The guidelines formulated by the New York State Workers Compensation Board aim to assist healthcare professionals in providing appropriate treatment for shoulder instability.
Tailored for medical practitioners, these Workers Compensation Board guidelines offer support in determining the right course of action for individuals experiencing shoulder instability.
It’s important to highlight that these guidelines do not replace clinical judgment or professional experience. The ultimate decision regarding treatment for shoulder instability should be a collaborative one, made in consultation between the patient and their healthcare provider.
Subluxation or Dislocation of the Glenohumeral Joint:
History and Mechanism of Injury:
Mechanism of Injury:
- Instability should be evident after a direct traumatic blow to the shoulder or indirectly, such as falling on an outstretched arm or applying significant traction to the arm.
- Cumulative trauma to the shoulder may also lead to instability.
- Symptoms should be exacerbated or provoked by work and initially relieved with a period of rest.
- Symptoms may also worsen with other non-work-related activities, like driving a car.
History may include:
- A slipping sensation in the arm;
- Severe pain with inability to move the arm;
- Abduction and external rotation produce a feeling that the shoulder might “come out”; or
- Feeling of shoulder weakness.
In subacute and/or chronic instabilities:
- Age of onset of instability is important in the history.
- Older age group (over age 30) tends not to re-dislocate.
- Younger age groups require a more aggressive treatment plan.
Avoid any aggressive treatment:
- In patients with a history of voluntary subluxation or dislocation.
- These patients may need a psychiatric evaluation.
Physical Findings:
Anterior Dislocations:
- Likely include loss of normal shoulder contour.
- Fullness in the axilla.
- Pain over the shoulder with any motion.
- Often, the patient holds the extremity in a very still position.
Posterior Dislocations:
- Usually occur with a direct fall on the shoulder or outstretched arm.
- Result in posteriorly directed forces to the humeral head.
- Patients present with an inability to externally rotate the shoulder.
Neurologic Examination:
- Could reveal most commonly axillary nerve injuries.
- Occasionally, musculocutaneous nerve injuries are seen.
Pain Indicators:
- Abduction and external rotation positioning produce pain in those with anterior instability.
- Direct posterior stress in a supine position produces pain in those with posterior instability.
- Longitudinal traction results in a “sulcus sign” (a large dimple on the lateral side of the shoulder) in cases of inferior instability.
Laboratory Tests:
Indication:
- Generally not indicated.
- Recommended in select patients where a systemic illness or disease is suspected.
Testing Procedures:
Recommended in select patients as clinically indicated:X-Ray:
- Indications: Plain x-rays to rule out bony deficit on the glenoid, including AP, axillary view, lateral in the plane of the scapula, and possibly the West Point view.
- Axillary view is used to identify a larger Hill-Sachs lesion of the humeral head.
MRI/CT:
- Indications: On more difficult diagnostic cases with subtle history and physical findings suggesting instability.
- MRI or CT-assisted arthrogram or MRI-assisted arthrogram may be ordered for lateral detachment after four to eight weeks of therapy (done only after other conservative therapies have failed).
Non-Operative Treatment Procedures:
First-Time Acute Severe Bony Involvement:
Therapeutic Procedures:
- Immobilization.
- Therapeutic Exercise.
- Superficial Heat and Cold.
- Ultrasound.
- TENS is not recommended.
- Alteration of Occupation and Workstation.
- May not return to work with overhead activity or lifting with the involved arm until cleared by the physician for heavier activities.
Additional therapies may include:
- Physical Medicine and Rehabilitation.
- Instruction in Therapeutic Exercise and Proper Work Techniques.
- Manual Therapy Techniques.
- Medications.
- Analgesics.
- Anti-inflammatories.
Biofeedback:
- Not recommended for first-time acute severe bony involvement.
Acute or chronic dislocations with large fracture fragments contributing to instability:
Attempt to treat with immobilization: If in an acceptable position, otherwise repair surgically. Return to work: May be directly related to the time it takes for the fracture to heal.
Subacute and/or chronic instability:
Provocative dislocation: Should first be treated similarly to acute dislocation. If acute treatment is unsuccessful: And still having findings of instability, consider operative repair
Operative Procedures:
Recommended in select patients as clinically indicated: Identify causative agent for instability: (e.g., labral detachment, bony lesion, or multidirectional instability).
- Bony block transfer;
- Capsular tightening; or
- Bankart lesion repair.
Post-Operative Procedures:
- The arm is immobilized in a sling for one to 12 weeks post-injury, depending upon the patient’s age.
- Isometric exercises for internal and external rotators and the deltoid are instructed while in the sling.
- Individualized rehabilitation program based upon communication among the physician, the surgeon, and the therapist.
- Depending on the type of surgery, the patient will be immobilized for three to six weeks.
- As soon as it is safe to proceed without damaging the repair, progressive therapy with consultation involving an occupational and/or physical therapist should begin with therapeutic exercise, physical medicine, and rehabilitation.
- During this period, the patient could resume working when:
- Medications: Which would predispose to injury are no longer being prescribed or used.
- The treating physician has cleared: The patient for specific vocational activities.
