What are the recommendations for post subluxation of the shoulder?

Management Recommendations for Post Shoulder Subluxation

For post shoulder subluxation, proper positioning, early mobilization, and a structured rehabilitation program focusing on gentle stretching exercises and strengthening of shoulder girdle muscles are essential for recovery and prevention of recurrence. 1

Initial Assessment and Positioning

• A comprehensive musculoskeletal evaluation should be performed to identify subluxation severity, evaluate spasticity, and test for regional sensory changes to guide management 1, 2
• Proper positioning of the affected shoulder is crucial - ensure joints on the paralyzed side are positioned higher than joints proximal to it 3, 1
• Special care must be taken to avoid pulling on the affected arm when repositioning or moving the patient to prevent further injury 3, 1
• Supportive devices such as slings, lap trays, and arm troughs can be used to protect the shoulder from traction injury and reduce pain, especially for wheelchair-bound patients 1, 4
• The elastic dynamic sling has shown better results in reducing horizontal subluxation distance compared to the Bobath sling, which holds only the proximal part 4

Early Mobilization and Exercise

• Begin early mobilization when the patient is hemodynamically stable to reduce risk of complications such as atelectasis, pneumonia, and contractures 3, 1
• Implement gentle stretching and mobilization techniques to increase external rotation, abduction, and restore proper alignment 1, 2
• Avoid overhead pulley exercises as they can worsen the condition by encouraging uncontrolled abduction 1, 2
• Focus on strengthening exercises for the rotator cuff and scapular stabilizers to improve joint stability 2
• Include range-of-motion exercises to prevent joint contractures and atrophy 3, 1

Pain Management

• Consider analgesics such as acetaminophen or ibuprofen for pain relief if there are no contraindications 1
• Neuromuscular electrical stimulation (NMES) can be considered for shoulder pain management and has shown significant treatment effect in favor of pain-free lateral rotation 1, 2
• Modalities such as ice, heat, and soft tissue massage may provide pain relief 2
• For persistent pain, suprascapular nerve blocks may be considered as an adjunctive treatment, shown to be effective for up to 12 weeks 1, 2

Advanced Interventions

• Botulinum toxin injection to the subscapularis and pectoralis muscles may be beneficial for cases with spasticity-related pain 1, 2
• For cases with neuropathic pain components, consider a trial of neuromodulating pain medications 2
• In severe cases with spasticity and restricted range of motion, surgical options like tenotomy of pectoralis major, lattisimus dorsi, teres major, or subscapularis muscles may be considered 1, 2

Prevention of Recurrence

• For primary dislocations in patients under 30 years, 3 weeks of immobilization is recommended to reduce recurrence rates, while 1 week is sufficient for older patients 5
• Immobilization in external rotation versus internal rotation has not shown significant differences in preventing recurrent instability after primary anterior shoulder dislocation 6
• Conservative treatment with kinesitherapy and physical therapy should be attempted for at least 6 months before considering surgical intervention for recurrent subluxation 7
• For atraumatic recurrent posterior subluxation, surgical treatment should be based on the underlying pathologic lesion and only after failed conservative management 7

Education and Monitoring

• Patient and family education on proper positioning and range of motion exercises is essential to prevent further subluxation and promote recovery 1
• Regular assessment for signs of complex regional pain syndrome (shoulder-hand syndrome) is crucial to prevent long-term complications 1
• Monitor for recurrent instability, which may present as a second documented dislocation or multiple episodes of shoulder subluxation 6

Special Considerations

• Younger patients (under 30 years) have higher rates of redislocation compared to older patients 5
• Manual laborers experience more numerous redislocations than office workers 5
• The greater the initial trauma to the shoulder, the lower the incidence of recurrence 5
• Bilateral involvement is common in atraumatic recurrent posterior subluxation, occurring in more than half of all cases 7