118 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

[ CLINICAL COMMENTARY ]ROBERT Y. WANG, MD, FRCSC¹ MD² MD, MS³

The Recognition and Treatment ofFirst-Time Shoulder Dislocation in

Active Individuals

1Orthopaedic Sports Medicine Fellow, New England Musculoskeletal Institute, UConn Health Center, Farmington, CT. 2Professor, Department of Orthopaedic Surgery, UConnHealth Center, Farmington, CT; Chief, Sports Medicine Division, Department of Orthopaedic Surgery, UConn Health Center, Farmington, CT; Director, Orthopaedic Sports MedicineFellowship Program, New England Musculoskeletal Institute, UConn Health Center, Farmington, CT. 3Assistant Professor, Department of Orthopaedic Surgery, New EnglandMusculoskeletal Institute, UConn Health Center, Farmington, CT. Address Correspondence to Dr R. A. Arciero, New England Musculoskeletal Institute, UConn Health Center, 263Farmington Avenue, Farmington, CT 06030. Email: arciero@nso.uchc.edu

There is a spectrum of presentation with shoulder instability.Traumatic anterior dislocation represents one end of thespectrum, as described by Matsen.20 The patient withhyperlaxity, bidirectional instability, and little or no provocation

for their symptoms would represent the other end. The clinician shouldrecognize the degree of crossover that can occur between these 2 ends ofthe spectrum. For example, a hyperlax patient can sustain a traumaticshoulder dislocation. Acute traumatic anterior shoulder dislocation isa relatively common occurrence, especially in the athletic population.

sport and timing during the season. Non-operative or operative intervention maybe selected based on these factors, after athorough discussion with the patient.

PathoanatomyThe overall stability of the glenohumer-al joint involves passive and active re-straints. Passive or static factors includejoint conformity, adhesion/cohesion,finite joint volume, and ligamentousrestraints including the labrum.17 Theactive mechanism in glenohumeral sta-bility is primarily provided by the rotatorcuff muscles. When capsuloligamentousstructures are damaged, alterations inproprioception also occur and can bepartially restored with operative repair.16

The type and severity of pathoanatomiclesions is influenced by the patient age,the mechanism of injury, and severity oftrauma. For example, younger patientstend to sustain labral tears, whereas olderpatients with a shoulder dislocation sus-tain associated rotator cuff tears. High-energy trauma, such as in collision sports,may result in a greater amount of soft tis-sue damage and also bony injury.

The inferior glenohumeral ligament(IGHL) complex is the primary ligamen-tous restraint to anterior glenohumeraltranslation, specifically with the arm in anabducted and externally rotated position

Recognition and treatment of the first-time dislocation in active individualsrequires a systematic clinical evalua-tion as well as an understanding of thepathoanatomy.3

Glenohumeral instability affects ap-proximately 2% of the population, andposterior instability occurs in only 2% to

5% of those with shoulder instability.19

Given the rarity of posterior instability,19,31

this review will focus on the first-time an-terior dislocation in athletes. The athleteposes a unique set of circumstances toconsider in making treatment decisions.Generally speaking, the goal of promptand safe return to play is affected by the

Anterior shoulder dislocationoccurs in the general population; however, theincidence is doubled in the young athletic popula-tion. Over 90% of shoulder dislocations are in theanterior direction. For the first-time dislocation,a systematic approach to evaluating the patientand prompt reduction are critical. This injuryis frequently witnessed on the field or later inthe emergency department. On the field, closedreductions, without prereduction radiographs, iscontroversial. If the athlete is encountered in theemergency department, radiographs should beobtained prior to a closed reduction. After a closedreduction is achieved, several factors, such as

timing in the season, type of sport, position, andpatient goals, must be considered when decidingwhether further surgical intervention is required.Conservative management will usually consist ofa brief period of immobilization in a sling, followedby rehabilitation. Surgical treatment consists of anarthroscopic Bankart repair.

