1. [ CLINICAL COMMENTARY ]
ROBERT Y. WANG, MD, FRCSC¹ MD² MD, MS³
The Recognition and Treatment of
First-Time Shoulder Dislocation in
Active Individuals
here is a spectrum of presentation with shoulder instability. sport and timing during the season. Non-
T Traumatic anterior dislocation represents one end of the
spectrum, as described by Matsen.20 The patient with
hyperlaxity, bidirectional instability, and little or no provocation
for their symptoms would represent the other end. The clinician should
recognize the degree of crossover that can occur between these 2 ends of
operative or operative intervention may
be selected based on these factors, after a
thorough discussion with the patient.
Pathoanatomy
The overall stability of the glenohumer-
the spectrum. For example, a hyperlax patient can sustain a traumatic al joint involves passive and active re-
shoulder dislocation. Acute traumatic anterior shoulder dislocation is straints. Passive or static factors include
joint conformity, adhesion/cohesion,
a relatively common occurrence, especially in the athletic population.
finite joint volume, and ligamentous
Recognition and treatment of the first- 5% of those with shoulder instability.19 restraints including the labrum.17 The
time dislocation in active individuals Given the rarity of posterior instability,19,31 active mechanism in glenohumeral sta-
requires a systematic clinical evalua- this review will focus on the first-time an- bility is primarily provided by the rotator
tion as well as an understanding of the terior dislocation in athletes. The athlete cuff muscles. When capsuloligamentous
pathoanatomy.3 poses a unique set of circumstances to structures are damaged, alterations in
Glenohumeral instability affects ap- consider in making treatment decisions. proprioception also occur and can be
proximately 2% of the population, and Generally speaking, the goal of prompt partially restored with operative repair.16
posterior instability occurs in only 2% to and safe return to play is affected by the The type and severity of pathoanatomic
lesions is influenced by the patient age,
Anterior shoulder dislocation timing in the season, type of sport, position, and the mechanism of injury, and severity of
occurs in the general population; however, the patient goals, must be considered when deciding trauma. For example, younger patients
incidence is doubled in the young athletic popula- whether further surgical intervention is required. tend to sustain labral tears, whereas older
tion. Over 90% of shoulder dislocations are in the Conservative management will usually consist of patients with a shoulder dislocation sus-
anterior direction. For the first-time dislocation, tain associated rotator cuff tears. High-
a brief period of immobilization in a sling, followed
a systematic approach to evaluating the patient
by rehabilitation. Surgical treatment consists of an energy trauma, such as in collision sports,
and prompt reduction are critical. This injury
is frequently witnessed on the field or later in arthroscopic Bankart repair. may result in a greater amount of soft tis-
the emergency department. On the field, closed Therapy, level 5. sue damage and also bony injury.
reductions, without prereduction radiographs, is J Orthop Sports Phys Ther 2009; 39(2):118-123. The inferior glenohumeral ligament
controversial. If the athlete is encountered in the doi:10.2519/jospt.2009. 2804 (IGHL) complex is the primary ligamen-
emergency department, radiographs should be
tous restraint to anterior glenohumeral
obtained prior to a closed reduction. After a closed apprehension, Bankart, gle-
reduction is achieved, several factors, such as nohumeral joint, instability, physical therapy translation, specifically with the arm in an
abducted and externally rotated position
1
Orthopaedic Sports Medicine Fellow, New England Musculoskeletal Institute, UConn Health Center, Farmington, CT. 2 Professor, Department of Orthopaedic Surgery, UConn
Health Center, Farmington, CT; Chief, Sports Medicine Division, Department of Orthopaedic Surgery, UConn Health Center, Farmington, CT; Director, Orthopaedic Sports Medicine
Fellowship Program, New England Musculoskeletal Institute, UConn Health Center, Farmington, CT. 3 Assistant Professor, Department of Orthopaedic Surgery, New England
Musculoskeletal Institute, UConn Health Center, Farmington, CT. Address Correspondence to Dr R. A. Arciero, New England Musculoskeletal Institute, UConn Health Center, 263
Farmington Avenue, Farmington, CT 06030. Email: arciero@nso.uchc.edu
118 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

2. throgram for diagnosis and treatment.
