Mastering Shoulder Reduction: A Comprehensive Guide to Safe and Effective Techniques

A dislocated shoulder is a common yet debilitating injury, causing intense pain and restricted movement. For healthcare professionals, the ability to safely and effectively reduce a dislocated shoulder is a critical skill. This guide delves into the practical aspects of shoulder reduction, focusing on clear, actionable steps and real-world examples to equip you with the knowledge to manage this condition competently and confidently. We will strip away the theoretical fluff and get straight to the “how-to,” ensuring every technique is explained with precision and practicality.

Understanding the Landscape: Pre-Reduction Essentials

Before attempting any shoulder reduction, a thorough understanding of the patient’s condition and the specific type of dislocation is paramount. This initial assessment phase isn’t just a formality; it’s a critical safety net that guides your choice of reduction method and minimizes potential complications.

Pain Assessment and Management: The Foundation of Patient Cooperation

Pain is the immediate and most pressing concern for a patient with a dislocated shoulder. Effective pain management is not just about comfort; it’s about facilitating muscle relaxation, which is crucial for a successful and less traumatic reduction.

Actionable Steps for Pain Management:

Rapid Initial Assessment: Quickly gauge the patient’s pain level using a 0-10 scale. Observe their demeanor, guarding, and vocalizations. This gives you a baseline.
- Example: A patient clutching their arm tightly, grimacing, and unable to articulate full sentences due to pain likely warrants immediate and aggressive pain relief.
Pharmacological Interventions:
- Intravenous (IV) Analgesia: This is often the most rapid and effective route.
  - Opioids: Fentanyl (25-100 mcg IV push, titrate slowly) or Hydromorphone (0.5-2 mg IV push, titrate slowly) are excellent choices. Start with a lower dose and titrate to effect, typically aiming for a pain score of 3-4/10.
  - NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Ketorolac (15-30 mg IV) can be administered concurrently for its anti-inflammatory properties, providing sustained pain relief post-reduction.
- Local Anesthesia (Intra-Articular Injection): This technique directly numbs the joint, providing targeted and often profound pain relief.
  - Procedure:
    1. Aseptic Technique: Thoroughly clean the skin over the posterolateral aspect of the shoulder, inferior to the acromion, with an antiseptic solution (e.g., chlorhexidine or povidone-iodine).
    2. Needle Insertion: Use a 21- or 22-gauge needle (1.5 inches long). Palpate the humeral head and aim the needle into the glenohumeral joint space. The needle should be directed medially and slightly superiorly.
    3. Aspiration (Optional but Recommended): Gently aspirate to confirm you are not in a blood vessel.
    4. Injection: Inject 5-10 mL of 1% lidocaine without epinephrine. You should feel minimal resistance. If resistance is high, slightly reposition the needle.
  - Example: A patient who is still significantly apprehensive despite IV opioids might benefit greatly from an intra-articular lidocaine injection, which can provide a “dead arm” sensation, allowing for much greater muscle relaxation.
Non-Pharmacological Adjuncts:
- Reassurance and Explanation: Calmly explain what you are doing and why. Anxiety exacerbates pain.
- Comfortable Positioning: Support the injured arm in a comfortable position, often adducted across the chest with a sling, to minimize movement and spasm.
- Ice Application: While not a primary pain reliever for acute dislocation, ice packs applied to the shoulder can help reduce swelling and provide some local analgesic effect.

Confirmation of Dislocation and Exclusion of Complications

Before any reduction attempt, it’s non-negotiable to confirm the dislocation and rule out associated injuries that could complicate or contraindicate reduction.

Actionable Steps for Assessment:

