Glenohumeral Dislocation

Upper Limb

Overview

Glenohumeral dislocation is a complete displacement of the humeral head from the glenoid fossa, most commonly occurring in the anterior direction (95% of cases). This is a serious acute injury requiring immediate medical assessment and reduction, followed by a structured rehabilitation program to restore stability, strength, and function.

Pathophysiology

The glenohumeral joint is the most mobile joint in the body but relies heavily on dynamic stabilization from rotator cuff muscles and static stabilization from the labrum and joint capsule. Dislocation typically results from high-energy trauma or forceful external rotation with abduction, causing rupture of the anterior labrum (Bankart lesion), stretching of the anterior joint capsule, and potential rotator cuff tears. Posterior dislocations, while less common, result from violent internal rotation and are associated with seizures or high-energy trauma. Recurrent dislocations suggest chronic instability from inadequate healing or neuromuscular control deficits.

Patient Education

Glenohumeral dislocation is a medical emergency requiring immediate reduction; after reduction, progressive rehabilitation focusing on rotator cuff strengthening and proprioceptive training is critical to prevent recurrent instability and restore normal shoulder function.

Typical Presentation

Site

Anterior shoulder (95%), posterior shoulder (5%), with radiation down the lateral arm; pain often in the suprascapular region

Quality

Severe, sharp, tearing pain; sense of the shoulder being 'out of place'; numbness or tingling if neurovascular compromise

Intensity

Severe (8-10/10) at onset; moderate (4-6/10) post-reduction and during early recovery; varies with activity level

Aggravating

Any attempt at movement, external rotation, abduction, horizontal adduction, heavy lifting, throwing activities, contact sports, reaching across body

Relieving

Complete immobilization in early phase; sling and swath; gentle passive range of motion as tolerated; ice and NSAIDs in acute phase

Associated

Visible deformity ('squared-off' appearance in anterior dislocation), significant swelling and bruising, guarding and muscle spasm, potential axillary nerve injury (deltoid weakness, sensory loss over lateral shoulder), potential fractures of greater tuberosity or glenoid rim, apprehension and fear of re-injury

Orthopaedic Tests

Apprehension Test (Crank Test)

Procedure

Patient supine or seated with shoulder abducted 90° and externally rotated. Examiner applies gentle overpressure into external rotation and notes reproduction of apprehension or fear of dislocation.

Positive Finding

Patient experiences apprehension or fear that the humeral head will dislocate anteriorly; patient may guard or resist further external rotation

Sensitivity / Specificity

72% / 98%

Hegedus et al., 2008, British Journal of Sports Medicine

Interpretation

Highly specific for anterior glenohumeral instability. Apprehension (fear) is more diagnostic than pain alone. A positive test suggests anterior labral pathology and functional instability.

Relocation Test (Jobe Relocation Test)

Procedure

After positive apprehension test, examiner applies posterior-directed pressure to the humeral head (or anterior pressure to the posterior shoulder) while patient is in the same position (90° abduction, external rotation).

Positive Finding

Apprehension or pain is relieved or diminished with posterior pressure applied to the humeral head

Sensitivity / Specificity

67% / 97%

Hegedus et al., 2008, British Journal of Sports Medicine

Interpretation

Positive result confirms anterior glenohumeral instability and anterior labral involvement. Supports diagnosis of anterior dislocation risk or anterior labral tear.

Anterior Drawer Test

Procedure

Patient supine with shoulder abducted 80–120° and externally rotated. Examiner stabilises the scapula with one hand and translates the humeral head anteriorly with the other, assessing degree of humeral head translation and reproduction of apprehension.

Positive Finding

Increased anterior translation of the humeral head (grades 2–3 on a 0–3 scale); apprehension or sense of instability; humeral head subluxates and reduces

Sensitivity / Specificity

Unknown / Unknown

Interpretation

Quantifies anterior translation and functional instability. Grades 2–3 translation suggests significant capsulolabral laxity and increased dislocation risk.

