There is acute onset of localised swelling and pain over the anterior part of the shoulder with deformation, after an excessive external rotation and abduction trauma. This is the most common type of dislocation in sports (85-90 per cent). Movements of the arm cause pain and the patient will protect the arm in the ‘Napoleon position’.
First dislocations occur after a forceful direct trauma or tackle to the shoulder or after a fall on to an outstretched arm. In the majority of cases, the arm is abducted and the shoulder is externally rotated. This is common in rugby, ice hockey, riding and cycling. In patients with lax shoulders or previous dislocations, dislocation can occur after much less trauma. The anteriorly dislocated humeral head causes a labrum tear of the anterior and inferior labrum, a Bankart injury, and a typical impression fracture, Hill Sachs lesion, on the posterior superior humeral head.
A first dislocation in a young athlete usually requires relaxation (under anaesthesia) to be repositioned, unless a team doctor is trained in the specific manoeuvres involved. After reposition, the apprehension test is positive, as well as the reposition test.
This is a clinical diagnosis. X-rays should be taken in different planes to rule out fracture and demonstrate the type of dislocation (to rule out rare cases of posterior dislocation). MRI is usually not required in the acute phase for the diagnosis but may be done in cases involving great trauma, to investigate associated injuries.
Age and activity level is the most important factor in determining management. A rugby player younger than 25 years old will need
surgery, a Bankart repair, followed by four to six months’ rehabilitation, while a 40–year-old runner who has had a fall can most often be treated with stabilising training guided by a physiotherapist. In older age groups, associated injuries to the rotator cuff and other structures are more common and may cause pain and need surgery for that purpose at a later stage. The risk of re-dislocation after surgery in the younger ‘overhead’ athletes is around 5 to 10 per cent with surgery but up to 100 per cent without.
Refer to Dr Kevin Yip (+65 6664 8135) senior consultant orthopaedic surgeon to determine the diagnosis and for consideration of surgery. Refer to physiotherapist to start a six month rehabilitation programme.
Most sports and activities, such as cycling and cross-training, can be maintained but avoid further direct or indirect trauma to the shoulder. Running should initially be avoided since the shoulder will be sensitive to this type of impact and holding the arm still while running will cause secondary upper back and neck pain. Swimming should also wait for at least three months, though other water exercises are fine. The specific rehabilitation should aim at a full range of controlled motion, good posture and thoraco-scapular control after three months, followed by functional training for up to six months, before resuming sports like rugby.
EVALUATION OF TREATMENT OUTCOMES
Normal clinical symptoms and signs. The apprehension test should be negative. Functional strength, control and flexibility should be comparable with the other shoulder.
Fractures must be ruled out. Multi-directional and general joint laxity is a complicating factor that must be addressed before surgery.
Excellent-Fair, depending on the severity of the trauma. Multiple dislocations can lead to osteoarthritis in the long term.