Injury Spotlight - Shoulder Dislocation: What to do when your shoulder is unstable!

There are many different things that can go pop in the shoulder, but I’m talking about something very specific today – shoulder dislocations and subluxations. Thankfully, this isn’t the most common injury in pole dancers, but it can be a challenging one to rehabilitate when it occurs in an overhead weight bearing athlete. AKA a pole dancer. In today’s blog I’m going to cover the most common questions I see from pole dancers after experiencing a traumatic shoulder injury.

Firstly just to get you up to date on the lingo –

• a subluxation is when the shoulder (glenohumeral joint) partially leaves its socket

• a dislocation is when it fully leaves its socket

Ok, let’s understand a bit more about the shoulder joint:

Relevant Shoulder Anatomy

The shoulder is comprised of three bones: the humerus, clavicle and scapula and is considerably the most unstable joint in our body. And for a good reason. It has a huge range of motion with very little physically stopping it. In fact the humeral head is like a golf ball sitting on a tee and a lot of effort is required to keep it centred in the joint.

Stability in the shoulder is a delicate balancing act achieved by strong ligamentous/capsular and muscular supports. But when the system is working together, the joint surfaces line up perfectly with one another.

Ligament stability Our passive restraints of the shoulder are our ligaments and labrum. Our labrum is our joint cartilage that creates a suction or vacuum-like effect on the shoulder joint to keep it in place. The labrum is commonly injured in a shoulder dislocation. And once our labrum is torn, the suction effect is diminished and we rely heavily on other structures to keep the shoulder in its socket. Labral tears can also occur without the dislocation from acute trauma or overuse.

Our anterior ligaments and synovial joint capsule make up our other form of passive constraint. The inferior glenohumeral ligament is the main constraint to shoulder movement anteriorly when the arm is raised over head, specifically when abducted and/or externally rotated. So this ligament is particularly important for pole dancers, particularly on the pushing on.

Muscular stability Despite all of our ligamentous stability, we rely primarily on our muscles to stabilise the joint. All of the muscles that attach to the shoulder have a direction of pull, however the primary dynamic stabilisers of the shoulder are the rotator cuff muscles and the biceps, helping to keep the shoulder in its socket.

So where does it all go wrong? For the shoulder to dislocate, there must be a disruption in the net glenohumeral joint reaction force which causes the humeral head to fall outside the socket. There are two common ways a shoulder will dislocate: anteriorly or posteriorly. Usually a shoulder will dislocate anteriorly from direct trauma or force applied to the shoulder/arm in a posterolateral direction. But some people are genetically more susceptible to a dislocation because of general ligament laxity.

Anterior dislocation In the general population 97% of these dislocations are anterior, meaning the shoulder dislocates through the front of the joint. When an anterior dislocation occurs, the ligaments and capsule are stretched, losing their integrity, and often the lowest most anterior part of the labrum is detached. This is known a Bankart lesion. In severe cases damage to the rotator cuff also occurs.

Posterior dislocation In the pole dance community I frequently see posterior shoulder translation in the bottom arm. These injuries are usually less acute in nature and have occurred over time due to the high amounts of body weighted load without correct muscular engagement. Our bodies weren’t really designed to be upside down, but what can I say, it’s addictive!

Acute posterior dislocations are usually caused by a fall onto an outstretched hand by combining movements of flexion, adduction and internal rotation. These injuries are often associated with labral and rotator cuff pathology.

Ok you’ve dislocated your shoulder, what do you do next?

Most likely you were taken by ambulance to hospital to either 1: check your shoulder self relocated back in the joint or 2: to get it put back in. An X-ray is a must here as a bare minimum to confirm there are no fractures involving the joint. From here it’s up to the discretion of your physio or specialist as to whether further imaging is required.

Is my pole career over? No, absolutely not! You should be treated with a lot more caution than the average Joe/Joanne because of the high demands of pole. However, if someone tells you you’ll never be able to pole again after 1 dislocation, then it’s probably time to find a new surgeon/therapist. Return to pole takes a great deal of rehab, but it is possible after dislocation.

If a shoulder dislocation is managed well the first time, then it will allow for a return to overhead weight bearing activities including pole. This does take time so don’t expect to be back at pole within 6 weeks!

