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Immobilizing the Shoulder in External Rotation

Posted Apr 21 2009 12:11am

Today’s post comes from Dan Lorenz, MS, PT, ATC/L, CSCS.  Dan is a graduate of the sports physical therapy fellowship at Duke University and is currently a sports medicine specialist at Providence Medical Center.  He has great experience with a wide variety of orthopedic and sports medicine patients, including stints with the USOlympic Training Center, Chicago White Sox, and most recently the Kansas City Chiefs.  Dan has previously guest posted on the relationship between hip motion and low back pain.

Challenging 2000 Years of Conventional Wisdom – Immobilizing the Shoulder in External Rotation

ER-immobilization For 2000 years, individuals with shoulder dislocations have been immobilized with their upper extremity resting on the trunk in the hopes of preventing recurrence 1,2. While this has been the standard practice, no literature on the scientific basis of this exists. Recurrent dislocation rate varies from 47% to 100% 3-7. Within the last few years, researchers have proposed a new position for immobilization, external rotation, after anterior shoulder dislocations. While the concept may seem radical, it certainly is thought-provoking, and it truly challenges us to “think outside the box.”

A cadaveric study by Itoi and others 8 sought to determine the position of a Bankart lesion following immobilization in different positions. Researchers found that with the arm in adduction and from full internal rotation to 30° of external rotation, the Bankart lesion was “coapted”, or re-united, with the glenoid. With the arm in 30° of flexion or abduction, the edges of the lesion were coapted in neutral and internal rotation but were separated in external rotation. The study suggested that positions that increase soft tissue tension, such as adduction and ER or abduction and neutral rotation, may be preferable to the conventional position. Similarly, Miller et al 9 found that the glenoid-labrum contact in ten cadaveric shoulders immobilized in external rotation was much higher, potentially increasing the healing of a Bankart lesion.

Itoi and colleagues 10 sought to use MR imaging to measure the affect of arm rotation on the approximation of Bankart lesions following dislocation of the shoulder. Eighteen patients with traumatic anterior dislocations were included in the study. Twelve had recurrent dislocations, and six were first time dislocations. MR imaging of the glenohumeral joint was taken at neutral and at the range of external rotation that felt most comfortable to the patient. Imaging studies showed that in internal rotation, the joint cavity of the glenoid was wide open. With the arm in external rotation, the anterior joint cavity was closed and the labrum lay on the glenoid rim.

The same group of researchers then followed up this study with a prospective study to determine if positioning the arm in external rotation would reduce the rate of recurrence 11. Forty patients with initial dislocations were assigned to conventional internal rotation and 10° of external rotation. The first ten were alternatively assigned, and then the remaining thirty were randomly assigned. Both groups were immobilized for three weeks, and compliance rates were reported. Recurrence rate was 30% in the internal rotation group and 0% in the external rotation group. It is interesting to note that in the subjects younger than thirty years old, recurrence in internal was 45% and 0% in external. The average follow up was 15.5 months. An anterior apprehension test was performed at follow-up, and the test was positive in 14% of internal and 10% of external.

DJ ultrasling Deyle and Nagel 12 described a six-week immobilization period in 30° of abduction and neutral rotation in a 19 year-old recreational basketball player. In addition to the prolonged immobilization, the patient had protected range of motion activity for 6 additional weeks. At 20 month follow up, the patient had no recurrent instability. Recently, Itoi et al 13 did a randomized, controlled trial of 168 patients with initial anterior dislocations who were randomly assigned to be treated with immobilization for three weeks in either internal rotation or external rotation. After a two-year follow up, the recurrence rate was 26% and 42% in external and internal rotation, respectively. Additionally, in subjects aged thirty years or younger, the relative risk reduction was 46%.

EDITOR’S NOTE: Very interesting information. Looks like the evidence to support immobilizing in external rotation is becoming available as many sources are reporting similar research. What has your experience been with immobilizing in external rotation? Have you found it successful?

References

1. Havelius L, Augustini BG, Fredin H, et al. Primary anterior dislocation of the shoulder in young patients: a ten-year prospective study. J Bone Joint Surg Am 1996; 78: 1677-84.

2. Rowe CR. Prognosis in dislocations of the shoulder. J Bone Joint Surg Am. 1956; 38: 957-77.

3. Arciero RA, Wheeler JH, Ryan JB, McBride JT. Arthroscopic Bankart repair versus nonoperative treatment for acute, initial anterior shoulder dislocations. Am J Sports Med. 1994; 22:589-94.

4. Henry JH, Genung JA. Natural history of glenohumeral dislocation – revisited. Am J Sports Med. 1982; 10: 135-7.

5. Hovelius L, Eriksson K, Fredin H, et al. Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment. J Bone Joint Surg Am. 1983; 65: 343-9.

6. Marans HJ, Angel KR, Schemitsch EH, Wedge JH. The fate of traumatic anterior dislocation of the shoulder in children. J Bone Joint Surg Am. 1992; 74: 1242-4.

7. Vermeiren J, Handelberg F, Casteleyn PP, Opdecam P. The rate of recurrence of traumatic anterior dislocation of the shoulder. A study of 154 cases and a review of the literature. Int Orthop. 1993; 17: 337-41.

8. Itoi E, Hatakeyama Y, Urayama M, et al. Position of immobilization after dislocation of the shoulder: a cadaveric study. J Bone Joint Surg. 1999; 81: 385-390.

9. Miller BS, Sonnabend DH, Hatrick C, et al. Should acute anterior dislocations of the shoulder be immobilized in external rotation? A cadaveric study. J Shoulder Elbow Surg. 2004. 13: 589-592.

10. Itoi E, Sashi R, Minagawa H, et al. Position of immobilization after dislocation of the glenohumeral joint: a study with use of magnetic resonance imaging. J Bone Joint Surg. 2001; 83: 661-667.

11. Itoi E, Hatakeyama Y, Kido T, et al. A new method of immobilization after traumatic anterior dislocation of the shoulder: a preliminary study. J Shoulder Elbow Surg. 2003; 12: 413-415.

12. Deyle GD, Nagel KL. Prolonged immobilization in abduction and neutral rotation for a first-episode anterior shoulder dislocation. J Orthop Sports Phys Ther. 2007; 37: 192-198.

13. Itoi E, Hatakeyama Y, Sato T, et al. Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence: a randomized controlled trial. J Bone Joint Surg. 2007; 89: 2124-2131.

Itoi, E., Hatakeyama, Y., Sato, T., Kido, T., Minagawa, H., Yamamoto, N., Wakabayashi, I., & Nozaka, K. (2007). Immobilization in External Rotation After Shoulder Dislocation Reduces the Risk of Recurrence. A Randomized Controlled Trial The Journal of Bone and Joint Surgery, 89 (10), 2124-2131 DOI:10.2106/JBJS.F.00654

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