Shoulder Subluxation: Difference between revisions

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== Definition  ==
== Definition  ==
[[File:Inferior-subluxation-of-the-humerus.jpeg|thumb|Inferior-subluxation-post overdose.]]


Glenohumeral subluxation is defined as a partial or incomplete dislocation that usually stems from changes in the mechanical integrity of the joint. In a subluxation, the humeral head slips out of the glenoid cavity as a result of weakness in the rotator cuff or a blow to the shoulder area. A subluxation can occur in one of three types: anterior (forward), posterior (backward), and inferior (downward).&nbsp;The difference with a shoulder dislocation is the fact that the humeral head pops back into its socket.  Anterior dislocation often occurs when the arm is outstretched and is forced backwards. <sup>[21]</sup><br>  
Shoulder subluxation, a subset of [[Shoulder Instability|shoulder instability]], occurs when the shoulder joint partially dislocates. In this condition the [[Humerus|humeral]] head slips out of the [[Glenoid Labrum|glenoid]] cavity as a result of weakness of [[Rotator Cuff|rotator cuff]]  or looseness of the glenohumeral ligaments.<ref name=":0" />   
== Epidemiology ==
Studies are limited that investigate the epidemiology of shoulder subluxation, with most studies focus more on shoulder dislocations.<ref name=":0">Vitoonpong T, Chang KV. [https://www.ncbi.nlm.nih.gov/books/NBK507847/ Shoulder Subluxation]. InStatPearls [Internet] 2020 Aug 29. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK507847/ (accessed 8.1.2023)</ref>


== Clinically relevant anatomy  ==
* In a study on shoulder subluxations, 45.5% experienced the first subluxation event, while the remaining 54.5% had recurrent shoulder subluxation.<ref name=":0" />
* Shoulder subluxations frequently occur in people with hemiplegic stroke or with a paralysed upper limb (see [[Hemiplegic Shoulder Subluxation]]). The reported incidence varies greatly from 17% to 81% <ref name="Huang SW et al, 2012">Huang SW, Liu SY, Tang HW, Wei TS, Wang WT, Yang CP. Relationship between severity of shoulder subluxation and soft-tissue injury in hemiplegic stroke patients. J Rehabil Med. 2012 Sep;44(9):733-9.</ref>&nbsp;<ref name="Hartwig M et al, 2012">Hartwig M, Gelbrich G, Griewing B. Functional orthosis in shoulder joint subluxation after ischaemic brain stroke to avoid post-hemiplegic shoulder-hand syndrome: a randomized clinical trial. Clin Rehabil. 2012 Sep;26(9):807-16.</ref>.&nbsp;


The [http://www.physio-pedia.com/Glenohumeral_Joint shoulder joint] (or glenohumeral joint) permits the greatest range of motion of any joint. Because it is also the most frequently dislocated joint, it provides an excellent demonstration of the principle that stability must be sacrificed to obtain mobility.<sup>[19]</sup> The shoulder joint consists of 3 bone structures: humerus, scapula and clavicula. These bones make a total of 3 synovial joints: gleno-humeral , sterno-clavicular and acromio-clavicular joint. Besides these you also find the subacromial “joint” and the scapular-thoracal “joint”.<sup>[1, Level 4]</sup> The size of the glenoid cavity is increased by a fibrous cartilaginous glenoid labrum, which continues beyond the bony rim and deepens the socket. The bones of the pectoral girdle provide some stability to the superior surface, because the acromion and coracoid process project laterally superior to the head of the humerus. But most of the stability is provided by the surrounding skeletal muscles, with help from their associated tendons and various ligaments. The major ligaments that help stabilize the shoulder joint are the glenohumeral, coracohumeral, coracoacromial and the acromiohumeral ligaments. The acromioclavicular ligament reinforces the capsule of the acromioclavicular joint and supports the superior surface of the shoulder. The muscles that move the humerus stabilize the shoulder more than all the ligaments and capsular fibers combined. Muscles originating on the trunk, pectoral girdle and humerus cover the anterior, superior and posterior surfaces of the capsule. The tendons of the M. supraspinatus, M. infraspinatus, M. teres minor and M. subscapularis reinforce the joint capsule and limit the range of motion. These muscles, known as the rotatorcuff, are the primary mechanism for supporting the shoulder joint and limiting its ROM.<sup>[19]</sup>
== Etiology ==
Causes can be classified as traumatic, non-traumatic or neuromuscular:


