Shoulder Reduction Techniques: From FARES to Traction

Shoulder reduction is the process of maneuvering a dislocated humeral head back into its socket, and dozens of named techniques exist for doing it. The shoulder’s ball-and-socket design gives it remarkable range of motion but also makes it the most commonly dislocated major joint in the body. When the humeral head slips out of the glenoid cavity, the reduction technique chosen by the treating clinician can make a real difference in how much pain the patient feels, how quickly the joint goes back in, and whether sedation is even necessary. A systematic comparison of closed techniques found that scapular manipulation and the FARES method consistently rank among the fastest and least painful options, while older traction-based approaches, though highly successful, tend to hurt more and take longer.

Why the Shoulder Dislocates So Easily

The glenohumeral joint is inherently predisposed to instability by its bony architecture: the socket (glenoid) is shallow relative to the ball (humeral head), a bit like a golf ball sitting on a tee.¹ Stability depends heavily on soft tissues, including the labrum (a rim of cartilage that deepens the socket), the joint capsule, and the rotator cuff muscles. When a force overwhelms those stabilizers, the humeral head pops out. About 95% of shoulder dislocations are anterior, meaning the ball slips forward, typically during a fall onto an outstretched hand or a collision that forces the arm into an extreme position. Posterior dislocations, where the ball moves backward, are rare and often missed on initial examination.²

What Happens Before Any Reduction Attempt

Before anyone tries to put the shoulder back, the clinical team checks for nerve and blood vessel damage. A standard exam confirms that the pulses below the shoulder are intact, that sensation is normal in the distributions supplied by the axillary, median, radial, and ulnar nerves, and that the hand still has full motor strength. Point-of-care ultrasound is increasingly used to confirm the dislocation and check joint position before X-rays are even ordered. Imaging matters because roughly 60% of shoulder dislocations come with associated injuries, including fractures, labral tears, and cartilage defects.³ A Hill-Sachs lesion, which is an impression fracture on the back of the humeral head caused by impact against the glenoid rim, can complicate the reduction and alter follow-up treatment.⁴ Greater tuberosity fractures are also common and were found in about 15% of anterior dislocations in one prospective study, sometimes combined with nerve injury.⁵ Posterior dislocations carry an even higher rate of associated injuries: a systematic review found that about 65% had fractures, reverse Hill-Sachs defects, or rotator cuff tears.⁶

Identifying these injuries beforehand is not academic. A fracture-dislocation may require a completely different approach, and forcing a standard reduction maneuver on a shoulder with an unrecognized fracture can cause further damage.

How the Techniques Are Classified

There is no single “best” technique for every patient, but the major methods fall into a few biomechanical families. Understanding the categories helps explain why one clinician might choose gentle muscle relaxation while another reaches for traction.

Biomechanical relaxation (BRT): Techniques that rely on relaxing the spasming muscles around the joint rather than overpowering them. The Cunningham technique and the Stimson (dangling weight) method belong here.
Leverage: Methods that use the arm as a lever to walk the humeral head back into the socket. The Milch technique and external rotation method are classic examples.
Traction-countertraction (TCT): Approaches that pull on the arm while an assistant holds the body still. The Hippocratic method and Matsen traction-countertraction are traditional versions.
Scapular manipulation: Techniques that reposition the socket around the ball, rather than the ball back into the socket, by pushing and rotating the scapula while the arm is held in a fixed position.
Oscillatory: The FARES method, which adds a gentle back-and-forth oscillation to slow arm movements, fits its own niche.

A meta-analysis that pooled data on patient-reported pain found that biomechanical relaxation techniques were substantially less painful than leverage methods, and slightly less painful than traction-countertraction, when performed without sedation or intra-articular analgesia.⁷

Scapular Manipulation and the FARES Method

In a combined analysis across studies, scapular manipulation came out on top by nearly every metric: a 97% success rate, an average reduction time of under two minutes, and the lowest pain scores of any technique.⁸ The technique typically has the patient lying face down with the arm hanging off the edge of the bed. One clinician stabilizes the arm in gentle traction while another pushes the tip of the scapula inward and rotates it. A key advantage is that it rarely requires sedation or opioid painkillers.⁹

The FARES method (short for Fast, Reliable, and Safe) is a close runner-up. The patient lies on their back, and the clinician slowly abducts the arm while continuously oscillating it in small back-and-forth movements. In a randomized trial comparing FARES to both the Hippocratic and Kocher methods, FARES succeeded in about 89% of patients versus roughly 73% for the Hippocratic technique and 68% for the Kocher. The average reduction time with FARES was about two and a half minutes, compared with over five minutes for the Hippocratic method and over four minutes for the Kocher. Pain scores were dramatically lower with FARES as well.¹⁰ No complications were noted in any group in that trial.

