










































MANUSCRIPT TYPE


Comparison of the Closed Shoulder Reduction Techniques: An Evidence-to-Practice Review  

 

58 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

Comparison of the Closed Shoulder Reduction Techniques: An 
Evidence-to-Practice Review 
Kaitlin Sznajder, MS, ATC; Dylan Arango, MS, ATC; Zachary K. Winkelmann, PhD, SCAT, ATC 
University of South Carolina, Columbia, SC 

  

 
ABSTRACT 
The shoulder joint is one of the most dislocated joints in the 
body. It does not have substantial bony support which allows 
for a large range of motion. Shoulder joints most commonly 
dislocate anteriorly, and less often dislocate posteriorly and 
inferiorly. There is a myriad of ways to reduce a shoulder 
dislocation including closed and open techniques. The purpose 
of this evidence-to-practice review is to summarize which 
closed shoulder reduction techniques are most effective and 
apply those results to an athletic training setting. The authors 
of this guiding systematic review studied multiple articles that 
compared different closed shoulder reduction techniques on 
the following criteria: pain experienced by the patient, ease 
of technique for clinician (time to reduce the shoulder joint), 
success rate, and complication rates. The authors chose to 
include randomized control trials, prospective studies, and 
retrospective studies. The literature revealed that the 
scapular manipulation technique had the best outcomes in all 
the criteria, however, every patient that had a shoulder 
dislocation that was reduced using that method also had 
intravenous analgesics. The Fast, Reliable, and Safe (FARES) 
method was found to be the third most successful and least 
painful during relocation and was often used without 
intravenous analgesics. Based on rate of success and patient 
comfort during reduction, the FARES method is the best option, 
suggesting that it should be taught to healthcare providers 
more often. Depending on the state practice act and 
physician oversight, athletic trainers who are allowed to 
reduce dislocations should be informed and educated on how 
to properly reduce and also allow for the best possible 
outcome and comfort for the patient. 
 
Key Phrases 
General Medical Interventions, Clinic and Hospital Patient 
Population 
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, 
SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Sznajder K, Arango D, Winkelmann ZK. Comparison 
of the closed shoulder reduction techniques: An 
evidence-to-practice review. Clin Pract Athl Train. 
2022;5(1): 58-66. 
https://doi.org/10.31622/2022/0005.01.9.     
 
Submitted: April 23, 2020 Accepted: January 25, 2021. 

 
 
 
 

ORIGINAL REFERENCE 
Alkaduhimi H, van der Linde JA, Willigenburg NW, 
van Deurzen DFP, van den Bekerom MPJ. A 
systematic comparison of the closed shoulder 
reduction techniques. Arch Orthop Trauma Surg. 
2017;137(5):589-599. 
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 
Shoulder dislocations account for over 50% of 
joint dislocations, making it the most commonly 
dislocated joint of the body.1,2 In the United 
States, glenohumeral dislocations occur at a rate 
of 23.9 per 100,000 person-years, of which 95% 
occur in an anterior dislocation.2,3 These injuries 
can cause a lot of pain for the patient, and 
improper relocation of the joint may cause 
complications such as tears of the biceps tendon, 
deep vein thrombosis, and iatrogenic fractures, 
and other neurological impairments.2 Of the 
shoulder dislocations that presented to emergency 
departments in the United States between 2002-
2006, 48.3% of them occurred during sport or 
recreation, and most of those occurring in sport or 
recreation occurred in males (86.7%).4 Shoulder 
instability is often a result of a dislocation; an 
epidemiologic study of athletes at three 
universities demonstrated that football had the 
highest prevalence of shoulder instability at 
29.3% of cases, followed by basketball, and 
wrestling.5 The same study found that the most 
common type of instability was an occasional, 
traumatic anterior dislocations, and the majority 
of shoulder dislocations and instability were 
traumatic in nature.5 The National Athletic 
Trainers’ Association (NATA) does not recommend 
reduction by an athletic trainer if the shoulder joint 
has dislocated posteriorly or if a fracture is 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2022/0005.01.9


Comparison of the Closed Shoulder Reduction Techniques: An Evidence-to-Practice Review 
 

