National Athletic Trainers' Association Position Statement: Immediate Management of Appendicular Joint Dislocations

Glenohumeral Joint

• 15.

  Under the direction of a physician, an AT can perform an onsite reduction of a first-time or recurrent anterior shoulder dislocation as long as the diagnosis is readily apparent. However, if a fracture or a posterior dislocation is suspected, immobilization in a position of comfort and referral for radiographic evaluation should replace onsite reduction. If reduction of an anterior dislocation is not possible, the shoulder should be immobilized in a position of comfort and the patient referred for appropriate treatment. Multiple attempts at reduction are not recommended.^2,21,23,49 SOR: C

Femoroacetabular Joint

• 16.

  Under the direction of a physician, an AT can attempt to reduce a hip dislocation. Ideally, the team physician would reduce this dislocation with the AT, although this is not absolutely necessary. Because many hip dislocations have associated fractures, referral for radiographic evaluation is always recommended. Concomitant neurovascular injury is common, so careful attention should be paid to the neurovascular status of the extremity before and after any reduction attempts.^7,42 SOR: C

Tibiofemoral Joint

• 17.

  Under the direction of a physician, an AT can perform an onsite tibiofemoral joint reduction. Because the incidence of vascular and neural damage is high with this injury, it is important for the AT to determine the presence or absence of peripheral pulses and neurologic function before and after any reduction attempt. A patient with multiple ligament injuries should be managed as if he or she had a knee dislocation that spontaneously reduced. Immediate referral for radiographic evaluation and monitoring of the vascular supply to the extremity is highly recommended.^{26,28,29,50–53} SOR: C

Patellofemoral Joint

• 18.

  Under the direction of a physician and as long as the diagnosis is readily apparent, an AT can reduce an acute patellar dislocation. Multiple attempts at reduction are not recommended.^26,28,54 SOR: C

Humeroulnar Joint and Proximal Radioulnar Joint

• 19.

  Onsite reductions should not be attempted in most cases given that elbow dislocations typically involve fracture(s) and significant potential for neurovascular compromise. If emergency transport will be delayed, an AT, under the direction of a physician, may attempt a reduction provided no signs and symptoms of fracture or neurovascular damage are present. Multiple attempts at reduction are not recommended.^3,6,20,41 SOR: C

Metacarpophalangeal Joints

• 20.

  Under the direction of a physician, an AT can reduce a dislocated metacarpophalangeal (MCP) joint but should use caution as these dislocations often have associated fractures or interposed soft tissue (ie, tendons), which can prevent complete reduction. Some MCP injuries involve complex entrapment of the phalanx in the soft tissue, in which case closed reduction may not be possible. Multiple attempts at reduction are not recommended. ^2,8,55–57 SOR: C

Interphalangeal Joints of the Fingers

• 21.

  Under the direction of a physician, an AT can reduce dislocations of the interphalangeal joints of the fingers. When associated fractures or interposed soft tissue may be present, reduction attempts should be deferred until radiographs confirm the exact diagnosis. Multiple attempts at reduction are not recommended.^8,22,56,58 SOR: C

Metatarsophalangeal Joints

• 22.

  Under the direction of a physician, an AT should use caution when attempting to reduce metatarsophalangeal-joint (MTP) dislocations because associated fractures or interposed soft tissue frequently prevent reduction. Multiple attempts at reduction are not recommended.^59–61 SOR: C

Interphalangeal Joints of the Toes

• 23.

  Under the direction of a physician, an AT can reduce a dislocated interphalangeal joint of the toes. Multiple attempts at reduction are not recommended.^62,63 SOR: C

Special Population Considerations

• 24.

  Because of the greater underlying risk of fracture in senior athletes, onsite reduction of dislocations should only be attempted for the simplest of dislocations (eg, proximal interphalangeal [PIP] dislocations of the fingers). SOR: C

• 25.