Sulcus Sign

Procedure

Patient seated or standing with arms at sides and shoulder in neutral rotation. Examiner applies downward traction (inferior translation) to the humerus and observes for a depression or sulcus beneath the acromion.

Positive Finding

Visible depression or sulcus appears between the acromion and humeral head; depth measured in finger-breadths (>1.5 cm or >2 cm suggests significant laxity)

Sensitivity / Specificity

72% / 86%

Hegedus et al., 2008, British Journal of Sports Medicine

Interpretation

Positive sulcus sign indicates inferior glenohumeral laxity and capsular redundancy. In context of anterior apprehension, suggests multidirectional instability or recurrent dislocation risk.

Surprise/Release Test (Jerk Test Variant)

Procedure

After relocation test with posterior pressure applied, examiner suddenly releases the posterior pressure while patient remains in the 90° abduction, external rotation position.

Positive Finding

Immediate return or reproduction of apprehension or fear of dislocation upon release of stabilising pressure

Sensitivity / Specificity

71% / 92%

Hegedus et al., 2008, British Journal of Sports Medicine

Interpretation

Confirms that relief of apprehension during relocation test was due to posterior capsular stabilisation. Positive result strengthens diagnosis of anterior instability and labral pathology.

Load-and-Shift Test

Procedure

Patient supine or seated with shoulder 90° abducted and externally rotated. Examiner loads (compresses) the humeral head into the glenoid and then translates it anteriorly and posteriorly, grading the degree of humeral head translation relative to glenoid rim.

Positive Finding

Humeral head translates beyond the glenoid rim (grade 2–3 on a 0–3 scale); reproduction of apprehension or instability symptoms

Sensitivity / Specificity

50–72% / 96–98%

Hegedus et al., 2008, British Journal of Sports Medicine

Interpretation

High specificity for glenohumeral instability. Grades the severity of translation; useful for assessing functional stability and predicting recurrence risk in dislocation.

⚠ Red Flags

  • •First-time dislocation requiring immediate emergency reduction
  • •Neurovascular compromise (absent radial pulse, severe paresthesia, limb cooling, significant sensory/motor deficit)
  • •Signs of associated fractures (greater tuberosity avulsion, glenoid rim fracture, humeral head fracture)
  • •Open dislocation with soft tissue disruption
  • •Inability to reduce dislocation after initial attempt (irreducible dislocation)
  • •Recurrent dislocations in young athletes may warrant surgical consultation
  • •Severe pain disproportionate to clinical findings (complex regional pain syndrome risk)
  • •Loss of active shoulder function beyond expected recovery timeline

⚡ Yellow Flags

  • •High-risk occupation or sport requiring overhead activities
  • •Secondary gain concerns or litigation involvement
  • •Excessive fear-avoidance behavior or catastrophizing about re-injury
  • •Poor compliance with immobilization or rehabilitation in early phases
  • •Previous shoulder instability episodes or family history of dislocations
  • •Psychological distress following traumatic injury event
  • •Unrealistic expectations for rapid return to sport or heavy labor
  • •Signs of depression or anxiety following injury

Osteopathic Techniques

Region

Glenohumeral joint capsule and anterior labrum (post-reduction, weeks 2-6)

Technique

Soft Tissue

Rationale

Gentle soft tissue mobilization to the anterior shoulder, pectoralis minor, and subscapularis reduces muscle guarding, improves local circulation, and promotes healing of labral tears and capsular damage without destabilizing the joint

Region

Rotator cuff muscles (supraspinatus, infraspinatus, teres minor)

Technique

MET

Rationale

Muscle energy techniques restore dynamic stability and proprioception; gentle isometric contractions of rotator cuff muscles activate mechanoreceptors, improve neuromuscular control, and rebuild strength without aggressive joint stress

Region

Scapulothoracic articulation and thoracic spine

Technique

Articulation

Rationale

Restoration of scapular mobility and thoracic mobility is essential for proper shoulder biomechanics and dynamic stability; restricted thoracic extension or scapular dyskinesis increases glenohumeral instability

Region

Cervical and upper thoracic spine (C4-T4)

