A recent guest post from Dan Lorenz discussed immobilizing the shoulder in a position of external rotation following an anterior dislocation. While this concept appears counterintuitive at first glance, there is enough evidence now to support the use of this position of shoulder immobilization. Studies have shown better approximation of the capsule to the glenoid and a reduced rate of recurrent instability when immobilized in external rotation. I would not say that any of this is currently definitive as there are also some studies that challenge the exact mechanism of this concept, however, it is certainly worth watching and the early results appear reasonable enough to try this in our practices.
How Long Should You Immobilize the Shoulder After Dislocation?
Another common question regarding the immobilization of shoulders after dislocations involves the length of immobilization. A new study in AJSM sought to examine how long acute anterior dislocations should be immobilized in external rotation.
The study involved 22 subjects split evenly between a group that was immobilized for 3 weeks and another that was immobilized for 5 weeks. Both groups were immobilized in a position of 30 degrees of external rotation in a DonJoy Ultrasling. Displacement and separation of the capsulolabral complex was measured using MRI.
The authors report that immobilization yielded improved results regardless of the length of immobilization. There was no significant difference in results when comparing the group immobilized for 3 weeks with the group immobilized for 5 weeks. The results of this study are interesting and certainly support the use of an immobilization brace in external rotation, though it doesn’t seem that lengthy immobilization of more than 3 weeks will achieve superior results.
Standardized or Individualized?
I personally think that there should be a little variation in the immobilization protocol based on the specific patient. I would say that I routinely immobilize patients anywhere from 2 to 6 weeks based on their history of dislocations, amount of concomitant trauma, their tissue type, and the status of their dynamic stabilizers. For example, patients with congenital laxity that suffer frequent dislocations probably need to be immobilized longer than a person with an acute, first-time, dislocation.
This study also examined the effect of rotation on the approximation of the labrum and again noted that the more external rotation the better. A word of caution, there are some braces on the market that I do not believe achieve enough external rotation. My brace of choice has always been the DonJoy Ultrasling in slight abduction and 30 degrees of external rotation, I highly recommend it. Your patients will also like it as it seems to be one of the more comfortable braces available.
What has your experience been with acute anterior dislocations? How long do you usually immobilize? Do you have a brace you prefer? Do you see large variations in protocols from different physicians in your area?
Also, there was a great discussion last week on the role of the transverse abdominis. Feel free to continue that discussion and join in, let us know how or why not you work on the transversus abdominis group in your patients with low back pain.
Scheibel, M., Kuke, A., Nikulka, C., Magosch, P., Ziesler, O., & Schroeder, R. (2009). How Long Should Acute Anterior Dislocations of the Shoulder Be Immobilized in External Rotation? The American Journal of Sports Medicine DOI: 10.1177/0363546509331943