What is the initial management for a patient with shoulder subluxation?

Initial Management of Shoulder Subluxation

The initial management for shoulder subluxation should focus on proper positioning, protection, and handling of the affected arm to prevent further injury and reduce pain. 1

Assessment and Immediate Management

1. Clinical Assessment

   • Musculoskeletal evaluation
   • Evaluation of spasticity (if post-stroke)
   • Identification of subluxation severity
   • Testing for regional sensory changes 1

2. Imaging

   • Standard radiographs (anteroposterior views in internal and external rotation, axillary or scapula-Y view) to rule out fractures and identify associated injuries 2
   • Consider ultrasound for evaluating soft tissue injuries 1

3. Immediate Positioning and Support

   • Properly position the affected arm with joints positioned higher than proximal joints
   • Consider supportive devices and slings to stabilize the subluxed shoulder 1
   • Avoid overhead pulley exercises as they may worsen the condition 1

Management Based on Etiology

For Post-Stroke Subluxation

1. Education

   • Healthcare staff, patients, and family should be educated on correct protection, positioning, and handling of the involved arm 1
   • Proper positioning techniques to prevent further subluxation and pain

2. Support Devices

   • Use of slings during ambulation to protect from traction injury 1
   • For wheelchair-bound patients, consider lap trays and arm troughs to reduce shoulder pain and subluxation 1

3. Pain Management

   • Taping of the affected shoulder may reduce pain 1
   • Consider neuromuscular electrical stimulation (NMES) for pain management 1

For Traumatic/Atraumatic Subluxation

1. Conservative Management

   • Initial approach should prioritize conservative management for 3-6 months before considering surgical options 2
   • Physical therapy focusing on rotator cuff and scapular stabilization exercises 2
   • NSAIDs for pain management 2

2. Immobilization

   • Consider appropriate immobilization period:
     • 3-4 weeks for younger patients (<20 years) to enhance capsulolabral complex healing
     • Shorter period for older patients 3

3. Rehabilitation Program

   • Specific exercise program targeting:
     • Strengthening of dynamic shoulder stabilizers
     • Strengthening of scapular stabilizing muscles
     • Enhancing neuromuscular control over the glenohumeral joint 3
   • For atraumatic subluxation, exercise programs have shown 80% good to excellent results 4

Special Considerations

• Avoid Harmful Practices

  • Aggressive range-of-motion exercises may cause more harm than good if done improperly 1
  • Overhead pulley exercises are not recommended 1

• Differentiate Types of Subluxation

  • Traumatic subluxation responds less favorably to conservative treatment (only 16% good/excellent results) compared to atraumatic subluxation (80% good/excellent results) 4
  • Recurrent transient anterior subluxation ("dead arm" syndrome) requires careful differentiation from other causes of shoulder pain 5

• Monitoring Progress

  • Dynamic ultrasound can be used to monitor progress and response to treatment 2
  • Consider surgical referral if conservative management fails after 3-6 months 2, 6

When to Consider Surgical Management

• Failure of conservative measures after 3-6 months
• Significant functional limitations despite therapy
• Evidence of continued instability
• Young, active patients with high physical demands 2
• For voluntary subluxation cases, surgery should only be considered if the voluntary component has been eliminated 6

Remember that the approach should be guided by the underlying etiology of the subluxation, with proper positioning and education being the cornerstone of initial management in all cases.