Shoulder reduction

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Shoulder reduction
Reduction of a dislocated shoulder with a Hippocratic device.
TypesTraction: Stimson, Spaso, traction-countertraction[1]
Leverage: External rotation, Kocher[1]
Biomechanical: FARES, Cunningham[1]

Shoulder reduction is the process of returning the shoulder to its normal position following a shoulder dislocation. Normally, closed reduction, in which the joint is manipulated externally without surgery, is used.[2] A number of techniques exist, with some preferred due to fewer complications or easier execution.[3] In cases where closed reduction is not successful, surgery may be needed.[4]

Techniques may be grouped by the primary principles, including: traction, leverage, and biomechanical.[1] FARES (Fast, Reliable, and Safe) may have benefits over other techniques.[5] Two of them, the Milch and Stimson techniques, have been directly compared.[6] Pain can be managed during the procedures either by procedural sedation and analgesia or by injecting lidocaine into the shoulder joint.[7]

Techniques have similar rates of success at about 80%.[1] X-rays are used to confirm success and absence of associated fractures. The arm should be kept in a sling or immobilizer for several days, prior to supervised recovery of motion and strength.

External rotation

The person's arm is brought against their side.[4] The elbow is then bent to 90 degrees and the forearm is slowly and gently externally rotated.[4] Any discomfort or spasm interrupts the process until the person is able to relax. Reduction usually takes place by the time full external rotation has been achieved.[8]


This is an extension of the external rotation technique. The externally rotated arm is gently abducted (brought away from the body into an overhead position) while external rotation is maintained. Gentle in-line traction is applied to the arm while some pressure is applied to the humeral head via the operator's thumb in the armpit to keep the head from moving inferiorly.[4][9]


FARES, which stands for "fast, reliable, and safe", starts with the person lying on their back, with the affected arm at the side and the elbow fully extended. The operator holds the person's hand with the forearm in neutral position. Next, the operator gently applies longitudinal traction and slowly moves the arm into abduction (away from the person's body). At the same time, continuous vertical oscillating movement at a rate of 2–3 "cycles" per second is applied throughout the process.[10][11]


An example of the Stimson maneuver. The person is lying on their stomach with a 4 kg weight tied to their wrist.

In the Stimson technique, also known as prone technique, the person lies on their stomach on a bed or bench and the arm hangs off the side, being allowed to drop toward the ground. A 5–10 kg weight is suspended from the wrist to overcome spasm and to permit reduction by the force of gravity.[6] It is a traction technique.[1]


The person is on their back and gentle upward traction is applied to the arm together with external rotation.[4]


Cunningham technique

The Cunningham technique is a method that uses positioning (analgesic position), voluntary scapular retraction, and biceps muscle massage.[12] If performed correctly most people do not require pain medication. Inappropriate use traction will result in pain with subsequent spasm and failure to reduce. If the person is unable to bring the upper arm near the body or unable to cooperate with positioning the technique should not be attempted. The person may require pain medication or sedation if they are unable to relax spasming muscles.

Traction countertraction

Traction countertraction involves pulling the dislocated arm down and outwards while an assistant pulls the body upwards.[4] It is also known as the Hippocratic method.[1]


The Kocher method is a leverage technique.[1] It involves pressing the arm bent at the elbow towards the body, turning outward until resistance is felt, and than lifting the outwardly rotated upper arm as far as possible. Finally the arm may be slowly turning it inward.[13]

It was described in 1870 and has been incorrectly associated with neuromuscular complications and humeral fractures due to the inappropriate addition of traction by later users. It was designed for subcoracoid dislocations.


  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Baden, DN; Visser, MFL; Roetman, MH; Smeeing, DPJ; Houwert, RM; Groenwold, RHH; van der Meijden, OAJ (June 2023). "Effects of reduction technique for acute anterior shoulder dislocation without sedation or intra-articular pain management: a systematic review and meta-analysis". European journal of trauma and emergency surgery : official publication of the European Trauma Society. 49 (3): 1383–1392. doi:10.1007/s00068-023-02242-8. PMID 36856781.
  2. Dong, H; Jenner, EA; Theivendran, K (April 2021). "Closed reduction techniques for acute anterior shoulder dislocation: a systematic review and meta-analysis". European journal of trauma and emergency surgery : official publication of the European Trauma Society. 47 (2): 407–421. doi:10.1007/s00068-020-01427-9. PMID 32607775.
  3. Dislocations, Shoulder~workup at eMedicine
  4. 4.0 4.1 4.2 4.3 4.4 4.5 Bonz, J; Tinloy, B (May 2015). "Emergency department evaluation and treatment of the shoulder and humerus". Emergency Medicine Clinics of North America. 33 (2): 297–310. doi:10.1016/j.emc.2014.12.004. PMID 25892723.
  5. Gonai, S; Yoneoka, D; Miyoshi, T; da Silva Lopes, K (April 2023). "A Systematic Review With Pairwise and Network Meta-analysis of Closed Reduction Methods for Anterior Shoulder Dislocation". Annals of emergency medicine. 81 (4): 453–465. doi:10.1016/j.annemergmed.2022.10.020. PMID 36797133.
  6. 6.0 6.1 Amar, E; Maman, E; Khashan, M; Kauffman, E; et al. (Nov 2012). "Milch versus Stimson technique for nonsedated reduction of anterior shoulder dislocation: a prospective randomized trial and analysis of factors affecting success". J Shoulder Elbow Surg. 21 (11): 1443–9. doi:10.1016/j.jse.2012.01.004. PMID 22516569.
  7. Sithamparapillai, Arjun; Grewal, Keerat; Thompson, Cameron; Walsh, Chris; McLeod, Shelley (December 2022). "Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis". Canadian Journal of Emergency Medicine. 24 (8): 809–819. doi:10.1007/s43678-022-00368-z. PMID 36181665.
  8. Harnroongroj, T; Wangphanich, J; Harnroongroj, T (Dec 2011). "Efficacy of gentle traction, abduction and external rotation maneuver under sedative-free for reduction of acute anterior shoulder dislocation: retrospective comparative study". J Med Assoc Thai. 94 (12): 1482–6. PMID 22295736.
  9. Singh, S; Yong, CK; Mariapan, S (Dec 2012). "Closed reduction techniques in acute anterior shoulder dislocation: modified Milch technique compared with traction-countertraction technique". J Shoulder Elbow Surg. 21 (12): 1706–11. doi:10.1016/j.jse.2012.04.004. PMID 22819577.
  10. Sayegh, Fares E.; Kenanidis, Eustathios I.; Papavasiliou, Kyriakos A.; Potoupnis, Michael E.; Kirkos, John M.; Kapetanos, George A. (2009-12-01). "Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods". The Journal of Bone and Joint Surgery. American Volume. 91 (12): 2775–2782. doi:10.2106/JBJS.H.01434. ISSN 1535-1386. PMID 19952238.
  11. "FARES method to reduce acute anterior shoulder dislocation: a case series and an efficacy analysis". Hong Kong Journal of Emergency Medicine. January 2012.
  12. "Cunningham | DISLOCATION.COM.AU". Archived from the original on 2020-02-13.
  13. "Welcome to DISLOCATION.COM.AU". DISLOCATION.COM.AU. Archived from the original on 16 June 2021. Retrieved 14 October 2021.