ANTERIOR SHOULDER

DISLOCATION

Presented by: Ovesh talashi M.P.T IST YEAR

INTRODUCTION
 Introduction
 Anterior shoulder dislocation : The head of humerus dislocates anteriorly and
medially in relation to its normal anatomical position, opposite to the scapular
glenoid fossa.(3) In the competitive athlete, it is a relatively common problem.
The etiology of glenohumeral dislocation that can affect the athlete runs a wide
spectrum, from an isolated traumatic dislocation to repeated microtrauma or
congenital laxity.(6 )

 The anatomy of the shoulder allows for greater mobility yet sacrifices stability.
For this reason the shoulder is one of the most commonly dislocated joint in the
body. Approximately 2% of the general population and 7% of the young athletes
suffer from glenohumeral joint dislocation (2).
• Shoulder dislocations or subluxation are the
most common athletic injuries of the shoulder
in young athletes.(4)
• The shoulder displaces in an anterior
direction –98% and in about 2% of cases it
displaces in the posterior direction.(3)
• It occurs frequently in athletes with peaks in
the second and sixth decades of life .(2,3)
ANATOMY AND BIOMECHANICS
 Anatomy and Biomechanics

 The anatomic configuration of the shoulder

joint (glenohumeral joint) is often compared to a golf ball on a tee.(6)

 This analogy is used because the articular surface of the round humeral head is
approximately four times greater than that of the relatively flat scapular glenoid
fossa.(6)

 Glenohumeral joint is a multiaxial, ball and socket, synovial joint that depends
upon primarily on the muscles, ligaments rather than bones for its support,
stability and integrity. This joint has 3 axes and 3 degrees of freedom

 The stability and movement of the shoulder is controlled by the rotator cuff
muscles, ligaments, and the capsulolabral complex of the shoulder.
 Joint Stability Depends Upon: (3,5,6)

STATIC FACTORS DYNAMIC FACTORS

• Bony congruence of the joint
surfaces
• Scapular stabilizers
• The geometry of the
• Rotator cuff muscles and the
glenohumeral joint,
long head of the biceps
• The glenoid labrum
• Proprioceptive input and
• The joint capsule and ligaments
• The negative intraarticular Neuromuscular control

Pressure
Static stability
 The bony surface of the glenoid is almost
flat. The depth of the glenoid cavity has been
found to average only 2.5 mm in the
transverse plane and 9.0 mm in the caudal-
cranial plane [7].

 The labrum is a fibrocartilaginous ring

which attaches to the bony rim of the
glenoid fossa. The labrum doubles the
depth of the glenoid fossa to provide
stability.(5)

 The labrum provides attachment of the

capsule, the glenohumeral ligaments
anteriorly, and the biceps tendon
superiorly.
 The geometry of the glenohumeral joint (5)

 The angle between the humeral neck and shaft is about 130 to 140 degree.

 The humeral head is retroverted 30 – 40 degrees relative to the transepicondylar

axis.

 The scapula rests in a position of 30 to 45 anterior to the coronal plane, and the
glenoid in the resting position has a 5 degree superior tilt and 7 degree
retroverted.

 The orientation of the glenoid fossa relative to the humeral head provides a
barrier to posterior and inferior glenohumeral joint instability .
 The Joint Capsule , Ligaments And Negative
Intraarticular Pressure (5)

The glenohumeral joint capsule attaches proximally to the glenoid labrum

and distally to the surgical neck of the humerus. The capsule is lax in the
mid ranges of glenohumeral joint motion and becomes taut at the extremes
of motion. The glenohumeral joint capsule acts as a static stabilizer at end
ranges of glenohumeral joint motion.

The glenohumeral ligaments are thickenings of the glenohumeral joint

capsule. The primary ligaments of GH joint - the superior, middle, and
inferior glenohumeral ligaments – play an important role in stabilizing the
shoulder. Another ligament involved in the static stability of the
glenohumeral joint is the coracohumeral ligament.
Any translation of the humerus on the glenoid would result in tension of the
capsuloligamentous structures on the same and opposite sides of the translation.