Another type of lesion that may occur
with an anterior shoulder dislocation is a
lateral detachment of the IGHL from the
humeral neck. This injury is referred to as
a humeral avulsion of the glenohumeral
ligament (HAGL lesion) ( ). This is
a rare pathologic finding with a first-time
anterior dislocation that was found in
only 1 of 63 patients in a series reported
Cadaveric specimen demonstrating the by Taylor and Arciero.30
Arthroscopic view of a humeral avulsion
inferior glenohumeral ligament (arrow).
of the glenohumeral ligament (HAGL) lesion. The tip Traumatic glenoid and humeral head
of the arthroscopic probe is pointing to the humeral fractures can occur with an anterior
avulsion of the glenohumeral ligament. shoulder dislocation. The Hill-Sachs le-
sion is found on the humerus and is an
impression fracture caused by the humer-
al head being dislocated anteriorly and
impacting on the anterior glenoid. The
lesion is generally located at the posteri-
or-superior portion of the humeral head.
Taylor and Arciero30 found 57 Hill-Sachs
lesions out of 63 patients with a first-
time acute anterior dislocation; however,
Arthroscopic view of an anterior labral they noted that none of these were large.
ligamentous periosteal sleeve avulsion (ALPSA)
Two types of fractures occur involving
lesion. The arrow is pointing to the anterior labral
ligamentous periosteal sleeve which has peeled off the anterior inferior glenoid: the glenoid
the glenoid rim and displaced medially. rim fracture and the avulsion fracture.
The glenoid rim fracture is secondary to
( ).32 Detachment of the anterior- compression of the anterior inferior rim
inferior labrum and capsule (Bankart by the humeral head ( ). During
lesion) is considered one of the major tension failure of the IGHL, it is also pos-
pathoanatomical features of traumatic sible to cause an avulsion of the glenoid
anterior shoulder instability.22 By displac- rim.
ing the anterior labrum, glenoid depth is
decreased by up to 50%, and passive re- Etiology and Epidemiology
straints, such as the concavity-compres- For an anterior shoulder dislocation to
Three-dimensional computer tomography
sion mechanism, is also lost.11,15 Bigliani reconstruction demonstrating an anterior glenoid rim
occur, the mechanism of injury typically
et al2 have demonstrated that even plastic fracture. involves a position of combined shoulder
deformation of the capsule was a funda- abduction and external rotation, as seen
mental component of anterior instability. tween Bankart lesion and what he termed in many collision sports. The overall in-
From a surgeon’s perspective, this is an the anterior labral ligamentous periosteal cidence of traumatic shoulder instability
important concept, because, in addition sleeve avulsion lesion (ALPSA) ( in the general population has been re-
to surgical repair of the glenoid labrum, 2). In his description, the capsule and ported to be approximately 1.7%.26 How-
capsular redundancy may require plica- labrum are not detached as in a Bankart ever, the incidence can be doubled in the
tion. This is of particular importance in lesion, but the anterior IGHL, labrum, high-physical-demand population. In
recurrent dislocation given the extent and the anterior scapular periosteum are the United States Military Academy, the
of capsular laxity typically seen in that stripped and displaced in a sleeve-type 1-year incidence of traumatic shoulder in-
population. The incidence of Bankart fashion, medially on the glenoid neck.20 stability was 2.8%.23 Traumatic instability
lesion after an initial anterior shoulder Antonio1 found a high prevalence of can also occur in the form of subluxation.
dislocation has been reported to be 87% ALPSA following a first-time shoulder The same West Point study found 85% of
to 100%.21,30 dislocation in a younger patient popu- instability events were due to traumatic
Neviaser,20 in 1993, differentiated be- lation and suggested an early MRI ar- subluxation.23
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 119

3. [ CLINICAL COMMENTARY ]
conscious sedation. It is imperative that a
Following an acute anterior shoulder dis- repeat neurovascular exam be conducted
location in the athlete, the clinician usu- postreduction. The other scenario is that
ally encounters the athlete on the field, the dislocation is not reduced on the field
in the training room, or in the emer- and the physician first sees the patient in
gency department. If medical personnel the emergency department. By the time
are covering the game from the sideline, the patient arrives, because of muscle
they may have witnessed the mechanism guarding and pain, a closed reduction is
of injury. The focused history should rule usually not possible without conscious se-
out associated injuries by asking about dation or intra-articular local anesthetic.
other symptomatic areas. In an acute Miller18 has shown that the intra-articular
first-time dislocation, the athlete will be injection of lidocaine to facilitate reduc-
in obvious discomfort and experiencing tion with the Stimson technique is a safe
intense pain. The physical examination of and effective method for treating acute
the shoulder should follow a systematic shoulder dislocations in an emergency
approach to avoid missing concurrent room setting. The Stimson technique re-
Stryker notch view to identify posterior
pathology. It is important to perform a quires the patient to be prone, with the superior humeral head defect.
