Shoulder dislocation

Shoulder dislocation: a comprehensive guide to understanding and treating this injury

Approximately 2% of the population will experience at least one episode of shoulder dislocation during their lifetime, and this injury accounts for nearly 50% of all joint dislocations. Here's the good news: even though a shoulder dislocation is painful and alarming, your shoulder is designed to heal. With the right treatment and appropriate rehabilitation, most people regain normal function, and there are concrete ways to significantly reduce the risk of recurrence.

For a quick overview of this condition and our treatment services, visit our page on shoulder dislocation. This in-depth guide will help you understand why dislocations occur, how to recognize the signs that require immediate attention, and, most importantly, how physical therapy can help you regain a stable and functional shoulder.

What is a shoulder dislocation?

A shoulder dislocation occurs when the head of the humerus (the arm bone) completely slips out of the glenoid cavity (the socket in the shoulder blade that forms the joint). In Quebec, we often hear the expression "the shoulder has come out," which is a fairly accurate description of what happens.

The shoulder joint functions like a golf ball placed on a tee: it allows extraordinary mobility in all directions, but this freedom of movement also makes it more vulnerable to dislocation than any other large joint in the body.

There are two distinct situations to understand. Subluxation occurs when the humerus partially slips out of the joint and then spontaneously returns to its normal position. You will feel a sensation of slippage or instability, followed by a return to the normal position. Complete dislocation occurs when the humerus comes completely out of the glenoid cavity and remains displaced. The shoulder appears deformed and cannot return to its normal position without medical assistance.

In more than 95% of cases, the dislocation is anterior, meaning that the humerus slips out toward the front of the joint. Posterior dislocations are much rarer and usually occur during falls with the arm outstretched or during seizures.

Who is affected by shoulder dislocations?

Shoulder dislocations do not affect everyone equally. Certain profiles are at much greater risk.

Working young adults

The first dislocation occurs in 77% of cases in men aged 20 to 35. The peak incidence is between 15 and 29 years of age, particularly in those who participate in contact sports or sports with a risk of falling.

The impact of age

The age at the time of the first dislocation changes everything for the prognosis. If you are under 20 at the time of your first dislocation, your risk of recurrence is 80 to 90%. Between the ages of 20 and 40, this risk decreases to about 60%. After age 40, it drops to only 10 to 15%.

This dramatic difference can be explained by several factors: young people's tissues are more elastic, which promotes recurrence; their activity levels are generally higher; and they have more years ahead of them in which to be exposed to new risk situations.

The athletes

Athletes are at the forefront when it comes to shoulder dislocations. Sports such as hockey, football, volleyball, gymnastics, and rock climbing pose a high risk. Any activity involving contact, possible falls, or rapid movements of the arm above the head increases vulnerability.

If you recognize yourself in one of these profiles and have just experienced your first dislocation, your priority is clear: invest in comprehensive rehabilitation to prevent your shoulder from dislocating repeatedly.

What are the symptoms of a dislocated shoulder?

A shoulder dislocation does not go unnoticed. The symptoms are usually obvious and appear immediately after the injury.

The intense, sudden pain strikes at the moment of injury and remains very present. Unlike other injuries that gradually worsen, dislocation hurts from the very first second. When the shoulder dislocates, you may hear or feel a distinct pop, followed by a very clear sensation that something is wrong.

When comparing your two shoulders, you will notice that the dislocated shoulder looks different and is visibly deformed. The shoulder may appear more square or lower, or the bone may create an unusual bump under the skin. You will not be able to lift your arm, rotate it, or move it away from your body. Even small movements will be impossible or extremely painful.

Emergency signs that should never be ignored

Go to the emergency room if you notice numbness or loss of sensation in your arm, hand, or fingers that persists or worsens, an inability to move your fingers or hand that does not improve, coldness or discoloration of the hand or fingers (a sign of a circulatory problem), or significant weakness in the arm that does not correspond to the pain.

These signs may indicate nerve or vascular damage that requires urgent intervention. Nerves and blood vessels run very close to the shoulder joint and can be stretched or compressed during a dislocation.

What really causes a shoulder dislocation?

The popular myth is "I have a weak shoulder" or "My shoulder is fragile." The reality is different: during a first dislocation, it is not your shoulder that is weak, it is the force of the trauma that exceeds the resistance capacity of any normal shoulder.

For a healthy shoulder to dislocate the first time, considerable force must be applied in a vulnerable position. Falls with landing on an outstretched arm throw the humerus out of the glenoid cavity with a force that the ligaments cannot withstand. Direct contact during sports such as hockey checks, football tackles, or basketball collisions can cause dislocation. Extreme twisting movements where the arm remains stuck while the body continues to rotate, and car accidents with sudden deceleration combined with the position of the arm are also common causes.

Why do some shoulders dislocate repeatedly?

After an initial dislocation, structural damage occurs that changes the situation. A Bankart lesion involves tearing of the labrum, a ring of cartilage that deepens the glenoid cavity, often accompanied by tearing of the ligaments that stabilize the front of the shoulder. It is as if the rim that prevented the ball from coming off the tee is now broken.

