Physiotherapists and orthopedic surgeons spend significant amounts of time and effort treating shoulder injuries and conditions, of which there are many. The shoulder, an unstable joint with a very large range of movement, the greatest in the body, is vulnerable in many situations to injury or mechanical stresses. Its instability means it can be relatively easily dislocated in a fall or activity at end range. We use the arm to save ourselves if we fall, making fractures common and heavy or overhead work over time leads to rotator cuff tears.

Due to the very large number of potential injuries, fractures and operations which can affect the shoulder it is very important to know the exact diagnosis and plan of treatment. Physiotherapists specialise in managing post-operative and post-trauma shoulder problems, following the surgical and trauma protocols agreed with the shoulder surgeons. On meeting the patient initially a good strategy is to review the progress of their case so far, as this can occasionally throw up unexpected anomalies which need exploring. The patient should have a short time to tell their story or they may not feel they have been heard.

As the arm hangs from the shoulder and needs effort to keep it in place, after operation or injury it may be useful to relieve this load by using a sling. The typical triangular bandage broad arm slings are not comfortable, difficult to apply, pull at the back of the neck and are not easily adjusted to the physiotherapist's requirements. Foam padding around the knot at the back of the neck can help but the Seton type sling with Velcro straps is much better tolerated by patients and is much more adjustable and comfortable.

To get the best fitting and most comfortable fit for the sling the physiotherapist needs to take a few actions for success. The gutter for the arm should have the elbow placed back as far as it will go and the hand can be kept out of the sling by folding back the cuff part. The small Velcro strap to close the forearm gutter should not be tightly fixed as it may cut in to the upper arm, particularly if there is a lot of oedema as swelling can occur after fractures of the upper arm. Tightening up the main strap which runs across the back and upwards over the shoulder is a little more difficult to achieve a good result.

Due to the materials from which the slings are made there is a degree both of elasticity and friction against surfaces when they are adjusted. As the sling is adjusted and tightened up the elbow is often not well supported by the sling at all and patients are usually aware that the support is not that good. The physiotherapist can easily feel that the sling is not giving the correct support and if they just tighten up the strap it solely tightens up at the front but does not improve the support of the arm. This needs another strategy.

To get the sling right needs two people, the patient and a helper. The helper lifts the elbow of the affected arm in the sling while the patient tries to let the shoulder relax. Then the helper gets hold of the part of the strap along the back and pulls it up towards the shoulder, holding it there. The helper lets go of the elbow and adjusts the strap whilst still holding the back part of the strap under tension with the other hand. Having completed this maneuver the elbow should now feel heavy and supported in the sling and the patient feel it is quite comfortable.

General advice to patients about sling management should be given to cope with daily activities, the sling only being off for dressing and washing. To wash the armpit the patient should hold their arm in a position as if the sling was on and then bend forward, allowing the arm to bend forward with gravity. To put clothes on the affected arm should be placed on first and with no significant movement of the arm involved.