The superior glenohumeral ligament is limiting inferior translation in adduction and

also acts as a restraint to anterior translation and to lateral rotation up to 45 deg.
abduction .
The coracohumeral ligament seems to have a similar role to the superior
glenohumeral ligament in preventing anterior and inferior glenohumeral joint
instability and helps limit lateral rotation below 60 degree abduction.

The middle glenohumeral ligament is the least consistent of the glenohumeral

ligaments and is the primary restraint to anterior glenohumeral joint instability when
the humerus is limits lateral rotation between 45 - 90 degree abduction.
The inferior glenohumeral ligament is the most important of the three
ligaments and it includes an anterior band and a posterior band, which are
divided by a loose area of capsule referred to as the axillary pouch .With the
humerus in 90 of abduction, the anterior band of the inferior glenohumeral
ligament becomes the primary restraint to anterior glenohumeral instability.

The intact glenohumeral joint has a negative intra-articular pressure creating a

vacuum effect across the glenohumeral joint . Loss of this intraarticular
pressure results in inferior subluxation of the glenohumeral joint. Although the
vacuum-stabilizing effect of the negative intra-articular pressure is primarily a
stabilizer against inferior instability, it also serves to prevent instability in all
other directions.
Dynamic stability
 Rotator cuff muscles (3,5)
 Concavity compression refers to the compressive forces placed on the
glenohumeral joint during rotator cuff muscle cocontractions. These forces press
the humeral head into the glenoid fossa, center the humeral head within the
glenoid fossa, and help resist glenohumeral translation.
 Because the glenohumeral ligaments are lax in the mid ranges of glenohumeral
joint motion, coordinated rotator cuff muscle contraction and concavity
compression are particularly important mechanisms for glenohumeral joint
stability in these ranges .
 With rotator cuff muscle contraction, it is possible that the glenohumeral joint
capsule develops tension and increases in stiffness, acting as a dynamic
musculoligamentous stabilizing system.
 The rotator cuff muscles also provide glenohumeral joint stability through
passive muscle tension and act as barriers to glenohumeral joint translation during
active motion.
 In particular, the subscapularis seems to be an important stabilizer of anterior and
posterior glenohumeral joint stability
 Origin on Attachment
Muscle Function Innervation
scapula on humerus

Superior n
Supraspinat supraspinous middle facet Abducts Suprascapular
us muscle fossa Greater Humerus nerve (C5)
tubercle
Posterior Suprascapular
Infraspinatu infraspinous externally
facet greater nerve (C5-
s muscle fossa rotates the
tubercle C6)
Inferior facet externally
Teres minor Middle half Axillary
greater rotates
muscle lateral border nerve (C5)
tubercle humerus
Upper and
lesser
internally Lower
Subscapular subscapular tubercle (60%
rotates humer subscapular
is muscle fossa ) or humeral
us nerve (C5-
neck (40%)
C6)
Proprioception and neuromuscular control

 Proprioception and neuromuscular control refer to the mechanism

by which the position and movements of the shoulder girdle are
sensed (proprioception), are processed, and result in an appropriate
motor response (neuromuscular control) [5]. Glenohumeral joint
instability often is associated with delay in proprioception. The
abnormal proprioception is restored after surgical correction of the
joint instability, suggesting that the mechanism of proprioceptive
deficits in unstable glenohumeral joints is a lack of appropriate
capsuloligamentous tension.
CLASSIFICATION
Classification of glenohumeral joint instability (5)

 It includes the degree, frequency, etiology, and direction of instability.

1. The degree includes dislocation, subluxation, and microinstability.

A dislocation implies that the humeral head is disassociated from the

glenoid fossa and often requires manual reduction.

A subluxation occurs when the humeral head translates to the edge of the
glenoid, beyond normal physiologic limits, followed by self reduction.

