Subluxation is an incomplete dislocation that is caused by the displacement of one of two bones that makes up a joint. This situation affects the normal alignment of the joint and may compromise the functions of nerves by triggering multiple physical problems. Although they do not always cause pain, it is important to treat them to avoid serious complications.
“Subluxation: A lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity.
Subluxation complex (vertebral): A theoretical model and description of the motion segment dysfunction, which incorporates the interaction of pathological changes in nerve, muscle, ligamentous, vascular and connective tissue.”1
Subluxation produces an interference in the constant flow of energy and communication between the brain and the rest of the body. Therefore, although at the beginning it can be imperceptible and painless, it can trigger symptoms and pathologies that slowly diminish the patient’s quality of life. It is very important to act in a timely manner and be attentive to any type of subluxation since its progression can reduce joint mobility and the functions associated with the affected nerves. Therefore, it is necessary to review its main causes, symptoms and the type of treatment they require so that its effects do not grow out of control.
“Subluxations are categorized by anatomic location as there are no eponymic terms.
- facet s.: malalignment of opposing facet, allowing one cervical body to rotate around another.
- patellar s.: most commonly in a lateral direction.
- radioulnar s.: involves the distal ulnar radial joint.
- sacroiliac s.: involves the sacroiliac joint; usually associated with a pelvic fracture and other dissociations of the pelvic ring.
- shoulder s.: involves the glenohumeral joint (as opposed to the acromioclavicular joint).
- wrist s.: involves the proximal carpal bones on the radius and ulna.”2
The difference between a subluxation and a dislocation is that a subluxation is the partial sliding out of position of a joint by the stretching of soft tissues. A dislocation occurs when bones completely move out of their normal position at the joint.
Subluxations can be produced by micro and macro traumas. Most often, the region that is usually affected by this condition is the spine, compromising the structural stability of the body.
“Injuries of the cervical spine are common and of great variety. Often they are readily detected radiologically as outright fractures and dislocations. However, injury may be limited to ligaments, joint capsules, and intervertebral discs. The radiologic evidence in such cases may be subtle, but significant disability may result if these injuries are not recognized. An important injury of dorsal ligaments is the hyperflexion sprain resulting in anterior subluxation.”2
Some of the causes that we can mention include: unhealthy postures, inappropriate movement of the joints, exaggerated physical exertion and out-of-range bone rotations, among others.
Besides other types of injuries, there are some factors that increase the predisposition of subluxation. The most common are poor diet, a sedentary lifestyle, sports injuries and sleep disorders.
Many cases are difficult to detect in a timely manner since it does not always manifest with obvious ailments or signs. In other cases, symptoms may include an articulation that first looks deformed or out of place, followed by inflammation, severe pain, numbness, tingling sensations, immobility of the joint, discoloration and bruised appearance.
Immediate attention to any suspicion of subluxation can be the decisive factor for a successful treatment. Although they do not always generate major annoyances, it is essential to correct them as soon as possible.
To diagnose a subluxation, the doctor begins by performing a physical evaluation of the patient. Then, to confirm it, he or she can suggest an X-ray to see if there are other joints damaged. Finally, the doctor can also request an MRI scan to analyze the surrounding soft tissue.
Differences between Dislocations and Fractures
At first, it is difficult to distinguish between a dislocated bone and a fractured bone.
Dislocations – These are more common than is realized. Many may be incorrectly described as fracture-dislocations, because it is not always easy to interpret lateral radiographs of the neck and there is a widespread belief that forward displacement does not often take place without an associated fracture of thee articular process or laminae. Dislocation, however, may occur without fracture if the posterior ligaments are torn. Displacement may also occur spontaneously in patients with spondylolisthesis of the neural arch.
Fracture-dislocations – As previously stated, a sever compression fracture is nearly always associated with dislocation of the articular facets or with their fracture. Dislocation is not infrequently accompanied by a minor compression fracture. In cases of fracture-dislocation the upper vertebra may be fractured and move forward with the upper one. The displacement is often unequal on the two sides; so asymmetry of the head and neck may be obvious clinically.”3
However, given that both conditions are emergencies, it is important to provide first aid and go to a hospital or a health center. The first steps that must be taken are:
- Check the patient’s breathing and circulation.
- Immobilize the injury if it is in the leg, back or head.
- If the lesion has broken skin, poking around the wound must be avoided at all costs. Instead, rinse and cover with sterile bandages before splinting or until a specialist arrives. To splint the affected joint, you should avoid moving it from the position in which it was found. Then, splints are placed above and below the wound.
- If the skin is not broken, press around the affected joint to gauge circulation.
The immobilization of the joint before receiving medical attention is relevant. This can prevent major damage to muscles, blood vessels, ligaments and nerves. When the doctor evaluates the injury, he or she can determine which medications and therapies are appropriate. In some cases, the doctor will administer medication to anesthetize and numb the affected area.
Shoulder subluxation and dislocation
“In traumatic shoulder subluxation, the immediate treatments include ice packing to reduce soft tissue swelling, avoiding postures leading to recurrent subluxation, and wearing a protective arm sling. Narcotics or non-steroid anti-inflammatory drugs can be used for pain control. Passive or active assistive range of motion exercise of upper limb and scapular stabilization exercise can start as early as possible, followed by strengthening of shoulder girdles muscles, and glenohumeral joint proprioceptive training to improve dynamic shoulder stability.