Clinical Examination:
- Inspection: Observe the characteristic deformity: the shoulder appears “squared off,” the acromion is prominent, and there’s a palpable hollow beneath the acromion. The humeral head may be palpable anteriorly or inferiorly (most commonly anteriorly).
- Palpation: Gently palpate for the humeral head’s abnormal position. Assess for tenderness over the clavicle or AC joint, which might indicate a fracture.
- Range of Motion (Passive): Extremely limited and painful external rotation and abduction are characteristic of an anterior dislocation. Do not force movement.
- Neurovascular Assessment: This is critical.
  - Axillary Nerve: Test sensation over the lateral deltoid (regimental badge area). Test deltoid muscle strength (shoulder abduction).
  - Musculocutaneous Nerve: Test sensation over the lateral forearm. Test biceps muscle strength (elbow flexion and supination).
  - Radial, Median, Ulnar Nerves: Assess sensation and motor function in the hand and fingers.
  - Vascular: Check radial and ulnar pulses. Assess capillary refill in the fingertips.
  - Example: A patient presenting with numbness over the lateral deltoid area or weakness in shoulder abduction, in addition to the dislocation, immediately raises concern for axillary nerve compromise and necessitates careful documentation and follow-up.
Imaging Studies (X-rays):
- Standard Views: Obtain at least two orthogonal views:
  - Anteroposterior (AP) View: Shows the relationship of the humeral head to the glenoid.
  - Scapular Y View: This view is crucial for differentiating anterior from posterior dislocations and visualizing the glenoid. The humeral head should normally be centered over the “Y” formed by the scapular spine, coracoid, and inferior angle. In an anterior dislocation, the humeral head is anterior to the Y; in a posterior, it’s posterior.
  - Axillary View (if pain allows): Provides the best visualization of the glenoid and humeral head relationship, especially for posterior dislocations.
- Purpose of X-rays:
  - Confirm Dislocation: Absolutely essential before reduction.
  - Determine Type of Dislocation: Anterior (most common), posterior, inferior.
  - Rule Out Fractures: Humerus head (Hill-Sachs lesion, greater tuberosity), glenoid rim (Bankart lesion), scapula, clavicle. Attempting reduction with an unrecognized fracture can cause further displacement or comminution.
  - Example: An AP X-ray showing the humeral head inferior and medial to the glenoid, combined with a Scapular Y view confirming the humeral head is anterior to the glenoid, confirms an anterior dislocation. If the X-ray reveals a displaced greater tuberosity fracture, then orthopedic consultation is immediately warranted as closed reduction may be contraindicated or require specific modifications.
Patient History:
- Mechanism of Injury: Was it a fall on an outstretched arm (anterior) or a direct blow to the front of the shoulder (posterior)?
- Previous Dislocations: Recurrent dislocations are common and may affect the ease of reduction and post-reduction management.
- Comorbidities: Any underlying conditions (e.g., osteoporosis, neurological disorders) that might influence the procedure or recovery.

The Art of Reduction: Techniques and Practical Application

Once the pre-reduction essentials are met, you can proceed to the reduction. The key to success lies in choosing the appropriate technique, ensuring adequate analgesia and muscle relaxation, and executing the maneuvers smoothly and with controlled force. Avoid forceful, uncontrolled tugging, which can cause further injury.

General Principles for All Reduction Techniques

Adequate Analgesia and Muscle Relaxation: As discussed, this is non-negotiable. The more relaxed the muscles, the easier and less traumatic the reduction.
Slow, Steady Traction: Most techniques involve some form of traction. Apply it slowly and steadily, allowing muscles to fatigue and relax. Jerking movements are counterproductive.
Counter-Traction: Often, a second person or a physical restraint (e.g., sheet) is used to provide counter-traction, stabilizing the torso and allowing for more effective traction on the arm.
Listen for the “Clunk”: A successful reduction is often audibly and/or palpably confirmed by a “clunk” as the humeral head relocates into the glenoid.
Post-Reduction Assessment: Immediately after reduction, reassess neurovascular status and range of motion.

Anterior Shoulder Dislocation Reduction Techniques

Anterior dislocation is by far the most common type. Several techniques exist, each with its advantages and specific scenarios where it might be preferred.

1. The Stimson Maneuver (Weight-Based Traction)

This is an excellent, low-force technique, often successful with good muscle relaxation, and particularly useful for cooperative patients.

Actionable Steps:

Patient Positioning: Patient lies prone on a stretcher or examination table with the affected arm hanging off the side. Ensure the arm is completely free to hang.
Weight Application: Attach a weight (typically 5-10 kg, e.g., a bag of saline or sand) to the patient’s wrist. Start with 5 kg and increase if needed after 5-10 minutes.
Time and Patience: This technique relies on gravity and muscle fatigue. Allow 10-20 minutes for the muscles to relax and the humeral head to descend. Avoid rushing.
Gentle Internal/External Rotation (Optional): After 5-10 minutes, if reduction hasn’t occurred, you can gently oscillate the arm with slight internal and external rotation to help disengage the humeral head.
Confirmation: Listen for the “clunk.” Once reduced, remove the weight and support the arm.
- Example: A patient, after receiving 100 mcg IV fentanyl, is positioned prone with their arm hanging. A 7 kg bag of saline is tied to their wrist. After 15 minutes of gentle, passive hanging, a distinct “clunk” is heard and felt, indicating successful reduction.