Picture 1, shoulder joints&nbsp;[[Image:Anatomy shoulder.jpg]]&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;[[Image:1.jpg|center|300x300px]]  
# Traumatic cause: more frequent in active young individuals. Prevalent in for example: boxers,; non-contact sport with repetitive shoulder movements; a hand in the outstretched position.
# Non-traumatic cause: multifactorial. For example: patients may have suboptimal shoulder muscle control or tendon/ligament injury in the rotator cuff interval
# Neuromuscular causes: for example stroke, cerebral palsy, and brachial plexus injury.<ref name=":0" />
'''Watch''' this 4 minute video for an introduction to shoulder sunluxation.{{#ev:youtube|hz6gjsAniPI}}<ref>Dr. David Geier. Shoulder subluxation. Available from: http://www.youtube.com/watch?v=hz6gjsAniPI [last accessed 25/4/2022]</ref>


== Epidemiology/Ethiology  ==
== Characteristics/clinical presentation  ==


Studies show that there is no relationship between shoulder pain, shoulder subluxation and gender. It equally occurs within men and women.<br>Shoulder subluxations frequently occur in people with hemiplegic stroke or with a paralyzed upper limb.<sup>[9, Level 2B]</sup> The reported incidence varies greatly, from 17% to 81%<sup>[2, Level 4][3, Level 1B]</sup>
The main problem with shoulder subluxation is the&nbsp;[[Anterior Shoulder Instability|instability]] of the glenohumeral joint. Common symptoms of chronic shoulder instability include:


Traumatic subluxations of the shoulder can occur in many sports, including football, rugby, wrestling and boxing.  
* Recurrent shoulder dislocations
* Periodic instances of the shoulder giving out
* A persistent feeling of the shoulder being loose or slipping in and out of the joint.
* Pain <ref>Orthoinfo [https://orthoinfo.aaos.org/en/diseases--conditions/chronic-shoulder-instability/ Chronic Shoulder Instability] Available:https://orthoinfo.aaos.org/en/diseases--conditions/chronic-shoulder-instability/ (accessed 8.1.2023)</ref>


== <br>Characteristics/clinical presentation<br>  ==
Research by Basmajian determined that the supraspinatus and in minor ways also the posterior fibres of the deltoid muscle play a key role in maintaining glenohumeral alignment<ref>Reed D, Cathers I, Halaki M, Ginn K. [https://www.akot.com.ar/cokiba/cursos/2017/15_oyt/files/dolor_hombroMR3.pdf Does supraspinatus initiate shoulder abduction?.] Journal of Electromyography and Kinesiology. 2013 Apr 1;23(2):425-9.</ref>. Chaco and Wolf did confirm this in their study, which said that the supraspinatus is very important in preventing the downward subluxation of the humerus.


The main problem with shoulder subluxation is the&nbsp;[[Anterior Shoulder Instability|instability]] of the gleno-humeral joint. The anatomy of this joint permits a large range of movement, but it sacrifices stability. Research by Basmajian determined that the musculus supraspinatus and in minor ways also the posterior fibers of the deltoid muscle play a key role in maintaining glenohumer alalignment. Chaco and Wolf, did confirm this in their study, which said that the supra spinatus is very important in preventing the downward subluxation of the humerus. Subluxation occurs with the shoulder in abduction and externally rotation.Other research shows that the most important ligamental structure to maintain correct shoulder position and also to prevent shoulder subluxation is the [[Glenohumeral Joint|inferior glenohumeral ligament]].This ligament is most important during external rotation and abduction during the cocking face of the throwing motion.<br>Shoulder subluxation can lead to soft tissue damage as traction damage can occur due to gravitational pull forces and poor protection is offered by a weak shoulder.  
Subluxation occurs with the shoulder in abduction and external rotation.  