In the atraumatic group, the goal of treatment is to restore the shoulder function. The rehabilitation should emphasize the progressive strengthening of the rotator cuff, deltoid, and scapular stabilization muscles. Exercises to improve shoulder coordination with lifestyle modification is also recommended.
The hemiplegic shoulder subluxation, functional electrical stimulation (FES) is effective in reducing subluxation in the acute stage. Shoulder support or orthosis such as Bobath, Rolyan humeral cuff or standard hemi sling may reduce the subluxation. To prevent further subluxation in stroke patients, supporting the hemiplegic limb in the proper position is crucial.
The modalities for pain control, including ice in an acute phase, ultrasound therapy, transcutaneous electrical nerve stimulation (TENS), electrical stimulation (ES), and moist heat.”4
“The shoulder is the most commonly dislocated large joint. A traumatic shoulder dislocation is often accompanied by a labral lesion, which predisposes the patient to developing chronic shoulder instability. The incidence of primary shoulder dislocation varies between 15.3 and 56.3 per 100 000 person-years. Most patients are men aged under 40 years and most dislocations are sports injuries. Both these facts make shoulder dislocation and possible subsequent chronic instability an important health issue for young, active patients and their treating clinicians.
Acute treatment of a dislocated shoulder is closed reduction, which should be performed as soon as possible, either on the field or in an emergency department. Some patients develop recurrent dislocations or symptomatic subluxations even in daily activities. This has prompted suggestions that surgical stabilization may be indicated after the first dislocation—a treatment strategy that has been investigated in several randomized controlled trials (RCT), with mixed results.
There is considerable variation in the management of patients after a primary traumatic shoulder dislocation (both between surgeons and disciplines). Most patients with chronic post-traumatic shoulder instability are offered stabilization surgery, while the surgical methods vary widely. Some evidence suggests that in the management of musculoskeletal conditions patients are more likely to undergo surgical treatment if the treating physician is a surgeon versus a non-surgical specialty (eg, physiotherapy), and that surgeons more easily recommend surgical treatment if the evidence regarding the effectiveness of surgery is inconclusive. Thus, to provide the best care, physiotherapists, physical medicine specialists, sports medicine specialists and orthopedic surgeons should know what is the best quality evidence for treatment of shoulder instability.”5
After evaluating the severity of the injury, the specialist can suggest:
Reduction: a process in which the doctor makes maneuvers the bone to return it to its place.
Immobilization of the joint: after putting the bone in place, the professional puts a cast on the joint to leave it immobile for a few weeks.
Medications: if the pain persists, the use of muscle relaxants and analgesics is recommended.
Surgery: this procedure is only suggested when the person has already undergone several subluxations or the injury involves the muscles, blood vessels and nerves.
Rehabilitation: in all cases, chiropractic or physiotherapy techniques are suggested to correct the subluxations and to restore the movement and strength of the joint.
All types of subluxations trigger painful disorders and tend to get complicated. Therefore, even if it may seem superficial and painless at first, it is essential to seek professional attention as soon as possible to avoid negative consequences.
(1) World Health Organization. (2005). WHO guidelines on basic training and safety in chiropractic. Available online at https://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf
(2) Nelson, F. R., & Blauvelt, C. T. (2014). A Manual of Orthopaedic Terminology E-Book. Elsevier Health Sciences. Available online at https://books.google.co.ve/books?hl=es&lr=&id=BXZYBAAAQBAJ&oi=fnd&pg=PP1&dq=Classifications+of+Fractures,+Dislocations,+and+Sports-Related+Injuries+Fred+R.T.+Nelson+MD,+FAAOS,+Carolyn+Taliaferro+Blauvelt&ots=HU7PXEH2HD&sig=kEiBVJrFG6IsQtj0RfRxu1ZkMls&redir_esc=y#v=onepage&q&f=false
(2) Green, J. D., Harle, T. S., & Harris, J. H. (1981). Anterior subluxation of the cervical spine: hyperflexion sprain. American Journal of Neuroradiology, 2(3), 243-250. Available online at https://pdfs.semanticscholar.org/aafa/01262ef3c21b1b0a5d7646da4e4c13b770c5.pdf
(3) Durbin, F. C. (1957). Fracture-dislocations of the cervical spine. The Journal of bone and joint surgery. British volume, 39(1), 23-38. Available online at http://degreesofclarity.com/emsbasics/library/durbin%20-%20FRACTURE-DISLOCATIONS%20OF%20THE%20CERVICAL%20SPINE%20.pdf
(4) Vitoonpong, T., & Chang, K. V. (2018). Shoulder, Subluxation. In StatPearls [Internet]. StatPearls Publishing. Available online at https://www.ncbi.nlm.nih.gov/books/NBK507847/
(5) Kavaja, L., Lähdeoja, T., Malmivaara, A., & Paavola, M. (2018). Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis. Br J Sports Med, 52(23), 1498-1506. Available online at https://bjsm.bmj.com/content/52/23/1498