Glenohumeral Dislocation
Upper LimbOverview
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
Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.
Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).
Release (Surprise) Test
Procedure
Straight after the relocation test, with the backwards pressure applied and the shoulder in abduction and external rotation, suddenly release the pressure.
Positive Finding
Sudden return of apprehension, or the patient guards.
Sensitivity / Specificity
Reference: Lo IK et al., Am J Sports Med 2004; PMID 14977651
Interpretation
The most informative of the apprehension group for anterior instability. A positive result supports anterior instability and a labral or capsular lesion. Perform gently; it can be distressing. (The jerk test is a separate test for posterior instability.) Lo (2004) found the surprise (anterior release) test the single most accurate of the three instability tests (64% sensitivity / 99% specificity); apprehension and relocation alone were less accurate.
Anterior Apprehension Test
Procedure
Not for an acute unreduced dislocation. After reduction or in recurrent instability: patient supine, shoulder abducted to 90° and elbow bent to 90°. Slowly externally rotate the shoulder.
Positive Finding
The patient shows or reports apprehension (a feeling the shoulder will come out). Pain alone is less meaningful.
Sensitivity / Specificity
Reference: Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of three common tests for traumatic anterior shoulder instability. J Bone Joint Surg Am. 2006;88(7):1467-74.
Interpretation
Apprehension supports anterior instability. Use it with the relocation and release (surprise) tests; apprehension relieved by relocation and returning on release is the most informative combination. From 363 patients examined before shoulder arthroscopy (Farber 2006): 46 had traumatic anterior instability and 317 had other shoulder problems. Counting apprehension (not pain) as a positive result, the test was positive in 72% of those with instability and negative in 96% of those without, so a positive test strongly supports instability. Using pain as the positive sign made the test less accurate.
Relocation Test (Jobe Relocation Test)
Procedure
Straight after a positive apprehension test, in the same position, apply a backwards pressure on the front of the humeral head and continue external rotation.
Positive Finding
The apprehension eases with the backwards pressure, allowing more external rotation.
Sensitivity / Specificity
Reference: Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of three common tests for traumatic anterior shoulder instability. J Bone Joint Surg Am. 2006;88(7):1467-74.
Interpretation
Relief of apprehension supports anterior instability. Relief of pain alone is less meaningful. Follow with the release (surprise) test. From 363 patients examined before shoulder arthroscopy (Farber 2006): 46 had traumatic anterior instability and 317 had other shoulder problems. Counting relief of apprehension as a positive result, the relocation test was positive in 81% of those with instability and negative in 92% of those without. Using relief of pain instead made it less accurate.
Anterior Drawer Test
Procedure
Patient supine, shoulder abducted to about 80–120°, forward flexed and slightly externally rotated. Stabilise the scapula with one hand and draw the humeral head forwards with the other, comparing sides.
Positive Finding
More forward movement than on the other side, sometimes with a click or apprehension.
Interpretation
Shows anterior laxity. Laxity is not the same as instability; many people have lax shoulders without symptoms, so interpret it with the history and apprehension tests. In the same study as the apprehension figures (Farber 2006; 363 patients), the anterior drawer could be done in 87% of patients. When a positive test meant reproducing the patient's feeling of instability, it was positive in 53% of those with instability and negative in 85% of those without. Those figures are for that symptom-based definition, not for extra movement alone, so no figure is shown against this entry.
Sources
- Educational sitePhysiopedia. Anterior Drawer Test of the Shoulder.
- RelatedFarber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of three common tests for traumatic anterior shoulder instability. J Bone Joint Surg Am. 2006;88(7):1467-74.
Sulcus Sign
Procedure
Patient seated, arm relaxed at the side. Pull the arm gently downwards at the elbow and look for a dip below the acromion. Repeat with the shoulder externally rotated.
Positive Finding
A visible gap below the acromion, graded by its size and compared with the other side; a gap that persists in external rotation is more significant.
Interpretation
Shows inferior laxity. A large sulcus, especially on both sides, suggests generalised laxity or multidirectional instability, which is usually managed with rehabilitation first.
Load-and-Shift Test
Procedure
Patient seated or supine. Stabilise the scapula, press the humeral head gently into the glenoid (load), then glide it forwards and backwards (shift), noting the amount of movement compared with the other side.
Positive Finding
More translation than on the other side, especially if the head rides over the glenoid rim or reproduces symptoms.
Interpretation
Grades laxity, which helps describe the instability. Agreement between clinicians on grading is limited, and laxity alone does not mean instability.
⚠ 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
Refer first
An acute shoulder dislocation needs medical reduction before any manual treatment. After reduction, trials have only compared sling positions; none test rehab or manual therapy. Refer for medical assessment.
- Reference bookAbrams & Akbarnia · StatPearls 2023
- Journal articleBraun & McRobert · Cochrane 2019
Rehabilitation Exercises
Pendulum Circles (Codman's Pendulum)
Supine Passive Shoulder Flexion (with assistance or therapist)
Scapular Plane Elevation (arm at 45 degrees)
Sleeper Stretch (internal rotation stretch)
Cross-Body Shoulder Stretch
Isometric Internal Rotation at Side (early phase, pain-free range)
Isometric External Rotation at Side (early phase)
Prone Shoulder External Rotation with Light Resistance Band
Prone Horizontal Abduction (Y position) for Posterior Shoulder Activation
Quadruped Shoulder Stability (on hands and knees with gentle weight shifts)
Scapular Retraction with Proper Posture (wall angels or similar)
Standing Cable External Rotation (high elbow position for late-stage sport preparation)
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