Leverage and External Rotation Approaches

The external rotation method is straightforward: the clinician holds the patient’s elbow at 90 degrees against their side and slowly rotates the forearm outward, like opening a door. This gentle approach works well without anesthesia in many cases. One comparative study found an 88% success rate with external rotation versus about 69% for the Milch technique, with external rotation being easier to perform and less painful, though the difference in success rate did not reach statistical significance.¹¹

The Milch technique combines abduction, external rotation, and a direct push on the humeral head. Despite sounding more aggressive, it has a devoted following. One case series reported successful first-attempt reduction in all 76 consecutive patients without any anesthesia or complications.¹² The catch is that operator experience matters enormously with leverage techniques. In less practiced hands, the success rate can drop.

The Cunningham Technique and Muscle Relaxation

The Cunningham technique takes a philosophically different approach: rather than physically pulling or levering the bone back in, the clinician massages the biceps, deltoid, and trapezius to release the muscle spasm that is keeping the humeral head locked out of the socket. The patient sits upright, shrugs their shoulders back, and the clinician works on the muscles until the joint spontaneously reduces. A study comparing the Cunningham technique to external rotation found that both methods were effective, but the Cunningham technique produced a notable drop in pain scores during the transition phase before reduction. All three groups in that trial, including one that required procedural sedation, showed significant pain improvement after reduction.¹³ Patients who needed sedation (used with external rotation in that study) had the longest hospital stays, which is a practical consideration in busy emergency departments.

Traction-Countertraction and Newer Distraction Methods

The Hippocratic technique, one of the oldest documented medical maneuvers in history, uses steady traction on the arm with countertraction applied to the body. It works, but surgeons who have compared it head-to-head with gentler methods agree that both the Kocher and Matsen (traction-countertraction) techniques require more force, and patients tend to tense their muscles against the pain, making the procedure harder.¹⁴ A vicious cycle can develop: more force causes more pain, which causes more spasm, which calls for even more force.

A newer variation called the scapulohumeral distraction technique was tested in a randomized controlled trial against the Hippocratic technique. Both had comparable and high success rates (about 95% versus 93%), but scapulohumeral distraction required less procedure time, lower pain levels, and produced greater patient satisfaction.¹⁵ The trend in the literature is clear: the field has been drifting steadily toward lower-force, higher-finesse methods.

Pain Management During Reduction

The question of what to give a patient for pain during a shoulder reduction is almost as debated as which technique to use. The two main strategies are procedural sedation (putting the patient into a brief twilight state with drugs like propofol or midazolam) and intra-articular lidocaine, where a local anesthetic is injected directly into the joint. A randomized trial found that both approaches resulted in similar emergency department stays (about 124 to 133 minutes) and near-identical patient satisfaction scores. The lidocaine group required slightly more reduction attempts on average, but had zero adverse events. Two patients in the sedation group experienced brief episodes of apnea, both after receiving propofol, though the episodes resolved on their own without intervention.¹⁶

Many of the gentler techniques, particularly scapular manipulation, external rotation, and the Cunningham method, can succeed without any sedation at all. That is a significant practical advantage in settings where sedation carries logistic burdens: monitoring equipment, recovery time, and the need for a second provider to supervise airway safety.

When Things Go Wrong During Reduction

Iatrogenic fractures, meaning fractures caused by the reduction maneuver itself, are uncommon but real. A study examining cases where the reduction broke something found that conscious sedation was actually associated with more iatrogenic fractures than general anesthesia.¹⁷ That sounds counterintuitive, since general anesthesia provides complete muscle relaxation. The likely explanation is that under lighter sedation, patients still have some muscle tone and may guard or tense up, leading clinicians to use more force, while under general anesthesia the muscles go completely slack and less force is needed. Of 21 iatrogenic fracture cases in that study, 17 occurred under conscious sedation and only four under general anesthesia.

This finding underscores why technique choice matters so much. If you are using a method that requires substantial force, the type of anesthesia you provide becomes safety-critical. If you use a method that barely requires any force at all, the risk drops regardless of the sedation approach.

Reduction Outside the Hospital

Shoulder dislocations do not always happen near an emergency department. They happen on ski slopes, climbing routes, and backcountry trails. A systematic review of prehospital reduction found zero immediate complications across all studies examined, regardless of technique, and no documented subsequent adverse events. First-attempt success rates by skilled practitioners ranged from about 72% to 95%.¹⁸ Prompt prehospital reduction also resolved neurological symptoms faster, which makes sense: the longer a nerve is compressed by a displaced humeral head, the greater the risk of lasting damage.