prereduction and postreduction neu- affected arm hanging over the edge of the Published with permission. Mahaffey BL, Smith
rovascular exam. Nerve lesions include table. Downward traction on the affected PA. Shoulder instability in young athletes. Am Fam
injury to the axillary nerve (most com- arm can be achieved with gravity or with Physician. 1999 May 15;59(10):2773-82, 2787.
mon), suprascapular nerve due to trac- weights tied to the forearm. Scapular
tion, and long thoracic nerve. Visser et protraction, by pushing on the scapula, tion at a lower degree of external rotation
al33 reported axillary nerve injury in 42% is necessary to allow greater glenoid ante- compared to the contralateral shoulder.
of anterior shoulder dislocations. version in facilitating a reduction. If seen With the arm in this position, a posterior-
Immediate recognition of an acute in the emergency department, it would be directed force is applied to the proximal
anterior dislocation is possible by ob- prudent to first obtain radiographs (an- humerus as the relocation test. If the ap-
serving the characteristic position of the teroposterior, lateral, and axillary views) prehension is relieved by the posteriorly
athlete’s arm, which is held against the to confirm the direction of dislocation directed force, the relocation test is posi-
body and supported by the contralateral and to rule out associated fractures. tive. A sulcus test involves inferior trac-
arm. They will resist any attempt to move In the situation where the athlete has tion on the affected arm and determining
the affected arm. Physical exam findings sustained a traumatic subluxation with the distance between the lateral edge of
include the following: asymmetry of the spontaneous reduction, or the shoulder the acromion and the humeral head. If
deltoid contour (the affected side will has been reduced, additional special the sulcus is 2 cm or greater, underlying
demonstrate a sharp contour and a more clinical tests can be performed. A load- multidirectional instability is present.
prominent acromion when compared and-shift test is performed by grasping
with the unaffected side), and a palpable the humeral head and translating it in an
fullness below the coracoid process and anterior direction to test anterior instabil- Prereduction radiographs are necessary
towards the axilla that may occur on the ity. Grade 1 is minimal translation up to to determine the direction of disloca-
affected side. the labrum. In a grade 2 load-and-shift, tion and assess for associated fractures.
With an acute dislocation, the clini- the humeral head can be translated over A standard anterior-posterior view of the
cian needs to make a decision regarding the labrum but easily reduced. In grade 3, arm in slight internal rotation is used to
the timing of a closed reduction. Perform- the humeral head is easily translated over identify a fracture of the greater tuberos-
ing a closed reduction on the field or side- the glenoid rim and may be more difficult ity. Postreduction views, including a true
line, or in the training room, without first to reduce. During this test, we also pay scapular anterior-posterior radiograph,
obtaining a radiograph, is controversial. attention to whether there is a palpable can identify a glenoid fossa fracture. The
Many experienced physicians and train- “click,” which may be a clinical indicator West Point modified axillary view is used
ers will perform a closed reduction on of a labral tear. An apprehension test is to assess bony avulsions of the attach-
the field, with the rationale that a reduc- performed with the patient supine with ment of the IGHL, bony Bankart lesions,
tion can be achieved prior to the onset of the shoulder in 90° of abduction and or anterior-inferior glenoid deficiency.25
muscle spasm. This would allow a timely gradually bringing the shoulder into It is difficult to obtain this view acutely
reduction that would significantly reduce more external rotation. The athlete will because of patient guarding and pain;
the level of pain, without the need for typically report symptoms of a disloca- however, it can be obtained within sub-
120 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

4. from the neocortex in the humeral neck. More recently, Itoi et al12 demonstrated
A thin radiolucency is observed inferior with MRI better reapproximation of the
to the anatomic neck of the humerus, and Bankart lesion with the arm next to the
once again the fluid-filled, distended, U- body and the shoulder in 30° of external
shaped axillary pouch is converted into a rotation. A subsequent short-term clini-
J-shaped structure by the extravasation cal study revealed decreased recurrence
of contrast material.6 rates in patients immobilized in external
rotation compared to those immobilized
in internal rotation.12 After 3 weeks of im-
The decision for treatment in any patient mobilization, the external rotation group
after a dislocation should be individu- had a recurrence rate of 26%, while the
alized. Once the diagnosis is made and recurrence rate for those in the internal
the shoulder is reduced, the decision on rotation group was 42%, with a relative
Axial computer tomography demonstrating subsequent treatment can be made. Age risk reduction of 46% in patients younger
rim fracture. and activity level are the most important than 30 years.12 Although Itoi’s work is
factors guiding treatment. Generally, for appealing, its limitation is that his pa-
sequent days. The Hill-Sachs lesion, a young athletes, particularly those in- tient population varied in age; therefore,
posterior-superior humeral head defect, volved in contact sports and aged 15 to his conclusions may not be generalizable
can be quantified and evaluated by using 25 years, acute repair may be a viable op- to the young athletic population. Further-
a Stryker notch view ( ). tion based on the high risk of recurrence, more, maintaining arm position in 30°
A computerized tomography (CT) apprehension, impact on sports partici- of external rotation for 3 to 4 weeks may
scan can be an accurate means of fur- pation, and quality of life.2,5,13,14 We favor make compliance with this treatment dif-
ther quantifying the size of a glenoid rim arthroscopic instability repair for athletes ficult in the young, competitive athlete.
