Your Shoulder can dislocate out the front or out the back, but the former is more common. Usually this can be reduced in the emergency room and in most cases, after a couple of weeks in a sling, and physical therapy, full function returns. However, if you are younger than 40, there is a risk of recurrent instability---which may best be treated with surgical repair of the torn ligaments. An x-ray is critical to make certain that you have not fractured your glenoid or the greater tuberosity.
If you are older than 40 there is a statistically higher risk that you may have sustained a tear of your rotator cuff. It is also always important to ensure that you have not injured your axillary nerve due to the dislocation. This type of injury requires surgical treatment within 4-6 months of the injury if it does not resolve.
The most controversial subject nowadays revolves around acute surgery for the 1st time dislocator. In the early 1990's Dr Arciero reported favorable results after acute repair of West Point cadets who sustained dislocations. A high percentage of high demand patients were reported to have experienced recurrent instability---and this was much lower after acute surgery. And so it has become somewhat "dogmatic" that acute surgery in athletes and high demand patients is best. However, these studies are inherently flawed by bias and sample limitation. The literature does not control for those is a "nonsurgical treatment limb" who never dislocate again, and in light of more accurately tracking those who dislocate again and need surgery, overstates the dislocation risk. In other words, we know the numerator but not the denominator.
We do know that after a 1st time dislocation, an MRI will show capsuloligamentous disruption, intraarticular effusion and even SLAP tears or capsular avulsions. BUT--if after a few week of Therapy the patients has regained range of motion, is pain-free, and, most importantly, is stable on provactive testing (via a careful physical exam), then recurrent instability is much less likely as compared to the patient who still feels as though the shoulder is unstable.
The PDF below details a prospective evaluation of 1st time dislocators who were treated nonoperatively. It's worth noting that athletic participation had no impact on success, and that had surgery been performed acutely--as is often recommended nowadays--it would have been performed unnecesarily in 30-50% of cases.
So, what do I recommend?......... There is abssolutely no downside to allowing your shoulder to settle down for a week or two, during which physical therapy will work on range of motion, rotator cuff rehabilitation, and neuromuscular control (proprioception). The use of muscle inferential stimulation is also quite helpful in diminishing pain. If, after a 4-6 week period the shoulder still appears unstable on exam, then surgery can certainly be performed.
What I do not recommend is allowing the MRI to be "the tail that wags the dog". The MRI will always be abnormal. As an aside, if there appears not to be a labral injury in the setting of instability, one must rule out HAGL or reverse HAGL lesions (humeral avulsion of the glenohumeral ligaments), which can occur in up tp 9% of dislocations. The only absolute indications for truly acute surgery are a disloction that cannot be reduced closed, a displaced fracture(greater tuberosity or glenoid, for example) or an acute tear of the rotator cuff---and if one is older than 40 in the case of the latter, there my even be a role for a period of therapy .
If you are older than 40 there is a statistically higher risk that you may have sustained a tear of your rotator cuff. It is also always important to ensure that you have not injured your axillary nerve due to the dislocation. This type of injury requires surgical treatment within 4-6 months of the injury if it does not resolve.
The most controversial subject nowadays revolves around acute surgery for the 1st time dislocator. In the early 1990's Dr Arciero reported favorable results after acute repair of West Point cadets who sustained dislocations. A high percentage of high demand patients were reported to have experienced recurrent instability---and this was much lower after acute surgery. And so it has become somewhat "dogmatic" that acute surgery in athletes and high demand patients is best. However, these studies are inherently flawed by bias and sample limitation. The literature does not control for those is a "nonsurgical treatment limb" who never dislocate again, and in light of more accurately tracking those who dislocate again and need surgery, overstates the dislocation risk. In other words, we know the numerator but not the denominator.
We do know that after a 1st time dislocation, an MRI will show capsuloligamentous disruption, intraarticular effusion and even SLAP tears or capsular avulsions. BUT--if after a few week of Therapy the patients has regained range of motion, is pain-free, and, most importantly, is stable on provactive testing (via a careful physical exam), then recurrent instability is much less likely as compared to the patient who still feels as though the shoulder is unstable.
The PDF below details a prospective evaluation of 1st time dislocators who were treated nonoperatively. It's worth noting that athletic participation had no impact on success, and that had surgery been performed acutely--as is often recommended nowadays--it would have been performed unnecesarily in 30-50% of cases.
So, what do I recommend?......... There is abssolutely no downside to allowing your shoulder to settle down for a week or two, during which physical therapy will work on range of motion, rotator cuff rehabilitation, and neuromuscular control (proprioception). The use of muscle inferential stimulation is also quite helpful in diminishing pain. If, after a 4-6 week period the shoulder still appears unstable on exam, then surgery can certainly be performed.
What I do not recommend is allowing the MRI to be "the tail that wags the dog". The MRI will always be abnormal. As an aside, if there appears not to be a labral injury in the setting of instability, one must rule out HAGL or reverse HAGL lesions (humeral avulsion of the glenohumeral ligaments), which can occur in up tp 9% of dislocations. The only absolute indications for truly acute surgery are a disloction that cannot be reduced closed, a displaced fracture(greater tuberosity or glenoid, for example) or an acute tear of the rotator cuff---and if one is older than 40 in the case of the latter, there my even be a role for a period of therapy .
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