Shoulder subluxation is usually quite painful, and there might be a partial numbness of the shoulder, arm and hand.<sup>[21]</sup><br>
Other research shows that the most important ligamentous structure to maintain correct shoulder position and also to prevent shoulder subluxation is the inferior glenohumeral ligament.This ligament is most important during external rotation and abduction during the cocking face of the throwing motion.


== Differential Diagnosis ==
<br>Shoulder subluxation can lead to soft tissue damage as traction damage can occur due to gravitational pull forces and poor protection is offered by a weak shoulder. It is usually quite painful, and there might be a partial numbness of the shoulder, arm, and hand.
* Acromioclaviculair joint injury


[http://www.physio-pedia.com/Acromioclavicular_Joint_Disorders Acromioclavicular (AC) joint injuries] are common and often seen after bicycle wrecks, contact sports, and car accidents. The acromioclavicular joint is located at the top of the shoulder where the acromion process and the clavicle meet to form a joint. Several ligaments surround this joint, and depending on the severity of the injury, a person may tear one or all of the ligaments. Torn ligaments lead to acromioclavicular joint sprains and separations.<sup>[10 Level 2A]</sup> <br>
== Differential Diagnosis ==
* Bicipital tendonitis


[http://www.physio-pedia.com/Biceps_Tendonitis Bicipital tendinitis], or biceps tendinitis, is an inflammatory process of the long head of the biceps tendon and is a common cause of shoulder pain due to its position and function.<sup>[11, Level 2B][12, Level 2A][13, Level 2C][14, Level 3][15, Level 4]</sup>
* [[Acromioclavicular Joint Disorders|Acromioclaviculair joint injuries]]: common and often seen after bicycle wrecks, contact sports, and car accidents. The acromioclavicular joint is located at the top of the shoulder where the acromion process and the clavicle meet to form a joint. Several ligaments surround this joint, and depending on the severity of the injury, a person may tear one or all of the ligaments. Torn ligaments lead to acromioclavicular joint sprains and separations.
* [http://www.physio-pedia.com/Sternoclavicular_Joint_Disorders Clavicular injuries]
* [[Biceps Tendinopathy|Bicep tendinopathy]], is an inflammatory process of the long head of the biceps tendon and is a common cause of shoulder pain due to its position and function<ref>Raney EB, Thankam FG, Dilisio MF, Agrawal DK. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5489872/ Pain and the pathogenesis of biceps tendinopathy]. American journal of translational research. 2017;9(6):2668.</ref>.
 
* Clavicular injuries: Although [[Clavicular Fracture|clavicle fractures]] are common and usually heal regardless of the selected treatment, complications are possible, warranting careful attention to these [[Sternoclavicular Joint Disorders|injuries]]. <ref>O’Neill BJ, Hirpara KM, O’Briain D, McGarr C, Kaar TK. Clavicle fractures: a comparison of five classification systems and their relationship to treatment outcomes. International orthopaedics. 2011 Jun;35(6):909-14.</ref><ref>Lasanianos NG, Panteli M. Clavicle fractures. InTrauma and Orthopaedic Classifications 2015 (pp. 11-15). Springer, London.</ref>
Although clavicle fractures are common and usually heal regardless of the selected treatment, complications are possible, warranting careful attention to these injuries. Multiple attempts have been made to devise a classification scheme for clavicle fractures. The most common system is the following one, created by Allman, in which the clavicle is divided into thirds<sup>[16, Level 2A]</sup>: <br>• Group I fractures: Middle third injuries<br>• Group II fractures: Distal third injuries<br>• Group III fractures: Medial (proximal) third injuries
* [http://www.physio-pedia.com/Rotator_Cuff_Tears Rotator cuff injuries] are a common cause of shoulder pain in people of all age groups. They represent a spectrum of disease, ranging from acute reversible tendinitis to massive tears involving the supraspinatus, infraspinatus, and subscapularis. Diagnosis is usually made through detailed history, physical examination, and often, imaging studies.
* Rotator cuff injury
* [http://www.physio-pedia.com/Shoulder_Dislocation Shoulder dislocations] may occur from a traumatic injury or from loose capsular ligaments. Different conditions may affect the stabilising structures of the shoulder and, thus, negatively affect patients with shoulder dislocations.
 