2. The Scapular Manipulation Technique

This technique focuses on rotating the scapula around the humeral head, rather than direct traction on the arm. It can be surprisingly effective, especially in combination with light traction.

Actionable Steps:

Patient Positioning: Patient can be seated upright or prone. If prone, the arm should hang as in the Stimson maneuver, with some traction (manual or weight-based).
Scapular Stabilization (Assistant): An assistant stabilizes the superior aspect of the scapula to prevent it from moving with the manipulation.
Scapular Manipulation:
- Inferior Angle: Grasp the inferior angle of the scapula with one hand.
- Medial Border: Place the other hand on the medial border of the scapula.
- Rotation: Simultaneously rotate the inferior angle laterally and the medial border anteriorly. This effectively rotates the glenoid fossa.
Concurrent Traction (Optional but Recommended): While manipulating the scapula, apply gentle, sustained traction to the arm, either manually or via a weight.
Confirmation: Feel and listen for the “clunk.”
- Example: A patient is seated, and you apply gentle traction to their arm while an assistant stabilizes their scapula. You then grasp the inferior angle and medial border of the scapula, performing a gentle rotation. Within seconds, a “clunk” is felt, and the patient expresses immediate relief.

3. The Kocher Maneuver (Historically Popular, Use with Caution)

While historically common, the Kocher maneuver involves external rotation, adduction, and internal rotation. It has a higher risk of complications (e.g., humeral head fractures) if not performed carefully and with excellent muscle relaxation. It is often reserved for situations where other, gentler methods have failed.

Actionable Steps (Perform with extreme caution and adequate relaxation):

Patient Positioning: Patient supine.
Initial Traction: Apply gentle, sustained traction in line with the humerus.
External Rotation: While maintaining traction, slowly and gently externally rotate the arm to approximately 90 degrees. This should be performed very slowly, allowing muscle relaxation. Do not force if resistance is met.
Adduction: While maintaining external rotation, adduct the arm across the chest, aiming the elbow towards the patient’s opposite shoulder.
Internal Rotation: Finally, internally rotate the arm, bringing the hand towards the opposite shoulder.
Confirmation: The “clunk” should be felt during the adduction or internal rotation phase.
- Example: After deep sedation and muscle relaxation, you apply slow traction, then gently externally rotate the arm. If the patient stiffens, you hold the position until relaxation returns. Once at 90 degrees of external rotation, you slowly adduct the arm across the chest, and as you begin internal rotation, the shoulder reduces.

4. The Milch Maneuver (Modified External Rotation)

This technique is simple and often successful, relying purely on external rotation and elevation. It is considered a very safe and patient-friendly method.

Actionable Steps:

Patient Positioning: Patient supine.
Stabilization: Use one hand to stabilize the acromion and scapula.
External Rotation and Abduction: With the other hand, grasp the patient’s wrist and gently but firmly externally rotate the arm while simultaneously slowly abducting it overhead (similar to bringing the hand to the head, but with control).
Gentle Pressure (Optional): As the arm reaches near full abduction, gentle pressure can be applied to the humeral head (if palpable anteriorly) to guide it back into the glenoid.
Confirmation: The reduction should occur as the arm approaches overhead abduction.
- Example: A patient, after receiving pain medication, is supine. You stabilize their shoulder and gently externally rotate their arm while slowly raising it overhead. The patient breathes through the mild discomfort, and as the arm approaches 160 degrees of abduction, the shoulder spontaneously reduces with a soft clunk.

5. The Spaso Technique (Arm Traction and External Rotation)

A gentler alternative to Kocher, combining traction with external rotation.

Actionable Steps:

Patient Positioning: Patient supine.
Traction: Grasp the patient’s wrist or forearm and apply gentle, sustained longitudinal traction on the arm, directed slightly superiorly (towards the patient’s head).
External Rotation: While maintaining traction, slowly and gently externally rotate the arm.
Confirmation: The shoulder often reduces with a palpable “clunk” as the arm externally rotates.
- Example: You apply continuous gentle traction to the patient’s arm, maintaining it just above the level of the bed. Simultaneously, you slowly externally rotate the arm. After about 30 seconds of sustained traction and rotation, the shoulder reduces, causing a sigh of relief from the patient.