 

 
59 

Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

suspected.1 Posterior dislocations account for 
approximately 1-5% of all glenohumeral 
dislocations and are not common in athletics.1,2 The 
glenohumeral joint is the most commonly 
dislocated joint specifically in athletes competing 
in contact or collision sports.1 

There are multiple ways that a clinician can choose 
to relocate a shoulder, all with varying levels of 
pain experienced by the patient, ease of 
technique for the clinician (time to reduce the joint), 
success rate, and complication rates. In this guiding 
systematic review, ease of the reduction technique 
for the clinician was determined by the time the 
technique took to reduce the dislocation.2 
Typically, the method chosen is a result of the 
provider’s knowledge, comfort in performing, or 
guidance from a collaborating physician. Athletic 
trainers may come across an acute shoulder 
dislocation in the athletics setting, particularly in 
contact or collision sports. With the update to the 
2020 Commission on Accreditation of Athletic 
Training Education (CAATE) Standards, 
specifically Standard 70 stating that students must 
learn how to manage emergent conditions such as 
reductions of dislocations, more athletic trainers 
will be educated on those techniques. But this, does 
mean that there are many athletic trainers who 
are already certified and practicing without that 
knowledge, unless they have been instructed 
outside of their primary education.6 We believe 
there is a need for certified athletic trainers who 
were not taught these techniques to be 
knowledgeable on techniques to properly reduce 
joint dislocations to ensure improved patient 
outcomes. Athletic trainers also often work in rural 
areas, where oftentimes emergency personnel can 
take a long time to arrive. This knowledge of how 
to properly reduce a shoulder dislocation may 
save one of their patients a lengthy ride in an EMS 
truck and would also save the patient and their 
families money as the average cost of a closed 
shoulder dislocation is $2,200.7 Research has 
explored various individual techniques in 
reduction but has not compared the techniques to 

each other. The purpose of this article was to 
summarize what the systematic review states and 
compare what the literature indicates about 
closed reduction techniques in anterior shoulder 
dislocations, and determine which technique had 
the best score in each of the previously mentioned 
categories of pain experienced by the patient, 
ease of technique for the clinician (time to reduce 
the shoulder joint), success rate, and complication 
rates.  

SUMMARY OF LITERATURE 

The authors of this guiding article identified 2099 
different studies. From that search, articles were 
included if they focused on shoulder reduction 
techniques written in English, German, Dutch, and 
Arabic. Exclusion criteria included open reposition 
techniques and case reports, systematic reviews, 
meta-analyses, animal/cadaver/in vitro studies, 
biomechanical reports, letters to editors, and 
instructional courses. Additionally, each article 
that was reviewed was graded and given a 
modified Coleman Methodology score, which 
assessed the included articles’ methodology on a 
scale of 0-90.2 A modified Coleman 
Methodology score of less than 50 was 
considered poor, between 50-64 was fair, 
between 65-79 was good, and between 80-90 
was excellent.2 The Coleman Methodology score 
is a tool used by researchers to determine if a 
study’s methods and outcomes are considered to 
be of high or low quality, specifically for studies 
involving orthopedic injuries, surgeries, and 
rehabilitations; the authors of this systematic 
comparison modified it for their specific study.2 
Any study that was given a score of less than 50 
points was also excluded from the review. The 
article list was further narrowed down to 13 
articles (9 randomized control trials, 2 
retrospective studies, 2 prospective non-
randomized comparative studies). Once each 
article was selected, a comparison was done 
looking at reduction success, mean reduction time, 
mean hospital stays, pain, and complications.  