* [[Swimming Overuse Injuries|Swimmer's shoulder]] is the term used to describe the problem of shoulder pain in the competitive swimmer. Swimming is an unusual sport in that the shoulders and upper extremities are used for locomotion, while at the same time requiring above average shoulder flexibility and range of motion (ROM) for maximal efficiency. This is often associated with an undesirable increase in joint laxity<ref>De Martino I, Rodeo SA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970120/ The swimmer’s shoulder: multi-directional instability]. Current reviews in musculoskeletal medicine. 2018 Jun;11(2):167-71.</ref>.
[http://www.physio-pedia.com/Rotator_Cuff_Tears Rotator cuff injuries] are a common cause of shoulder pain in people of all age groups. They represent a spectrum of disease, ranging from acute reversible tendinitis to massive tears involving the supraspinatus, infraspinatus, and subscapularis. Diagnosis is usually made through detailed history, physical examination, and often, imaging studies.<sup>[17, Level 2B]</sup>
* Shoulder dislocation
 
[http://www.physio-pedia.com/Shoulder_Dislocation Shoulder dislocations] may occur from a traumatic injury or from loose capsular ligaments. Different conditions may affect the stabilizing structures of the shoulder and, thus, negatively affect patients with shoulder dislocations.<sup>[18, Level 2A]</sup>
* Swimmer’s shoulder
 
Swimmer's shoulder is the term used to describe the problem of shoulder pain in the competitive swimmer. Swimming is an unusual sport in that the shoulders and upper extremities are used for locomotion, while at the same time requiring above average shoulder flexibility and range of motion (ROM) for maximal efficiency. This is often associated with an undesirable increase in joint laxity.<br>  


== Diagnostic Procedures  ==
== Diagnostic Procedures  ==
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*Pain in the shoulder region  
*Pain in the shoulder region  
*Loss of range of movement&nbsp;  
*Loss of range of movement&nbsp;  
*Palpable gap between acromion and humeral head (this can be informally measure in finger-widths)
*The palpable gap between acromion and humeral head (this can be informally measured in finger-widths)


'''Functional testing'''<br>The [[Subluxationtest|subluxation test]] is&nbsp;positive = resistance is given, when patient brings arm in throwing stance, in internal rotation direction.<br>Pain in the ventral capsule indicates a frontal capsule lesion. <br>Pressure during resistance test on the dorsal part of the humerus can provoke ventral gliding. The result is sudden pain in the shoulder and in a number of cases there is a subluxation to the front. This test can be conducted in different degrees of abduction and with or without the support of the upper arm.
'''Functional testing'''  


Radiographic measurements are considered to be the most accurate way of evaluating the degree of subluxation<sup>[4, Level 2C]</sup>
* The subluxation test is&nbsp;positive = resistance is given when the patient brings arm in throwing stance, in internal rotation direction.
* Pain in the ventral capsule indicates a frontal capsule lesion. 
* Pressure during resistance test on the dorsal part of the humerus can provoke ventral gliding. The result is sudden pain in the 
* shoulder and in a number of cases there is a subluxation to the front. This test can be conducted in different degrees of abduction and with or without the support of the upper arm.


== Outcome Measures  ==
Radiographic measurements are considered to be the most accurate way of evaluating the degree of subluxation<ref name="Paci et al, 2005">Paci M, Nannetti L, Rinaldi LA. Glenohumeral subluxation in hemiplegia: An overview. J Rehabil Res Dev. 2005 Jul-Aug;42(4):557-68.</ref>


'''Oxford Instability Shoulder Score (OISS)'''<br>The OISS is a 12-item questionnaire with five possible Likert style responses for each question and has a range from 0 to 48 (with a score of 48 indicating better shoulder function). The OISS has been developed and validated for shoulder instability and has also undergone testing to assess responsiveness in shoulder instability patients.<br>A link to the questionnaire is added to the recources list below.<sup>[20, Level 4]</sup>
== Outcome Measures ==


