Zen and the Art of Shoulder Reduction

Neil Cunningham from shoulderdislocation.net has revolutionized our understanding of reducing dislocated shoulders. The eponymous Cunningham Technique is an intelligent and atraumatic approach to reduction that requires minimal to no sedation. Granted, if your patient is extremely agitated and can’t relax, they will need:

1. anxiolytics, or

2. another technique for reduction, or

3. your dulcet calming tones helping them achieve relaxation

Here’s a video breakdown of the hows and whys of this new technique. We have been using this technique in our shop for a few months and have met with good success. Let us know how it works for you and if you have any pearls to add that can benefit other Ercasters.





    1. Bill A.

      The point should be the procedure technique and not the calibre of the video used to demonstrate it. Well Done! Will make sure to use this technique !

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  2. Dustin

    I like it! I’ve tried scapular manipulation to evade the need to use procedural sedation but have had limited results. It’s hard to get some people into the position for that technique and I think the Cunningham technique might be easier for people because they can stay seated. I also like to inject the capsule with lidocaine and then just do external rotation/abduction.

    One thing from the video though, where were the other patients asking for their discharge papers, “where’s my Percocet”, “I haven’t got my sandwich yet”, and the “Wet” patient screaming in the backround?

    1. Dustin

      Alright, I finally had the chance to try this. I had a guy with a shoulder dislocation yesterday and used this technique to put it back with with extreme ease. This made me, the patient, and his nurse very happy. I did give him a lidocaine arthrocentesis and 2 mg of IM Delilah but that’s more because it’s hard to break old habits. I couldn’t believe how easily it went back into place. Thanks for giving me a new tool to add to the quiver.

  3. Gabe

    Thank you for the excellent summary and presentation of the Cunningham technique! Did this at my institution the other night: no analgesia, no anesthetics, no benzos -- just had the patient sitting upright in a chair. It’s phenomenal for all parties involved (oh yeah -- it took all of 46 seconds!).

    1. Rob Orman

      Gabe, it’s shocking how smooth this technique is (when it works). 46 seconds is the fastest I’ve heard of. Was the patient relaxed from the beginning?

      1. Gabe

        The patient had had multiple dislocations of that shoulder in the past (this one arising -- presumably -- during an altercation). The hardest part, it seems, had already been accomplished with the patient sitting in the stretcher with arm fully adducted. All I had to do was move him to the chair, speak calmly and reassuringly, perform the 3-point massage technique and ask for a proper shoulder shrug/upright posturing from the patient. POP!

  4. J Choi

    finally got to try to technique on the one pt i shouldn’t have…morbidly obese. took a while (about 10 minutes) but finally went in; on xray, saw that shoulder was still out and was bummed. 2 other tries (under sedation) by other ER doc and then ortho tried and post films still with no success; dubbed as chronic dislocator; one thing i realized is that the female physician may have trouble with the procedure as you are getting pretty darn close to the patient so there may be issues there.

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  6. Catherine

    Worked for me last night! 🙂 no injection or sedation needed. I did the analgesic position slightly different and I think it prolonged the procedure -- total time about 10 min. I looked like a baller though

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  8. ki-docs

    Just love the commentary

    ‘what, I’m a doctor -- no way am I going to do massage’

    ‘just slug ’em with some ketamine’

    You have changed my practice, and that is a good thing…

    1. Rob Orman

      Hi Scott,
      I have the patient shrug when they are relaxed -- after the massage portion. It’s hard to hold the shrug continuously, but I try to have them hold it for a few seconds if possible.

  9. Tom C

    I used the Cunningham technique twice on first time shoulder dislocations in a couple of high school kids, and it worked within 2 minutes both times. It has completely changed my management of shoulders. Your podcast is great! Keep up the good work!

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  11. JD

    Cunningham is my “go to” in my toolbox, hasn’t failed me yet. I usually counsel to pati not to focus on sitting up straight (like mom used to harass us about). They usually creep forward during the procedure regardless. Then when I feel the trap/bicep relax I tell them to “sit up straight” and/or reach around & tap the between the shoulder blades. And voila, reduction achieved. (My 2bits)

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