Comparison of the Closed Shoulder Reduction Techniques: An Evidence-to-Practice Review 
 

 

 
60 

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SUMMARY OF INTERVENTIONS  

The systematic review identified 23 different 
closed shoulder reduction techniques. However, 
only 10 reduction techniques were included from 
the 13 articles selected for the systematic 
comparison because the other techniques did not 
meet inclusion criteria or have not been 
researched. These techniques were then 
categorized into two groups: traditional and non-
traditional. Table 1 provides the list of traditional 
and non-traditional techniques that were included 
in this systematic comparison. Table 2 provides the 
complete list of 10 reduction techniques including 
the name, procedure of each reduction technique, 
is accompanied by a photo demonstration of how 
each technique should be performed. There were 
three non-traditional techniques (Boss-Holzach-
Matter, Bokor-Billmann, and Aufmesser’s 
techniques) that were mentioned but not examined 
in the guiding review article, and for that reason 
are not in Table 2. However, due to the uniqueness 
of the methods, we have provided brief 
instructions on the methods. To perform the Boss-
Holzach-Matter reduction technique, the patient 
sits with their hands around the knee on the same 
side of the affected shoulder, leans back, puts 
their neck into hyperextension, and shrugs the 
shoulders anteriorly creating a method of self-
reduction.8 The Bokor-Billmann technique involves 
the practitioner holding the patient’s wrist in one 
hand, and their elbow in the other, the elbow is 
flexed to 90 degrees, followed by flexing the 
glenohumeral joint to 90 degrees, then the 
shoulder is adducted completely, and then an 
internal rotation pressure in applied until 
reduction is felt at about 30 degrees.9 For the 
Aufmesser’s method, the patient is supine, the 
clinician holds the patient’s hand and fixes their 
acromion, applies traction to the arm while 
maintaining eye contact with instructions to relax, 
and if necessary the clinician’s trunk can be used 
as a fulcrum to provide extra force.10 

 

SUMMARY OF OUTCOMES 

Best clinical practice, in this case, was defined by 
which techniques had the best scores in the 
following categories: pain experienced by the 
patient, ease of technique for clinician, success 
rate, and complication rates. Pain levels were 
determined using the Visual Analogue Scale (VAS) 
with a score between 1-10, with 1 being the least 
amount of pain and 10 being the greatest amount 
of pain.2 Ease of technique was based on the 
length of time it took to complete the reduction; a 
reduction with a lower time was considered easier 
to perform.2 The success rate was determined by 
the percentage of reductions that were completed 
without further intervention, like having to proceed 
into an open reduction.2 Complication risks were 
determined by any condition that followed and 
was associated with the reduction such as fracture, 
deep vein thrombosis, and neuropraxia.2 The aim 
of this guiding systematic comparison was to 
determine which closed reduction technique is the 
best in terms of success rate, ease of technique, 
complications, and patient reported pain.2 

FINDINGS AND CLINICAL IMPLICATIONS  

This guiding systematic comparison sought to 
determine which relocation technique was the most 
effective, efficient, least painful, and had the 
fewest complications for a patient with a shoulder 
dislocation. There are many techniques and 
maneuvers that a clinician needs to consider, 
along with their own comfort and experience with 
each. When looking at each article, there were 
some varying values for each outcome. 

The highest values for successful reduction (Table 
1) were the scapular manipulation (97%), the 
traction-countertraction (95%), the FARES method 
(92%), the Spaso technique (92%), and the 
external rotation maneuver (91%).2 The Stimson’s 
technique was least likely to facilitate a successful 
reduction (28%).2 Scapular manipulation was the 
quickest (mean time 1.75 min), while the Stimson’s  



Comparison of the Closed Shoulder Reduction Techniques: An Evidence-to-Practice Review  

 

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Table 1: Reduction Techniques 

Techniques Reduction 
Style 

Pain Experienced 
by Patient 

 (VAS 1-10) 

Time to Reduce 
Shoulder 
(Minutes) 

Success 
Rate 
(%) 

Complications 

Kocher Maneuver Traditional 4.68 ± 2.00 4.19 ± 1.25 85 1 
Spaso Technique Traditional 4.69 ± 1.26 2.65 ± 0.59 92 0 
External Rotation 
Technique Traditional 3.39 ± 0.40 3.06 ± 0.28 91 0 

Milch Maneuver Traditional 5.28 ± 0.54 4.29 ± 0.14 80 0 
Chair Method Traditional 4.00 ± 0.60 3.00 ± 0.30 78 0 
Traction-
Countertraction Traditional 4.75 ± 0.55 6.05 ± 2.49 95 0 

Scapular 
Manipulation Traditional 1.47 ± 0.44 1.75 ± 0.38 97 0 

Stimson’s Technique Traditional 5.30 ± 0.14 8.84 ± 0.30 28 0 
Hippocratic 
Maneuver Traditional 4.88 ± 0.54 5.55 ± 0.39 73 0 

Fast, Reliable, and 
Safe (FARES) 
Method 

Non- 
Traditional 1.59 ± 0.46 2.24 ± 0.27 92 0 

technique took the longest (mean time 8.84 min).2 
Only three studies looked at mean hospital stay.  