'''Western Ontario Shoulder Instability Index (WOSI)'''<br>The WOSI score is a 21-item questionnaire with a 100-mm horizontal visual analogue scale under each question for patient responses and ranges from 0 to 2100 and is converted to a percentage, with 100% representing the highest possible shoulder-related quality of life. The WOSI is a rigorously designed and evaluated measurement tool for patients with shoulder instability and has been shown to have excel- lent responsiveness in posterior instability. <br>A download link to the questionnaire is added to the reference list below.<sup>[20, Level 4]</sup>
* [[DASH Outcome Measure|Disabilities of Shoulder, Arm, and Hand (DASH)]]
* Quick DASH
* [[Visual Analogue Scale]]
* [[Shoulder Pain and Disability Index (SPADI)|Shoulder Pain And Disability Index]]


== <sup></sup>Examination ==
== Examination ==
First, the examiner should ask the patient about the history of the reason he subluxated his arm. Then he can perform an inspection, when he does he should make sure that he can have a visual on both shoulders at the same time to see the difference.<br>After this you could use different tests to test whether the patient had a subluxation of the shoulder:


First the examinator should ask the patient about the history of the reason he subluxated his arm. Than he can perform an inspection, when he does he should make sure that he can have a visual on both shoulders at the same time to see the differents.<sup>[22]</sup> <br>After this you could use different tests to test whether the patient had a subluxation of the shoulder:
*[[Load and Shift|Load and shift test]]


*'''Load and shift test'''
*[[Apprehension Test]]
*[[Jobes Relocation Test|Relocation Test]]


In this test the examiner stabilizes the scapula and moves the humeral head to posterior and anterior. With this test the examiner can feel if the humeral head is going to subluxate.
<div class="row">
 
  <div class="col-md-6"> {{#ev:youtube|kQPb25BtYqQ|250}} <div class="text-right"><ref>The Physio Channel. The Load & Shift Test
*'''Push-Pull test'''
. Available from: http://www.youtube.com/watch?v=kQPb25BtYqQ [last accessed 27/4/2022]</ref></div></div></div>
 
The patients arm is placed in 90 degrees of aduction and 30 degrees of forward flexion. With his other hand the examiner grasps the midhumerus and provides posteriorly directed force. This test is used to measure the posterior laxity of the shoulder.  
 
*'''Protzman test'''
 
This test is similar to the Load and shift test but the second hand is placed in the axilla to feel for translation of the humeral head or to feel if the humeral head subluxates over the rim.<sup>[22]</sup><sup></sup>
== Physical Therapy Management  ==
== Physical Therapy Management  ==
'''Traumatic and Non-Traumatic Patient (see also detailed information here [[Shoulder Instability]])'''
[[File:External rotation.png|thumb|Rotator cuff exercise]]
Prevention of reccurance:<br>[[Strength Training|Strengthening exercises]] to re-establish the [[Rotator Cuff Tendinopathy|strength of the rotator cuff muscles]] is recommended.&nbsp;<br>Initial physical therapy interventions may include:


=== In the hemiplegic patient  ===
*Mobility exercises including PROM, AAROM, AROM
* Sling/support:
*[[Motor Control and Learning|Motor control]] training
Traditionally supportive devices, in the form of slings or braces, have been used to manage shoulder subluxation following CVA; the aim being to support the weight of the arm thus preventing/minimising the inferior pull on the humerus and reducing the stretch on the joint capsule. A Cochrane Review&nbsp;in 2009 concluded that there is insufficient evidence to conclude whether supportive devices are of benefit.&nbsp;<sup>[5, Level 2A]</sup>
*Scapular stabilization, see [[Dynamic Stabilisers of the Shoulder Complex]]
* Electrical Stimulation:<br>
*Isometric and low-grade strengthening exercises
In a Cochrane Review&nbsp;Functional Electrical Stimulation was found to bring about&nbsp;improvement in pain-free range of passive humeral lateral rotation and to reduce the severity of glenohumeral subluxation; however there was no significant effect on upper limb motor recovery.&nbsp;<sup>[6, Level 2A]</sup><br>
*[[Manual Therapy|Manual therapy]] directed at the Glenohumeral and [[Sternoclavicular Joint|Sterno-Clavicular joint]]