Microinstability is due to excessive capsular laxity, is multidirectional,

and is associated frequently with internal impingement of the rotator
cuff
 The frequency of instability can be acute or chronic. Acute instability
involves an acute injury resulting in subluxation or dislocation of the
glenohumeral joint. Chronic instability refers to repetitive instability
episodes.
 The etiology of glenohumeral joint instability can be traumatic or
atraumatic. Unidirectional instability frequently is caused by a
traumatic event resulting in disruption of the glenohumeral joint.
Atraumatic instability refers to glenohumeral joint instability due to
congenital capsular laxity or repetitive microtrauma.
 Glenohumeral joint instability can be unidirectional or multidirectional.
Unidirectional instability refers to instability only in one direction. The
most frequently occurring type of unidirectional instability is traumatic
anterior instability
ETIOLOGY
 ETIOLOGY
 The injury is common in ice hockey, wrestling, judo, rugby, football, basketball,
baseball, and gymnastics, volleyball, martial arts, throwing athletes, weight lifters
and swimmers.(8,6)

 Initial traumatic anterior dislocations may be due to a force applied directly to the
posterior aspect of the humeral head, driving it anteriorly. However, the more
common mechanism in sport is an indirect force via the externally rotated and
abducted limb, such as would be seen in a football player attempting to block a high
pass(8) and also seen in a basketball player who attempts to block an overhead
pass.(3)

 Other mechanisms of injury as a fall onto an elevated outstretched arm and direct
force application to the posterior aspect of the humeral head.
 Comparison of the incidence of soccer and rugby injuries clearly indicates that
rugby union is associated with a higher rate of injury than soccer.(6)

 Shoulder injuries in professional rugby players are highly occurred. Tackling

has been shown to be responsible for a large number of these injuries.(10)
Shoulder injury in Rugby players (1)

 The mechanoreceptors are unable to

accurately report shoulder position in the
outer range (stretch) position due to
repetitive tackling, then there is a
potential for the anterior structures to
become stressed before any
compensatory muscle contraction can
take place. These results highlight the
presence of sensorimotor system deficits
following repeated tackling. These deficits
Protective equipment for shoulder
 Injury in Tennis Player (12)

•Tennis players are prone to developing disorders of the shoulder because of the
repetitive nature of the game.
•In one study by Lehman, shoulder pain was present in 24% of 270 tennis players
between the ages of 12 and 19 years. The incidence of shoulder pain increased to
50% in middle-aged tennis players.
• Overhand throwing and racquet sports place repetitive high-velocity stress on
the shoulder joint, gradually resulting in subluxation or movement of the humeral
head anteriorly. This instability may
lead to subluxation and impingement
of the rotator cuff muscles.
 Injury in Martial Arts (13)

† Mixed Martial Arts (MMA) athlete present with a traumatic, anterior shoulder
dislocation.
† The athlete in Jiu Jitsu training (a form of martial arts which focuses on ground
fighting, or grappling, with emphasis on joint locks, chokes, and various forms of
submissions) .
† The object of this exercise is to force the opponent to concede defeat (or “tap
out”) with the application of a submission hold.
† At the time of incident, the patient with his opponent’s “guard” position whereby
the opponent is lying supine with his legs wrapped around the patient’s waist. The
opponent forcefully pulled the patient’s left arm into a position of horizontal
adduction causing dislocation.
 Injury in ice hockey (14)
Professional ice hockey is a fast-paced, physical game that puts high
demands on shoulder function. The shoulder is one of the most common
areas of injury in hockey. Most players use a left-handed grip, which means
that the left shoulder is the most dominant.
When the left hand and arm are moved suddenly into flexion above shoulder
height, as the positions of perceived instability.
Baseball pitchers have significantly
decreased joint position sense at the
extreme of external rotation than
normal rotation. This lack of
awareness of joint position could
potentially expose the GH joint to
unbearing loads and result in
injury.(1)
PATHOLOGY
Pathophysiology of shoulder instability(3)

