acute shoulder dislocation is one of the most common sports injuries especially in contact sports. recurrent dislocations are quite common after anterior dislocation of shoulder especially in young athletes who are engaged in sports with lots of overhead activities during their games. Bankarts lesion, Hill sachs lesion are common predisposing factors for recurrence. Simple acute first time dislocations may be reduced on the field by a trained person but further referral is must for detail evaluation. recurrent dislocation can be reduced on field too by less trained. complicated dislocations, neurovascular deficits, fracture dislocation are to be referred to hospital immediately. Practical scientific algorithms are presented for their appropriate management here.

1. Shoulder dislocations & Shoulder instabiliy in sports:
Management
Dr Bhaskar Borgohain
MBBS (AMC), MS Ortho (Delhi Univ.), DNB Ortho (NAMS),
AO Trauma Fellow, (Germany), Arthroplasty Fellow (Computer Navigation)
Professor & HoD, Orthopaedics
Head , Sports injury arthroscopy Clinic (SIAC)
NEIGRIHMS Shillong
www.neigrihms.gov.in
Part of proceedings of 32ND Midterm CME, NEROSA
3RD August, 2019 at historic city of Tezpur, Assam:
North East Regional Orthopaedic Surgeons’ Association , NE Chapter, Indian Orthopaedic Association (
NEROSA), India

2. Questions
• Is it OKEY to attempt closed reduction of a dislocated
shoulder of a sportsperson in the sports venue itself ?
• How long should we wait and do rehab before considering
surgery
• Should we go for Bankart surgery after the first dislocation
itself to prevent recurrent dislocation
• When can a sportsperson return to sports after reduction of a
shoulder dislocation or after a Bankart repair surgery

3. Scope of my presentation
• Basic epidemiology of shoulder dislocations especially risk of
recurrences
• Describe Basic types of shoulder instabilities
• Basic Management of acute anterior dislocations
• Management algorithm in acute anterior Dx
• Management algorithm: recurrent anterior Dx
• Touch the Basic patho-anatomy
• Basic surgical techniques commonly employed for recurrent
anterior dislocations

4. Anatomy
• An imperfect ball &
socket joint
• Shoulder has the greatest
range of motion, placing it
at risk for dislocation.
• The glenohumeral joint is
shallow - deepened by the
glenoid labrum.
• Shoulder stability is more
about ligamentous
restraints and muscular
control

5. Glenoidal Labrum’s contributing to added stability is of paramount
importance especially during extreme range of motions

6. Dynamic stability and muscle synergy are quite critical for overall stability
especially during sports activities

7. : Epidemiology

8. 1. Dodson 2008 OCNA

9. Shoulder Dislocations in sports: epidemiology
• The shoulder is the most commonly dislocated joint.
• It accounts for approximately half (54.9%) of sports-
related dislocations in high school athletes.
• The majority of shoulder dislocations (>95%) occur in an
anterior and inferior direction.
• Anterior dislocations commonly occur as a result of
forceful abduction and external rotation.
• Posterior dislocations are less common and result from
forceful internal rotation and adduction.

10. Types of anterior shoulder dislocations

11. Luxatio erecta
Fracture dislocation
Can we attempt to reduce these two
types of dislocations on the play
ground?

12. Epidemiology of primary anterior shoulder dislocation
• 2014 paper on Records of CR from
Canada
• Young male - highest incidence of
primary anterior shoulder dislocation
required CR - the greatest risk of
repeat shoulder CR.
• Patient, provider, and injury factors
all influence repeat shoulder CR risk.
• 19% patients (n= 3940) underwent
repeat shoulder CR after a median of
0.9 years, of which 41.7% were ≤20
years of age.
• Nearly 2/3 of all first repeat shoulder
CR events occurred within 2 years
• 95% redislocations occurred within 5
years.
• The risk of repeat shoulder CR was
lowest if the primary reduction had
been performed by an orthopaedic
surgeon
Leroux T, Wasserstein D, Veillette C,
Khoshbin A, Henry P, Chahal J, Austin
P, Mahomed N, Ogilvie-Harris D.
The American journal of sports
medicine. 2014 Feb;42(2):442-50.

