The Milch Technique for Reducing a Shoulder Dislocation

This post is contributed by Dr. Jeremy Joslin, an avid outdoor enthusiast who is currently training to become an emergency physician.

Here goes:

After a long day trekking through Utah's canyon country, you decide to start heading back to camp. Three days from a car, and an hour away from camp, your hiking partner slips while stepping over a downed tree and catches his arm on the large trunk while falling. As he scrambles back to his feet, he cries out in pain and cannot seem to move his right arm at the shoulder. He knows the feeling, and tells you exactly what's happened: he's dislocated his shoulder again.

Anterior dislocation (where the head [or “ball” of the ball-and-socket joint at the shoulder] of the humerus, which is the large bone of the upper arm, is dislocated forward in relationship to the socket) is the most common type of shoulder dislocation and happens when the arm gets pulled away from the body quickly (abduction), as in the scenario above. Shoulder dislocations are quite painful, and if you are near medical attention, that's where you'll want to head. In the meantime, if you're sure the shoulder is dislocated, waste no time in “reducing” it (putting it back into place). Prompt reduction is beneficial for the joint.

In order to help determine if a shoulder has, indeed, been dislocated, I will reference the Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care (2nd edition) (1), which lists these four features:

• Restriction of motion through the joint's normal range
• Obvious deformity in comparison with the uninvolved side
• Crepitus, or grating, of bone fragments is absent
• Often a typical, identifiable posture of the dislocated joint, which the patient will maintain to minimize pain

Once you've determined that the shoulder has been dislocated, you may want to attempt reduction. There are numerous methods of reduction for an anterior shoulder dislocation. My favorite technique for reduction is the Milch technique. Have the injured person sit, stand, or lie flat on his or her back, and then slowly reach, using the hand of their dislocated shoulder, behind their head and try to touch the opposite shoulder. Somewhere on the very slow, steady reaching, the shoulder will align itself and pop back into place. Another way to describe the positioning is to pantomime a pitcher's "wind up" before a pitch using the affecting side. Have the patient take their time and slowly reach upward and backwards as if they were going to pitch a baseball. If the "wind up" is slow enough, with plenty of rest if needed, you'll get the shoulder to pop back into place. This maneuver can be done solo or with assistance. If you are assisting, cup the victim’s elbow, giving it support and guiding their arm through the maneuver. Your other hand can be placed on their shoulder to apply support to the joint as it goes through the motion.

Why do I appreciate this maneuver so much? Here are my specific reasons:

• Compared with other maneuvers to reduce shoulders, this one seems to be the least painful. (2)
• Some medical providers swear that if the technique is done correctly and slowly, then the patient doesn't even need pain medication. (3)(4)
• It is easily described and easy to remember (the baseball pitch).
• It can be done for self rescue (just take your time and go as slow as possible).
• In my hands, this maneuver has been more successful than other techniques.

I'd like to hear about your favorite technique), or if you've ever needed to reduce a shoulder in the wilderness setting, how you achieved success. Finally, if you're interested in reading more about this very historic subject, begin by following the link to an interesting article.

photo of Jeremy Joslin, M.D.

Tags: shoulder dislocation, Milch technique, Jeremy Joslin, wilderness medicine, outdoor medicine, healthline

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