Adduction techniques and analgesic position 1

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These include the Cunningham technique and Kocher’s method. I use analgesic position 1 as the starting point for both of these techniques.

This is the position at which the stretch on the capsule is reduced, and the operator takes over control of the affected limb, allowing the patient to reduce their spasm. A stretched capsule provides a nauseating visceral type of pain and a move to the analgesic position results in a marked reduction of pain and distress. It is achieved by a combination of humeral adduction, a ‘hold’, and voluntary retroversion of the scapula. A short video displaying the anatomy of these movements can be found here, for more details on shoulder anatomy in anterior dislocation jump to the ‘anatomy of a dislocation’ section. 

Adduction- the humeral head is moved closer to the glenoid rim using adduction, and the humerus is placed in a ‘hold.’ 

‘Hold’- this is a firm steady downward hold (not a pull) designed to move the humeral head towards where it needs to be, taking off some of the stretch from the capsule (reducing pain), and providing confidence to the patient that you have taken control of the limb. Once you are in this position, it can be useful to ask the patient their pain level, and explain again what you are going to do. It’s important to note that the elbow is not being supported from below, but is being placed in a downwards ‘hold’.

Scapular retroversion– getting the patient to either shrug and relax, or specifically bring their scapulae towards each other at the back will have the result of moving the glenoid rim posteriorly. This decreases the obstruction posed by the glenoid rim to the lateral movement required by the reducing humeral head.

Position your patient:

- With the humerus adducted, the biceps shortened and the operator’s wrist resting on the patient’s forearm, the patient will usually feel immediately more comfortable.

- Don’t pull, you’ll only get spasm, pain and an uncooperative patient. 

- The humerus can be gently moved forwards and back in order to find the perfect angle.

Position yourself:

- Face directly opposite to the patient and kneel next to them - this avoids any external rotation/flexion of the humerus (which happens if you start off too far away from your patient). 

- This closeness to the patient also means that they are resting their hand on your shoulder, not reaching for it and clutching with the fingers.

Sit your patient up (without slouching) 

The affected arm is adducted (next to the body) and the elbow fully flexed (optimally shortens the biceps muscle, allowing full relaxation)

The humerus points directly down and should be in a neutral position (no forward flexion or external rotation)

Ask the patient to put their “shoulders back, chest out.” 

Kneel next to your patient and place your wrist onto their forearm, with their hand resting on your shoulder. An option for this is to place a ‘hold’ on their elbow with one hand and hold their wrist in external rotation with the other – this is a good option if you choose to go straight to a Kocher’s manoeuvre.

Sometimes once you have your analgesic position in place, the shoulder will reduce without any further moves. See how in this video.

My wife Nicola was in hospital recovering from a procedure when I received a phone call from her – “You’re on TV!” Either the drugs were too strong or something else was going on. She had just started watching the first episode of a new British TV show about a young doc who goes to India to find herself. Scene one in the chaotic clinic she’s been assigned to is the head doctor putting a shoulder back in before discussing the Cunningham technique. Artistic licence taken on the details of the technique but fun to be the go-to plot device for any self-respecting new medi-drama! Trailer below - click on the button to link.