Posterior Shoulder Dislocation Reduction

Posterior dislocations are much less common but require a different approach. They often result from seizures, electric shocks, or direct blows to the front of the shoulder.

Actionable Steps (Requires significant muscle relaxation due to strong internal rotators):

Patient Positioning: Patient supine.
Counter-Traction: An assistant applies counter-traction to the chest with a sheet.
Axial Traction: Apply strong, sustained axial traction to the arm in the line of the humerus, with the arm adducted and internally rotated.
Gentle Elevation and External Rotation: While maintaining traction, gently lift the humerus anteriorly (towards the ceiling) and slowly externally rotate the arm. This aims to lift the humeral head over the posterior glenoid rim.
Confirmation: A palpable “clunk” indicates reduction.
- Example: After deep sedation, an assistant secures a sheet around the patient’s chest for counter-traction. You apply strong, sustained traction to the arm, which is held in adduction and internal rotation. While maintaining traction, you gently lift the arm anteriorly and slowly externally rotate, allowing the humeral head to pop back into place.

Inferior (Luxatio Erecta) Shoulder Dislocation Reduction

This is the rarest type, where the arm is fixed in abduction directly overhead.

Actionable Steps:

Patient Positioning: Patient supine.
Counter-Traction: An assistant applies strong counter-traction to the ipsilateral axilla.
Axial Traction: Apply strong, sustained axial traction directly to the arm, which is fixed in the overhead position.
Adduction: As traction is maintained, gently adduct the arm downwards towards the patient’s side. The humeral head will typically pop out inferiorly and then slide anteriorly or posteriorly.
Confirmation: The “clunk” and a return to normal arm position.
- Example: A patient presents with their arm stuck overhead. After robust analgesia and sedation, an assistant applies counter-traction in the axilla. You apply strong downward traction on the arm, and as you slowly adduct it towards the patient’s side, the humeral head is levered out and then back into the joint.

Post-Reduction Care and Management

The successful reduction of a shoulder is only half the battle. Proper post-reduction care is crucial to prevent re-dislocation, manage pain, and facilitate rehabilitation.

Immediate Post-Reduction Assessment

Neurovascular Reassessment: Immediately re-check all neurovascular functions (sensation, motor, pulses, capillary refill). Document any changes.
- Example: After reduction, immediately ask the patient to wiggle their fingers and assess sensation in all dermatomes. If a new deficit is noted, prompt orthopedic consultation is required.
Range of Motion (Gentle): Gently assess the patient’s active and passive range of motion to confirm the shoulder is reduced and stable. Do not force movement.
Pain Assessment: Reassess pain levels and administer additional analgesia if needed.

Post-Reduction Imaging

Post-Reduction X-rays: Always obtain post-reduction X-rays (AP and Scapular Y views) to confirm successful reduction and rule out any iatrogenic fractures (fractures caused by the reduction attempt).
- Example: After a successful reduction, X-rays show the humeral head concentrically reduced within the glenoid, and no new fractures are evident.

Immobilization

Sling Application: Immobilize the arm in a sling (typically an arm sling with an immobilizer) to prevent abduction and external rotation, which are positions that can lead to re-dislocation.
- Duration: For a first-time anterior dislocation, immobilization for 2-3 weeks is common, especially in younger patients. Older patients or those with recurrent dislocations may require shorter periods or alternative strategies.
- Example: A young athlete with a first-time anterior dislocation is placed in a sling and swathe for three weeks to allow for capsular healing.

Pain Management and Education

Oral Analgesia: Prescribe appropriate oral analgesics (e.g., NSAIDs, acetaminophen, short course of opioids if necessary) for pain management.
Patient Education:
- Activity Restrictions: Advise the patient to avoid overhead activities, heavy lifting, and any movements that could stress the shoulder joint.
- Sling Use: Instruct them on proper sling use, including when to remove it for hygiene.
- Signs of Re-dislocation: Educate them on the signs and symptoms of re-dislocation and when to seek immediate medical attention.
- Importance of Follow-up: Emphasize the crucial role of follow-up with an orthopedic surgeon or physical therapist.
- Example: “You will need to keep this sling on for the next three weeks, only taking it off for showering or gentle elbow exercises. Avoid lifting anything heavier than a coffee cup with this arm. If you feel your shoulder pop out again, or if you experience new numbness or weakness, come back immediately. You have an appointment with an orthopedic surgeon in three days to discuss further rehabilitation.”

