Management of Traumatic Dislocation of Shoulder - From POLICE to PEACE & LOVE

February 21, 2019


The majority (98%) of traumatic shoulder dislocations are in the anterior direction.  Recurrence rates following primary anterior dislocations are significantly high (up to 100%).  There is a debate as to whether immobilization in IR (traditional view) or in ER in a functional brace (current view) is more effective in reducing the recurrence rates.This concept was first proposed by Ito et al (2001) base on cadaveric and MRI findings demonstrating significantly less labral separation and displacement when the shoulder is placed in ER as compared with IE.

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Hurley et al., (2021) published a meta-analysis of 9 RCTs with 795 patients.  This Level 1 systematic review concluded that immobilization of the shoulder in ER in a functional brace results:
- more functional position for ADL
- higher compliance rate / comfort
- lower recurrent dislocation rate, including younger patients, who are at higher risk for recurrence.
- higher rate of return to play
as compared with immobilization in IR in traditional shoulder immobilizer.

Immobilization of the shoulder in ER after a traumatic first-time anterior shoulder dislocation results in a higher compliance rate, a lower recurrent dislocation rate and a higher rate of return to play as compared with immobilization in IR.

Immobilization in external rotation after first-time traumatic anterior shoulder instability reduces recurrent instability: a meta-analysis

Hurley  ET et al., J ISAKOS. 2021 Jan; 6(1):22-27

Immobilization in ER reduced the risk of surgical intervention compared with IR in the long term

Long-term effect of immobilization in external rotation after first-time shoulder dislocation: an average 18-year follow up

Itoi E et al., J Shoulder Elbow Surg. 2021 Oct 14; S1058-2746(21)00727-8

Immobilization using both ER braces could maintain the arm position in abduction-external rotation with comparable user-friendliness, although Donjoy Ultrasling ER is more comfortable during daily activities

Immobilizing performances, comfort, and user-friendiness of the shoulder abducation-external rotation braces.

Hatta T et al., Ups J Med Sci. 2013 May; 118(2):105-10


So, what should a shoulder rehabilitation protocol include?  Firstly, it requires to be phased.  Phases determined by the structures involved and patient compliance.  There are two acronyms currently in use that guide acute soft tissue injury management and rehabilitation.  POLICE (Protect-Optimal-Loading-Ice-Compression-Elevation) (Bleakley, 2012) is aimed at immediate interventions and PEACE and LOVE (Protect-Elevation-Avoid Anti-inflammatory-Compression-Education and Loading-Optimism-Vascularization-Exercise) at interventions throughout the rehab process and putting the patient at the center of the decision-making process (Dubois and Esculier, 2020).Both these acronyms include Protection and Optimal Loading.  Protection, as we have discussed, can be provided by bracing.  Optimal Loading using closed kinetic chain exercises should be commenced early in Phase I.

View full video: Shoulder Post-op Pain Free Return to ADL at home with Functional Bracing and Cryocompression

PEACE & LOVE also suggests avoiding anti-inflatmmation medications which may negatively affect long-term tissue healing, and to use external mechanical pressure (C for Compression) to help limit intra-articular oedema and tissue haemorrhage.  Due to the opioid epidemic globally, opioid addiction was cited as the "FDA's biggest crisis". Cryocompression with Cryocuff Shoulder could help patient to return to ADL at home and encourage pain free rehab exercises.

Supplementary Materials

Blogs about Shoulder Instability:

Management of Traumatic Dislocation of Shoulder - From POLICE to PEACE & LOVE

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Rehabilitation Programme for the Best Outcomes Following Anterior dislocation of the shoulder

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Product Brochures mentioned in above clinical evidence papers can be downloaded here:

Aircast Cyro/Cuff IC

Donjoy Ultrasling Pro

DJO Shoulder Post-Op Rehabilitation Concept

Chattanooga Lightforce

Continue Education:

Up to Date Reverse Shoulder Arthroplasty in the USA

presented by Dr. Thomas Bradley Edwards
Live Q&A and discussion with Dr. Sugaya and Dr. Matsumura in Postoperative Management and Posttreatment in Shoulder Arthroplasty - Apr 28th 2022

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The Shoulder Series 2 of 3 – Too Loose (dislocation)

Dr. Chan Kin Yuen and Mr. Cliff Eaton shared their expertise and openly discuss about Shoulder dislocation with high recurrent rate, especially with young patients.

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DJO Institute - Electrical Stimulation for Muscle RE-education & Strengthening

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