sling may be used for up to 3 weeks

 • medication - pain relief or muscle relaxants                                                                                         

 Anterior Shoulder Dislocation 

 Posterior Shoulder Dislocation  

Inferior Shoulder Dislocation

EXERCISES:-

 MOBILITY

 • avoid combined upward lateral rotation arm movements, which are more prone to dislocation 

• PENDULUM EXERCISES – (good early stage exercise when pain free) gently swing the arm forwards, backwards and sideways whilst leaning forwards, increase the range of motion slowly, avoiding upward and outward rotation

 • POLE ASSISTED SHOULDER MOBILITY MOVEMENTS:-

 - Abduction/Adduction – Hold a pole with both hands shoulder-width apart. Push the injured arm to the side, using the good arm and back towards the body. Repeat in the opposite direction.

 - Flexion/Extension – grip the hand of your injured side with the good side and slowly bring the arms up and towards your head. Stop if the shoulder feels like it may pop out.

 - Rotation – holding the pole, hands shoulder width apart and keeping the elbows at your side, move the pole to the left and right in front of you

 STRENGTHENING

 • Again avoid movements combining abduction and lateral rotation but these exercises can start once pain allows if dislocation was in the anterior shoulder. Start with static/isometric exercises and slowly progress 

• ISOMETRIC EXERCISES:-

 - isometric extension – Stand against a wall with arms by your side. Keep elbows and wrists straight and push back into the wall

 - isometric flexion – this time face the wall and push into the wall - isometric adduction – place a small pillow between the injured arm and torso, squeeze inwards and hold 

- isometric abduction – stand side-on to a wall, with the injured arm next to it. Push the back of the wrist against the wall and hold 

- external rotation – stand side on to a wall with injured arm next to it.Bend the elbow to 90 degrees and push the back of the hand against the wall then hold 

- internal rotation – stand side on to a door frame with the palm of the injured side facing the frame. Bend the elbow to 90 degrees, and push the palm into the door frame and hold

 • ROTATOR CUFF EXERCISES 

–once you can do the isometric exercises comfortably, try internal and external rotation, abduction and adduction and flexion exercises using a resistance band. 

FUNCTIONAL 

• Designed to replicate every day movements or sports specific movements. 

These are for the ADVANCED stage of rehabilitation,so check with GP/physio before starting.

 • WOBBLE BOARD EXERCISE - to improve joint awareness. Start on all fours, hands on the wobble board - hold the board still for 1 minute - perform circles with the board - perform mini push-ups while maintaining the central position

 • SWISS BALL SHOULDER STABILITY – works on the core muscles as well as shoulder stabilisation. Balance on the ball at the hips and place hand on wobble board, maintaining balance while moving the arms 

• REBOUND EXERCISES – work on dynamic strength. Stand facing a wall and throw a light ball at chest height and catch it again. Progress with a heavier ball/using only the injured side/throwing higher 

HOW MASSAGE HELPS FOLLOWING DISLOCATION

 • manual lymph drainage can be used in the proximal limb to improve circulation of any fluid build up 

• trigger points relating to the injury can be treated 

• massage will be kept light and will not aim to reduce the protective muscle spasms of muscles crossing the shoulder joint until past the acute stage 

• in later sub-acute stages of recovery massage can work on reducing adhesions which restrict the tendons and joint capsule 

• generally maintains tissue health during the recovery process

 Also in cases of chronic dislocation:-

 • can reduce oedema due to restrictive connective tissue 

CONTRAINDICATIONS TO MASSAGE FOLLOWING DISLOCATION

 • removing protective muscle spasms 

• the acute stage of recovery

 • no distal limb work in acute/sub-acute stages

 • any positioning that involves abduction and lateral rotation 

• no weight application in acute/sub-acute stages

 • no working on restoring range of motion until the muscles crossing the joint are restored