What is a shoulder dislocation?
A dislocation involves the ball-and-socket joint of the shoulder. It occurs when the ball portion of the joint (the top of the humerus/upper arm bone) leaves the socket of the shoulder blade. The structure of the shoulder joint allows for great mobility, but it also makes it unstable, which is why it is the most frequently dislocated joint in the body. The humerus can slide too far forward (anterior dislocation), downward (inferior dislocation), or backward (posterior dislocation). Most commonly, dislocations will occur anteriorly. Sometimes the humerus will return to the socket on its own (this is called self-reduction), but if it doesn’t, you will have to go to the hospital to get it reduced. It is important that it is reduced by a doctor and not on your own, by a coach, or parent because there are a lot of important structures that surround the area which could become damaged if it’s not reduced properly.
What is a shoulder separation?
A shoulder separation involves the joint between the highest point of your shoulder blade (called the acromion) and your collar bone (clavicle). This joint is called the acromioclavicular joint (AC joint) and sits over top of the ball-and-socket joint. With a shoulder separation, the clavicle is pulled away from the acromion, and this can result in sprains, or even tears, of the ligaments surrounding the joint. Depending on which ligaments are affected, the separation can be graded on a scale of 1-3.
What causes a dislocation or a separation
Both injuries typically result from a trauma to the shoulder joint. They most often occur in teenagers and young adults (typically in their 20’s) who participate in sports or other physical activities that put them at risk of injury. Sports that involve forceful contact (e.g. hockey, football) or have the risk of high impact falls (e.g. skiing, gymnastics) most often result in these injuries. A shoulder dislocation usually occurs when the arm is forcefully pulled or when the arm is out to the side and is jarred (such as during a trip and fall). or when the arm is out to the side and meets extreme resistance (i.e. a trip and fall). Less commonly, it could occur as a result of a car accident, following stroke (due to paralysis of muscles), or even an epileptic seizure.
A shoulder separation most commonly occurs as a result of a fall directly on the AC joint or a blow directly to the AC joint (e.g. being body checked into the boards in hockey).
Symptoms of a dislocation or a separation
- Feel a shift or “clunk” at the time of the injury
- Intense pain
- Unable to move the joint
- Visible deformity/the joint looks out of place (may have a bump in the front of the joint or the back of the joint, depending on which way it has dislocated)
- Muscle spasm
- Intense pain
- Tenderness of the collar bone
- Visible deformity (there is a bump or the collarbone appears shifted upwards)
How are they diagnosed?
Both will show up on an x-ray. Oftentimes, an x-ray for a shoulder separation will involve you holding a weight in the arm to try and pull the AC joint apart for more clear imaging.
As physiotherapists, we do have some tests that we can perform in clinic to help us try to diagnose either condition, but ultimately an x-ray will help confirm the diagnosis of either one of these injuries.
What should I do for treatment?
There is typically an initial period of immobilization immediately following the injury. Dislocations could result in wearing a sling for 4-6 weeks, and separations could mean wearing a sling for 1-2 weeks, or not at all (depending on the severity).
Research shows that the first line of treatment for either condition should be conservative therapy/physiotherapy. In both cases, it is recommended that the physiotherapy begin immediately following the injury.
The initial goals of treatment will be pain control and education with respect to promoting the ideal healing environment. Progressive exercises are given to gradually increase range of motion without stressing the area of the shoulder joint that has been compromised in the dislocation. The next phase of exercise focuses on strengthening and proprioception of the shoulder joint, and this is the most important when it comes to preventing future dislocations.
Specific strengthening exercises for the rotator cuff and surrounding musculature will be provided, and will be done in a safe progressive order, avoiding positions that stress the vulnerable area of the shoulder.
Proprioception is your awareness of where your body is in space, and what movements it is performing. Specific exercises help to awaken this sense and fires up the nerves from your shoulder to your brain. Physiotherapy will help your brain re-learn where your shoulder is in space, help it remember how to move, and how to respond to movement. These are unique exercises which can also help to predict those at risk for recurrent dislocations.
With some first-time dislocations, surgery may be considered as a first line of treatment. Typically most surgeons will want to see how the shoulder responds to conservative therapy before doing surgery. Surgery is more commonly an option for those who suffer from repeated dislocations. While every surgeon can have a slightly different approach, rehabilitation is intensive after this type of surgery. The use of sling for a full 6 weeks, and then gradual range of motion and strengthening is typical. Return to moderate level of activities takes approximately 3-4 months, and return to sport can take longer.
In most cases, the collar bone will be left to “settle” on its own through the use of a sling. It is quite rare to see surgery for a shoulder separation. As a result, most people are left with a lifetime “bump” above the shoulder joint. We can usually tell in your 40’s who played hockey in their 20’s. Separated shoulders plague hockey players because of the impact of falling onto the ice or being checked into the boards with the force through their shoulders.
After a brief period in a sling (which may not be required based on severity of injury), patients will receive conservative treatment/physiotherapy to address pain and gradually restore range of motion while allowing healing of the ligaments of the AC joint. Pain is often the limiting factor, and even with a low grade separation (Grade 1), the pain can be quite intense. People often cannot lift their arm to shoulder height for 1-2 weeks after this type of injury.
Commonly physiotherapy can progress clients through range of motion and early strengthening within the first 4-6 weeks. Advanced strengthening and return to sport takes another 2-4 weeks. Many hockey players, with the assistance of tape for support, are able to return to play at 5-6 weeks following a separation, depending on the severity.
Surgery is not common for separations in the shoulder. In more severe cases they may consider surgery, in particular if there are any concerns that the collar bone could move and compromise the nearby lung.
What does physiotherapy have in common for both?
- Initial education on important healing factors, positions, pain control and activities to avoid
- Progressive but controlled range of motion exercise programs that protect the area while it heals
- Progressive strengthening to strengthen surrounding musculature to prevent reoccurrences
- Advanced exercises that are sport specific (throwing, swimming, overhead sports), to minimize future reoccurrences