  Under the direction of a physician, ATs can reduce patellar dislocations in children. However, other joint dislocations in children should be reduced only after radiographs are obtained due to the presence of open physes and the greater likelihood of bony injury.^15,17,64 SOR: C

• 26.

  Onsite reduction of acute dislocations in athletes with diabetes mellitus is not recommended.¹⁵ SOR: C

• 27.

  Onsite reduction of joint dislocations resulting from generalized tonic-clonic seizures is not recommended.^14,65 SOR: C

Glenohumeral Joint

The glenohumeral joint is the most commonly dislocated major joint, especially in athletes participating in contact sports,²³ with the most frequent complication being a high recurrence rate.² Anterior glenohumeral dislocations occur often,⁶⁹ can cause the patient a tremendous amount of pain, and are much more difficult to reduce once swelling and muscle spasm have developed.² In the absence of any obvious signs of fracture or significant neurovascular compromise, radiographs may not be necessary, and an onsite attempt to reduce an anteriorly dislocated glenohumeral joint is indicated.²³ However, delayed reduction rarely results in significant harm, so if there is any question or concern about the diagnosis or the possibility of fracture, reduction of the glenohumeral joint can be safely deferred most of the time until radiographs are obtained. Yet if the attempt at early reduction is delayed, muscle spasm and guarding may make subsequent reduction attempts more difficult to accomplish.^23,70 Anterior glenohumeral-joint dislocations are easily reduced, although infrequently, soft tissue or osseous interposition may impede or prevent satisfactory reduction.^9–11 Additionally, fractures of the humerus or glenoid can occur before or during an attempt to reduce an anteriorly dislocated glenohumeral joint. Even though iatrogenic fracture is uncommon, reduction of the glenohumeral joint should not be forceful.

Posterior dislocation of the glenohumeral joint is rare, accounting for only 1% to 2% of all shoulder dislocations.⁷¹ The most common causes of posterior dislocation are epileptic seizures, electrical shock, and falls on the outstretched hands.⁷² Cuffolo et al⁷³ reported on a posterior dislocation that occurred secondary to losing control of weights while performing the extension portion of the bench-press exercise in the supine position. Posterior dislocations may be associated with surgical neck fractures, fractures of the tuberosities (about 10% of the time), or a ventral impression fracture of the humeral head known as a reverse Hill-Sachs lesion.^71,72

Glenohumeral-joint reduction is aimed at achieving an atraumatic reduction as soon as possible, thereby providing the athlete with pain relief.⁴⁹ Once the glenohumeral joint has been successfully reduced, a postreduction neurovascular examination should be performed, paying particular attention to the axillary and musculocutaneous nerves.²³ Additionally, the patient should be splinted and referred to the appropriate health care facility for radiographs to assure satisfactory joint alignment and rule out associated fractures.²³

Femoroacetabular Joint

Unlike glenohumeral-joint dislocations, dislocations of the hip joint rarely occur in the athletic setting.^41,74–76 However, hip dislocations with accompanying bone and soft tissue trauma have been reported in many different sports, including basketball, football, gymnastics, jogging, rugby, and skiing.^{7,12,30,76–83}

Immediate management of a hip dislocation necessitates a thorough physical examination, including a neurovascular assessment with special attention to the sciatic nerve and the peroneal branch.⁷ Due to its proximity to the femoral head, the sciatic nerve can be injured with a posterior hip dislocation.^13,30,31 However, sciatic nerve injury is more common after a fracture-dislocation than after an isolated or simple dislocation.⁴¹ If a thorough examination determines the patient is stable and conscious and has no obvious precluding injuries (such as a fracture), a single attempt at closed reduction can be made onsite by qualified personnel.⁷ Nevertheless, it is important to keep in mind that a mechanical block (ie, “buttonholing” through the capsule) or interposition of the hip joint's anatomical structures (ie, capsule, labrum, ligamentum teres; bone fragments; or rectus femoris, iliopsoas, piriformis, or gluteus maximus muscles) may result in a sport-induced hip dislocation that cannot be reduced by closed methods.^12,13