Therapy, level 5.J Orthop Sports Phys Ther 2009; 39(2):118-123.doi:10.2519/jospt.2009. 2804

apprehension, Bankart, gle-nohumeral joint, instability, physical therapy

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( ).32 Detachment of the anterior-inferior labrum and capsule (Bankartlesion) is considered one of the majorpathoanatomical features of traumaticanterior shoulder instability.22 By displac-ing the anterior labrum, glenoid depth isdecreased by up to 50%, and passive re-straints, such as the concavity-compres-sion mechanism, is also lost.11,15 Biglianiet al2 have demonstrated that even plasticdeformation of the capsule was a funda-mental component of anterior instability.From a surgeon’s perspective, this is animportant concept, because, in additionto surgical repair of the glenoid labrum,capsular redundancy may require plica-tion. This is of particular importance inrecurrent dislocation given the extentof capsular laxity typically seen in thatpopulation. The incidence of Bankartlesion after an initial anterior shoulderdislocation has been reported to be 87%to 100%.21,30

Neviaser,20 in 1993, differentiated be-

tween Bankart lesion and what he termedthe anterior labral ligamentous periostealsleeve avulsion lesion (ALPSA) (2). In his description, the capsule andlabrum are not detached as in a Bankartlesion, but the anterior IGHL, labrum,and the anterior scapular periosteum arestripped and displaced in a sleeve-typefashion, medially on the glenoid neck.20

Antonio1 found a high prevalence ofALPSA following a first-time shoulderdislocation in a younger patient popu-lation and suggested an early MRI ar-

throgram for diagnosis and treatment.Another type of lesion that may occurwith an anterior shoulder dislocation is alateral detachment of the IGHL from thehumeral neck. This injury is referred to asa humeral avulsion of the glenohumeralligament (HAGL lesion) ( ). This isa rare pathologic finding with a first-timeanterior dislocation that was found inonly 1 of 63 patients in a series reportedby Taylor and Arciero.30

Traumatic glenoid and humeral headfractures can occur with an anteriorshoulder dislocation. The Hill-Sachs le-sion is found on the humerus and is animpression fracture caused by the humer-al head being dislocated anteriorly andimpacting on the anterior glenoid. Thelesion is generally located at the posteri-or-superior portion of the humeral head.Taylor and Arciero30 found 57 Hill-Sachslesions out of 63 patients with a first-time acute anterior dislocation; however,they noted that none of these were large.Two types of fractures occur involvingthe anterior inferior glenoid: the glenoidrim fracture and the avulsion fracture.The glenoid rim fracture is secondary tocompression of the anterior inferior rimby the humeral head ( ). Duringtension failure of the IGHL, it is also pos-sible to cause an avulsion of the glenoidrim.

Etiology and EpidemiologyFor an anterior shoulder dislocation tooccur, the mechanism of injury typicallyinvolves a position of combined shoulderabduction and external rotation, as seenin many collision sports. The overall in-cidence of traumatic shoulder instabilityin the general population has been re-ported to be approximately 1.7%.26 How-ever, the incidence can be doubled in thehigh-physical-demand population. Inthe United States Military Academy, the1-year incidence of traumatic shoulder in-stability was 2.8%.23 Traumatic instabilitycan also occur in the form of subluxation.The same West Point study found 85% ofinstability events were due to traumaticsubluxation.23

Cadaveric specimen demonstrating theinferior glenohumeral ligament (arrow).

Arthroscopic view of a humeral avulsionof the glenohumeral ligament (HAGL) lesion. The tipof the arthroscopic probe is pointing to the humeralavulsion of the glenohumeral ligament.

Arthroscopic view of an anterior labralligamentous periosteal sleeve avulsion (ALPSA)lesion. The arrow is pointing to the anterior labralligamentous periosteal sleeve which has peeled offthe glenoid rim and displaced medially.

Three-dimensional computer tomographyreconstruction demonstrating an anterior glenoid rimfracture.

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[ CLINICAL COMMENTARY ]

Following an acute anterior shoulder dis-location in the athlete, the clinician usu-ally encounters the athlete on the field,in the training room, or in the emer-gency department. If medical personnelare covering the game from the sideline,they may have witnessed the mechanismof injury. The focused history should ruleout associated injuries by asking aboutother symptomatic areas. In an acutefirst-time dislocation, the athlete will bein obvious discomfort and experiencingintense pain. The physical examination ofthe shoulder should follow a systematicapproach to avoid missing concurrentpathology. It is important to perform aprereduction and postreduction neu-rovascular exam. Nerve lesions includeinjury to the axillary nerve (most com-mon), suprascapular nerve due to trac-tion, and long thoracic nerve. Visser etal33 reported axillary nerve injury in 42%of anterior shoulder dislocations.

Immediate recognition of an acuteanterior dislocation is possible by ob-serving the characteristic position of theathlete’s arm, which is held against thebody and supported by the contralateralarm. They will resist any attempt to movethe affected arm. Physical exam findingsinclude the following: asymmetry of thedeltoid contour (the affected side willdemonstrate a sharp contour and a moreprominent acromion when comparedwith the unaffected side), and a palpablefullness below the coracoid process andtowards the axilla that may occur on theaffected side.

