Key Considerations Post Anterior Shoulder Dislocation

There’s plenty to think about when deciding what comes next after an anterior shoulder dislocation. Is there an associated nerve injury? What is the risk of recurrence? Is surgery indicated? And if it is, how do you approach rehabilitation and prepare the patient to return to sport?

In his Case Study, expert physio Matthew Rees works through these decisions using the case of a 17-year-old goalkeeper following a first-time traumatic anterior shoulder dislocation. In this blog, we’ll highlight some of the key considerations that shaped his management.

If you want to see exactly how an expert reasons his way through this case, watch Matthew Rees’ full Case Study here.

Could there be a nerve injury?

The patient dislocated his shoulder while diving to save a shot with his arm extended. The shoulder self-reduced with a noticeable clunk, and subsequent MRI identified a Hill-Sachs lesion and an anteroinferior labral tear.

By the time he presented to Matthew, he had regained functional range of motion and his pain was minimal. However, examination revealed poor motor control towards end-range flexion, pain and weakness with resisted external rotation, and a positive apprehension sign. Further investigation identified an axillary nerve neuropraxia.

The axillary nerve is the nerve most frequently affected during an anterior shoulder dislocation. Although many nerve injuries associated with dislocation are neuropraxias and recover over time, identifying them is important. A nerve injury may help explain persistent weakness or altered motor control, while more significant injuries may require further investigation and timely management.

Surgery or conservative management?

A major decision following a first-time dislocation is whether the patient should undergo surgical stabilisation or pursue conservative management.

There isn’t a single answer for every patient. Age, sport, mechanism of injury, structural damage, recurrence risk and the patient’s goals all need to be considered. Recurrence is particularly important in younger patients, with males participating in contact sports reported to have recurrence rates as high as 68%.

This doesn’t mean every first-time anterior dislocation requires surgery. However, understanding the factors associated with recurrent instability allows clinicians to contribute to shared decision-making and give patients realistic information about their options.

Watch Matthew explain his treatment decision-making and why a Bankart repair was ultimately chosen for this patient in this clip from his Case Study:

What about post-surgical immobilisation?

If surgery is performed, another question quickly follows: how much immobilisation is required?

Following his Bankart repair, this patient was immobilised in a sling for six weeks. However, immobilisation protocols following shoulder stabilisation aren’t uniform. There is research suggesting that shorter periods of immobilisation can be safe and effective, and clinicians may encounter variation in both the duration of sling use and when movement is introduced.

This makes communication with the surgeon particularly important. Rehabilitation needs to respect the procedure performed and any surgical restrictions while also considering the consequences of prolonged protection.

And of course, being immobilised doesn’t mean rehabilitation has to stop completely. Consider what can safely be addressed during this period rather than treating sling removal as the point at which rehabilitation suddenly begins. Keeping the patient generally physically active, where appropriate, can also be valuable for both the physical and psychological sides of recovery.

Where should rehab start?

For this patient, the end goal was returning to goalkeeping, so the demands of goalkeeping need to be considered from the outset.

The shoulder needs to do much more than produce isolated strength. A goalkeeper must tolerate rapid reaching, forceful contact with the ball, falling onto the upper limb, diving and unpredictable loading, often in positions that may closely resemble the mechanism of the original injury.

But that doesn’t mean trying to address everything at once; active range of motion and motor control provide a foundation for what comes next. Rehabilitation will look different for every patient depending on their presentation, goals and circumstances, but Matthew uses a structured approach to determine where to start and how to progress.

Watch him talk through his approach in this clip from his Case Study:

Wrapping up

Anterior shoulder dislocations can look very different by the time they reach the physio. Pain may have settled and movement may have returned, but that doesn’t necessarily tell you the whole story.

Picking up the axillary nerve injury, understanding his risk of recurrence, and knowing exactly what he needed to get back to as a goalkeeper all influenced the decisions that followed.

See how Matthew Rees approached the case from start to finish in his full Case Study.