After a hip dislocation has been successfully reduced onsite and the patient's neurovascular status assessed and documented, he or she should be transported to an appropriate health care facility to determine the presence of a possible intra-articular hip-joint injury.^41,83 In reporting on arthroscopy among 14 professional athletes whose traumatic hip dislocations were reduced, Philippon et al⁸³ noted that all athletes had a labral tear and chondral defects. Additionally, patients presented with intra-articular loose fragments and disruption of the ligamentum teres.⁸³ These findings suggest that, even in the absence of an articulating bone fracture, a traumatic hip-joint dislocation may be accompanied by intra-articular joint injury.

It has been suggested that prompt reduction of a dislocated hip is important because delaying relocation could contribute to the development of avascular necrosis (AVN) of the femoral head.^1,68 By reducing the dislocation in a timely fashion, blood flow to the femoral head may be reestablished as tension across the femoral and circumflex blood vessels is lessened.⁶⁸ However, experts are not in agreement as to the hours of delay required to cause AVN or even if a delay in reduction actually causes AVN.^1,7 Research⁴ suggested that reduction of a hip dislocation should be accomplished within 6 hours to avoid AVN, yet other investigators^1,7 believed AVN might be more related to the direction of the dislocation and the severity of the initial trauma in conjunction with the extent of any associated injuries.

Tibiofemoral Joint

Due to gross deformity, unreduced knee dislocations are readily apparent upon observation and physical examination.²⁶ However, many knee dislocations spontaneously reduce and present only as multiple-ligament injuries.^26,28,52 Therefore, all multiple-ligament knee injuries should be evaluated and treated as dislocations until proven otherwise.^53,84

The neurovascular status of a potentially dislocated tibiofemoral joint should be carefully determined. Vascular injury occurs with knee-joint dislocation in 10% to 64% of patients.^26,50 The popliteal artery is at significant risk for injury because disarticulation of the knee joint produces direct or intimal damage to the artery, resulting in occlusion.⁸⁵ In addition to the popliteal artery, an onsite examination of a potentially dislocated tibiofemoral joint should include the dorsal pedal and posterior tibial pulses. Yet the presence of a dorsal pedal pulse may not eliminate the possibility of a significant arterial lesion.²⁹ The onsite neurologic assessment should include motor and sensory testing of the tibial and peroneal nerves.^26,28 The peroneal nerve is more frequently injured via a dislocation mechanism than the tibial nerve because it is relatively tethered at the fibular head and has less intrinsic protection from tensile forces.^86–90

It has been suggested^85,91 that onsite management of a suspected knee-joint dislocation consists of immediate splinting of the knee in extension, or in the most comfortable position, with immediate transport to the nearest appropriate health care facility. Conversely, proponents^2,26,50,51 of onsite reduction of a tibiofemoral joint dislocation advise attempting immediate reduction in an effort to preserve neurovascular structures that may have been subjected to prolonged compromise while the joint was disarticulated.

Whether or not onsite reduction is achieved, the neurovascular status should be continually assessed and the joint immobilized, preferably with a rigid splint to prevent further displacement and potential injury to the neurovascular structures. The patient should be treated for pain and emergency medical services activated for expeditious transport to a hospital.^2,26 Because of their significant association with neurovascular injuries,^26,50,87 tibiofemoral-joint dislocations are considered orthopaedic emergencies²⁶ and potentially limb threatening.⁹¹ As such, a poorly managed or misdiagnosed tibiofemoral-joint dislocation can have limb-threatening consequences.⁵¹

Patellofemoral Joint

Patellofemoral-joint dislocations occur commonly in the athletic setting and may be categorized as an acute primary (first-time) traumatic patellar dislocation or a recurring chronic injury. Almost all patellar dislocations occur laterally, resulting in trauma to the medial patellar stabilizers. Superior patellar dislocations without patellar tendon disruption have been reported,^92–94 but these rare cases typically occurred in nonathletic, aged patients.