With an acute dislocation, the clini-cian needs to make a decision regardingthe timing of a closed reduction. Perform-ing a closed reduction on the field or side-line, or in the training room, without firstobtaining a radiograph, is controversial.Many experienced physicians and train-ers will perform a closed reduction onthe field, with the rationale that a reduc-tion can be achieved prior to the onset ofmuscle spasm. This would allow a timelyreduction that would significantly reducethe level of pain, without the need for

conscious sedation. It is imperative that arepeat neurovascular exam be conductedpostreduction. The other scenario is thatthe dislocation is not reduced on the fieldand the physician first sees the patient inthe emergency department. By the timethe patient arrives, because of muscleguarding and pain, a closed reduction isusually not possible without conscious se-dation or intra-articular local anesthetic.Miller18 has shown that the intra-articularinjection of lidocaine to facilitate reduc-tion with the Stimson technique is a safeand effective method for treating acuteshoulder dislocations in an emergencyroom setting. The Stimson technique re-quires the patient to be prone, with theaffected arm hanging over the edge of thetable. Downward traction on the affectedarm can be achieved with gravity or withweights tied to the forearm. Scapularprotraction, by pushing on the scapula,is necessary to allow greater glenoid ante-version in facilitating a reduction. If seenin the emergency department, it would beprudent to first obtain radiographs (an-teroposterior, lateral, and axillary views)to confirm the direction of dislocationand to rule out associated fractures.

In the situation where the athlete hassustained a traumatic subluxation withspontaneous reduction, or the shoulderhas been reduced, additional specialclinical tests can be performed. A load-and-shift test is performed by graspingthe humeral head and translating it in ananterior direction to test anterior instabil-ity. Grade 1 is minimal translation up tothe labrum. In a grade 2 load-and-shift,the humeral head can be translated overthe labrum but easily reduced. In grade 3,the humeral head is easily translated overthe glenoid rim and may be more difficultto reduce. During this test, we also payattention to whether there is a palpable“click,” which may be a clinical indicatorof a labral tear. An apprehension test isperformed with the patient supine withthe shoulder in 90° of abduction andgradually bringing the shoulder intomore external rotation. The athlete willtypically report symptoms of a disloca-

tion at a lower degree of external rotationcompared to the contralateral shoulder.With the arm in this position, a posterior-directed force is applied to the proximalhumerus as the relocation test. If the ap-prehension is relieved by the posteriorlydirected force, the relocation test is posi-tive. A sulcus test involves inferior trac-tion on the affected arm and determiningthe distance between the lateral edge ofthe acromion and the humeral head. Ifthe sulcus is 2 cm or greater, underlyingmultidirectional instability is present.

Prereduction radiographs are necessaryto determine the direction of disloca-tion and assess for associated fractures.A standard anterior-posterior view of thearm in slight internal rotation is used toidentify a fracture of the greater tuberos-ity. Postreduction views, including a truescapular anterior-posterior radiograph,can identify a glenoid fossa fracture. TheWest Point modified axillary view is usedto assess bony avulsions of the attach-ment of the IGHL, bony Bankart lesions,or anterior-inferior glenoid deficiency.25

It is difficult to obtain this view acutelybecause of patient guarding and pain;however, it can be obtained within sub-

Stryker notch view to identify posteriorsuperior humeral head defect.Published with permission. Mahaffey BL, SmithPA. Shoulder instability in young athletes. Am FamPhysician. 1999 May 15;59(10):2773-82, 2787.

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from the neocortex in the humeral neck.A thin radiolucency is observed inferiorto the anatomic neck of the humerus, andonce again the fluid-filled, distended, U-shaped axillary pouch is converted into aJ-shaped structure by the extravasationof contrast material.6

The decision for treatment in any patientafter a dislocation should be individu-alized. Once the diagnosis is made andthe shoulder is reduced, the decision onsubsequent treatment can be made. Ageand activity level are the most importantfactors guiding treatment. Generally, foryoung athletes, particularly those in-volved in contact sports and aged 15 to25 years, acute repair may be a viable op-tion based on the high risk of recurrence,apprehension, impact on sports partici-pation, and quality of life.2,5,13,14 We favorarthroscopic instability repair for athletesin this age group. Patients aged 25 to 40years old have a much lower recurrencerate of dislocation, and conservative reha-bilitation is generally the best treatment.Older patients, greater than 40 years old,who sustain an anterior dislocation havemuch lower recurrence rates in general(10%-15%), but can have residual dis-ability from associated soft tissue injuriessuch as rotator cuff tear, nerve injury, orvascular injury.27

