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Which is the Best Position to Immobilize the Shoulder After a Dislocation?

Immobilization is commonly performed after acute first time shoulder dislocations.  The goal of immobilization is to protect the shoulder and allow healing in an attempt to minimize recurrent instability down the road, which isn’t uncommon.

Unfortunately, once you dislocate your shoulder, you have a decent chance of it happening again.


Traditionally, immobilization has occurred with the shoulder in a sling by the person’s side.  This puts the shoulder in adduction and internal rotation.  Considering that most anterior dislocations occur with the arm in an abducted and externally rotated position, this seemed to make sense to take stress of the tissue.

However, a study was published in 2001 by Itoi in the Journal of Bone and Joint Surgery discussing a new position of immobilization in shoulder external rotation.  

The authors used MRI to examine the capsule in both the position of shoulder internal rotation and external rotation.  They showed that the anterior capsule tissue was better approximated in the externally rotated position.  Other recent studies have agreed with these results.

which is the best position to immobilize the shoulder after a dislocation

This was an interesting finding and lead to a follow up study by the same group that was published in 2003 in the Journal of Shoulder and Elbow Surgery.  In this study, the authors prospectively assessed the recurrent instability rate in people that were immobilized in either internal or external rotation.

The results showed that there was a 30% recurrent instability rate in those immobilized in the traditional internally rotated sling position, compared to 0% in those immobilized in external rotation.

 

Which Position is Best to Immobilize the Shoulder After a Dislocation?

Based on these two studies, many began immobilizing the shoulder after dislocation in this position of external rotation.  There are now many shoulder immobilization braces on the market that position the shoulder in ER.

shoulder immobilization in external rotation

Since these two studies many have tried to replicate the original results of Itoi with mixed results.  

I must admit that any time a novel technique, clinical test, or approach is introduced in the literature and the original author has a 100% success rate, I proceed a little cautiously until others have replicated their research.

Clinically, there appears to be no difference in recurrence rates when comparing immobilizing the shoulder in either internal or external rotation.  This has been shown in several studies.

A recent meta-analysis was published in the American Journal of Sports Medicine that reviewed 6 randomized control trials and found no significant difference in recurrence rate.  This was consistent with a prior systematic review of the Cochran Database, which agreed.

 

Basic Science Vs. Clinical Studies

This is an interesting situation, where basic science studies appear to show that immobilization in external rotation may be theoretically more beneficial after shoulder dislocations, but clinical studies have not shown any benefit or reduced occurrence of recurrent instability.  It appears anatomically that immobilizing in a position of external rotation would put the labral tissue in the best position to heal.

I personally see this as a challenging study as many people are simply not compliant with immobilization after dislocations, especially once the acute trauma tends to settle down.  One particular study reported a compliance rate between 53-72%.  

That’s not great.

As of now, it seems like we need more research to make a more definitive decision.  However, keep in mind that these studies have not shown immobilization in internal rotation to be MORE beneficial, they just showed no difference between the two.  So as of now, if I dislocated my shoulder tomorrow, I would probably immobilize myself in external rotation based on the anatomical studies that show better tissue approximation.

For those out there, what are you seeing clinically in your area?  I would imagine this varies a lot based on your location and physicians you work with each day.  Are docs still immobilizing people in external rotation?  Have you found outcomes to differ from those immobilized in internal rotation?  Comment below and let me know.

 

How Rehab Differs Between Traumatic and Atraumatic Shoulder InstabilityHow Treatment Differs Between Atraumatic and Traumatic Shoulder Instability

If you are interested in learning more on this topic, I have an Inner Circle presentation on How Treatment Differs Between Atraumatic and Traumatic Shoulder Instability.  We discuss this topic, plus a lot more, in much greater detail.

How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability

The latest Inner Circle webinar recording on How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability is now available.

How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability

How Rehab Differs Between Traumatic and Atraumatic Shoulder InstabilityThis month’s Inner Circle webinar is on How Rehab Differs Between Traumatic and Atraumatic Shoulder Instability.  In this presentation, I highlight the major differences in the evaluation and treatment process.

This webinar will cover:

  • The difference between traumatic and atraumatic shoulder instability
  • The import factors to consider that will change your rehab progression
  • Should you immobilize or not?
  • The primary focus for rehab for each type of instability

To access this webinar:

Laxity Does Not Mean Instability

Several years ago, when Eric Cressey and I released Optimal Shoulder Performance, I discussed the Beighton Laxity Scale and how I use it to determine the amount of laxity that individuals may possess.  This is just one of the many factors that go into how I design my rehabilitation and performance programs, as an individual’s amount of laxity influences program design.