Frequently, patients classified as chronic dislocators will spontaneously reduce a lateral patellar dislocation with little to no intervention, but patients sustaining a first-time patellar dislocation and some habitual dislocators may not spontaneously reduce the dislocation. When the patella does not reduce spontaneously, some authors^2,26 indicated the patella should be reduced manually. It is important to keep in mind that athletes who have sustained a patellofemoral dislocation should be suspected of having an accompanying osteochondral fracture.⁵⁴ Interestingly, the patellar fracture may occur from the initial dislocation or from the subsequent spontaneous or manual reduction. The chondral injury may occur as the patella dislocates,^95,96 or the reduction itself may create the osteochondral lesion as the patella relocates by riding over the lateral femoral condyle.⁹⁷ Therefore, any manual reduction of a patellar dislocation should be accomplished as atraumatically as possible.

Humeroulnar Joint and Proximal Radioulnar Joint

Except for the glenohumeral joint, the humeroulnar joint is the most frequently dislocated large joint in the human body.^20,98 Elbow dislocations are classified as either simple or complex, depending on the absence or presence, respectively, of a fracture of the articulating bones.⁴¹ Yet simple dislocations can also be accompanied by small bone fragments originating from the epicondyles or the coronoid process that do not affect joint stability.⁴¹ Simple dislocations are described based on the location of the radius and ulna relative to the humerus (ie, posterior, anterior, lateral, medial, or divergent) with the majority of elbow-joint dislocations being posterior or posterolateral.^3,41 An anterior elbow dislocation, although a less commonly occurring simple dislocation, always involves a fracture of the olecranon.^99,100 Divergent dislocations, in which the ulna dislocates medially and the radius dislocates laterally, are very rare but present with the least stable patterns due to the extensive soft tissue disruption.¹⁰¹ A traumatic dislocation of the proximal radioulnar joint typically results in significant joint pain and dysfunction, even though gross deformity may be absent upon examination.¹⁰¹ Most complex elbow dislocations involve a fracture of the coronoid process and significant disruption of the ulnar collateral ligament or radial collateral ligament (or both)³ but are usually stable after closed reduction.²⁰

An elbow dislocation typically presents with marked deformity, swelling, and severe pain.²⁰ The patient may hold the involved elbow with the contralateral hand and be unwilling or unable to move the elbow through any range of motion. Prereduction management includes a thorough musculoskeletal examination to identify the type of deformity, any open injury,^20,41 and crepitus, which may indicate a fracture.⁶ The presence of a fracture negates consideration of onsite reduction. It should also increase the AT's suspicion of a brachial artery injury, which most often occurs in the presence of a fracture associated with an open²⁰ or closed dislocation.^27,102–105

A neurovascular examination should also be conducted and the results documented before and after any joint-reduction attempts.²⁰ A diminished radial or ulnar pulse or prolonged capillary refill indicates a possible brachial artery injury.²⁷ During the neurovascular examination, the median and ulnar nerves should also be assessed, as these structures may become entrapped within the joint as a result of the incongruency or the subsequent reduction.²⁷ Although rare, complex elbow dislocations can result in brachial artery injury or ulnar nerve neurapraxia (or both).^6,20 However, most neurovascular compromise is relieved with reduction.⁶

The literature^27,106–108 clearly suggests that early closed reduction of uncomplicated elbow dislocations produces positive outcomes. Yet elbow dislocations can be very painful, making onsite reduction difficult. Some authors believe that onsite reduction of an elbow dislocation should not be attempted^3,6,20 or should only be attempted when the examination reveals neurovascular compromise or if transport to the appropriate health care facility cannot take place quickly.^3,6