fracture initially observed on plain radio- in this age group. Patients aged 25 to 40 The athlete who sustains a disloca-
graphs. CT 3-D reconstructions, particu- years old have a much lower recurrence tion during a competitive season poses a
larly the sagittal view, is an accurate tool rate of dislocation, and conservative reha- unique clinical dilemma. Buss et al,8 in a
to evaluate this injury.29 Currently the bilitation is generally the best treatment. review of 30 athletes who sustained an
senior author utilizes CT to quantify the Older patients, greater than 40 years old, anterior dislocation during their sport
size of an anterior rim fracture after an who sustain an anterior dislocation have season, showed that a regimen of early
acute dislocation ( ). much lower recurrence rates in general range of motion and a shoulder brace re-
Magnetic resonance imaging (MRI) is (10%-15%), but can have residual dis- stricting abduction and external rotation
used for assessment of associated pathol- ability from associated soft tissue injuries allowed 26 athletes to return and com-
ogy. Contrast enhancement improves the such as rotator cuff tear, nerve injury, or plete the season. Many of these athletes
diagnostic ability to detect labral tears vascular injury.27 coped with instability during the season,
(both superior and anterior-inferior), Traditional nonoperative treatment and 16 athletes required surgical stabili-
rotator cuff tears (both partial and full has included a period of immobiliza- zation at the end of the season. Although
thickness), and articular cartilage le- tion with the arm in internal rotation. not definitely proven, it is intuitive that,
sions. However, in the acute setting, The length of immobilization (up to 6 with more dislocations or subluxations,
contrast agent is not necessary because weeks) has not reduced recurrence rates. more damage to the articular cartilage,
of the excellent contrast afforded by the In a 10-year follow-up on immobiliza- bone, and capsule develops.7 For the ath-
hemarthrosis that universally accom- tion outcomes after anterior shoulder lete who sustains a first-time dislocation
panies a primary dislocation.2 With a dislocations, Hovelius10 found no effect at the end of the season or spring practice,
HAGL lesion, MR images in the midsag- on recurrence rates related to the length one option is early mobilization, rehabili-
ittal coronal oblique plane show the de- of immobilization. Out of 247 primary tation, and return to full activity. Another
tachment of the inferior glenoid labrum anterior shoulder dislocations, 50% of option is to immobilize the athlete in ex-
and the axillary pouch converted from shoulders had a recurrent dislocation at ternal rotation for 3 to 4 weeks, proceed
a full distended U-shaped structure to 10 years out.10 Interestingly, degenerative with rehabilitation, and return the athlete
a J-shaped structure, as the inferior joint disease was found in both surgical to sport after 6 to 8 weeks. Itoi’s work sug-
glenoid labrum drops inferiorly.28 This and nonsurgical cases, with 11% of the gests a reduced recurrence rate; however,
has been further defined in a follow-up patients who underwent surgery having a study using this treatment regimen in
study that describes the MR appearance mild secondary degenerative joint disease young collision athletes is still required.
of a HAGL lesion as an avulsion fracture at the 10-year follow-up.10 In the young, contact athlete, modern
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 121

5. [ CLINICAL COMMENTARY ]
operative stabilization techniques (open repaired and imbricated tissue must be
and arthroscopic) reduce the recurrence respected. The first goal is to maintain
rate from the 80% to 90% range to the anterior-inferior stability. The second
3% to 15% range, and improve overall goal is to restore adequate motion, spe-
quality of life.2,5,13,14 cifically external rotation. The third goal
If we are to treat the young athlete is a successful return to sports or physical
with a first-time dislocation nonop- activities of daily living in a reasonable
eratively, we still use a sling with the amount of time.