Since then, I have started to hear comments from people that their clients may have Ehlers-Danlos syndromeLoeys-Dietz syndrome or Marfan syndrome because of their Beighton score.

Laxity is Normal

Beighton Scale Laxity InstabilityIf you Google “Beighton Score,” you see that this is a scale often used to diagnose the above hypermobility syndromes, however each has their own specific features.  A Beighton score is not the only factor involved, and actually is probably not the most important finding in any of these syndromes.

Laxity is not a syndrome, in fact, laxity is normal.

We all have a certain degree of laxity, you’ve probably seen many people along this spectrum from the really tight to the really loose.  A high Beighton score does not indicate that they have a syndrome or problem, it just helps determine where they sit in the laxity spectrum.

Laxity Does Not Mean Instability

While joint laxity is normal, a high amount of laxity does not necessarily mean you have instability.  Stability is a combination of the function of your static and dynamic stabilizing systems.  Instability is when you have an issue with either (or both) of the static and dynamic stabilizers.  Functional stability is the ability to dynamically stabilize a joint during functional activities to allow proper control and movement.  This is the basis behind our entire Functional Stability Training programs.

Check out this video of my friend Sam’s Beighton score.

As you can see, Sam has a high Beighton score and a lot of joint laxity.  But Sam can deadlift over 2x her body weight.  That is laxity combined with functional stability.  She doesn’t have any problems because she can control her laxity.

Don’t automatically assume a lot of laxity is a bad thing, in fact many professional athletes possess a high amount of laxity.  Remember laxity is normal, does not mean instability, does not mean you have a clinical syndrome, and something you can control with the right program.

Nonoperative Treatment of Anterior Shoulder Dislocations – 25 Year Follow-Up

Bankart2 For this short holiday week, I have a guest post from my Friend and frequent contributor, Dan Lorenz.  This time, Dan talks about a couple of recent studies that assess the success of nonoperative treatment following anterior shoulder dislocations over a 25-year period.

RESEARCH UPDATE: LONG TERM FOLLOW-UP ON NON-OPERATIVE MANAGEMENT OF PRIMARY ANTERIOR SHOULDER DISLOCATIONS AT 25 YEAR FOLLOW-UP

Dan Lorenz, PT, DPT, ATC/L, CSCS

In the last two years, Hovelius et al have published two studies that examined the long term sequelae of primary anterior shoulder dislocations. Both studies were in patients that were managed non-operatively. Interestingly, both groups of patients were followed for twenty-five years.

First, a prospective, multi-center study analyzed 257 shoulders in 255 patients aged 12-40 years followed for 25 years. After 25 years, 229 shoulders were available for follow-up. Radiographic imaging was performed in 97% of those. Researchers found that 44% of the shoulders were normal radiographically. Arthropathy was mild in 29%, moderate in 9%, and severe in 17%. Of shoulders without recurrence, 18% had moderate/severe arthropathy. 39% of shoulders suffered a recurrence once or more without surgery, and 26% for surgically stabilized shoulders. Shoulders that did not recur had less arthropathy than shoulders that recurred or stabilized over time. Shoulders surgically stabilized had less arthropathy than those that became stable over time. Factors correlated with moderate/severe arthropathy were: alcoholism (all 7 with severe were alcoholics), age > 25 years old at primary dislocation, dislocation caused by high-energy sports activity, and recurrence of dislocation. Of note, researchers were unclear about how the patients were managed, either with immobilization or activity as tolerated.

The second study was from the same group of patients, but non-operative treatment was discussed and patients were measured via questionnaire and the DASH score. 43% did not redislocate and 7% did once, 14% of recurrent dislocations stabilized over time, and nearly 8% were recurrent. 27% underwent stabilization procedures due to recurrent instability. Women had worse DASH scores than men. Researchers found that immobilization with the arm tied to the torso for three to four weeks did not change the prognosis compared to those who had immediate mobilization. Researchers also propose that the prognosis for younger ages is neither very good nor very bad. They argue that most first-time dislocations should be treated non-operatively and that immediate operation to stabilize shoulders may result in unnecessary operations in up to 30% or up to 50% if shoulders that stabilize over time are included. Regarding athletic activity, they did not identify an association between athletic activity and recurrence, nor was there a difference between males and females.

References:

Hovelius L, Saeboe M. Neer Award 2008: Arthropathy after primary anterior shoulder dislocation – 223 shoulders prospectively followed up for twenty-five years. J Shoulder Elbow Surg. 2009; 18: 339-347.

Hovelius L et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five year follow up. J Bone Joint Surg Am. 2008; 90: 945-952.

How Long Do You Immobilize the Shoulder After a Dislocation?

auxiliary view of glenohumeral joint

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.

DonJoy Ultrasling brace

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 abdominisFeel 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

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?

References

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