Do I need surgery? This depends on quite a few factors; primarily the extent of the damage and how your body has processed the injury, if you’re a repeat offender, your strength, your joint laxity and your age to name a few. For non-pole athletes we usually recommend non-surgical care with intense physiotherapy guided rehabilitation.

However I generally have a lower surgical tolerance for pole dancers/aerialists because our entire body force goes through our shoulder joint! So here are the facts that are important to know:

• Rates of re-dislocations are very high in the 15-25 year old group, reportedly as high as 92-96% (Boone & Arciero, 2010)

• First time shoulder dislocaters aged between 25-40 are less likely to dislocate, with a re-injury rate of 40%

• Rates of re-dislocations are very low in the 40 year old group, at around 15%

• If you dislocate your shoulder twice, you’re likely to keep re-dislocating it

So when a patient presents to me post shoulder dislocation, I’m considering all potential risk factors of re-dislocation and in conjunction with the surgeon are determining whether they can be managed conservatively or require surgery.

Are there different types of shoulder surgeries? Yes – a few! Currently there are 2 types of surgeries commonly performed in Australia for shoulder dislocations.

Arthroscope For a non-pole dancer, an arthroscopic reconstruction is the first point of call, where the damaged ligaments and labrum are sown back up to re-establish passive joint stability. From here it’s up to the therapist and patient to work on active muscle stability. The main benefit of this surgery is it’s a relatively simple surgery performed arthroscopically (small wound incision). The negative is that a number of these operations fail and go on to have follow up surgery. A study in 2019 showed a 33.3% risk of recurrent instability/apprehension post-surgery and a 25% rate of re-dislocation/subluxation (Kramer et al., 2019). This study is consistent with other past studies.

Laterjet Approach In some cases, specifically repeat dislocaters or multi-trauma injuries, a surgeon may first suggest a Laterjet approach. The benefit is that shoulders post this surgery rarely dislocate and these patients report considerable confidence in their shoulder. The cons are it’s an open procedure, and there has been some reported ongoing loss of muscle strength in subscapularis and loss in shoulder abduction and external rotation range of motion (Garwell et al., 2014). This is my preferred choice of surgery for weightbearing athletes due to the barely non-existent risk of re-dislocation, but like anything should be discussed in detail with your surgeon due to the potential complications.

Rehab Time

Dependent on surgery, the patient’s baseline assessment and several other factors, rehabilitation of a shoulder dislocation takes between 3-6 months on average. Return to pole however is not decided on time post operation, but instead passing of strength and stability criteria, i.e my patients go back to pole/aerial at 6 months if they aren’t meeting set criteria, but they can go back as early as 3 months if they are.

Hitting certain strength milestones and stability milestones reduces your risk of re-injury and chances of success. So if you have to rehabilitate an injury, don’t get too fixated on the time frame (easier said than done, I know!). Focus instead on the journey to actually getting as strong as can be and preventing future injury. And use any time off pole to work on other things that need improving too, i.e leg strength and range of movement to assist with a whole range of tricks when you return! Future you will thank you!

Are you recovering with a traumatic shoulder injury and can’t seem to make it back to the pole?

Online telehealth appointments can be booked with the Pole Physio via our ‘Book Online’ page that can be found here. Assessment and tailored rehabilitation are provided in accordance with best practice and evidence-based treatment to help you unleash your 'poletential'.

Until next time, train safe.

The Pole Physio

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References:

• Boone, J. L., & Arciero, R. A. (2010). First-time anterior shoulder dislocations: has the standard changed? Br J Sports Med, 44, 355-360

• Garewal, D., Evans, M., Taylor, D., Hoy, G. A., Barwood, S., & Connell, D. (2014). Shoulder Structure and Function Following the Modified Latarjet Procedure: A Clinical and Radiological Review, Shoulder Elbow, 6(1): 23–28.

• Kramer, J., Gajudo, G., & Pandya, N. K. (2019). Risk of Recurrent Instability After Arthroscopic Stabilization for Shoulder Instability in Adolescent Patients. Orthopaedic journal of sports medicine, 7(9).