arm held to the side. However, it is our Our protocol includes immobilization
preference to perform arthroscopic in- postoperatively in a shoulder immobi-
stability repair for the first-time dislo- lizer. Codman exercises, combined with
cation in young athletes because of the Arthroscopic view of a repaired Bankart pendulum exercises, are started immedi-
lesion. The anterior labrum has been reconstituted
improved quality of life and reduced ately. Active assisted range-of-motion ex-
with 3 suture anchors.
recurrence rate. ercises for external rotation (0°-30°), and
forward elevation (0°-90°) are also start-
can be accomplished through the ASP ed at this time. This regime is maintained
or AIP, or both. Particularly when using for the first 6 weeks. The use of cold ther-
For operative repair of an acute disloca- a motorized burr, it is important not to apy devices has been successful in reduc-
tion, it is our preference to perform the remove anterior glenoid bone. The goal ing postoperative pain. From weeks 6 to
repair arthroscopically within 2 weeks of is to decorticate the medial neck to al- 12, active assisted as well as active range-
the injury, taking advantage of the good low a bleeding surface for labral healing, of-motion exercises are started with the
condition of the capsulolabral tissue. The without removing excessive bone. The ar- goal of establishing full range of motion.
focus of the surgery is the repair of the throscope is then placed in the ASP and a No strengthening exercises or repetitive
capsulolabral avulsion with suture an- “suture first” technique is performed. An exercises are started until after full range
chors ( ). Bigliani4 showed that “O” PDS is first passed through the cap- of motion has been established.
with any type of capsular failure there sule (approximately 1 cm from the edge This protocol is based on tendon-to-
was a significant amount of capsular of the labrum) and labrum, and used as a bone healing in a dog model.24 Early re-
elongation, suggesting plastic deforma- traction suture. We do not perform a for- sistance exercises, with aggressive early
tion of the capsule. A limited antero- mal capsulorrhaphy in an acute repair; postoperative rehabilitation, do not ap-
inferior capsulorraphy is performed in however, a slight inferior-to-superior pear to offer substantial advantages and
combination with a Bankart repair to shift (capsular pinch and tuck) allows re- could compromise the repair. Strength-
address the capsular stretch and reten- tensioning of the IGHL. One PDS limb ening is begun once there is full, painless,
sioning of the IGHL. is retrieved from the posterior portal. active range of motion. Strengthening is
We routinely perform an arthroscopic The first anchor is then placed at the 5 begun at 12 weeks, with sports-specific
Bankart repair with the patient in lateral o’clock position. If the AIP does not allow exercises started at 16 to 20 weeks. Fi-
decubitus position, supported by a bean adequate access to the 5 o’clock position, nally, contact sports are started between
bag. The arm of the operated shoulder is a percutaneous transsubscapularis por- 20 to 24 weeks postoperatively.
placed in 5 lb (2.27 kg) of longitudinal tal is required. After anchor placement, 1
traction and 7 lb (3.18 kg) of lateral trac- anchor suture limb is retrieved from the
tion. A bump/roll is placed under the ax- posterior portal and shuttled anteriorly Many studies have reported improved
illa to facilitate clear visualization of the 6 via the PDS. The suture ends are then outcomes following acute arthroscopic
o’clock position. A posterior portal is first tied, respecting loop and knot security. repair. In Kirkley’s13 prospective ran-
established. With the arthroscope in the If the condition is acute, we do not domized trial, arthroscopic repair not
posterior portal, the anterosuperior (ASP) perform an extensive capsular plication only decreased recurrence rates, but
and anteroinferior portals (AIP) are then or closure of the rotator interval. Rota- also resulted in improved quality of life.
created, first using a spinal needle to de- tor interval closure is controversial; there Several other authors have reported
termine adequacy of portal trajectory and are no clinical studies supporting this improved outcomes following acute ar-
help locate the 5 o’clock position. technique in the treatment of a first-time throscopic repair.5,9,14 Therefore, it can be
An arthroscopic elevator is used to acute dislocation. concluded that acute arthroscopic repair
lift the labrum off the glenoid. The me- for the athlete with a first-time traumatic
dial glenoid neck is prepared using a anterior dislocation leads to improved
handheld rasp or motorized burr. This The biological healing response of the outcomes.
122 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

6. Am J Sports Med. 2004;32:1165-1172. http:// anterior instability of the shoulder. Arthroscopy.
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