Shoulder Dislocation Repair
Surgery for shoulder dislocation may be indicated if patients are unable or unwilling to change their occupation or avoid participating in high-risk sports and if they have recurrent dislocations or subluxations. Surgery should be avoided in patients with voluntary shoulder dislocations associated with psychiatric illnesses because the instability is likely to recur.
• Medical Therapy
The Hippocratic method involves longitudinal traction on the arm and a counterforce to the axilla, usually with the heel of the foot.
The Kocher method involves traction to the elbow with external rotation of the humerus and adducting the elbow toward the chest. This method is not currently recommended because of its association with neurovascular complications and proximal humerus fractures.
The external rotation method, which is a modification of the Kocher maneuver, involves flexing the elbow to 90° and slowly adducting the arm to the patient's side. The arm is then carefully externally rotated stopping every few degrees to wait for the muscle spasms to subside.
The Stimson technique requires the patient to be positioned prone. The patient's arm is allowed to hang over the edge of the bed with about 10 pounds of weight hanging from the wrist.
The Milch technique is very successful and relatively atraumatic. It involves the surgeon abducting the patient's arm with one hand while applying pressure to the humeral head with the other hand. When the patient's arm is fully abducted, external rotation and traction are applied. The success rate of this technique is 72-89%. Only about one third of patients require sedation or analgesia. Lacey and associates modified this technique by performing the Milch maneuver with the patient in the prone position.
CAUTION: Your shoulder will be very susceptible to reinjury. It is extremely important to follow the postoperative instructions provided by your surgeon and physical therapist.
Physical therapy after your shoulder surgery is essential to restore your shoulder’s function. Your rehabilitation typically will be divided into 4 phases:
• Phase I (maximal protection).
This phase lasts for the first few weeks after your surgery, when your shoulder is at the greatest risk of reinjury. Your arm will be placed in a sling, and you likely will need assistance or special strategies to accomplish everyday tasks, such as bathing and dressing.
Your physical therapist will teach you gentle range-of-motion and very light strengthening exercises using only the weight of your arm.Your therapist may provide hands-on techniques, such as gentle massage, to help ease any pain, swelling, and stiffness, and will offer advice on how you can reduce your pain. Cold compression or electrical stimulation also may be applied for pain relief. Some of the treatments begun in this phase may continue as needed, until approximately the 12-week mark.
• Phase II (moderate protection).
This phase typically begins about 1 month following surgery, with the goal of restoring mobility to the shoulder. You will reduce the use of your sling, and your range-of-motion and strengthening exercises will progressively become more challenging throughout this period. In the early parts of this phase, strengthening will not include extra resistance; that will be included at a later point in your rehabilitation.
Your physical therapist will add exercises to strengthen the "core" muscles of your trunk and shoulder blade (scapula), and your "rotator cuff" muscles—the ones that provide additional support and stability to your shoulder. You will be able to begin using your arm for daily activities, but you'll still avoid any heavy lifting with your arm both during physical therapy and at home. Your physical therapist may use special joint mobilization techniques during this phase to help restore your shoulder's range of motion. With clearance from your surgeon, you may begin light cardiovascular activities, such as riding a stationary bike or walking on a treadmill.
•Phase II (moderate protection).
This phase will typically begin about 3 months after surgery, with the goal of restoring your strength and joint awareness to equal that of your other shoulder. At this point, you should have full use of your arm for daily activities, but you will still be unable to participate in activities such as sports, yard work, or physically strenuous work-related tasks. Your physical therapist will increase the difficulty of your exercises as you progress. You might be able to start a modified weight-lifting or gym-based program during this phase.
• Phase IV (return to occupation/sport).
This phase will typically begin about 4 months after surgery with the goal of helping you return to sports, work, and other higher-level activities. Your physical therapist will instruct you in activity-specific exercises to meet your needs. For certain athletes, this may include throwing and catching drills. For others, it may include practice in lifting heavier items onto shelves or instruction in raking, shoveling, or housework. Your physical therapist also might recommend a shoulder brace to allow you to gradually and safely return to your regular activity level without reinjury.