Conservative or surgical management for that shoulder dislocation?
A number of factors—including patient age and risk for recurrence—influence treatment choices. Here’s a closer look at what to consider.
PRACTICE RECOMMENDATIONS
› Start with conservative management of shoulder dislocation in patients older than 30 years and those with uncomplicated injuries. B
› Discourage strict immobilization; its utility is debated and it may not change outcomes. B
› Recommend a progressive rehabilitative program after the initial acute shoulder injury. B
› Consider surgical management for patients younger than 30 years who have complicated injuries with bone or cartilage loss, rotator cuff tears, or recurrent instability or for the highly physically active individual. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Immobilization may benefit some
Recent evidence has determined that the duration of immobilization in internal rotation does not impact recurrent instability.8,9 In patients older than 30, the rate of repeat dislocation is lower, and early mobilization after 1 week is advocated to avoid joint stiffness and minimize the risk of adhesive capsulitis.10
Arm position during immobilization remains controversial.11 In a classic study by Itoi et al, immobilization for 3 weeks in internal rotation vs 10° of external rotation was associated with a recurrence rate of 42% vs 26%, respectively.12 In this study, immobilization in 10° of external rotation was especially beneficial for patients ages 30 years or younger.12
Cadaveric and magnetic resonance imaging (MRI) studies have shown external rotation may improve the odds of labral tear healing by positioning the damaged and intact parts of the glenoid labrum in closer proximity.13 While this is theoretically plausible, a recent Cochrane review found insufficient evidence to determine whether immobilization in external rotation has any benefits beyond those offered by internal rotation.14 A recent systematic review and meta-analysis found that immobilization in external rotation vs internal rotation after a first-time traumatic shoulder dislocation did not change outcomes.2 With that said, most would prefer to immobilize in the internal rotation position for ease.
More research is needed. A Cochrane review highlighted the need for continued research.14 Additionally, most of the available randomized controlled trials to date have consisted of young men, with the majority of dislocations related to sports activities. Women, nonathletes, and older patients have been understudied to date; extrapolating current research to those groups of patients may not be appropriate and should be a focus for future research.2
Physical therapy: The conservative standard of care
Rehabilitation after glenohumeral joint dislocation is the current standard of care in conservative management to reduce the risk for repeat dislocation.15 Depending on the specific characteristics of the instability pattern, the approach may be adapted to the patient. A recent review focused on the following 4 key points: (1) restoration of rotator cuff strength, focusing on the eccentric capacity of the external rotators, (2) normalization of rotational range of motion with particular focus on internal range of motion, (3) optimization of the flexibility and muscle performance of the scapular muscles, and (4) increasing the functional sport-specific load on the shoulder girdle.
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