Metacarpophalangeal Joints

Dislocations of the joints of the thumb and fingers occur often in the athletic setting, especially to players in sports that involve routine contact of the hands with another player, an object such as a ball, or a fixed surface.^2,8,109 The first MCP joint of the thumb is the most commonly dislocated MCP joint,⁵⁵ typically dislocating secondary to a forceful hyperextension mechanism.⁵⁶ The lesser MCP joints of the hand, although less frequently dislocated, can dislocate in either a dorsal or volar direction.²

Management of simple dorsal first MCP dislocations should include an attempt at onsite reduction.² Because reduction techniques for this dislocation may be subtly different than those for PIP and dorsal interphalangeal (DIP) dislocations, ATs should consult with their supervising physicians for education on these techniques.² Similarly, onsite reduction of simple lesser (second through fifth) MCP dislocations, in which the proximal phalanx lies dorsal to the metacarpal head, paralleling the shaft of the metacarpal and involving no soft tissue obstruction, is a relatively easy procedure.^54–56 However, in complex dislocations, the reduction attempt often fails due to the buttonholing effect of the soft tissue.⁸ These more complex injuries typically require surgical reduction under anesthesia.⁸

Interphalangeal Joints of the Fingers

Due to its inherent stability, the interphalangeal (IP) joint of the thumb rarely dislocates.¹¹⁰ Most dislocations of the thumb IP joint are reducible, and only a few cases of irreducible dislocations have been reported in the literature.¹¹⁰ The inability to reduce a dislocation of the IP joint of the thumb has been attributed to interposition of the flexor pollicis longus tendon between the ulnar condyle of the proximal phalanx and the base of the distal phalanx,¹¹¹ imposition of a free-floating sesamoid bone,¹¹² rupture of the palmar plate,^111,113 or a combination of 2 or more of these anatomic elements.^110,114,115

The IP joints of the lesser (second through fifth) digits of the hand are among the more commonly dislocated joints in athletes.^22,58,116 The most frequent finger IP dislocations occur dorsal to the PIP joints.^22,58,116 A dorsal dislocation indicates the distal segment has dislocated dorsally in relation to the proximal segment. Conversely, a volar dislocation of the PIP is characterized by displacement of the middle phalanx anterior to the head of the proximal phalanx.

A dorsal PIP dislocation can be a straight dorsal dislocation or accompanied by radial or ulnar deviation.^8,22 However, for a dorsal PIP dislocation to occur, the volar plate and a portion of 1 or both collateral ligaments must be ruptured.^58,117 Volar and lateral PIP dislocations occur less often than dorsal PIP dislocations and may present with various angles of deformity.^8,56,57,117

Reduction of a lesser digit dorsal PIP joint dislocation can often be performed very quickly with simple traction and appropriately applied pressure.^8,22,56,58 Closed reduction of an uncomplicated IP joint dislocation should be attempted as early as possible because swelling may continue for 24 to 48 hours postinjury; the accumulated hemorrhage and edema in the soft tissue decreases tissue elasticity, which may contribute to a more difficult reduction.⁵ A musculoskeletal examination to assure the deformity is due to a simple IP joint dislocation and not due to an associated fracture should precede an onsite reduction attempt. Any signs of fracture preclude an attempt at reduction.²² Abnormal neurovascular examination findings may prompt, rather than preclude, immediate joint reduction.²² After a successful reduction, the PIP joint should be splinted and the patient evaluated by a physician, who may obtain radiographs to evaluate joint congruity.^22,43,44 The decision to return a patient to activity after a successful PIP reduction should be based on the absence of other injuries, potential forces at the joint, and performance expectations.^80,118

Rarely, a dorsally dislocated PIP joint cannot be reduced due to impingement of the proximal phalangeal head between the central slip and the lateral bands.^57,58,117 Similarly, a volar dislocation tends to rupture the extensor mechanism, which may include the central slip, causing the proximal phalanx to become interposed between the central slip and the lateral band.^24,25 In both situations, onsite closed reduction may not be possible.¹¹⁷ If the onsite reduction cannot be performed, the reduction should be deferred until either radiographs are obtained or a digital nerve block can be administered. Postreduction, most dorsal PIP joint dislocations are stable because the collateral ligaments remain attached to the middle phalanx.^57,109 However, volar dislocations are generally unstable after reduction.¹¹⁹