Stretching of the joint capsule means that the envelope surrounding the joint becomes distended. Even after healing, it remains looser than before, reducing natural stability. A Hill-Sachs lesion means that the head of the humerus can become slightly deformed as it moves out of the joint, creating a small bone depression that makes future dislocations more likely.

Once this damage is present, it does not take a major traumatic force for the shoulder to dislocate again. Some people report that their shoulder dislocates simply when putting on a coat, throwing a ball, or rolling over in bed.

The liberating message is that your body is not defective. Recurrent dislocations are the predictable consequence of specific structural damage, and this damage can be treated.

What should you do immediately after a dislocation?

The first few hours after a dislocation are crucial. Your immediate actions will influence your recovery and your risk of complications.

If this is your first dislocation

Never attempt to reset the shoulder yourself; go to the emergency room. Reduction must be performed by a healthcare professional, as an X-ray is essential to rule out a fracture before reduction. Approximately 25% of first-time dislocations are accompanied by small fractures, and improper technique can worsen damage to nerves, vessels, or bones.

In Quebec, physical therapists can order X-rays if the injury occurred less than 72 hours ago. If you do not have quick access to a doctor, a physical therapist can refer you and order the necessary imaging.

While waiting for medical care

The first phase of management follows the PEACE protocol. Protect the shoulder by immobilizing the arm against the body. Use a sling, triangular bandage, or even your other hand to hold the arm in a comfortable position. Keep the arm supported and do not let it hang down. Avoid anti-inflammatory drugs for the first 48 hours. Tylenol (acetaminophen) is acceptable for pain relief. Compression can be used with caution, but immobilization is more important. Understand your injury and follow appropriate medical advice.

Practical tips for the first few days

To reduce pain, support your arm with a pillow under your armpit, place your hand in your pants pocket to relieve the weight on your shoulder, and use an armrest if you are at a desk.

When sleeping, make sure your neck is well supported with a pillow, keep your arm alongside your body or supported by a pillow, avoid sleeping on the injured shoulder, and never sleep with your arm behind your head.

How does physical therapy treat a shoulder dislocation?

After a doctor has put your shoulder back in place, the real rehabilitation begins, and that's when physical therapy becomes your best ally in regaining a functional and stable shoulder. Our comprehensive guide to shoulder pain provides more details on the various conditions that can affect this joint.

Phase 1: Controlled immobilization (0-3 weeks)

Immediately after reduction, your shoulder will be immobilized with a splint or sling for 2 to 3 weeks. During this phase, your physical therapist will assess the integrity of your structures, introduce pendulum movements to maintain a minimum of mobility, and teach you how to protect your joint.

Phase 2: Restoration of mobility (3-6 weeks)

Once immobilization is removed, the real work begins with joint mobilization and manipulation. The physical therapist gently guides your shoulder in different directions, gradually restoring range of motion. Active-assisted exercises allow you to begin moving your shoulder actively but with assistance. Nerve glides are specific exercises that gently mobilize the nerves in the arm.

Phase 3: Strengthening and stabilization (6-12 weeks)

This is the most critical phase for preventing recurrence. Strengthening the rotator cuff targets these four deep muscles, which are the main stabilizers of the shoulder. Scapular stabilization ensures that the shoulder blade is stable so that the shoulder can function properly. Neuromuscular control allows your shoulder to relearn how to stabilize itself instinctively. Plyometric exercises prepare athletes' shoulders for the demands of explosive sports.

Stabilizing muscle exercises and muscle strengthening and endurance exercises are an integral part of this crucial phase.

Phase 4: Return to activities (3-6 months)

The typical time frame for returning to sports is 3 to 6 months, depending on the sport and your progress. For some contact sports, this time frame can extend to 6 to 12 months if surgery was necessary.

With comprehensive and well-monitored rehabilitation, most people regain normal range of motion, sufficient strength for daily activities and sports, and stability that allows them to safely return to their activities.

Our clinic offers specialized physical therapy programs for shoulder pain that can guide you through each phase of your rehabilitation.

Why do some shoulders dislocate repeatedly?

If your shoulder has dislocated a second time, you are probably wondering why and whether it will continue to happen. The answer depends on several factors, some of which you can control and others you cannot.

Recidivism statistics

The statistics are sobering. If you are under 20, the risk of recurrence is 80 to 90%. Between the ages of 20 and 40, this risk decreases to about 60%. After age 40, it drops to only 10 to 15%. After a second dislocation, the risk of a third increases to 44%, regardless of your age.

Even more troubling, the majority of recurrences occur within the first two years after the initial injury.

Risk factors

Among the factors that you cannot change, age at the time of the first dislocation plays a major role because the younger you are, the more elastic your tissues are and the less tightly they heal. Males are three times more likely to experience recurrence. Hyperlaxity, where the joints are naturally loose, increases the risk by 2.7 times.

Among the factors you can influence, the quality of rehabilitation is paramount because completing a structured program significantly reduces the risk of recurrence. Respecting recovery times is essential because returning to sport too quickly dramatically increases the risk. Sustained muscle strengthening creates a protective "muscular armor." Modifying activities to avoid extreme positions preserves stability.