 Glenohumeral joint is stabilized by dynamic

and static restraints.
 Superficial and deep musculature acts as a

dynamic stabilizer.
 The capsuloligamentous structures, glenoid

labrum, glenoid's articular surface, with the

negative intra-articular pressure, and the
three dimensional anatomy of the humeral
head serve as static stabilizers.
 Shoulder instability occurs when one or more
 The labrum, attached to the rim of the glenoid,
contribute near 50% to the total depth of the
socket . In addition, joint congruity is maintained
by a negative intra-articular pressure, which can
be lost following a damage to the capsule.
 The middle glenohumeral ligament restrains
anterior translation of the shoulder, when the arm
is in external rotation at the mid-range of
abduction. The anterior band of the inferior
glenohumeral lig. restrains the anterior
translation of the humeral head, when the arm is
in abduction and external rotation. By this
movement the arm is dislocated anteriorly when
sufficient force is applied.
 Tear of the anterior band of the inferior
glenohumeral ligament, with subsequential
detachment of the anterior labrum, i.e. "Bankart
lesion", is the main cause of traumatic anterior
instability. Anterior detachment of the labrum
decreases the socket depth in the
anteroposterior plane. In 97% of patients with
traumatic anterior instability the underlying
pathology is a Bankart lesion. A displaced
labrum reduces the depth of the glenoid by half,
and a lax IGHL has been shown to double
glenohumeral translation.
 A forceful impact of the posterolateral humeral
head against the bony glenoid in anterior
BANKART LESION
Hill sach Lesion
RISK FACTORS
Predisposing factors for recurrent shoulder
dislocation after treatment (9)

Redislocations and Redislocations

Age and Gender

Redislocation
and Type of
Lesion

Redislocations
Redislocations and Time from
and Dominant the First
Side Dislocation to
Surgery
 The patient’s age at the time of injury is
inversely related to the incidence of
dislocation recurrence rate. The outcome of
non-operative treatment for acute traumatic
anterior instability of the shoulder especially
in the younger population is poor.
Dislocation recurs in 66% to 100% of people
aged 20 years or under, 13% to 63% of
people aged between 20 and 40 years, and
0% to 16% of people aged 40 years or older.
(3)
ASSESSMENT
 Assessment (5)
1. Demographic data: the patient’s chief complaint, age, hand dominance, and
vocational and avocational activities.

 Common complaints of patients with shoulder instability include pain, popping,

catching, locking, an unstable sensation, stiffness, and swelling .

2. Pain history: the location, quality, intensity, and any radiation of the pain should be
determined.

3. The patient should be asked about exacerbating and alleviating factors.

 It also is important to determine when the symptoms first were noticed, the frequency
of symptoms, and positions or activities that result in instability episodes. A history of
acute trauma or chronic, repetitive microtrauma should be obtained.
Physical examination (5)

 Inspection
 Palpation
 Glenohumeral joint range of motion (ROM)
 upper extremity strength
 sensation (including proprioception),
 reflex evaluations, and
 special tests for glenohumeral joint instability.
Inspection
Shoulder girdle should be inspected for :
 posture, discoloration,swelling, scars,
muscle atrophy, and deformity.
 Scapular position :Winging of the scapula may be associated with
scapulothoracic dyskinesis, muscle imbalance or fatigue, or an
injury to the spinal accessory nerve or long thoracic nerve.
 Scars that are thin or spreading may suggest an underlying
connective tissue disorder.
Special tests for anterior dislocation

1. Anterior apprehension (crank) and relocation tests

2. Anterior drawer test

3. Load and shift test

Anterior apprehension (crank)
and relocation tests
 The patient is placed in the supine position.
The examiner abducts the patient’s shoulder 90
and flexes the elbow 90. The examiner uses
one hand slowly to externally rotate the
patient’s humerus using the patient’s forearm
as the lever, while the other hand is placed
posterior to the patient’s proximal humerus and
exerts an anteriorly directed force on the
humeral head. The test is considered positive if
the patient indicates a feeling of anterior
dislocation. The relocation test is positive if the
examiner removes the hand from behind the
proximal humerus, places it over the anterior
proximal humerus, and exerts a posteriorly
directed force, and the patient reports a
reduction in the apprehension
 Anterior Drawer test

