Bilateral Anterior Shoulder Dislocation in a Weight Lifter
Irfan Esenkaya, MD; Hakan Tuygun, MD; I. Metin Türkmen, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 3 - MARCH 2021
In Brief: A young man experienced bilateral anterior dislocation of the shoulders while doing seated behind-the-neck military presses. When improperly performed, military presses can cause injury because the shoulder muscles may be unable to support the weight being lifted. To improve form, avoid injury, and maximize gain from workouts, beginning weight lifters and those with shoulder instability should be counseled to use safer alternative techniques such as frontal military presses that do not allow movement posterior to the plane of the body.
Weight lifting and weight training have become popular activities (1-3); however, excessive weight training, the use of improper techniques, or a combination of the two can lead to acute or chronic injuries (2,4,5). Musculoskeletal injuries from weight lifting have been reported more frequently (1-3,5-8). We report a case of a rare injury, bilateral anterior shoulder dislocation in a young male weight lifter.
A healthy, 22-year-old male amateur weight lifter came to the emergency department complaining of acute bilateral shoulder stiffness and pain. He had been seated while doing a behind-the-neck military press (figure 1) with a 108-lb (50-kg) weight. As he was returning to the starting position (figure 1a), he felt that his shoulders were going out of place, and he lost control of the bar behind his neck. His training partner was unable to help him avoid injury. The patient reported that he felt immediate pain and was unable to move his arms. He was taken to the hospital immediately.
Physical examination and history. When the patient arrived at the emergency department, his arms were in slight abduction and external rotation, and he had stiffness and pain. Physical examination showed bilateral flattened contour of the shoulders below the tip of the acromion. There was anterior fullness, but the patient had no neurologic or vascular abnormalities. Radiologic examination showed bilateral anterior shoulder dislocation without fracture (figure 2).
The patient was an accountant, right-handed, and had done weight training regularly for 3 years. He weighed about 180 lb (83.3 kg) and was 5 ft 10 in. (178 cm) tall. The patient had no history of dislocation or injury to either shoulder or other joints. Neither he nor his family had any history of hyperlaxity disorders, epilepsy, or convulsions. He had not had any alcohol within 24 hours of the training session.
Treatment. Reduction was achieved with Kocher's maneuver after the patient received 10 mg of intravenous diazepam. X-rays taken after the procedure showed that reduction was satisfactory (figure 3). Reduction was maintained by having the patient wear a bilateral body bandage for 3 weeks. He wore the bandage at all times and was seen weekly by his physicians. After the bandages were removed, the patient underwent 6 weeks of physical therapy. He discontinued weight lifting completely and had full range of motion 6 months after the injury. He had had no redislocation at follow-up 5 years later.
Baseball, tennis, and volleyball have been associated with symptomatic occult glenohumeral instability. During these activities, the joint is forced into abduction and external rotation, the same position as is required in many weight lifting techniques. Repetition of techniques that force abduction and external rotation adds extra weight at the end of the extended lever arm and can result in instability and dislocation (7). The joint is prone to dislocation because its stability is largely dependent on the integrity of the surrounding soft tissues (1,9,10).
Incidence. Bilateral simultaneous dislocation of the shoulders is rare. Most cases are posterior and have been reported after drug-induced seizures, electroconvulsive therapy, or in patients with neuromuscular deficiencies or severe emotional disturbances (psychogenic dislocation) (9-12). Bilateral anterior dislocation has occurred in patients who have epileptic seizures (10,13), drug-induced seizures (9), or diabetic nocturnal hypoglycemia (14), and in patients who have loose joints and dislocate shoulders while engaged in voluntary movements (15) or experiencing trauma (10). A few cases have occurred among weight lifters (1,8) and those participating in other activities (eg, water skiing) (10). Simultaneous undiagnosed bilateral anterior shoulder dislocation has also been described; the patient was an elderly woman (16).
Mechanism. Anterior dislocation of the shoulder occurs when forced extension, abduction, and external rotation of the arm levers the humeral head out of the glenoid fossa. Sometimes a direct blow on the posterior aspect of the shoulder or direct forward traction can cause dislocation (1,8-10).
Mechanism in weight lifting. Our patient lifted weights for bodybuilding but reported that the military press (17) was not one of his usual exercises. His training partner was unable to prevent the loaded bar from falling as the patient was returning the bar to the starting position, a common way for the injury to occur—with the shoulders abducted and elbows extended. As the bar was being lowered, the muscles and joint capsule were the only stabilizing structures. The weight was likely greater than the combined muscle strength and capsular resistance at that angle, allowing a dislocation to occur (1).
Two other cases of bilateral anterior glenohumeral dislocation during weight training have been reported (1,8). In the first case, the lifter was doing bench presses while he grasped the bar with his hands about shoulder width apart. On the 15th lift of the first set, both his arms suddenly became stiff and painful. He lost control of the weight, and the bar fell backward, but it was caught by his training partner (8). In the second case, the athlete's shoulders were abducted as he tried to lift a long bar while lying on a bench. He attempted to bring the loaded bar from his head to his knees without flexing his elbows; the shoulders were thus kept in fixed rotation. The athlete reasoned that the weight must have been in the most cephalad position when the dislocation occurred (1).
Preventive measures. Bodybuilding is a kind of weight training method that is exceedingly popular among younger people. The primary goal is to attain significant, symmetric muscle hypertrophy; strength gains are secondary. Bodybuilders are at risk of both acute injuries (eg, from loss of control of a weight) and overuse injuries from eccentric contractions, forced repetitions, supersets, and compound sets (2). Because patients who experience shoulder dislocations have a high risk of redislocation, minimizing risks for the initial injury are important. Modification of some techniques is needed to avoid high-risk positions (2,4,7). For beginners and athletes who have shoulder problems, the golden rule when weight training is to keep the elbows in front of the body. Exercises that do not employ movement behind the neck or posterior to the plane of the body serve this purpose.
Dr Esenkaya is assistant professor in the department of orthopaedics and traumatology at the University of Inönü Turgut Ozal Medical Center in Malatya, Turkey. Dr Tuygun is an orthopedic surgeon and Dr Türkmen is associate professor in the department of orthopaedics and traumatology at Haydarpasa Numune Hospital in Istanbul, Turkey. Address correspondence to Dr Irfan Esenkaya, Dept of Orthopaedics and Traumatology, Box 150, University of Inönü Turgut Ozal Medical Center, 44100 Malatya, Turkey; fax: 90-422-325-8283.