===== Advice/Management:  =====
*[[Manual Techniques for the Cervicothoracic Spine|Manual therapy of cervicothoracic spine]] and upper ribs
 
**Teach patient/carers/relatives how to position the limb so that the weight of the arm is supported&nbsp;<ref name="Kaplan et al, 1995">Kaplan MC. Hemiplegic shoulder pain-early prevention and rehabilitation. West J Med. Feb 1995;162(2):151-2</ref>
**Judicious passive or active assisted exercises should be started within 24 hours poststroke with the aim of maintaining range of movement of the shoulder joint<sup>[8, Level 2B]</sup>
=== In the non-hemiplegic patient  ===
* Prevention of recurrence - Strengthening exercises to re-establish the strength of the rotator cuff muscles is recommended.&nbsp;Initial physical therapy interventions may include:
 
* Mobility exercises including PROM, AAROM, AROM
 
*Motor control training
*Scapular stabilization
*Isometric and low-grade strengthening exercises
*Manual therapy directed at the [[Glenohumeral Joint|Gleno-humeral]], Acromio-Clavicular and Sterno-Clavicular joint
*Manual therapy of cervicothoracic spine and upper ribs
*Activity modification
*Activity modification


These are different types of thoracic and upper ribs manipulations:
Late stages of rehabilitation of rotator cuff injury include progressive resistive strengthening, [[proprioception]] and sport-specific exercises.


&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
This 2 minute video shows treating subluxation of the shoulder, use a sling and an exercise ball (to strengthen the shoulder) muscles.
{{#ev:youtube|z7USK15hEwU}}<ref>ehowhealth. Physical Therapy Treatments : How to Treat Subluxation
. Available from: http://www.youtube.com/watch?v=z7USK15hEwU [last accessed 25/4/2022]</ref>


1. cervicothoracic junction distraction manipulation<sup>[23, Level 1A]</sup>
For Hemiplegic Patient see [[Hemiplegic Shoulder Subluxation]]


<sup>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Image:Cervicothoracic junction distraction manipulation.jpg|200x200px]]</sup>
== References  ==
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;2. Supine flexion/opening manipulation<sup>[23, Level 1A]</sup>
 
<sup>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Image:Supine flexion-Opening manipulation.jpg|200x200px]]</sup>
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;3. Supine unilateral rib manipulation<sup>[23, Level 1A]</sup>
 
<sup>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Image:3 Supine unilateral rib manipulation.jpg|200x200px]]</sup>
 
&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;4. Prone extension/closing manipulation<sup>[23, Level 1A]</sup>


<sup>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;[[Image:4 Prone extension-closing manipulation.jpg|200x200px]]</sup>
<references /><br>
 
Late stages of rehabilitation of rotator cuff injury include progressive resistive strengthening, proprioception and sport-specific exercises.
 
== Resources  ==
 
OISS: http://www.isis-innovation.com/outcomes/documents/FINAL_OSIS_English_UK.pdf <br>WOSI http://clarkstownortho.com/forms/WOSI%20shoulder%20instability.pdf
== References  ==


<references /><br>
[[Category:Shoulder]]
[[Category:Conditions]]


[[Category:Shoulder]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]] [[Category:Stroke]] [[Category:Shoulder Conditions]]
[[Category:Shoulder - Conditions]]
[[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]
[[Category:Sports Medicine]]
[[Category:Sports Injuries]]

Latest revision as of 02:20, 9 January 2023


Original Editor ­ Bart Moreels

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Definition[edit | edit source]

Inferior-subluxation-post overdose.

