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Simultaneous bilateral shoulder dislocations are extremely rare occurrences and are rarely associated with exercise. We present an unusual case of bilateral simultaneous shoulder dislocation which occurred during an unsupervised Pilates Reformer exercise session. A 41-year-old female felt sudden severe pain and forward displacement in both shoulders during abduction and external rotation. Bilateral anterior shoulder dislocation was confirmed with initial X-rays in the emergency department. Spontaneous reduction of the right shoulder was observed in the emergency room and then the left side was reduced under general anesthesia. Physical therapy modalities, exercises for shoulder girdle and core strength were implemented as conservative management. The patient returned to desk work and had pain-free range of motion with satisfactory strength on both sides in the fourth week and performed daily life activities without any symptoms in the tenth week. This case highlights the importance of training under supervision of an exercise instructor, even if it is considered a “so-called safe” exercise method.

Simultaneous bilateral shoulder dislocation during pilates reformer exercise: A case report