Technique

HVLA

Rationale

Addressing segmental restrictions in the cervical and upper thoracic spine improves upper limb neurodynamics and reduces referred pain; this optimizes proprioceptive feedback to the shoulder stabilizers

Region

Posterior and inferior shoulder capsule (weeks 3-8, addressing tightness)

Technique

Soft Tissue

Rationale

Posterior capsule tightness is common post-dislocation and restricts internal rotation; progressive soft tissue release combined with stretching restores normal glenohumeral mechanics and reduces compensatory patterns

Region

Lymphatic drainage to shoulder and upper limb

Technique

Lymphatic

Rationale

Gentle lymphatic techniques promote reduction of post-traumatic edema, improve tissue healing, reduce pain, and enhance overall recovery in acute and early subacute phases

Add-On Approaches

Chinese Medicine

TCM approaches include acupuncture to local points (LI15 Jianyu, TE14 Jianliao, SI9 Jianzhen) and distal points (LI4 Hegu) to reduce pain and improve qi and blood circulation; moxibustion may support tissue healing in chronic phases; herbal medicines such as San Huang Pao Mo Tang may address acute trauma and inflammation

Chiropractic

Chiropractic management includes thoracic spine manipulation to restore extension and improve shoulder mechanics; scapulothoracic mobilization and proprioceptive rehabilitation; avoidance of aggressive shoulder manipulation in acute phase due to dislocation risk

Physiotherapy

Structured physiotherapy includes progressive range of motion exercises (passive, active-assisted, active), rotator cuff strengthening (internal and external rotation), scapular stabilization exercises, proprioceptive training (balance activities, closed-chain exercises), and progressive return-to-sport protocols; phase-based progression from immobilization through functional training

Remedial Massage

Remedial massage addresses muscle guarding in upper trapezius, levator scapulae, and pectoralis muscles; soft tissue release of subscapularis and chest wall musculature; progressive deep tissue work to posterior shoulder and scapular stabilizers; emphasis on improving tissue extensibility while respecting joint protection in early phases

Rehabilitation Exercises

Pendulum Circles (Codman's Pendulum)

Range of MotionBeginner

Supine Passive Shoulder Flexion (with assistance or therapist)

Range of MotionBeginner

Scapular Plane Elevation (arm at 45 degrees)

Range of MotionBeginner

Sleeper Stretch (internal rotation stretch)

StretchingBeginner

Cross-Body Shoulder Stretch

StretchingBeginner

Isometric Internal Rotation at Side (early phase, pain-free range)

StrengtheningBeginner

Isometric External Rotation at Side (early phase)

StrengtheningBeginner

Prone Shoulder External Rotation with Light Resistance Band

StrengtheningIntermediate

Prone Horizontal Abduction (Y position) for Posterior Shoulder Activation

StrengtheningIntermediate

Quadruped Shoulder Stability (on hands and knees with gentle weight shifts)

BalanceIntermediate

Scapular Retraction with Proper Posture (wall angels or similar)

PosturalIntermediate

Standing Cable External Rotation (high elbow position for late-stage sport preparation)

StrengtheningAdvanced

Referral Criteria

  • •Immediate emergency department referral for acute dislocation requiring reduction
  • •Orthopedic consultation for suspected labral tears (Bankart lesion), associated fractures (greater tuberosity, glenoid rim), or rotator cuff tears
  • •Orthopedic surgery consultation for recurrent dislocations (typically >2 episodes) or failure of conservative management
  • •Neurological referral for axillary nerve injury not resolving within expected timeframe (>8-12 weeks) or for brachial plexus injuries
  • •Vascular surgery referral for neurovascular compromise or arterial injury
  • •Psychologist or mental health professional for post-traumatic stress, severe anxiety about re-injury, or depression
  • •Physiotherapist for structured progressive rehabilitation program, particularly for return-to-sport protocols
  • •Referral back to physician if recurrent dislocation occurs or if severe pain persists beyond expected recovery timeline suggesting complex regional pain syndrome