Traditional nonoperative treatmenthas included a period of immobiliza-tion with the arm in internal rotation.The length of immobilization (up to 6weeks) has not reduced recurrence rates.In a 10-year follow-up on immobiliza-tion outcomes after anterior shoulderdislocations, Hovelius10 found no effecton recurrence rates related to the lengthof immobilization. Out of 247 primaryanterior shoulder dislocations, 50% ofshoulders had a recurrent dislocation at10 years out.10 Interestingly, degenerativejoint disease was found in both surgicaland nonsurgical cases, with 11% of thepatients who underwent surgery havingmild secondary degenerative joint diseaseat the 10-year follow-up.10

More recently, Itoi et al12 demonstratedwith MRI better reapproximation of theBankart lesion with the arm next to thebody and the shoulder in 30° of externalrotation. A subsequent short-term clini-cal study revealed decreased recurrencerates in patients immobilized in externalrotation compared to those immobilizedin internal rotation.12 After 3 weeks of im-mobilization, the external rotation grouphad a recurrence rate of 26%, while therecurrence rate for those in the internalrotation group was 42%, with a relativerisk reduction of 46% in patients youngerthan 30 years.12 Although Itoi’s work isappealing, its limitation is that his pa-tient population varied in age; therefore,his conclusions may not be generalizableto the young athletic population. Further-more, maintaining arm position in 30°of external rotation for 3 to 4 weeks maymake compliance with this treatment dif-ficult in the young, competitive athlete.

The athlete who sustains a disloca-tion during a competitive season poses aunique clinical dilemma. Buss et al,8 in areview of 30 athletes who sustained ananterior dislocation during their sportseason, showed that a regimen of earlyrange of motion and a shoulder brace re-stricting abduction and external rotationallowed 26 athletes to return and com-plete the season. Many of these athletescoped with instability during the season,and 16 athletes required surgical stabili-zation at the end of the season. Althoughnot definitely proven, it is intuitive that,with more dislocations or subluxations,more damage to the articular cartilage,bone, and capsule develops.7 For the ath-lete who sustains a first-time dislocationat the end of the season or spring practice,one option is early mobilization, rehabili-tation, and return to full activity. Anotheroption is to immobilize the athlete in ex-ternal rotation for 3 to 4 weeks, proceedwith rehabilitation, and return the athleteto sport after 6 to 8 weeks. Itoi’s work sug-gests a reduced recurrence rate; however,a study using this treatment regimen inyoung collision athletes is still required.In the young, contact athlete, modern

sequent days. The Hill-Sachs lesion, aposterior-superior humeral head defect,can be quantified and evaluated by usinga Stryker notch view ( ).

A computerized tomography (CT)scan can be an accurate means of fur-ther quantifying the size of a glenoid rimfracture initially observed on plain radio-graphs. CT 3-D reconstructions, particu-larly the sagittal view, is an accurate toolto evaluate this injury.29 Currently thesenior author utilizes CT to quantify thesize of an anterior rim fracture after anacute dislocation ( ).

Magnetic resonance imaging (MRI) isused for assessment of associated pathol-ogy. Contrast enhancement improves thediagnostic ability to detect labral tears(both superior and anterior-inferior),rotator cuff tears (both partial and fullthickness), and articular cartilage le-sions. However, in the acute setting,contrast agent is not necessary becauseof the excellent contrast afforded by thehemarthrosis that universally accom-panies a primary dislocation.2 With aHAGL lesion, MR images in the midsag-ittal coronal oblique plane show the de-tachment of the inferior glenoid labrumand the axillary pouch converted froma full distended U-shaped structure toa J-shaped structure, as the inferiorglenoid labrum drops inferiorly.28 Thishas been further defined in a follow-upstudy that describes the MR appearanceof a HAGL lesion as an avulsion fracture

Axial computer tomography demonstratingrim fracture.

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[ CLINICAL COMMENTARY ]operative stabilization techniques (openand arthroscopic) reduce the recurrencerate from the 80% to 90% range to the3% to 15% range, and improve overallquality of life.2,5,13,14

If we are to treat the young athletewith a first-time dislocation nonop-eratively, we still use a sling with thearm held to the side. However, it is ourpreference to perform arthroscopic in-stability repair for the first-time dislo-cation in young athletes because of theimproved quality of life and reducedrecurrence rate.

For operative repair of an acute disloca-tion, it is our preference to perform therepair arthroscopically within 2 weeks ofthe injury, taking advantage of the goodcondition of the capsulolabral tissue. Thefocus of the surgery is the repair of thecapsulolabral avulsion with suture an-chors ( ). Bigliani4 showed thatwith any type of capsular failure therewas a significant amount of capsularelongation, suggesting plastic deforma-tion of the capsule. A limited antero-inferior capsulorraphy is performed incombination with a Bankart repair toaddress the capsular stretch and reten-sioning of the IGHL.

