What is the recommended plan of care for a patient with a shoulder dislocation at 3 weeks?

Management of Shoulder Dislocation at 3 Weeks Post-Injury

At 3 weeks post-shoulder dislocation, the recommended plan of care should focus on progressive rehabilitation with range-of-motion exercises, rotator cuff strengthening, and scapular stabilization exercises while avoiding aggressive overhead movements.

Rehabilitation Protocol

Range of Motion Exercises

• Begin active and passive range of motion exercises in all planes, including:
  • Forward flexion
  • Abduction
  • External rotation
  • Internal rotation
• Compare motion with the contralateral side to establish goals 1
• Avoid aggressive overhead movements that could stress the healing capsulolabral structures

Strengthening Program

• Implement rotator cuff strengthening exercises:
  • Focus on external rotators (infraspinatus/teres minor)
  • Include internal rotators (subscapularis)
  • Incorporate deltoid and biceps strengthening 1
• Add scapular stabilization exercises to improve shoulder mechanics and prevent recurrence

Manual Therapy

• Consider supervised physical therapy which shows better outcomes than unsupervised home exercise 1
• Include manual therapy techniques to address any developing stiffness or restrictions

Follow-up Evaluation

Clinical Assessment

• Evaluate for signs of recurrent instability:
  • Apprehension in abduction and external rotation
  • Anterior translation on load and shift testing
  • Pain with provocative maneuvers
• Assess for proper healing and progress of rehabilitation at the 3-month mark 1

Imaging Considerations

• If clinical assessment suggests complications or poor progress, consider:
  • Plain radiographs to evaluate bony structures
  • MR arthrography (gold standard) for evaluating labral tears and soft tissue pathology if recurrent instability is suspected 1

Activity Modifications

Return to Activities

• Avoid above chest level activities until healing is evident 2
• Educate patient on proper positioning and handling of the affected arm 2, 1
• Advise against return to contact sports for at least 3 months post-injury

Risk Factors for Recurrence

• Age under 30 years is a significant predictor of recurrence 3, 4
• Participation in contact sports increases recurrence risk 5
• Educate younger patients and athletes about higher recurrence rates and the potential need for surgical intervention if instability persists

Special Considerations

Surgical Evaluation

• Consider referral for surgical consultation if:
  • Patient is under 30 years of age (higher recurrence risk)
  • Patient participates in high-demand or contact sports
  • Evidence of significant Hill-Sachs lesion or Bankart tear on imaging
• Early arthroscopic stabilization has shown reduced redislocation rates in young patients (15.9% vs 47% with conservative treatment) 6

Pain Management

• NSAIDs for pain and inflammation control as needed 1
• Avoid prolonged use of sling beyond the initial 3 weeks as it may lead to stiffness 3

Common Pitfalls to Avoid

1. Overly aggressive rehabilitation: Excessive early range of motion can increase the risk of recurrence
2. Neglecting rotator cuff strengthening: Weak rotator cuff muscles contribute to instability
3. Returning to sports too early: Premature return increases risk of recurrent dislocation
4. Ignoring scapular mechanics: Poor scapular control contributes to shoulder dysfunction
5. Prolonged immobilization: Extended immobilization beyond 3 weeks shows no additional benefit in reducing recurrence rates 3, 4

By following this structured approach to rehabilitation at the 3-week mark post-dislocation, patients can maximize their recovery while minimizing the risk of recurrent instability.