14. Types of Shoulder instability
Requires good clinical examination/assessment besides radiology
AIOS
AMSI
AMSI- Asymptomatic Mild shoulder instability
AIOS- Acquired instability, overused shoulders- SLAP

17. Better understanding of the pathological findings: 2011 paper
• Advances in arthroscopy and imaging has given a great contribution to a better
understanding of the pathological findings of shoulder instability.
• Today we know that between the classical TUBS and AMBRI there is a new
group of instabilities defined as minor or occult instabilities (AIOS and AMSI).
• AIOS & AMSI are more difficult to diagnose and sometimes wrongly identified
with a subacromial pathology .
• Capsular avulsion from the humeral head named HAGL and PHAGL lesion can
be responsible of shoulder instability.
• These kind of lesions can be diagnosed arthroscopically and some can be also
treated at the same time with satisfactory outcomes.
• However, not all of these minor capsulo-ligamentous lesions can be
successfully treated by means of arthroscopy,
• Particularly some HAGL lesions, and in selected cases we prefer to switch to
open surgery.
Garofalo, Conti, Borroni et al . LO SCALPELLO-OTODI Educational. 2011, 25( 2), pp
105–109

19. MR Arthrography can be very very useful

20. MR Arthrography can be very very useful

21. HILL SACHS LESION OF HUMERAL HEAD:
ON TRACK OR OFF TRACK

22. CT Scan can be very useful

23. CT Scan:
Bony defects of glenoid rim: Inverted pear shape glenoid

24. SIZE
LOCATION
ON TRACK
OFF TRACK
CT Scan
Remplissage procedure

25. A Hill-Sachs lesion has a risk of engagement and dislocation if it extends
medially over the medial margin of the glenoid track.
Remplissage procedure

26. Management
Algorithm for 1st
time dislocator
For CR/ Rx by Orthopedician
Rehab
RISK
ASSESSMENT
IMAGING
SURGERY
AGE
REHAB
High index of suspicion for RCTIs he Symptomatic?Elicit Signs of instability: Apprehension test

27. 80% cases are covered in this algorithm

30. Usual Management
• Minor injuries including an
undisplaced labral tear or
partial RCT can often be
treated conservatively if they
occur early in the season.
• If a player continues to have
problems surgery may then be
considered.
• Most stabilisations are performed
arthroscopically.
• high risk groups for recurrent
dislocation or patients who have
dislocated in the past And failed
Bankart surgery may require an
open stabilising procedures
e.g.Laterjet procedure.

32. Open Bankart repair was the gold standard

33. Neviaser described a fairly common pattern of medialized
capsulolabral healing associated with recurrent dislocation. If we
repair the capsule in a medialized position, the position of an
ALPSA lesion, we would expect a higher recurrence rate.
Arthroscopic Bankart repair is equivalent now

37. Triple blocking.
(A) Normal position of subscapularis providing no inferior support in
provocative position of the shoulder (i.e., abduction and external rotation);
(B) completed Latarjet with arm in neutral position. Anterior bone block is
visualized with the capsule repaired to CAL;
(C) the inferior displacement of the subscapularis by the conjoint tendon
creates a sling beneath the anteroinferior capsule, especially in the abducted,
externally rotated position of the arm. With permission from (15). CAL,
coracoacromial ligame
The inverted pear glenoid: an indicator of significant glenoid bone loss

38. Latarjet in anterior bony defect: Open or Arthroscopic both possible

39. Modified latarjet procedure

40. EXTRA-ARTICULAR PROCEDURES

41. Enigma: Is it ok to reduce a shoulder dislocation in the sports
venue ?
• To date, there is no
standardized management
protocol published for the
initial management of an
anterior dislocated
shoulder in a pitch-side
setting.
• All papers are on in
house- hospital
reduction
• Reduction by
Orthopaedic surgeon
less recurrent
dislocation

42. Is it ok to reduce a shoulder dislocation in the sports venue ?:
The Conclusion- Shah R, Chhaniyara P, Wallace WA et al
• Even in the absence of clinically
validated guidelines, pitch-side
reduction of an ‘uncomplicated’
anterior dislocation is common
practice.
• A good history and through
clinical examination to exclude
potentially limb-threatening
injuries that require urgent
referral to hospital for x-ray-
doppler etc
• When a decision is made to
reduce an anteriorly dislocated
shoulder, do so at the earliest
opportunity to avoid overcoming
increasing resistance due to
muscle spasm using techniques
that you are familiar with.
• However, we recommend those
‘pitch-side’ medical practitioners
who provide this form of support
should have attended appropriate
training and ensure adequate
malpractice cover.
• Once reduced, the shoulder
should be immobilised in the
most comfortable position and
referred for an expert opinion.