Shoulder subluxation, a subset of shoulder instability, occurs when the shoulder joint partially dislocates. In this condition the humeral head slips out of the glenoid cavity as a result of weakness of rotator cuff or looseness of the glenohumeral ligaments.[1]

Epidemiology[edit | edit source]

Studies are limited that investigate the epidemiology of shoulder subluxation, with most studies focus more on shoulder dislocations.[1]

  • In a study on shoulder subluxations, 45.5% experienced the first subluxation event, while the remaining 54.5% had recurrent shoulder subluxation.[1]
  • Shoulder subluxations frequently occur in people with hemiplegic stroke or with a paralysed upper limb (see Hemiplegic Shoulder Subluxation). The reported incidence varies greatly from 17% to 81% [2] [3]. 

Etiology[edit | edit source]

Causes can be classified as traumatic, non-traumatic or neuromuscular:

  1. Traumatic cause: more frequent in active young individuals. Prevalent in for example: boxers,; non-contact sport with repetitive shoulder movements; a hand in the outstretched position.
  2. Non-traumatic cause: multifactorial. For example: patients may have suboptimal shoulder muscle control or tendon/ligament injury in the rotator cuff interval
  3. Neuromuscular causes: for example stroke, cerebral palsy, and brachial plexus injury.[1]

Watch this 4 minute video for an introduction to shoulder sunluxation.

[4]

Characteristics/clinical presentation[edit | edit source]

The main problem with shoulder subluxation is the instability of the glenohumeral joint. Common symptoms of chronic shoulder instability include:

  • Recurrent shoulder dislocations
  • Periodic instances of the shoulder giving out
  • A persistent feeling of the shoulder being loose or slipping in and out of the joint.
  • Pain [5]

Research by Basmajian determined that the supraspinatus and in minor ways also the posterior fibres of the deltoid muscle play a key role in maintaining glenohumeral alignment[6]. Chaco and Wolf did confirm this in their study, which said that the supraspinatus is very important in preventing the downward subluxation of the humerus.

Subluxation occurs with the shoulder in abduction and external rotation.

Other research shows that the most important ligamentous structure to maintain correct shoulder position and also to prevent shoulder subluxation is the inferior glenohumeral ligament.This ligament is most important during external rotation and abduction during the cocking face of the throwing motion.


Shoulder subluxation can lead to soft tissue damage as traction damage can occur due to gravitational pull forces and poor protection is offered by a weak shoulder. It is usually quite painful, and there might be a partial numbness of the shoulder, arm, and hand.

Differential Diagnosis[edit | edit source]

  • Acromioclaviculair joint injuries: common and often seen after bicycle wrecks, contact sports, and car accidents. The acromioclavicular joint is located at the top of the shoulder where the acromion process and the clavicle meet to form a joint. Several ligaments surround this joint, and depending on the severity of the injury, a person may tear one or all of the ligaments. Torn ligaments lead to acromioclavicular joint sprains and separations.
  • Bicep tendinopathy, is an inflammatory process of the long head of the biceps tendon and is a common cause of shoulder pain due to its position and function[7].
  • Clavicular injuries: Although clavicle fractures are common and usually heal regardless of the selected treatment, complications are possible, warranting careful attention to these injuries. [8][9]
  • Rotator cuff injuries are a common cause of shoulder pain in people of all age groups. They represent a spectrum of disease, ranging from acute reversible tendinitis to massive tears involving the supraspinatus, infraspinatus, and subscapularis. Diagnosis is usually made through detailed history, physical examination, and often, imaging studies.
  • Shoulder dislocations may occur from a traumatic injury or from loose capsular ligaments. Different conditions may affect the stabilising structures of the shoulder and, thus, negatively affect patients with shoulder dislocations.
  • Swimmer's shoulder is the term used to describe the problem of shoulder pain in the competitive swimmer. Swimming is an unusual sport in that the shoulders and upper extremities are used for locomotion, while at the same time requiring above average shoulder flexibility and range of motion (ROM) for maximal efficiency. This is often associated with an undesirable increase in joint laxity[10].

Diagnostic Procedures[edit | edit source]

Symptoms
Patients with shoulder subluxations commonly present with:

  • Pain in the shoulder region
  • Loss of range of movement 
  • The palpable gap between acromion and humeral head (this can be informally measured in finger-widths)

Functional testing

  • The subluxation test is positive = resistance is given when the patient brings arm in throwing stance, in internal rotation direction.
  • Pain in the ventral capsule indicates a frontal capsule lesion.
  • Pressure during resistance test on the dorsal part of the humerus can provoke ventral gliding. The result is sudden pain in the
  • shoulder and in a number of cases there is a subluxation to the front. This test can be conducted in different degrees of abduction and with or without the support of the upper arm.