We routinely perform an arthroscopicBankart repair with the patient in lateraldecubitus position, supported by a beanbag. The arm of the operated shoulder isplaced in 5 lb (2.27 kg) of longitudinaltraction and 7 lb (3.18 kg) of lateral trac-tion. A bump/roll is placed under the ax-illa to facilitate clear visualization of the 6o’clock position. A posterior portal is firstestablished. With the arthroscope in theposterior portal, the anterosuperior (ASP)and anteroinferior portals (AIP) are thencreated, first using a spinal needle to de-termine adequacy of portal trajectory andhelp locate the 5 o’clock position.

An arthroscopic elevator is used tolift the labrum off the glenoid. The me-dial glenoid neck is prepared using ahandheld rasp or motorized burr. This

can be accomplished through the ASPor AIP, or both. Particularly when usinga motorized burr, it is important not toremove anterior glenoid bone. The goalis to decorticate the medial neck to al-low a bleeding surface for labral healing,without removing excessive bone. The ar-throscope is then placed in the ASP and a“suture first” technique is performed. An“O” PDS is first passed through the cap-sule (approximately 1 cm from the edgeof the labrum) and labrum, and used as atraction suture. We do not perform a for-mal capsulorrhaphy in an acute repair;however, a slight inferior-to-superiorshift (capsular pinch and tuck) allows re-tensioning of the IGHL. One PDS limbis retrieved from the posterior portal.The first anchor is then placed at the 5o’clock position. If the AIP does not allowadequate access to the 5 o’clock position,a percutaneous transsubscapularis por-tal is required. After anchor placement, 1anchor suture limb is retrieved from theposterior portal and shuttled anteriorlyvia the PDS. The suture ends are thentied, respecting loop and knot security.

If the condition is acute, we do notperform an extensive capsular plicationor closure of the rotator interval. Rota-tor interval closure is controversial; thereare no clinical studies supporting thistechnique in the treatment of a first-timeacute dislocation.

The biological healing response of the

repaired and imbricated tissue must berespected. The first goal is to maintainanterior-inferior stability. The secondgoal is to restore adequate motion, spe-cifically external rotation. The third goalis a successful return to sports or physicalactivities of daily living in a reasonableamount of time.

Our protocol includes immobilizationpostoperatively in a shoulder immobi-lizer. Codman exercises, combined withpendulum exercises, are started immedi-ately. Active assisted range-of-motion ex-ercises for external rotation (0°-30°), andforward elevation (0°-90°) are also start-ed at this time. This regime is maintainedfor the first 6 weeks. The use of cold ther-apy devices has been successful in reduc-ing postoperative pain. From weeks 6 to12, active assisted as well as active range-of-motion exercises are started with thegoal of establishing full range of motion.No strengthening exercises or repetitiveexercises are started until after full rangeof motion has been established.

This protocol is based on tendon-to-bone healing in a dog model.24 Early re-sistance exercises, with aggressive earlypostoperative rehabilitation, do not ap-pear to offer substantial advantages andcould compromise the repair. Strength-ening is begun once there is full, painless,active range of motion. Strengthening isbegun at 12 weeks, with sports-specificexercises started at 16 to 20 weeks. Fi-nally, contact sports are started between20 to 24 weeks postoperatively.

Many studies have reported improvedoutcomes following acute arthroscopicrepair. In Kirkley’s13 prospective ran-domized trial, arthroscopic repair notonly decreased recurrence rates, butalso resulted in improved quality of life.Several other authors have reportedimproved outcomes following acute ar-throscopic repair.5,9,14 Therefore, it can beconcluded that acute arthroscopic repairfor the athlete with a first-time traumaticanterior dislocation leads to improvedoutcomes.

Arthroscopic view of a repaired Bankartlesion. The anterior labrum has been reconstitutedwith 3 suture anchors.

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@ WWW.JOSPT.ORG

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Acute anterior shoulder dislo-cation is common in the generalpopulation, but the incidence is

doubled in the young athletic population.Immediate recognition of this injury isimportant so that a closed reduction canbe performed promptly, whether this isaccomplished on the field or in the emer-gency department. For this patient popu-lation, arthroscopic Bankart repair yieldsgood results with lower redislocationrates and improved overall outcome. Thisdecision is made after considering severalfactors, including the patient’s age, tim-ing during season, and athletic level (con-tact versus noncontact sport).