The Cunningham Shoulder Reduction: Awake and Painless

I, sir, am a convert.

I had read about Dr. Cunningham’s technique at his website, I was amazed at his videos, but honestly didn’t believe them. Painless? No pulling? And no procedural sedation? I didn’t think it was possible.

Until last week.

A 16 year-old boy came into our busy Peds ED after having been pushed, and had fallen onto the shoulder; he was neurovascularly intact but clearly out. He was in pain as I unwrapped the EMS triangle gauze wrap and placed him in a shoulder sling, but was very calm, not screaming or tearful, and I thought, today’s the day to try this. I gave him a shot of subcutaneous morphine, and by the time he was back from x-ray, he was resting comfortably. I explained my two options like this: “I have one technique that I can try right now, it will have no pain, and can try to get your shoulder back in in about 5 minutes. And if that doesn’t work, we will put in an IV, and give you some medicines to make you sleepy, and then put it in that way.” Wanting no needle for the line, he wanted to try the Cunningham technique. Literally 3 minutes later, it was reduced.

Dr. Cunningham does a much better job of explaining his technique at his site than I would, so I’ll recommend everyone to head over there and read through it, but after it worked last night, I was on Cloud 9. None of my colleagues believed me. “Painless? No sedation? No way.” (This was especially satisfying and helpful, as I was also managing a little girl with a spiral tibia fracture that needed procedural sedation for some reduction; it would have been nursing suicide to tie up two nurses for two procedural sedations. We were being triaged a good 7 patients an hour at the time.)

I do want to share several tips and suggestions on this technique:

  • Read through Dr. Cunningham’s analgesic positions. There are essentially two positions in which a patient will hold their arm if it’s dislocated, and these are positions that are pain-free for the patient. More on position 1 and position 2.
  • Watch the videos a couple times. They really are amazing.
  • You have to have a calm, compliant patient, and they have to trust you. The technique truly is painless, but if they don’t trust that you aren’t going to hurt them, or they’re anxious or tense, it’s not going to work. I tried this technique a few weeks ago with an obese, very tense woman (despite narcotics) and it didn’t work. I had to sedate her with a tiny touch of Fentanyl/Versed, and it popped in immediately with 30 seconds of the FARES technique.
  • I’ve emailed back and forth with Dr. Cunningham for some clarifications that I wanted to share with you about his technique. The most common mistakes?

    Patient position – shoulder slumped forwards or to the side (abduction). You can massage all you like, the humeral head won’t slide laterally in this position. Again “sit straight up, lift your head up, chest out, shoulders back, relax as much as you can.”
    Your position – sat/knelt too far forwards or to the side, pulling patient’s humerus into anterior flexion or abduction.
    Traction – the more you pull, the more the patient will pull against it, stopping relocation.
    Spasm at point of reduction – prep your patient that the actual relocation might feel a bit strange (whatever technique you use) and that if they feel the shoulder move and it feels strange to just relax and let it move, if they spasm at this point it might hurt and abort the reduction (OK as long as you can explain this to them, take your time and go again).

    What does “shrug your shoulders” mean to him? (I described this to my patient as “When your teachers tell you you’re slouching, and they ask you to sit up straight and fix your posture.”)

    Shrug – I use the term shrug as the simplest way to describe to a patient what I’m actually aiming for. Most patients will be starting with the shoulder slumped forwards, this has the effect of placing the scapula in an anterior position (rotated and anteverted). In this position the humeral head has to move a long way anteriorly past the glenoid rim before it can move laterally and reduce – this basically means that it will not reduce in any of the ‘humerus in adduction’ manoeuvres (mine, Kocher’s, external rotation etc). The scapular position you are aiming for is retroversion and a posterior position (glenoid rim moves back, little anterior humeral head movement required, can just slide laterally). Possibly a better way to word this is (to patient) “sit straight up, lift your head up, chest out, shoulders back, relax as much as you can.” (Try this on yourself, you’ll feel your own back, scapulae and shoulders moving where you want them). You definitely don’t want them actively shrugging or nothing will move.

    Dr. Cunningham also admits that we should always be tailoring our technique to our patient: “If you find yourself spending >5 mins on massage (and happy that patient as relaxed as can be) then the problem is almost certainly positioning, try and visualise yourself and your patient from ‘a few steps back’ to see what you can improve, or try a different technique.”

  • Update: A few more pointers from Dr. Cunningham. On my obese patient I had tried it with and failed:

    It can be difficult/impossible to perform Kocher’s or Cunningham manoeuvre on obese patients simply because they can’t adduct the humerus enough. This means that the articular surface of the humeral head is not opposed to the labrum (for an easy slide) and the anterior joint is under more tension. I normally prefer either a Milch or a scapular manipulation manoeuvre for the obese.