 The patient is placed supine on the

examination table. The hand of the patient’s
affected shoulder is placed in the examiner’s
axilla and grasped by the examiner’s arm.
The patient’s shoulder is abducted 80 to 120
and flexed 0 to 20. The examiner uses the
other hand to stabilize the scapula and
monitor for anterior translation of the
shoulder. The examiner grasps the patient’s
proximal humerus with the remaining hand
and exerts an anteriorly directed force on the
humeral head. A positive test is indicated by
excessive anterior translation of the humerus
relative to the glenoid
 Load and shift test

 The patient is in a seated position with

the arms at the sides. The examiner
stabilizes the patient’s affected
shoulder with one hand, while pressing
the humeral head into the glenoid fossa
with the other hand. An anterior and
posterior force is placed on the
proximal humerus, and the amount of
humeral anterior and posterior
translation is assessed.
The instability severity index score

•J Bone Joint Surg

[Br] 2007;89-
B:1470-7.
MANAGEMENT
The classified glenohumeral joint instabilities into two broad
categories: traumatic and atraumatic.
Based on the classification system of glenohumeral
instability, as well as several other factors, a non-operative
rehabilitation program may be developed.
Seven key factors should be considered when designing a
rehabilitation program for a patient with an unstable shoulder.
 Treatment

 The treatment options for glenohumeral joint dislocation

include :
Nonoperative Operative

Reduction Surgical
Immobilization Postoperative
Physical rehabilitation -rehabilitation

Traumatic Atraumatic
NON OPERATIVE TREATMENT
 Goals of conservative treatment

 The nonoperative treatment of glenohumeral joint instability should

include
1. pain and edema control,
2. monitoring and restoring shoulder girdle ROM,
3. protection of the static glenohumeral joint stabilizers,
4. obtaining full function of the dynamic stabilizers,
5. restoring joint proprioception, and correcting associated kinetic chain
deficits.
The ultimate goal of this program should be the unrestricted return of the
patient to preinjury activities.
REDUCTION
 Closed reduction techniques for acute
anterior shoulder dislocation (15)

 Most dislocations can be reduced in the emergency department using

simple methods. The ideal method should be simple, easy, quick,
effective, atraumatic, pain-free, require little assistance or medication,
and cause no additional injury to the shoulder joint, musculoskeletal or
neurovascular structures.

 Closed reduction must be performed under relaxation and sedation in

order to avoid additional bony or soft tissue injuries.

 The techniques usually involve one or more manoeuvres – traction,

rotation, pulsion and/or abduction.
 They can be classified according to their principal mode of
action as follows: -

A. Traction-countertraction

• In adduction –by Hippocrates

• In forward flexion – by Stimson and Spaso

B. Leverage – by Kocher and Milch

C. Scapular manipulation
 Hippocratic method (15)
The physician's foot is placed in the patient's axilla against the chest wall while leaning
backward. Slow, gentle longitudinal traction is applied to the affected arm in 30-40° abduction
for about one minute. The foot acts as a counterforce and as a lever to push the humeral head
laterally while the physician pulls the head toward the patient's foot along the surface of the
glenoid, effectively adducting the affected arm. It has
been suggested that the elbow should be flexed 90° to
relax the biceps muscle.
Internal or external rotation of the shoulder may
also facilitate reduction. It has been claimed to be
most effective for subglenoid dislocations.
The method requires one operator only.
Brachial plexus and vessel injuries are common.
 Stimson or hanging arm (gravity) method (15)

The patient lies prone. Appropriate weights around 5-7 Kg are taped to the
wrist, forearm or above the elbow. The affected arm hangs free over the edge of
the stretcher. It may take 20-30 minutes for reduction to occur. The Stimson
method is simple, easy to learn, safe, atraumatic, and effective
Spaso method ("reversed Stimson") (15)

