Shoulder Dislocation: An Overview

Shoulder dislocation refers to the displacement of the humeral head from its normal position in the glenoid fossa of the scapula. It is the most common major joint dislocation seen in the emergency department.


  • Shoulder dislocations account for about 50% of all major joint dislocations.
  • The incidence is 11.2 per 100,000 person-years in the general population.
  • Young adults between 20-30 years old are most commonly affected.
  • Males are more frequently affected than females with a ratio of 3:1.
  • Up to 92% of primary anterior shoulder dislocations occur due to traumatic injury.
  • Recurrent shoulder instability affects 73% of patients under the age of 30 after a first-time anterior shoulder dislocation.

Mechanism of Injury

  • The mechanism of injury typically involves forced external rotation and abduction of the shoulder.
  • Common mechanisms include sports injuries (rugby, football, wrestling, skiing, basketball), falls, and motor vehicle accidents.
  • Less common mechanisms include seizure, electric shock, or electroconvulsive therapy.

Anatomy and Classification

  • The shoulder joint is prone to dislocation due to its wide range of motion and relatively unsupported shallow glenoid fossa.
  • Dislocations are classified by direction:
  • Anterior (95-98%): humeral head displaced anteriorly and inferiorly
  • Posterior (<5%): humeral head displaced posteriorly
  • Inferior: humeral head displaced inferiorly into the axilla

Injuries Associated with Shoulder Dislocation

Soft Tissue Injuries

  • Bankart lesion: detachment of the anteroinferior labrum
  • Present in up to 80% of first-time dislocations
  • Hill-Sachs lesion: posterolateral humeral head impaction fracture
  • Present in up to 90% of first-time dislocations
  • Rotator cuff tears: more common in older patients
  • Ligamentous injuries: capsule, inferior glenohumeral ligament

Bony Injuries

  • Glenoid rim fracture: bony fragment attached to labrum
  • Reverse Hill-Sachs lesion: impression fracture of anterior glenoid rim
  • Greater tuberosity fracture: may occur with traumatic dislocation
  • Proximal humerus fracture: uncommon but may be associated

Neurovascular Injuries

  • Axillary nerve injury: stretching with anterior dislocation
  • Present in up to 55% of patients
  • Usually neuropraxia, full recovery expected
  • Brachial plexus injury: traction injury
  • Less common, seen in high energy traumatic dislocations
  • Axillary artery injury: rare but serious complication
  • Risk increased in older patients
  • Can lead to limb threatening ischemia if missed


  • History: mechanism of injury, prior shoulder instability
  • Physical exam: deformity, pain, range of motion
  • Unable to externally rotate the shoulder
  • Imaging:
  • X-ray: AP, scapular Y, axillary views
  • MRI: evaluate soft tissue injuries
  • CT: evaluate bony anatomy


  • Reduce dislocation as soon as possible
  • Usually done closed reduction, procedural sedation often required
  • Immobilization in sling or brace for 2-6 weeks
  • Physical therapy for range of motion and strengthening
  • Surgery may be indicated for recurrent instability
  • Bankart repair, reattachment of labrum
  • Latarjet procedure: augmentation of glenoid with coracoid process


Shoulder dislocation is a common orthopedic emergency. It often results in soft tissue or osseous injuries around the shoulder joint. Prompt diagnosis and reduction is key, followed by a period of immobilization and physical therapy. Recurrent instability may require surgical stabilization procedures. Close follow up is important to monitor for associated neurovascular complications.

Preventing Shoulder Dislocation

Shoulder dislocation occurs when the humeral head is displaced from the glenoid fossa. While anyone can experience a shoulder dislocation, there are risk factors that increase susceptibility as well as preventative strategies that can reduce the chances of dislocation.

Risk Factors for Shoulder Dislocation

  • Age:
  • Highest incidence in young adults 20-30 years old
  • The glenoid fossa is shallower and more susceptible to instability in this age group
  • Sex:
  • Males have a 3 times higher incidence than females
  • Prior dislocation:
  • Up to 90% recurrence rate in young athletes
  • Sports participation:
  • Collision sports – rugby, wrestling, football
  • Overhead throwing sports – baseball, volleyball
  • Winter sports – skiing, snowboarding
  • Water sports – surfing, water polo
  • Ligamentous laxity:
  • Generalized hypermobility or Ehlers-Danlos syndrome
  • Increases risk especially in overhead athletes
  • Bony abnormalities:
  • Glenoid hypoplasia, humeral retroversion
  • Can contribute to instability

Prevention Strategies

  • Strengthening exercises:
  • Focuses on rotator cuff and periscapular muscles
  • Improves dynamic stability
  • Proprioception training:
  • Enhances shoulder position sense
  • Done with balance board and plyometric drills
  • Technique modification:
  • Avoid vulnerable arm positions during sports
  • Keep elbow tucked while tacking in football
  • Proper slide technique in baseball
  • Protective equipment:
  • Shoulder pads, chest protectors
  • Helps dissipate force in contact sports
  • Rule changes:
  • Limit aggressive checking in hockey
  • No spear tackling in football
  • Reduces dangerous collisions
  • Activity modification:
  • Limit overhead throwing volume
  • Avoid fatigue which impairs mechanics
  • Adjust water sport activities based on conditions
  • Avoid play while injured:
  • Dislocated shoulder needs adequate time to heal
  • Higher risk of recurrence if return too soon

Post-Dislocation Prevention

  • Allows capsule and labrum to heal
  • Physical therapy:
  • Gradually restores range of motion
  • Strengthens dynamic stabilizers
  • Consider surgery:
  • Bankart repair reinforces anterior structures
  • Latarjet procedure reinforces glenoid
  • Return to sport protocol:
  • Follow gradual progression in throwing, swimming, weightlifting
  • Ensure mechanics normal and strength restored


Shoulder dislocation can often be prevented by addressing modifiable risk factors. A combination of focused strengthening, proprioception, technique adjustments, protective equipment, and activity modification can reduce risk. After an initial dislocation, recurrence can be minimized with immobilization, physical therapy, and possible surgery. A gradual return to sports protocol is crucial to ensure the shoulder is fully rehabilitated.