Rehabilitation and Follow-Up

Orthopedic Referral: All patients with a dislocated shoulder should be referred to an orthopedic surgeon for definitive management. This is especially important for:
- First-time dislocations (to discuss recurrence risk and surgical options).
- Recurrent dislocations.
- Associated fractures or neurovascular deficits.
- Patients with persistent pain or instability.
Physical Therapy: Physical therapy is essential for restoring strength, range of motion, and stability to the shoulder. This typically begins after the initial immobilization period.
- Phases of Rehab:
  - Phase 1 (Pain and Edema Control, Gentle ROM): Focus on reducing pain and swelling, gentle pendulum exercises, and passive range of motion.
  - Phase 2 (Gradual Strengthening): Introduce isometric exercises, then light resistance exercises as pain allows.
  - Phase 3 (Return to Function): Progress to functional exercises, sport-specific training (if applicable), and dynamic stability exercises.
- Example: After three weeks in the sling, the patient begins physical therapy focusing on pendulum exercises and gentle passive external rotation. Over the next six weeks, they progress to resistance band exercises for rotator cuff strengthening and scapular stabilization, aiming to return to their sport in 3-4 months.

Potential Complications and How to Mitigate Them

While shoulder reduction is generally safe, complications can occur. Awareness and proactive measures are key to minimizing their incidence and managing them effectively.

Nerve Injury

Most Common: Axillary nerve (sensory deficit over lateral deltoid, deltoid weakness).
Mitigation: Thorough pre- and post-reduction neurovascular assessment. Gentle, controlled reduction techniques. Avoid excessive force.
Management: Most axillary nerve neuropraxias resolve spontaneously within weeks to months. Monitor closely. If no improvement, nerve conduction studies and EMG may be warranted, and neurosurgical consultation considered.

Vascular Injury

Rare: Damage to the axillary artery or vein.
Mitigation: Gentle techniques. Vigilant pre- and post-reduction pulse checks and capillary refill assessment.
Management: Immediate surgical consultation for any signs of arterial insufficiency (absent pulses, pallor, cold limb).

Fractures

Types: Humeral head (Hill-Sachs lesion – a compression fracture of the posterior humeral head from impact with the anterior glenoid rim; greater tuberosity fracture; surgical neck fracture), glenoid rim (Bankart lesion – an avulsion of the anterior-inferior labrum from the glenoid rim).
Mitigation: Pre-reduction X-rays are paramount. Avoid forceful, uncontrolled reduction.
Management: Many fractures (e.g., small greater tuberosity avulsion) can be managed non-operatively. Larger displaced fractures or significant glenoid fractures often require orthopedic surgical intervention.

Rotator Cuff Tears

Risk Factors: More common in older patients.
Mitigation: Gentle handling of the arm.
Management: Symptoms include persistent pain, weakness, and limited active range of motion post-reduction. Diagnosis confirmed with MRI. May require surgical repair depending on tear size and patient factors.

Recurrent Dislocation

Risk Factors: Young age at first dislocation, male sex, engaging in contact sports, hyperlaxity.
Mitigation: Appropriate immobilization duration, diligent physical therapy, patient education on avoiding risky movements.
Management: Often managed surgically (e.g., Bankart repair, capsular plication) to stabilize the joint and prevent further episodes.

Stiffness (Adhesive Capsulitis/Frozen Shoulder)

Risk Factors: Prolonged immobilization, inadequate rehabilitation, older age, diabetes.
Mitigation: Appropriate duration of immobilization (avoiding prolonged periods), early initiation of gentle range of motion exercises as guided by a therapist.
Management: Aggressive physical therapy, pain management, and sometimes corticosteroid injections or manipulation under anesthesia if conservative measures fail.

Conclusion: Empowering Safe Shoulder Reduction

Facilitating a safe and effective shoulder reduction requires a systematic approach, combining meticulous assessment, skilled execution of chosen techniques, and comprehensive post-reduction care. By prioritizing patient comfort through adequate analgesia and muscle relaxation, diligently ruling out complications with appropriate imaging, and performing reduction maneuvers with precision and control, healthcare professionals can significantly improve outcomes and minimize patient distress. The journey doesn’t end with a successful “clunk”; it continues through meticulous follow-up and targeted rehabilitation, ensuring the patient regains full function and reduces the risk of future dislocations. Mastery of these principles empowers you to provide immediate relief and lay the groundwork for long-term shoulder health.