Shoulder Dislocation: Repair or Rehab?

Historically, it was recommended that shoulder dislocations should be treated with rehabilitation (therapy) alone unless a patient had multiple recurrent dislocations. However, several studies in the past decade have changed the approach to treatment.

What the natural history shows

It is now understood from well-conducted natural history studies that the chance of a repeat dislocation can be extremely high. The risk factors for recurrence are multiple but mainly include age, sex, activity level, ligamentous laxity, and bone loss. Age is the biggest factor. In particular, individuals under the age of 20 have about a 75% chance of re-dislocating the shoulder after a single traumatic dislocation.

The problem with re-dislocation is that it can lead to an increased chance of arthritis and damage to the shoulder that can change the severity of surgery required to achieve a stable shoulder.

What repair changes

• Robinson et al. demonstrated that an arthroscopic repair, after a single dislocation in patients under the age of 35, reduced the chance of re-dislocation down to 7% — a drastic reduction compared to the natural history above.
• More recently, Chahal et al. systematically reviewed the literature comparing studies of rehab and sling immobilization versus arthroscopic repair after a first-time shoulder dislocation. They found that the risk of repeat dislocation with repair was one fifth of that after non-operative treatment.

We have also examined the impact of number of dislocations on the type of treatment that is required to stabilize the shoulder. Our data shows that patients who have more shoulder dislocations are more likely to require more invasive or even open incision surgical procedures to stabilize the shoulder. This is not a surprise, since each dislocation leads to damage of the joint.

What I recommend

Given the evidence that repeated shoulder dislocations are associated with arthritis, I believe that younger patients (under 30 to 35 years of age) should strongly consider an arthroscopic repair after a single traumatic shoulder dislocation. A well-done minimally invasive arthroscopic repair, with care taken to assess bone loss prior to surgery, can lead to substantial reduction of the risk of repeat dislocation and may reduce the risk of future arthritis.