Shoulders reduced with the Milch maneuver had 
the shortest hospital stay (35 min), followed by 
those who were treated with scapular 
manipulation (92.4 min), the Oxford Chair (141 
min), and the traction-countertraction maneuver 
(320.4 min).2   

For patient experienced pain, the scapular 
manipulation technique tends to be the least 
painful during the reduction (VAS=1.47 during 
reduction), followed by the FARES method 
(VAS=1.59 during reduction).2 The Stimson’s 
method (VAS=5.30; SD 0.14) and the Milch 
method (VAS=5.28) tend to be the most painful.2 
Only one study reported a complication which 
occurred during implementation of the Kocher 
reduction technique, which was a fracture of the 
humeral neck.2 The authors of this systematic 
comparison also specifically mention that the 
Kocher method has previously been associated 
with a rupture of the pectoral muscles or humeral 
fractures and that the Hippocratic method has 
been associated with transient neuropraxia of the 
brachial nerve.2  

Evidence in this review identified that the FARES 
method had the best outcomes without any 
analgesic use reported.2 The scapular 
manipulation technique had a lower patient pain 
rating during relocation, but all patients receiving 
that technique on their dislocation were also given 
intravenous analgesics. It is evident that the 
scapular manipulation technique and FARES 
maneuver had the lowest amounts of pain during 
reduction and these two techniques also exhibited 
some of the highest rates of reduction success. The 
FARES method is new and considered non-
traditional compared to the scapular manipulation 
technique, but clearly shows promising outcomes in 
patient pain and reduction success.2 

However, there are many limitations to this 
systematic comparison that need to be addressed. 
Practitioner experience and bias were not 
examined, as some may be more likely to choose 
one method over another based-on patient 
characteristics or their own comfort and education 
in reduction. This analysis was done using studies 
that took place in the hospital setting, and 
therefore does not consider the hospital protocols, 
which could particularly influence the outcome of 
length of hospital stay. Furthermore, many 



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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
 

methods used accompanying analgesics or 
anesthetics and it was not determined if the use of 
these had been determined by hospital protocol, 
physician order, or upon patient request. The 
authors concluded that the techniques that also 
used analgesics or anesthesia generally had 
higher rates of successful reduction; it makes sense 
that a person in less pain would also have less 
muscle guarding, allowing for a better chance at 
a successful reduction. Along with the risks 
associated with closed reduction of a shoulder 
dislocation, the use of analgesics or anesthesia 
comes with its own set of concerns that affect 
patient comfort, such as vomiting and respiratory 
distress.2 

This is relevant to athletic trainers because, 
depending on the standing orders from the team 
physician or laws of the state in which they are 
practicing, the athletic trainer may be in a 
situation in which they are called on to relocate a 
shoulder and knowledge of which technique to use 
is important for best patient outcomes. Joint 
relocation has become part of the 2020 CAATE 
Standards, leaving many athletic trainers who 
have already completed their education without 
this training. We believe that education on these 
shoulder reduction techniques should be taught to 
athletic trainers who are already certified; it may 
be possible to do so at either at a conference or 
as a professional development course, as this is 
likely where many athletic trainers can gather for 
education. However, an online class, while more 
attainable, may not be the best option as 
techniques like this require firsthand practice. 
Based on the findings of the guiding systematic 
comparison and our own clinical analysis, we 
believe that the FARES method is the most clinically 
applicable for athletic trainers while also being 
cautious of patient comfort. The FARES method is 
simple and does not require intravenous 
analgesics, which some athletic trainers are not 
allowed to provide based on state practice acts 
and physician oversight. In our experience, 
athletic trainers may come across an acute 

shoulder dislocation in the athletics setting, 
particularly in contact or collision sports.  