American Journal of Emergency

MedicineVolume 27, Issue 4,May
2009
The Spaso technique: a
prospective study of 34
dislocations the Spaso technique
as a safe and effective manoeuvre
for the reduction of anterior
shoulder dislocations, with an
acceptable success rate.
 Scapular manipulation methods

The patient lies prone with the shoulder in 90° of

forward flexion and external rotation. The forearm
is suspended from the stretcher with the wrist
secured and the elbow flexed. Forward traction is
maintained with about 5-7 Kg of hanging weight
to the wrist or with manual traction for 5-10
minutes. With the patient relaxed, the physician
pushes medially on the tip of the scapula with
both thumbs (lifting it occasionally) while
externally rotating the superior and medial aspects
of the scapula
IMMOBILIZATION
Immobilization in 10° of external rotation for three weeks
reduces the relative risk of recurrence of a first-time traumatic
anterior shoulder dislocation when compared with the risk
associated with conventional immobilization in internal rotation.
This treatment is particularly beneficial for those who are thirty
years of age or younger.(4) COMPLICATIONS: There are a
temporary stiffness of the involved shoulder after immobilization
in external rotation. This problem resolved within a month or two
through the use of self-directed range-of-motion exercises. No
other complications related to immobilization are reported.(4)
Anterior instability taping. (5)
Tape is used to lift the head of the humerus
superiorly and posteriorly so that the head of
the humerus is slightly externally rotated. The
tape is pulled diagonally across the scapula,
ending just medial to the inferior border of
the scapula.

Taping can reduce anterior humeral head

translation and can be used to elevate and
center the humeral head in the glenoid fossa
for patients with multidirectional instability .
This positioning maintains proper shoulder
girdle alignment during neuromuscular
reeducation training.
NON-OPERATIVE REHABILITATION FOR
TRAUMATIC SHOULDER JOINT INSTABLITY
Traumatic dislocation rehabilitation protocol

 I. PHASE I - ACUTE MOTION PHASE

Goals:
• Protect healing capsular structures
• Re-establish non-painful range of motion
• Decrease pain, inflammation, and muscular spasms
• Retard muscular atrophy / Establish voluntary
muscle activity
• Re-establish dynamic stability
• Improve proprioception
 II. Phase II - Intermediate Phase
Goals:
• Regain and improve muscular strength
• Normalize arthrokinematics
• Enhance proprioception and kinesthesia
• Enhance dynamic stabilization
• Improve neuromuscular control of shoulder complex

Progress range of motion activities at 90 degrees abduction to

tolerance (painfree)
 III. Phase III - ADVANCED Strengthening Phase

Goals:
• Improve strength/power/endurance
• Improve neuromuscular control
• Enhance dynamic stabilizations
• Prepare patient/athlete for activity

Continue use of modalities (as needed)

Journal of Manipulative and Physiological Therapeutics
Volume 24 • Number 6 • July/August 2001
‘Stability pushups’ Patient performs a
plyometric pushup while simultaneously
resisting horizontal abduction of the affected
limb.
Weight bearing exercises through the limb (closed kinetic chain exercises)
facilitates the activity of the rotator cuff muscles, and can be utilised in positions
of forward lean standing or in four point kneeling from a four point kneeling
position joint position reproduction can be utilised (figure 3). These can be
progressed to a three point position ( by extending the other arm or either leg)
and further progressed to two point weight bearing which will facilitate the
posterior chain to aid with scapular stabilisation.
Atraumatic Instability protocol
OPERATIVE TREATMENT
 Bankart Repair
 Restoring the normal anatomy of the shoulder
is the most effective way of preventing recurrent
instability and improving function in the young
and athletic population. Restoring the anatomy
primarily means repairing the torn labrum back to
the rim of the glenoid. This is called a Bankart repair.
This can be done surgically with an arthroscopic
technique or an open technique.
 The arthroscopic technique involves making three very small incisions and
using a camera to “see” inside the shoulder joint. The torn tissue is identified
then suture anchors or bio-absorbable tacks are used to repair the torn tissue
back to its anatomic location
PHASE I (surgery to 6 weeks after surgery)
PHASE II (begin after meeting Phase I criteria,
usually 6 weeks after surgery)
PHASE III (begin after meeting Phase II criteria,
usually 10-11 weeks after surgery)
PHASE IV (begin after meeting Phase III criteria,
usually 15 weeks after surgery)
PHASE V (begin after meeting Phase IV criteria, usually 20
weeks after surgery)
Supraspinatus exercises with hand weights and
therabands. Always have your thumb pointing to the
floor, your arm out 45 degrees, and keep your arm
below shoulder height.