Dislocation of the DIP joint is uncommon¹²⁰ and usually caused by a crush-type injury mechanism.^117,121 It can occur dorsally or, much less often, volarly.⁵⁷ In the absence of a fracture or other contraindication to reduction, a DIP joint dislocation can be reduced and treated similarly to a PIP joint dislocation.⁵⁶

Metatarsophalangeal Joints

Traumatic dislocation of the first (hallux) MTP is infrequent^60,61 but may occur in sport activities. The first MTP's shallow, glenoidlike cavity contributes little to the joint's stability, most of which comes from the capsular-ligamentous-sesamoid complex.¹¹⁴ The first MTP joint can dislocate in any direction; the dorsal direction is most common,^61,122 but plantar and lateral dislocations have been described.¹²²

Irreducible first MTP joint dislocations have been attributed to the type of dislocation, involvement of the sesamoid complex, and interposition or locking of the abductor hallucis or flexor hallicus longus tendons.^123–126 However, not all hallux MTP joint dislocations are resistant to closed management ^61,122 Additionally, the location for successful reduction of a hallux MTP dislocation differed in the literature.^61,122 In a 2000 publication, Watson et al¹²² recommended attempting reduction of all closed dislocations, regardless of type, in the emergency department after a physical examination is conducted, appropriate radiographs are obtained, and adequate anesthesia is administered. More recently, a case report⁶¹ documented a successful onsite closed reduction of a football player's dorsal first MTP joint dislocation by an AT. The authors noted that their success may have been due to the short time between injury and treatment, which began with successful reduction.⁶¹ Regardless of the venue, all patients should be advised of the possible need for acute operative intervention should attempts at closed reduction fail.¹²²

Lesser toe (second through fifth) MTP joint dislocations are rare, with the fifth MTP joint dislocating more frequently than the 3 lesser toes.^59,63,127 Dislocation in the dorsal direction is most common.^59,127–129 In a retrospective analysis⁵⁹ of lesser toe MTP joint dislocations, 24 of 27 displaced dorsally, 3 displaced dorsolaterally, and closed reduction was successful in 16 of the 27 patients. As reported by others,^127–129 the plantar capsule and plate presented the most typical impediments to closed reduction.⁵⁹ Despite the high percentage (almost 30%) of lesser toe MTP joint dislocations unsuccessfully managed with closed reduction, Brunet and Tubin⁵⁹ suggested the initial treatment for acute lesser toe MTP joint dislocations include an onsite attempt at closed reduction.

Interphalangeal Joints of the Toes

Dislocation of the first or lesser toe IP joints is infrequent and rarely reported in the literature.^130,131 However, because these injuries are often self-reduced or reduced by medical or allied health personnel without subsequent medical referral, they may actually occur more often than reported. Similar to the fingers, most toe IP joint dislocations are simple in nature, and an onsite reduction should be attempted,^62,63 yet some IP joint dislocations may be irreducible and require open reduction.^{59,63,132,133}

Senior Patients

In treating seniors with joint dislocations, 2 competing realities exist. First, seniors are more likely than younger adults to have inadequate bone mineral density. This relative osteopenia compared with younger populations places them at greater risk of concomitant fracture in the event of a joint dislocation. Second, whereas the most likely complication of many dislocations in younger populations is recurrent instability,^16,19 the most likely risk in older populations is additional soft tissue injury (eg, torn rotator cuff) and residual joint stiffness. Osteopenia and the associated risk of concomitant fracture necessitate extra caution when performing an onsite reduction without prior radiographs. Therefore, all but the simplest dislocations in seniors (ie, PIP dislocations of the finger) should be reduced by a physician after radiographs have been obtained.