Radiographic measurements are considered to be the most accurate way of evaluating the degree of subluxation[11]

Outcome Measures[edit | edit source]

Examination[edit | edit source]

First, the examiner should ask the patient about the history of the reason he subluxated his arm. Then he can perform an inspection, when he does he should make sure that he can have a visual on both shoulders at the same time to see the difference.
After this you could use different tests to test whether the patient had a subluxation of the shoulder:

[12]

Physical Therapy Management[edit | edit source]

Traumatic and Non-Traumatic Patient (see also detailed information here Shoulder Instability)

Rotator cuff exercise

Prevention of reccurance:
Strengthening exercises to re-establish the strength of the rotator cuff muscles is recommended. 
Initial physical therapy interventions may include:

Late stages of rehabilitation of rotator cuff injury include progressive resistive strengthening, proprioception and sport-specific exercises.

This 2 minute video shows treating subluxation of the shoulder, use a sling and an exercise ball (to strengthen the shoulder) muscles.

[13]

For Hemiplegic Patient see Hemiplegic Shoulder Subluxation

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Vitoonpong T, Chang KV. Shoulder Subluxation. InStatPearls [Internet] 2020 Aug 29. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK507847/ (accessed 8.1.2023)
  2. ↑ Huang SW, Liu SY, Tang HW, Wei TS, Wang WT, Yang CP. Relationship between severity of shoulder subluxation and soft-tissue injury in hemiplegic stroke patients. J Rehabil Med. 2012 Sep;44(9):733-9.
  3. ↑ Hartwig M, Gelbrich G, Griewing B. Functional orthosis in shoulder joint subluxation after ischaemic brain stroke to avoid post-hemiplegic shoulder-hand syndrome: a randomized clinical trial. Clin Rehabil. 2012 Sep;26(9):807-16.
  4. ↑ Dr. David Geier. Shoulder subluxation. Available from: http://www.youtube.com/watch?v=hz6gjsAniPI [last accessed 25/4/2022]
  5. ↑ Orthoinfo Chronic Shoulder Instability Available:https://orthoinfo.aaos.org/en/diseases--conditions/chronic-shoulder-instability/ (accessed 8.1.2023)
  6. ↑ Reed D, Cathers I, Halaki M, Ginn K. Does supraspinatus initiate shoulder abduction?. Journal of Electromyography and Kinesiology. 2013 Apr 1;23(2):425-9.
  7. ↑ Raney EB, Thankam FG, Dilisio MF, Agrawal DK. Pain and the pathogenesis of biceps tendinopathy. American journal of translational research. 2017;9(6):2668.
  8. ↑ O’Neill BJ, Hirpara KM, O’Briain D, McGarr C, Kaar TK. Clavicle fractures: a comparison of five classification systems and their relationship to treatment outcomes. International orthopaedics. 2011 Jun;35(6):909-14.
  9. ↑ Lasanianos NG, Panteli M. Clavicle fractures. InTrauma and Orthopaedic Classifications 2015 (pp. 11-15). Springer, London.
  10. ↑ De Martino I, Rodeo SA. The swimmer’s shoulder: multi-directional instability. Current reviews in musculoskeletal medicine. 2018 Jun;11(2):167-71.
  11. ↑ Paci M, Nannetti L, Rinaldi LA. Glenohumeral subluxation in hemiplegia: An overview. J Rehabil Res Dev. 2005 Jul-Aug;42(4):557-68.
  12. ↑ The Physio Channel. The Load & Shift Test . Available from: http://www.youtube.com/watch?v=kQPb25BtYqQ [last accessed 27/4/2022]
  13. ↑ ehowhealth. Physical Therapy Treatments : How to Treat Subluxation . Available from: http://www.youtube.com/watch?v=z7USK15hEwU [last accessed 25/4/2022]


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