CLINICAL BOTTOM LINE  

There are several techniques to reduce a shoulder 
dislocation. Choosing which technique to use 
depends on clinician training, access to extraneous 
assistance such as intravenous analgesics, the 
direction of dislocation, and the setting that the 
clinician is providing care. According to this 
review, the FARES technique was the most 
successful, least painful, and quickest when the use 
of intravenous analgesics was not available.2 
Although the scapular manipulation method of 
reduction had the best results across all 
categories, all patients were treated with 
intravenous analgesics, which is not readily 
available in many athletic training settings. Also, 
athletic trainers are often not able to provide the 
intravenous analgesics so additional assistance 
may be required and is not always an option. The 
other techniques are valid but are not as effective 
based on the criteria. We believe that athletic 
trainers need more access to education on joint 
reduction techniques. Further research should 
include dislocation reductions involving athletic 
trainers and their prehospital care in a variety of 
patients that reflect an athletic trainers’ patient 
population.  

REFERENCES 

1. Rozzi SL, Anderson JM, Doberstein ST, 
Godek JJ, Hartsock LA, McFarland EG. 
National Athletic Trainers' Association 
Position Statement: Immediate Management 
of Appendicular Joint Dislocations. J Athl 
Train. 2018;53(12):1117-1128. 
https://doi.org/10.4085/1062-6050-97-
12.  

2. Alkaduhimi H, van der Linde JA, 
Willigenburg NW, van Deurzen DFP, van 
den Bekerom MPJ. A systematic comparison 
of the closed shoulder reduction techniques. 
Arch Orthop Trauma Surg. 
2017;137(5):589-599. 

https://doi.org/10.4085/1062-6050-97-12
https://doi.org/10.4085/1062-6050-97-12


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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
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https://doi.org/10.1007/s00402-017-
2648-4.  

3. Guler O, Ekinci S, Akyildiz F, et al. 
Comparison of four different reduction 
methods for anterior dislocation of the 
shoulder. J Orthop Surg Res. 2015;10:80. 
https://doi.org/10.1186/s13018-015-
0226-4.  

4. Zacchilli MA, Owens BD. Epidemiology of 
Shoulder Dislocations Presenting to 
Emergency Departments in the United States. 
JBJS. 2010;92(3):542-549. 
https://doi.org/10.2106/jbjs.I.00450.  

5. Wagstrom E, Raynor B, Jani S, et al. 
Epidemiology of Glenohumeral Instability 
Related to Sporting Activities Using the FEDS 
(Frequency, Etiology, Direction, and Severity) 
Classification System: A Multicenter Analysis. 
Orthop J Sports Med. 
2019;7(7):2325967119861038. 
https://doi.org/10.1177/2325967119861
038.  

6. Commission on Accreditation of Athletic 
Training Education. 2020 Standards for 
Accreditation of Professional Athletic Training 
Programs: Master’s Degree Programs. 
Accessed January 25, 2021. 
https://caate.net/wp-
content/uploads/2019/08/2020-
Standards-Final-7-15-2019.pdf  

7. Comadoll SM, Landry Jarvis D, Yancey HB, 
Graves BR. The financial burden associated 
with multiple shoulder dislocations and the 
potential cost savings of surgical 
stabilization. JSES Int. 2020;4(3):584-586. 
https://doi.org/10.1016/j.jseint.2020.04.02
3.  

8. Marcano-Fernández FA, Balaguer-Castro M, 
Fillat-Gomà F, Ràfols-Perramon O, Torrens 
C, Torner P. Teaching Patients How to 
Reduce a Shoulder Dislocation: A 
Randomized Clinical Trial Comparing the 
Boss-Holzach-Matter Self-Assisted Technique 
and the Spaso Method. J Bone Joint Surg 
Am. 2018;100(5):375-380. 
https://doi.org/10.2106/JBJS.17.00687.  