Pediatric Patients

The management of dislocations in pediatric patients, including children (aged 6–12 years) and adolescents (aged 13–18 years)¹³⁴ is complicated by the presence of open growth plates.^45–48 The open physes of the pediatric athlete present an area of relative weakness against the stress applied to the bone and adjacent tissues. Growth plate injury can result in complete or partial growth arrest.¹³⁵ Therefore, the possibility of underlying physeal injury must be taken into account.

In children, dislocations of the shoulder, elbow, hip, knee, and ankle are rare injuries. In the shoulder, children with open physes will be much more likely to sustain a Salter type 2 fracture of the proximal humerus than a glenohumeral dislocation.⁶⁴ Glenohumeral-joint dislocations become more common as children age and the physes close,¹³⁶ which occurs between 16 and 22 years of age, depending on the child's genetics and sex as well as numerous environmental factors. If a child sustains a suspected glenohumeral dislocation, it should not be reduced onsite. Instead, the young athlete should be splinted and transported for radiographic evaluation and subsequent care. When the growth plates close in adolescence, glenohumeral dislocations can be managed as in adults.

Elbow-joint dislocations in children are also rare, as fractures are much more frequent.¹⁷ A suspected elbow dislocation should not be reduced onsite. Radial head subluxation, or “nursemaid elbow,” is a common injury in children up to about age 5.¹⁵ The subluxation is usually easily reduced, but because of the age group in which it occurs, ATs will not often encounter it professionally.

Knee and ankle dislocations, as noted earlier, are rare injuries that should not be reduced by ATs onsite. However, patellofemoral-joint dislocations can occur more frequently in children. Although many of these reduce spontaneously, those that do not can be reduced in the same fashion as for an adult.

Diabetes Mellitus

Like seniors, patients with type 1 or 2 diabetes mellitus face an increased risk of postinjury joint-capsule stiffness and adhesive capsulitis.¹⁵ Young adults with well-controlled diabetes may not face the same increased risk of concomitant fracture that is present in senior and pediatric patients.¹³⁷ Currently, evidence is lacking to suggest that young patients with diabetes experience the same benefits from onsite joint dislocation reduction as those without diabetes. Therefore, onsite reduction of a joint dislocation by an AT is not recommended.

An additional concern in diabetic patients is joint instability. Individuals with neuropathic changes in the feet can be predisposed to progressive ligamentous instability in the foot and dislocations, most commonly in the midfoot region.¹⁸ Neuropathic foot conditions, or Charcot joints, are more frequent in patients with longstanding peripheral neuropathy. The degree of debilitation inherent in such an individual makes it extremely unlikely that this condition would be encountered in an athletic setting. Furthermore, these dislocations are not acute dislocations but chronic, progressive problems.¹³⁸ Reduction of these dislocations by an AT is not recommended.

Seizure Disorder

The violent muscular contractions that occur in an individual who sustains a generalized tonic-clonic seizure are strong enough to induce joint dislocations. The classic joint dislocation associated with seizure activity is the posterior shoulder dislocation. In the normal setting, posterior shoulder dislocations are dramatically less common than anterior dislocations, accounting for less than 5% of all shoulder dislocations.¹³⁹ However, with generalized seizure activity, the imbalanced, violent contractions of the muscles of the posterior shoulder girdle can result in a posterior dislocation, often with a concomitant humeral head fracture.⁶⁵ This can also occur bilaterally, resulting in what is referred to as triple E syndrome: bilateral locked posterior shoulder fracture-dislocations typically seen only with epilepsy, electrocution, and extreme trauma.¹⁴ Needless to say, it is inadvisable to attempt onsite reduction of such injuries. However, it is important to be aware of their possible presence. An individual in the postictal state may not be able to complain of shoulder pain from these injuries. Identifying these dislocations early can lead to more prompt treatment at the health care facility and decrease the likelihood that they go unrecognized.