What is the initial treatment for shoulder subluxation?

Initial Treatment for Shoulder Subluxation

The initial treatment for shoulder subluxation should include proper positioning of the affected shoulder, supportive devices such as slings or lap trays, and early mobilization with gentle stretching exercises while avoiding overhead pulley exercises. 1

Assessment and Diagnosis

• A comprehensive clinical assessment should be performed to guide management, including evaluation of musculoskeletal status, spasticity, subluxation severity, and regional sensory changes 1
• Ultrasound may be used as a diagnostic tool to identify soft tissue injuries associated with the subluxation 1
• Regular assessment for signs of complex regional pain syndrome (shoulder-hand syndrome) is crucial to prevent long-term complications 1

Initial Positioning and Support

• Proper positioning of the affected shoulder is essential to prevent further subluxation 2, 1
• For wheelchair-bound patients, lap trays and arm troughs can effectively reduce shoulder pain and subluxation 2, 1
• Supportive devices such as slings should be used to protect the shoulder from traction injury, especially during ambulation training 2, 1
• Ensure joints on the paralyzed side are positioned higher than joints proximal to it to help prevent subluxation 1
• Special care should be taken to avoid pulling on the affected arm when repositioning or moving the patient 1

Early Mobilization and Exercise

• Early, short, frequent mobilization should be started when the patient is hemodynamically stable 2, 1
• Daily stretching of the hemiplegic limbs is recommended to avoid contracture 2
• Positioning the hemiplegic shoulder in maximum external rotation for 30 minutes daily (in bed or chair) can help prevent shoulder contracture 2
• Overhead pulley exercises should be strictly avoided as they can worsen the condition 2, 3
• Gentle stretching and mobilization techniques should focus on increasing external rotation and abduction 1, 3

Pain Management

• If there are no contraindications, analgesics such as acetaminophen or ibuprofen can be used for pain relief 1, 3
• Neuromuscular electrical stimulation (NMES) can be considered for shoulder pain management, though evidence for its efficacy remains inconclusive 2, 1
• Botulinum toxin injection to the subscapularis and pectoralis muscles may be beneficial for cases with spasticity-related pain 1, 3

Rehabilitation Approach

• A structured rehabilitation program should focus on gentle stretching exercises, maintenance of shoulder range of motion, and motor retraining 2, 1
• Active range of motion should be gradually increased while restoring alignment and strengthening weak muscles in the shoulder girdle 1
• Recent evidence suggests that elastic dynamic slings may be more effective than traditional Bobath slings in reducing horizontal subluxation distance 4
• Kinesiology taping has shown promising results in improving subluxation distance, range of motion, pain, and functional outcomes in patients with hemiplegic shoulder subluxation 5

Patient and Family Education

• Patient and family education on proper positioning and handling techniques is essential to prevent further subluxation 1, 3
• Patients and families should be taught proper stretching techniques 2
• Acknowledgment of and education about associated conditions like pseudobulbar affect can help defuse potentially uncomfortable situations 2

Special Considerations for Different Types of Subluxation

• For atraumatic recurrent posterior shoulder subluxation, initial treatment should be conservative with kinesitherapy and physical therapy for at least 6 months before considering surgical options 6
• For primary anterior shoulder dislocations, immobilization in either external or internal rotation appears to have similar outcomes regarding recurrent instability 7