Immobilizing the Shoulder in External Rotation

Today’s post comes from Dan Lorenz, MS, PT, ATC/L, CSCS.  Dan is a graduate of the sports physical therapy fellowship at Duke University and is currently a sports medicine specialist at Providence Medical Center.  He has great experience with a wide variety of orthopedic and sports medicine patients, including stints with the US Olympic Training Center, Chicago White Sox, and most recently the Kansas City Chiefs.  Dan has previously guest posted on the relationship between hip motion and low back pain.

Challenging 2000 Years of Conventional Wisdom – Immobilizing the Shoulder in External Rotation

ER-immobilizationFor 2000 years, individuals with shoulder dislocations have been immobilized with their upper extremity resting on the trunk in the hopes of preventing recurrence1,2. While this has been the standard practice, no literature on the scientific basis of this exists. Recurrent dislocation rate varies from 47% to 100%3-7. Within the last few years, researchers have proposed a new position for immobilization, external rotation, after anterior shoulder dislocations. While the concept may seem radical, it certainly is thought-provoking, and it truly challenges us to “think outside the box.”

A cadaveric study by Itoi and others8 sought to determine the position of a Bankart lesion following immobilization in different positions. Researchers found that with the arm in adduction and from full internal rotation to 30° of external rotation, the Bankart lesion was “coapted”, or re-united, with the glenoid. With the arm in 30° of flexion or abduction, the edges of the lesion were coapted in neutral and internal rotation but were separated in external rotation. The study suggested that positions that increase soft tissue tension, such as adduction and ER or abduction and neutral rotation, may be preferable to the conventional position. Similarly, Miller et al9 found that the glenoid-labrum contact in ten cadaveric shoulders immobilized in external rotation was much higher, potentially increasing the healing of a Bankart lesion.

Itoi and colleagues10 sought to use MR imaging to measure the affect of arm rotation on the approximation of Bankart lesions following dislocation of the shoulder. Eighteen patients with traumatic anterior dislocations were included in the study. Twelve had recurrent dislocations, and six were first time dislocations. MR imaging of the glenohumeral joint was taken at neutral and at the range of external rotation that felt most comfortable to the patient. Imaging studies showed that in internal rotation, the joint cavity of the glenoid was wide open. With the arm in external rotation, the anterior joint cavity was closed and the labrum lay on the glenoid rim.

The same group of researchers then followed up this study with a prospective study to determine if positioning the arm in external rotation would reduce the rate of recurrence11. Forty patients with initial dislocations were assigned to conventional internal rotation and 10° of external rotation. The first ten were alternatively assigned, and then the remaining thirty were randomly assigned. Both groups were immobilized for three weeks, and compliance rates were reported. Recurrence rate was 30% in the internal rotation group and 0% in the external rotation group. It is interesting to note that in the subjects younger than thirty years old, recurrence in internal was 45% and 0% in external. The average follow up was 15.5 months. An anterior apprehension test was performed at follow-up, and the test was positive in 14% of internal and 10% of external.

DJ ultrasling Deyle and Nagel12 described a six-week immobilization period in 30° of abduction and neutral rotation in a 19 year-old recreational basketball player. In addition to the prolonged immobilization, the patient had protected range of motion activity for 6 additional weeks. At 20 month follow up, the patient had no recurrent instability. Recently, Itoi et al13 did a randomized, controlled trial of 168 patients with initial anterior dislocations who were randomly assigned to be treated with immobilization for three weeks in either internal rotation or external rotation. After a two-year follow up, the recurrence rate was 26% and 42% in external and internal rotation, respectively. Additionally, in subjects aged thirty years or younger, the relative risk reduction was 46%.

EDITOR’S NOTE: Very interesting information. Looks like the evidence to support immobilizing in external rotation is becoming available as many sources are reporting similar research. What has your experience been with immobilizing in external rotation? Have you found it successful?


1. Havelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients: a ten-year prospective study. J Bone Joint Surg Am 1996; 78: 1677-84.

2. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956; 38: 957-77.

3. Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med. 1994; 22:589-94.

4. Henry JH, Genung JA. Natural history of glenohumeral dislocation – revisited. Am J Sports Med. 1982; 10: 135-7.

5. Hovelius L, Eriksson K, Fredin H, et al. Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment. J Bone Joint Surg Am. 1983; 65: 343-9.

6. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am. 1992; 74: 1242-4.

7. Vermeiren J, Handelberg F, Casteleyn PP, Opdecam P. The rate of recurrence of traumatic anterior dislocation of the shoulder. A study of 154 cases and a review of the literature. Int Orthop. 1993; 17: 337-41.

8. Itoi E, Hatakeyama Y, Urayama M, et al. Position of immobilization after dislocation of the shoulder: a cadaveric study. J Bone Joint Surg. 1999; 81: 385-390.

9. Miller BS, Sonnabend DH, Hatrick C, et al. Should acute anterior dislocations of the shoulder be immobilized in external rotation? A cadaveric study. J Shoulder Elbow Surg. 2004. 13: 589-592.

10. Itoi E, Sashi R, Minagawa H, et al. Position of immobilization after dislocation of the glenohumeral joint: a study with use of magnetic resonance imaging. J Bone Joint Surg. 2001; 83: 661-667.

11. Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg. 2003; 12: 413-415.

12. Deyle GD, Nagel KL. Prolonged immobilization in abduction and neutral rotation for a first-episode anterior shoulder dislocation. J Orthop Sports Phys Ther. 2007; 37: 192-198.

13. Itoi E, Hatakeyama Y, Sato T, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence: a randomized controlled trial. J Bone Joint Surg. 2007; 89: 2124-2131.

Itoi, E., Hatakeyama, Y., Sato, T., Kido, T., Minagawa, H., Yamamoto, N., Wakabayashi, I., & Nozaka, K. (2007). Immobilization in External Rotation After Shoulder Dislocation Reduces the Risk of Recurrence. A Randomized Controlled Trial The Journal of Bone and Joint Surgery, 89 (10), 2124-2131 DOI: 10.2106/JBJS.F.00654

6 replies
  1. Jon Khan
    Jon Khan says:

    Daniel B. Whelan, Assistant Professor for the Division of Orthopedics at St. Michael’s Hospital, University of Toronto is in the process of doing work on this exact topic.

    His research seems to differ from the above. He is currently in the second of a two-stage of his investigation. His first stage questions the efficacy of external rotation splinting. The results of the study can be examined in the Journal of Bone and Joint Surgery Volume 93 No 5 (2010) @ 1262. He is a definitely a good person to follow on this topic.

  2. amy castillo
    amy castillo says:

    Hi Christie and Trevor…Yes I attended a my first Davies course 5 years ago and he was talking about the paradigm shift in immobilization then. You will love him, he is high energy, passionate, and really evidence based.

    Funny the Itoi article has be out for 10 years and clinically the conversation has really just started in some respect. I have seen immobilizaton in ER mainly in the older than 30 population.

    The 2003 Itoi et al article does demonstrate benefits in the under 30 group as well but I don’t see these patients managed non-operately. I think this age group is still a great pool of patients for surgeons — kinda like ACLs— automatic surgical repair.

  3. Physical Therapy Blog
    Physical Therapy Blog says:

    This is the trend, no doubt. I must admit there are some flaws with the Itoi studies, but in general I think he is on to something. The reason why ER was chosen was because it allows the subscap to tighten the joint and position the capsulolabral complex in approximation.

  4. Christie Downing, PT, DPT, cert. MDT
    Christie Downing, PT, DPT, cert. MDT says:

    We’ve had a handful a dislocations at our clinic who were immobilized in ER. I believe George Davies is teaching this in his courses as well. I hope to get to one of his courses some day.

  5. Trevor Winnegge DPT,MS,OCS,CSCS
    Trevor Winnegge DPT,MS,OCS,CSCS says:

    Interesting stuff here! I would like to know in that study by Deyle and Nagel, how they measured isntability at the 20 month follow up. Was that subjective reports of feeling unstable or dislocating/subluxing? Was it a manual joint play test? I think one person who is a recreational player having success is a good start but I wouldn’t change my practice habits based off this study if I were a doc. The study by itoi is interesting, showing a 16% difference in group immobilized in ER. It makes sense. Essentially they are in the open packed position-or pretty close to it, which will minimize the stress placed on structures of the joint. Seems right to me!!!!! Our docs immobilize in ER for dislocations and bankart/slap repairs. They have good results. I have treated other docs who use the traditional IR sling and those patients rehab well, although I never saw them a year later to find out if they did ok. Great stuff Dan!

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