9. Bokor-Billmann T, Lapshyn H, Kiffner E, Goos 
MF, Hopt UT, Billmann FG. Reduction of 
Acute Shoulder Dislocations in a Remote 
Environment: A Prospective Multicenter 
Observational Study. Wilderness Environ 

Med. 2015;26(3):395-400. 
https://doi.org/10.1016/j.wem.2014.12.02
7.  

10. Dreu M, Aufmesser W, Aufmesser H, Dolcet 
C, Feigl G, Sadoghi P. A simple and gentle 
technique for reduction after anterior 
shoulder dislocation. Arch Orthop Trauma 
Surg. 2015;135(10):1379-84. 
https://doi.org/10.1007/s00402-015-
2279-6.  

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.1007/s00402-017-2648-4
https://doi.org/10.1007/s00402-017-2648-4
https://doi.org/10.1186/s13018-015-0226-4
https://doi.org/10.1186/s13018-015-0226-4
https://doi.org/10.2106/jbjs.I.00450
https://doi.org/10.1177/2325967119861038
https://doi.org/10.1177/2325967119861038
https://caate.net/wp-content/uploads/2019/08/2020-Standards-Final-7-15-2019.pdf
https://caate.net/wp-content/uploads/2019/08/2020-Standards-Final-7-15-2019.pdf
https://caate.net/wp-content/uploads/2019/08/2020-Standards-Final-7-15-2019.pdf
https://doi.org/10.1016/j.jseint.2020.04.023
https://doi.org/10.1016/j.jseint.2020.04.023
https://doi.org/10.2106/JBJS.17.00687
https://doi.org/10.1016/j.wem.2014.12.027
https://doi.org/10.1016/j.wem.2014.12.027
https://doi.org/10.1007/s00402-015-2279-6
https://doi.org/10.1007/s00402-015-2279-6


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Table 2: How to perform each reduction technique included in systematic comparison  

Technique Name Performance Process Photo of Technique 

1. Kocher Maneuver 

1. Patient is supine, arm adducted, and elbow flexed 
to 90 degrees 

2. Clinician externally rotates arm until resistance is 
felt 

3. Clinician flexes arm in external rotation 
4. Clinician returns to adducted position 

 

2. Spaso Technique 

1. Patient is supine, shoulder flexed to 90 degrees 
2. Clinician pulls traction 
3. Clinician externally rotates shoulder while 

maintaining traction until relocation is felt 
 

 

3. External Rotation Technique 

1. Patient is supine with arm adducted and elbow 
flexed to 90 degrees each 

2. Clinician flexes shoulder to 20 degrees 
3. Clinician moves shoulder into external rotation until 

reduction is felt 

 



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4. Milch Maneuver 

1. Patient is supine 
2. Clinician holds arm at the wrist 
3. Clinician abducts and externally rotates arm until 

relocation is felt 

 

5. Chair Method 

1. Patient’s axilla is placed over back of a chair 
2. Clinician holds arm from wrist and elbow 
3. Clinician pulls downward traction until relocation 

occurs 

 

6. Traction-Countertraction 

1. Patient lies supine with a sheet or belt around 
thorax and around contralateral side of affected 
shoulder and clinician 

2. Patient elbow and shoulder are each flexed to 90 
degrees 

3. Clinician applies traction 
4. Typically requires two clinicians 

 

 



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7. Scapular Manipulation 

1. Patient is prone with shoulder hanging off the 
table at 90 degrees of flexion 

2. Patient holds weight in hand to provide traction 
3. Clinician rotates scapula medially 

 

8. Stimson’s Technique 

1. Patient is prone 
2. Arm hangs off edge of the table 
3. Manual or weighted traction is placed on the 

hanging arm 
4. Held for 10-20 min until shoulder relocates 

 

9. Hippocratic Maneuver 

1. Patient is supine 
2. Clinician places foot into injured side axilla 
3. Traction is applied while arm is abducted to 30 

degrees 

 

10. Fast, Reliable, and Safe 
(FARES) Method 

1. Patient is supine 
2. Clinician holds arm at the wrist 
3. Clinician slowly abducts the arm while providing 

constant traction and oscillation 

 


	ABSTRACT