43. Learning points
• Anterior dislocations account for up to 90%
of all shoulder dislocations.
• Athletes with a high index of suspicion for a
fracture should be referred to the nearest
hospital without any attempts at reduction
• Prior to attempting reduction, confirm that
the shoulder is anteriorly dislocated:
– Loss of normal shoulder contour
– Arm held in abducted and externally rotated
position
– Anteriorly palpable humeral head
• Always assess the neurovascular status of the
limb, prior to and after reduction.
Shah R, Chhaniyara P, Wallace WA, Hodgson L. Pitch-side
management of acute shoulder dislocations: a
conceptual review.
BMJ open sport & exercise medicine. 2017 Mar
1;2(1):e000116.
• Until 2016, No standardised management
protocol published for the initial
management of an anterior dislocated
shoulder in a pitch-side setting
• Despite the availability of different reduction
techniques, few are applicable in a pitch-side
setting.
• The Stimson and Spaso techniques are
simple and effective for pitch-side reduction
with the external rotation method being an
effective alternative.
• With regard to post-reduction care,
immobilise the limb in the most comfortable
position prior to referral to hospital.

44. On pitch
management
algorithm
in first time
dislocation or
recurrent
dislocation

45. Return to sports …
• Shoulder dislocation is an injury
risk and can result in a prolonged
absence from sport.
• Average return to play time can
vary from 14 -30 weeks and is
dependent on an athlete reaching
set goals.
• Most return after 5 months after
Bankart’s surgery
• Return to play is both player
specific and surgery specific,
taking into account the quality
and type of surgical fixation
achieved.
• ‘Return to play criteria’ is used to
help ensure the safe return of an
athlete to contact training. This
often includes an assessment of
the isokinetic strength of the
shoulder.
• With the help of the strength and
conditioning team the aim is to
ensure the athlete is globally
fitter and strong like pre-injury
presentation.
• However with appropriate
rehabilitation and exercise
selection post surgery it is
possible to make a very efficient
and successful return to sport.

46. Immediate Evaluation
• Better appreciated when comparing the injured shoulder to the
uninjured side.
• anterior dislocation - often hesitant to move the shoulder Duga’s
Test is quick and useful
• Posterior dislocations- typically place the arm in an internally
rotated and adducted position, with the arm at the patient’s side.
• Direct inferior dislocations (luxatio erecta) lock the shoulder in
abduction and can be especially difficult to reduce.
• With all suspected shoulder dislocations, assessment of axillary
nerve function should be performed by feeling for deltoid
contraction and evaluating sensation to light touch over the lateral
upper arm.

47. Reduction on the field
• Immediate assessment and treatment of a shoulder
dislocation is important because once muscle spasm occurs, it
is very difficult to reduce the shoulder joint without
anesthesia.
• The traction/counter-traction technique is a commonly used
method for reduction and is the most practical to perform on
the field immediately after injury.

48. Hippocrates maneuver

49. Milch Maneuvre

50. Kocher’s Maneuvre had 77% success rate in CR in a cohort of
111 patients with anterior type
Beattie et al, 1986, UK

51. Painless Reduction of Anterior Shoulder Dislocation
by Kocher’s Method
• The original procedure involves the patient initiating all steps of the
maneuver, while the doctor simply supports and reassures the
patient. With the patient supine, the physician holds the wrist and
supports the elbow on the affected side. The elbow is flexed to 90°
and adducted to lie at the side of the chest. Then the patient slowly
externally rotates the arm approximately 80 to 90° or until the point
of resistance. At that position, the patient should slowly lift the
elbow forward/upward until a pop is heard or felt. At this point, the
patient should be able to reach to touch the opposite shoulder.
Handly, N.B. Annals of Emergency Medicine 48 (2), 221 - 22

52. Strap method: traction counter-traction method:
Effective and safe method in our hand

53. The Spaso technique
• In conclusion, the Spaso
technique is a simple, rapid,
and reliable technique for
acute shoulder dislocation.
• It is a successful reduction
maneuver and had no
complications in this small
series of patients.
• Even in inexperienced
hands, the method could be
performed sufficiently
without anesthesia.

55. Rehab…rehab..rehab….its so important

56. Rehab…rehab..rehab….its so important

57. Rehab…rehab..rehab….its so important

58. Controversies :
Systematic reviews will guide you more

59. 2015: a systematic review and meta-analysis
• Risk factors which predispose first-time traumatic anterior shoulder
dislocations to recurrent instability in adults
• Conclusions:
• Sex, age at initial dislocation, time from initial dislocation, hyperlaxity and
greater tuberosity fractures were key risk factors (strong evidence).
• Although bony Bankart lesions, Hill Sachs lesions, occupation, non-
operative treatment and nerve palsy were risk factors for recurrent
instability ( weak evidence)
Olds M, Ellis R, Donaldson K, Parmar P, Kersten P. Br J Sports Med. 2015 Jul
1;49(14):913-22.

60. THANK YOU