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

Initial Treatment for Shoulder Subluxation

The initial treatment for shoulder subluxation centers on proper positioning with supportive devices (slings, lap trays, or arm troughs), early gentle mobilization when hemodynamically stable, and pain management, while strictly avoiding overhead pulley exercises that can worsen the condition. 1

Immediate Assessment and Positioning

• Perform a comprehensive musculoskeletal evaluation including assessment of subluxation severity, spasticity, and regional sensory changes to guide management 1
• Ultrasound can identify associated soft tissue injuries 1
• Proper positioning is the cornerstone of initial management - ensure the affected shoulder is positioned to prevent further subluxation by keeping joints on the paralyzed side higher than proximal joints 1
• Use supportive devices immediately: slings during ambulation to protect from traction injury, lap trays and arm troughs for wheelchair-bound patients 2, 1
• Position the hemiplegic shoulder in maximum external rotation for 30 minutes daily (either in bed or chair) to prevent contracture 2
• Never pull on the affected arm when repositioning or moving the patient 1

Early Mobilization Strategy

• Begin early mobilization once the patient is hemodynamically stable 1
• Implement gentle stretching and mobilization techniques focusing on increasing external rotation and abduction to restore proper alignment 1
• Daily stretching of hemiplegic limbs helps avoid contracture 2
• Strictly avoid overhead pulley exercises as they worsen the condition 2, 1, 3

The evidence strongly converges on this point across multiple guidelines - overhead pulleys encourage uncontrolled abduction and can cause harm rather than benefit 2, 3.

Pain Management

• Use acetaminophen or ibuprofen for pain relief if no contraindications exist 1, 3
• Consider neuromuscular electrical stimulation (NMES) for shoulder pain management, though evidence remains mixed 2, 1
• For spasticity-related pain, botulinum toxin injection to the subscapularis and pectoralis muscles may be beneficial 1, 3

Structured Rehabilitation Program

• Implement a rehabilitation program focusing on gentle stretching exercises, maintenance of shoulder range of motion, and motor retraining 1
• Gradually increase active range of motion while restoring alignment and strengthening weak muscles in the shoulder girdle 1
• Teach patients and families proper stretching techniques to continue at home 2

Critical Education Component

• Educate healthcare staff, patients, and family on correct positioning and handling of the affected arm to prevent further injury 1, 3
• This education is essential to prevent further subluxation and promote recovery 1

Monitoring for Complications

• Regularly assess for signs of complex regional pain syndrome (shoulder-hand syndrome) to prevent long-term complications 1, 3

Common Pitfalls to Avoid

• Aggressive passive range-of-motion exercises may cause more harm than good if done improperly - the evidence supporting aggressive ROM is missing, and improper technique can injure the complex shoulder joint 2
• Shoulder strapping/taping has insufficient evidence - the largest trial of 162 patients showed no statistically or clinically significant benefit 2
• Surface NMES compliance has been variable and is less well-tolerated than intramuscular NMES 2