Internal Rotation. Hold a
small ball or towel between
arm and side and slowly
rotate forearm across body.
External Rotation. Hold a
small ball or towel between
arm and side while holding a
weight or band; slowly
rotate forearm away from
side
Scapular Elevation, Shrugs.
Stand with arms at side in
straight standing posture,
shrug or raise shoulders up
towards ears.
 Shoulder Extension. Lie on
Scapular Protraction. Lie stomach and with arm
on back holding a hand hanging off the side of the
weight. bed.
Prevention

 Maintain excellent strength and stability of the shoulder and

upper back muscles.
 Try not to fall
 Shoulder braces and shock absorbers may help.
 Functional Brace (1)
 The Sully brace can be used in overhead
Sports, such as basketball or volleyball.
 The DukeWyre brace can be used in
contact sports such as football, lacrosse, or
rugby.
 Chu et al concluded that a Sully brace
improves active joint-reposition sense at 10
degrees from full external rotation for
subjects with unstable shoulders.
In a study of the effectiveness of the Duke Wyre harness and Sawa brace using a motion
analysis system, Weise et al found that neither brace could control abduction to their limit.
The braces protected against the position of 90 degrees abduction and external rotation
when the limit was set at 45 degrees. The Sawa brace was more effective than the Duke
Wyre brace for that purpose.
 References
1. Ian Horsley , Proprioception and the Shoulder
2. Current clinical trends in first time traumatic anterior
shoulder dislocation, Merit Research Journal, july 2013
3. J Orthop Sports Phys Ther 2002;32:497–509
4. Immobilization in External Rotation After Shoulder
Dislocation Reduces the Risk of Recurrence, 2007 by the
journal of bone and joint surgery
5. Glenohumeral instability and dislocation, Phys Med
Rehabil Clin N Am,(2004) 575
6. Injuries in youth amateur soccer and rugby, Br. J. Sports
Med. 2004;38;168-172)
7. Clin Sports Med 23 (2004) 335– 351, shoulder instability
9. Predisposing factors for recurrent shoulder dislocation after arthroscopic treatment,2009
by the journal of bone and joint surgery
10. Shoulder injuries in professional rugby: a retrospective analysis, Journal of Orthopaedic
Surgery and Research 2013, 8:9
11. Shoulder instability and surgical stabilization, sports medicine update november/december
2008
12. Musculoskeletal Injuries in Tennis, Phys Med Rehabil Clin N Am 17 (2006) 609–631
13. Traumatic anterior shoulder dislocation: a case study of nonoperative management in a
mixed martial arts athlete,, J Can Chiropr Assoc 2009; 53(4)
14. Chiropractic Management of a Professional Hockey Player with Recurrent Shoulder
Instability, Journal of Manipulative and Physiological Therapeutics Volume 24 • Number
6 • July/August 2001
15. Hong Kong j. emerg. med. Vol. 11(3) Jul 2004, Closed reduction techniques for acute
anterior shoulder dislocation
16. Rehabilitation Guidelines for Anterior ShoulderReconstruction with Arthroscopic Bankart
Repair, 2011, 6 2 1 S c i e n c e D r i v e
17. First-time traumatic anterior dislocation of the shoulder in young adults :The position of
the arm during immobilisation revisited, Acta Orthop. Belg., 2005, 71