A ten-year review of a ski patrol program that trained emergency medical technicians to diagnose and reduce anterior shoulder dislocations found they identified dislocations with 98% sensitivity. Their overall reduction success rate was 86%, and no instances of iatrogenic harm were identified. Patients who had a successful field reduction did not need ambulance transportation at all.¹⁹ Two fracture-dislocations and four misdiagnoses were manipulated during the program’s ten-year span, but none resulted in harm. The results suggest that well-trained non-physicians can safely perform reductions in the field, though the standard of care still calls for imaging and a thorough exam as soon as the patient reaches a medical facility.

First-Time Versus Recurrent Dislocations

If you have dislocated your shoulder once, the experience of a second dislocation is often different, and not just because you know what to expect. Recurrent dislocations tend to involve more structural damage to the labrum and capsule, which makes the joint pop out more easily but can make certain reduction maneuvers less straightforward. A tertiary center study found that surgical treatment (open reduction) was needed in about 24% of patients with recurrent dislocations, compared to roughly 5% of first-time cases.²⁰ Overall, about 12% of all cases in that study required hospitalization for surgery or closed reduction under general anesthesia.

Many people with recurrent instability can reduce their own shoulder or have a friend help, because the muscle guarding is less intense and the soft tissues have been stretched. That does not mean self-reduction is safe to do indefinitely without medical follow-up. Each additional dislocation chews away at the remaining bone and soft tissue, making the problem progressively worse.

What Happens After the Shoulder Goes Back In

Getting the joint back into the socket is half the battle. The other half is keeping it there while the torn structures heal. Traditionally, the arm is immobilized in a sling with the hand held against the belly (internal rotation). Research on cadavers and imaging studies showed that holding the arm in external rotation, with the forearm pointing away from the body, may press the torn labrum back against the socket rim more effectively. But when those promising anatomical findings were tested in clinical trials, the results were mixed.

A meta-analysis of randomized controlled trials found no overall significant difference in recurrence rates between external rotation and internal rotation immobilization.²¹ However, one randomized trial did find that external rotation reduced the risk of re-dislocation in patients aged 20 to 40.²² A literature review concluded that external rotation immobilization may benefit a specific population, particularly adults between 20 and 40 with certain injury patterns like Bankart lesions or greater tuberosity fractures, but the evidence is not strong enough to recommend it universally over the traditional sling approach.²³

Rehabilitation and Getting Back to Activity

British Elbow and Shoulder Society guidelines lay out rehabilitation in sequential phases: acute protection and education in the first three weeks, early movement and strengthening from weeks three to six, progressive strengthening from six to twelve weeks, and return to sport after twelve weeks.²⁴ These phases apply to both operative and non-operative patients, though the specifics differ: surgical patients typically use a sling for longer and delay resisted exercises.

For athletes, the timeline can be compressed. A clinical review found that return to sport typically happens two to three weeks after injury, though there is no rigid consensus. The agreed-upon criteria before returning are being pain-free and demonstrating symmetric shoulder strength, equal scapular strength on both sides, and functional range of motion that allows sport-specific participation.²⁵ That two-to-three-week number should be read with caution: it applies mainly to athletes with recurrent dislocations who have been through this before and can tolerate early activity. A first-time dislocator with a significant labral tear is looking at a much longer recovery.

The Stubborn Problem of Posterior Dislocations

Posterior dislocations deserve their own mention because they are a genuinely different animal. They account for a small fraction of shoulder dislocations, but the diagnosis is often delayed because standard front-to-back X-rays can look deceptively normal.²⁶ The delay allows the humeral head to become “locked” behind the glenoid, making closed reduction much harder or impossible. When a posterior dislocation is caught early, reduction under anesthesia with axial traction and gentle internal rotation can succeed. When it is caught late, the options narrow to surgical approaches. The clinical lesson is that any shoulder injury where the patient cannot externally rotate the arm should raise suspicion for a posterior dislocation, and an axillary or lateral X-ray view (or a CT scan) should be ordered to avoid missing it.

How the Approach to Shoulder Reduction Has Changed

The Hippocratic technique, which involves placing counterforce against the patient’s body while pulling the arm, dates back over two thousand years. Hippocrates himself considered a device called the ambe, essentially a lever used to force the shoulder back, to be the most powerful reduction tool. By the 19th century, the English surgeon Astley Cooper regarded the same device as a last resort because of the rib injuries and patient distress it caused. That arc from “most powerful” to “last resort” mirrors the broader trajectory of the field. Modern technique development has consistently moved toward methods that use less force, cause less pain, and work with the body’s muscles rather than against them. The randomized data increasingly support that direction: the lowest-force methods tend to be the fastest, least painful, and least likely to cause complications.