A dislocated shoulder usually occurs as a result of trauma, such as a fall. Urgent treatment is needed to “put the shoulder back” or reduce the joint. Unfortunately, the dislocation causes damage to cartilage and sometimes also to bone which helps to stabilise the shoulder. This in turn can result in instability and repeated dislocations. Surgery may be needed to help stabilise the shoulder…
If you have had a dislocated shoulder, the question remains whether surgery is needed. There are two broad aspects to shoulder dislocation. The first is treating a dislocated shoulder (this seldom requires surgery). The second is treating a shoulder which was dislocated previously but has already been put back (this often requires surgery). To put things differently once you have had a shoulder dislocation it is highly likely that you will require surgery.
How do you fix a dislocated shoulder?
A dislocated shoulder is an emergency and requires urgent reduction. Reduction means to put the shoulder back into joint. This can sometimes be done immediately after the shoulder has dislocated. This is often seen being performed by professionals on the sports field. Most people however will have the shoulder reduced in the emergency department of a hospital. A muscle relaxant with sedation is usually needed and specific manoeuvres are used to safely relocate the dislocated shoulder.
An examination is performed to ensure that no nerve injury has been sustained during the shoulder dislocation (and before the reduction). An x-ray will usually have been taken before the reduction. This is to ensure that there are no injuries and to confirm the direction of the dislocation. Another x-ray is required afterwards to confirm and document the success of the reduction.
What is the fastest way to heal a dislocated shoulder?
The fastest way to heal a shoulder dislocation (after it has been put back, of course) is a period of rest, followed by physiotherapy. Once the shoulder is reduced, an arm sling is worn for a few weeks. Sometimes a brace which immobilises the shoulder in a certain position is prescribed. This period of rest is necessary to allow the injured tissues to heal. Physiotherapy may then be started to restore range of movement and strength.
Do I need further surgery after a shoulder dislocation, even though the shoulder has been put back?
This is highly likely. A dislocated shoulder usually causes damage to the stabilising structures in the shoulder. This includes a tear of the cartilage (labrum) in the front of the joint. This is called a Bankart tear. Sometimes a small piece of bone is broken off with the cartilage tear. This is then referred to as a bony Bankart lesion. A Bankart tear or lesion predisposes you to having an unstable shoulder.
As you get older, the chances of having an unstable shoulder decrease. Patients in their 20’s and 30’s however, are at high risk for recurrent dislocations and instability. Surgery is therefore recommended for younger patients, even after only one shoulder dislocation.
A complete examination should be performed before the decision is made to operate. There may be clinical features to suggest instability such as the apprehension test and the relocation test. The apprehension test involves placing the arm in a vulnerable position where the shoulder is likely to dislocate. A person who has instability will be apprehensive and tense their muscles. This is a positive test. The relocation test involves applying pressure to the front of the shoulder while doing the apprehension test. If this reduces the apprehension, the test is positive. This strengthens the case to perform an anterior (front) stabilising procedure.
The examination is also necessary to rule out any nerve damage. Not uncommonly, the axillary nerve is injured in a shoulder dislocation. This results in an area of numbness on the outside of the shoulder and weakness of the muscle which helps lift the arm (deltoid).
Surgery for shoulder dislocation
The two commonest procedures performed for a dislocated shoulder are a Bankart repair and a Latarjet procedure.
The Bankart repair is an arthroscopic operation. This is minimally invasive “keyhole surgery”. This procedure is performed for patients who are involved in non-contact sports. The operation involves stitching the detached cartilage back to the bone and thereby restoring the stability to the shoulder. A bony Bankart procedure is essentially the same operation. The difference is that there is a small piece of bone attached to the torn cartilage. During the cartilage repair the bone is approximated to the site where it broke off to encourage healing. Occasionally, a large fragment of bone may need to be fixed with a small screw.
The Latarjet operation is an open procedure. This means that it is done through a large incision on the front of the shoulder. A small piece of bone from the scapula, (the coracoid process) is cut free. This is transferred to the area of instability on the front of the shoulder socket (glenoid). The coracoid and its tendons are fixed in this area with one or two screws. Some surgeons can perform this procedure arthroscopically, but this is extremely uncommon. The Latarjet procedure is favoured for patients who are involved in contact sports such as rugby. It may also be indicated if a Bankart repair has failed. Some surgeons prefer this as the primary procedure for shoulder dislocations.
There is much debate among shoulder surgeons as to which procedure is better. There is no clear-cut answer. Surgeons like myself who have had extensive training in arthroscopic surgery may favour the Bankart repair. If done correctly if all principles are adhered to this procedure can give excellent results. There is little debate, however, that the Latarjet procedure is better if you are involved in contact sports.
How long does it take to recover from a dislocated shoulder?
If you do not have surgery, then it may take only a few weeks to recover from a dislocated shoulder. Without surgery you may continue to have further dislocations and instability.
After a surgical procedure such as a Bankart repair, the first few weeks are spent in an arm sling protecting the repair. It is recommended that you receive regular physiotherapy to restore range of motion and strength. Typically, weight training is avoided until at least 3 to 4 months after the operation. By six months it is expected that you will have achieved full range of movement and may resume normal sporting activities.
Can a dislocated shoulder heal itself?
Sometimes a dislocated shoulder can spontaneously reduce. The question really is whether the associated cartilage and/or bone injury can heal. This is certainly possible as there are a percentage of patients who do not have any problems after a dislocation. The reasons behind this are multi-factorial, but age is one important consideration. The older you are the less likely you are to experience recurrent dislocations and instability. If the cartilage damage heals in such a way that it provides stability, then you may not have any further dislocations.
For a traumatic shoulder dislocation, surgery is usually needed. The younger you are the more likely you will be to have instability and recurrent dislocations. Repeated dislocations can damage the cartilage of the shoulder and lead to painful arthritis in later years.
As an orthopaedic surgeon with a special interest in shoulder surgery, I see and treat patients with shoulder dislocations and instability. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. I also treat patients from many other areas as well, including Rosebank, Sunninghill and Fourways.
Yours in good health,
MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)
(011) 304 6784