The recognition and Treatment of First-time Shoulder Dislocation in
Active Individuals. (Wang, Arcero and Mazzocca, 2009).
Glenohumeral instability affects approx 2% of the population and
posterior instability occurs in only 2% to 5% of those with shoulder
instability. It is doubled in younger athlete’s population.
The active mechanism in GHS is primarily provided by the rotator cuff
muscles. The type and severity of pathoanatomic lesions is influenced
by the patient age, mechanism of injury and severity of trauma.
Younger people tend to sustain labrel tears with dislocation; where as
older patients with dislocation sustain rotator cuff tears.
The inferior GHL (glenohumeral ligament) is the primary ligamentous
restraint to anterior glenohumeral translation specifically with the arm in
abduction and ER position.
Detachment of the anterior labrum and capsule (bankart lesion) is
considered one of the major pathoanatmoical features of traumatic
anterior labrum, glenoid depth is decreased up to 50% and passive
restraints is also lost. The incidence of bankart lesion after initial anterior
shoulder dislocation has been reported to be 87%-100%.
Lateral detachment of the IGHL from the humeral neck is another lesion
that can occur from anterior shoulder dislocation ASD. This injury is
referred to as humeral avulsion of the GHL.
Traumatic glenoid humeral head fractures can occur with ASD.
Two types of fractures involving anterior inferior glenoid: glenoid rim
fracture and avulsion fracture.
In the first time dislocation the athlete will be in obvious discomfort and
experiencing intense pain, important to perform a prereduction and
postreduction neurovascular exam. Most commonly 42% of people that
are involved in the anterior dislocation, the axillary nerve will be reported
to be injured, suprascapular nerve due to traction and the long thoracic
nerve. They will resist any attempt to move the effected arm.
Physical examination findings: asymmetry of the deltoid contour,
palpable fullness below coracoids process towards the axilla that may
occur on the affected side.
Treatment:
The decision for treatment in any patient after dislocation should be
individualised. Decisions are made based on the age, activity level of the
patient. Generally those that are involved in contact sports and ages 15
to 25 years acute repair may be a viable option based on the high risk of
reacurrance, apprehension, impact on sports participation and quality of
life, they favour arthroscopic instability repair for athletes in this age
group.
Patients who are age 25-40 have a much lower recurrence rate of
dislocation in general and conservative treatment is generally the best
RX. Older patients over 40, who sustain a Anterior dislocation have
lower recurrence rates again but can residual disability from associated
soft tissue injuries such as a rotator cuff tear, nerve injury or vascular
injury.
Traditional no-operative treatment has included a period of
immobilisation with the arm in internal rotation for 6 weeks, this has not
reduced the recurrence rate. Degenerative joint disease was found in
both surgical and non-surgical cases.
A short term clinical study revealed decreased recurrence rates in
patients that were immobilised in ER. After 3 weeks of immobilisation
they had a recurrence rate of 26% while those who were in IR had a
42% reccurance rate and 46% in patients that were younger than 30
years old.
Athletes who sustain a first time dislocation at the end of the season or
spring practice, one option is early mobilisation, rehabilitation and return
to full activity. Another option is to immobilise for 3-4weeks, proceed with
rehab, and return the athlete to sport after 6-8 weeks.
In the young, contact athlete, modern operative stabilisation (open and
arthoscopic) which reduces the recurance rate from the 80%-90%
range-3-15% range. This is preferred with first time dislocation as the
reccurane rate is decreased and it improves a better quality of life.
The first 2 weeks after the injury occurs is the best time to operate,
taking advantage of the good condition of the capsulolabral tissue.
Focus of surgery is to repair the capsulolabral avulsion with suture
anchors.
Postoperative Treatment
The first goal is to maintain anterior-inferior stability. The second is to
restore adequate motion, specifically ER. 3rd goal is to succefully return
back to sport or physical activity in a reasonable amount of time.
Protocol includes immobilisation, pendulum exercises also. Active
assisted ROM for ER and forward elevation are also started at this time.
This is maintained for 6 weeks. Cold therapy is good to reduce pain post
operatively. From 6-12 weeks AROM and active assisted are started
with the goal of estabilishing full ROM, no strengthing exercises or
repetitive exercise are started until after full range of motion has been
estabilished. This protocol is based on the tendon to tendon bone
healing. Strength training is begun once there is full, painless AROM at
12 weeks with sports specific exercises started at 16-20 weeks, finally
contact sports are started between 20-24 weeks postoperatively.
RESULTS:
Arthoroscopic repair not only decreases the recurrence rate but
increases the quality of life. Acute arthroscopic repair for the athlete in
first-time anterior dislocation leads to improved outcomes. The decsion
is made on patients age, timing during season, athletic level, contact vs.
non contact sports.
PS this article took me FOREVER TO READ!