    And on Analgesic Position 1:

    this is the easiest way to get the patient into the position but the key is the relationship between the humeral head and the scapular glenoid rim. So in fact you can get this position with the patient on a chair, trolley or I’ve done it with patient supine – standing next to bed with one hand around mid humerus and the other holding the wrist keeping the elbow at 90 degrees and the wrist supinated. Asking the patient to put chest out and shoulders back at this point while massaging biceps does the trick. I have used this a couple of times with trauma – awake patient with a cspine collar on who you really don’t want to manipulate neck/shoulder or sedate.

A big thanks to Dr. Cunningham for his technique, for helping my patient (and of course, making me look like a total baller in the department). In the right patient, it works like a charm, and the 3 minutes you invest in talking calmly to the patient, gaining their trust, and helping them relax is worth the 20-30 minutes you save filling out sedation paperwork, hooking them up to the monitor, having the nurse draw up the meds, sedate the person, reduce the person, and then wait for them to wake up before they can get post-reduction films.

Dr. Cunningham is working on putting together some more videos shortly that provide tips and troubleshooting. I look forward to them!

  1. #1 by Gerard Fennessy - July 5th, 2011 at 05:36

    Hi Graham, I work with Neil. I have changed a couple of links on the website, I’m really sorry – we have just redesigned it, and it was part of the process. Hope its not too much of a problem to change your links to the analgesic positions, etc.
    Gerard Fennessy

  2. #2 by Thomas Dwyer III - August 3rd, 2011 at 18:22

    For what it’s worth, I cannot praise Dr Cunningham enough. I had surgery after my 3rd shoulder dislocation and was perfect for about 4 years until a freak snowboard accident messed me up again earlier this February. After a violent sneeze caused another dislocation in June (followed by 2hrs in the ER waiting room before any doctor could even evaluate me), I started researching reduction techniques. I stumbled across the Cunningham Technique last week at, watched the videos, and quickly laughed it off as being completely unbelievable.

    Two days ago I was lying on my back in bed when the alarm clock went off. Still half asleep, I reached over to hit the snooze button without thinking. That simple action dislocated my left shoulder for the 7th time (4th time since the surgery). With Dr Cunningham’s videos still fresh in my mind, and having no desire to go sit in the ER waiting room again (how would I even get myself dressed?), I figured this technique was worth a shot. I couldn’t remember the website so I described the procedure to my girlfriend as best I could. We sat in two dining room chairs facing each other and gave it a try. Less than 60 seconds later, my shoulder was reduced and I was able to get ready for work as usual. Amazing!

  3. #3 by Frank Biondolillo, DO, FACEP - August 10th, 2011 at 20:47

    I usually do not write in and give my 2 cents, but I had to on this one! Today in the ED, a busy Wednesday afternoon, the opportunity arose to try this new technique I have heard and read so much about. The “painless shoulder Reduction” by Dr. Cunningham. I was a bit skeptical, but much to my surprise, it truly worked! Reduced the Ant/Inf. Shoulder dislocation in literally less than 3 minutes. Painless for me and the patient. This, what would have normally been 2+ hrs to do with procedural sedation, nursing support, recovery and observation was in & out of the ED in under an hour!!
    Absolutely amazing!!!. Really did great for the patient and a huge savings on ED Metrics and LOS !!
    Kudos to Dr. Cunningham!!

  4. #4 by Bill Hampton, DO - January 13th, 2012 at 14:07

    I used this technique today (for the first time) on 21-year-old male, chronic dislocator. Nursing staff was absolutely blown away. Our typical protocol is initial x-rays, procedural sedation, reduction, post-procedure x-rays. We’re a small shop, but our total patient time is often 90 minutes for this. Went back in like a charm! Just fantastic. I strongly encourage everyone who hasn’t tried this to give it a go.

  5. #5 by Pedram Bagheri, M.D. - January 28th, 2012 at 16:39

    I was introduced to this technique by one of my attending mentors in my residency/hospital, who read about it. According to his experience this procedure has worked about 50% of the time. Our combied experience with a patient in the ER was unsuccessful but it was due to the fact that the patient was not shruging the shoulder enough to the back. Traditional methods however worked. Nontheless, this is a great procedure that I enjoyed being exposed to as an intern in training.

  6. #6 by Iesha Dennis - March 2nd, 2012 at 07:22

    This is an informative post. I’m a nursing student and reading a post like this is of great significance to me. I know, I can apply and practice same thing whenever I’m on duty.

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