The alarm signal

If you develop a constant fear that your shoulder will dislocate in certain positions, known as apprehension, or if you regularly feel that your shoulder is slipping or about to pop out, these are signs of real instability that warrant surgical evaluation.

How can recurrent dislocations be prevented?

If you have already experienced one or more dislocations, your goal becomes clear: prevent it from happening again. Here are some strategies that work.

Complete and intensive rehabilitation

Rehabilitation is not optional; it is your first line of defense. Complete the entire program, as people who abandon their rehabilitation halfway through have much higher recurrence rates. Continue beyond the official end date by maintaining strengthening exercises 2 to 3 times a week for an additional 6 to 12 months, which creates lasting protection. Incorporate functional exercises and don't just stick to exercises with resistance bands. Incorporate movements that resemble your sport or daily activities.

Smart modification of activities

You don't have to give up sports, but you may need to adapt. Identify your risky positions, as most people with recurrent instability know exactly which movements are dangerous. Avoid these positions at the beginning of rehabilitation to give your tissues time to heal before challenging them. Gradually reintroduce these movements because, with strengthening, you may eventually be able to recover these positions, but it takes time.

Knowing when surgery becomes necessary

Surgery is not a failure; it is sometimes the most sensible solution. Indications for considering surgery include having had two or more complete dislocations despite serious rehabilitation, a shoulder that subluxates regularly several times a month, being under 25-30 years of age and participating in high-level contact sports, imaging showing significant Bankart lesion or significant bone loss, and a quality of life seriously affected by the constant fear of shoulder dislocation.

The main surgical options

Arthroscopic Bankart repair allows the surgeon to reattach the labrum and tighten the ligaments using small anchors. The success rate is 85 to 95%. Latarjet surgery is indicated for cases with significant bone loss in the glenoid, where the surgeon transfers a bone fragment to create a stop that prevents the humerus from dislocating.

Post-surgical recovery times are 3 to 6 weeks of immobilization, 2 to 4 weeks to return to office work, 3 to 4 months to return to physical work, 4 to 6 months to return to non-contact sports, and 6 to 12 months to return to contact sports.

The key message is that recurrent dislocations are not inevitable. With intensive rehabilitation, smart activity modifications, and surgery when indicated, you can regain a stable shoulder that allows you to live life to the fullest. The key is to be proactive rather than passively enduring dislocations. Each additional dislocation increases the damage, so don't let the situation get worse without taking action.

Conditions to monitor

A shoulder dislocation can sometimes be accompanied by other injuries or conditions that are important to be aware of. Injuries associated with ligament pain can affect the shoulder's supporting structures. Chronic joint pain can develop if rehabilitation is not complete. Rotator cuff injuries can accompany a dislocation, particularly in people over the age of 40.

Shoulder bursitis andshoulder sprains are conditions that can coexist with post-dislocation instability and must be evaluated as part of a comprehensive assessment.

When should you consult a professional?

Seek emergency medical attention immediately if this is your first shoulder dislocation, if you have persistent numbness in your arm or hand, if your hand or fingers are cold or discolored, or if you cannot move your fingers.

Consult a doctor or physical therapist promptly if you have had a dislocation that popped back into place on its own (subluxation), if your shoulder has dislocated repeatedly and you want to explore your options, or if you have had a dislocation in the past and are developing instability or apprehension.

Consult an orthopedic surgeon if you have had two or more complete dislocations, if your shoulder subluxates regularly, or if you are young and active with a first dislocation to discuss preventive surgery.

Physical therapists in Quebec have the expertise to assess your shoulder, order X-rays if necessary, and refer you to the best treatment option for your specific situation. Physical therapy for joint pain offers a comprehensive approach to treating the aftereffects of a dislocation.

Get help for your shoulder dislocation

Our physical therapists at Physioactif specialize in the assessment and treatment of shoulder dislocations and instability. We develop personalized programs to restore stability to your shoulder and prevent recurrence.

Don't let a shoulder dislocation limit your life or your sports activities. Contact Physioactif to schedule your comprehensive assessment. Our experienced team will evaluate the extent of the damage, identify your risk factors for recurrence, and develop a personalized treatment plan that will help you regain a stable and functional shoulder.

Sources

Kavaja L, Pajarinen J, Sinisaari I, et al. Osteoarthritis of the glenohumeral joint after arthroscopic Bankart repair: a long-term follow-up of 13 years. J Shoulder Elbow Surg. 2012;21(3):350-355.

Hovelius L, Saeboe M. Neer Award 2008: Arthropathy after primary anterior shoulder dislocation. J Shoulder Elbow Surg. 2009;18(3):339-347.

Owens BD, Duffey ML, Nelson BJ, DeBerardino TM, Taylor DC, Mountcastle SB. The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med. 2007;35(7):1168-1173.

Sachs RA, Lin D, Stone ML, Paxton E, Kuney M. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted? J Bone Joint Surg Am. 2007;89(8):1665-1674.

Itoi E, Hatakeyama Y, Sato T, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. J Bone Joint Surg Am. 2007;89(10):2124-2131.