Mechanism of Shoulder Dislocation in Sports

The mechanism of shoulder dislocation can vary depending on the forces generated in different sports activities. Understanding injury mechanisms in sports can help guide preventative strategies.


  • Tackling and being tackled account for majority of injuries.
  • Common mechanisms:
  • Direct blow to lateral shoulder during tackle.
  • Outstretched arm held in external rotation when hitting the ground.
  • Traction from opponent twisting or pulling on arm.
  • Forward momentum with arm outstretched when being tackled.
  • Dislocation usually anterior and inferior.
  • Associated injuries:
  • Bankart and Hill-Sachs lesions
  • Acromioclavicular joint sprains
  • Rotator cuff tears

American Football

  • Approximately 9% of injuries involve shoulder dislocation.
  • Most common mechanisms:
  • Direct blow to lateral shoulder from opponent.
  • Traction from bringing opponent to ground.
  • Falling on outstretched arm.
  • Linemen at risk when arm trapped during blocking.
  • Quarterbacks vulnerable while tackled during passing motion.
  • Anterior dislocation most frequent due to forced abduction and external rotation.


  • Strong valgus stress during overhead throwing.
  • Eccentric traction on capsule during follow through.
  • Fatigue leads to loss of mechanics and control.
  • Outfielders at risk when diving for ball.
  • Dislocation usually posterior due to repetitive microtrauma.


  • “Spike“ swing places great stress across glenohumeral joint.
  • Forced external rotation when hitting ball with outstretched arm.
  • Blocking at net can jam shoulder into abnormal position.
  • Diving for ball with abducted externally rotated arm.
  • Most often anterior dislocation.


  • Internal impingement during pressing movements above shoulder height.
  • Loss of weightlifting bar behind head results in sudden traction.
  • Attempting catch of heavier-than-expected weights.
  • Injury usually due to forced extension, abduction and external rotation.

Winter Sports

  • Falls in skiing and snowboarding frequently cause dislocation.
  • Outstretched arm hits ground while body continues to fall.
  • High speed crashes lead to trauma.
  • Head-first dives onto ice in hockey.
  • Delay in diagnosis common given heavy clothing.

Water Sports

  • Traction on abducted externally rotated arm during water polo shot.
  • Surfing falls with hand anchored to board.
  • Canoeing/kayaking capsizes with arm outside of boat.
  • Swimmers forceful reach during stroke.
  • Lifting body out of pool with one arm.


Shoulder dislocation can result from a variety of mechanisms unique to different sports. Understanding the common injury patterns in each sport allows for targeted preventative interventions and technique modifications to help reduce risk.

Long Term Outcomes of Untreated Shoulder Dislocation

Shoulder dislocation refers to displacement of the humeral head from its normal anatomical position. While prompt treatment is recommended, some patients may present late or leave shoulder dislocations untreated. This can lead to long term complications.

Persistent Instability

  • Without treatment, up to 90% of patients under 30 years old experience recurrent instability after a first-time anterior shoulder dislocation.
  • Recurrent dislocations cause progressive labrum and capsular injury, leading to multidirectional instability.
  • Chronic dislocations may occur if the humeral head remains displaced anteriorly or posteriorly. This leads to difficulty with overhead activities.

Loss of Function

  • Persistent subluxation or dislocation leads to altered mechanics and weakness of the rotator cuff and deltoid.
  • Dynamic muscle stabilizers get stretched out, resulting in deficient active stabilization.
  • Loss of normal shoulder contour impacts function of entire upper extremity.
  • Activities requiring shoulder mobility become difficult like combing hair, reaching overhead, throwing.

Arthritic Changes

  • Recurrent dislocations cause shear forces that damage the joint surfaces.
  • Post-traumatic osteoarthritis develops in up to 60% of untreated recurrent dislocations.
  • Hill-Sachs lesions lead to engagement of the humeral head causing cartilage wear.
  • Loss of joint congruity results in abnormal loading and accelerated degeneration.

Nerve Injury

  • Chronic stretch on the axillary nerve can occur if the shoulder remains dislocated.
  • Up to 25% of patients develop persistent neuropathic symptoms like numbness, weakness, or neuropathic pain.
  • Axillary nerve palsy leads to weakness and atrophy of the deltoid muscle.

Vascular Compromise

  • While rare, neglected anterior dislocations can compress or kink the axillary vessels.
  • Positioning of the humeral head can obstruct arterial flow leading to ischemia.
  • Venous thrombosis and subsequent pulmonary embolism have been reported with chronic dislocations.

Bone Erosion

  • Prolonged contact of the humeral head on the anteroinferior glenoid results in bone loss over time.
  • The compressed area becomes osteoporotic and prone to fracture.
  • Glenoid defects make subsequent stabilization surgery more challenging.


Shoulder dislocations that are left untreated lead to short and long term consequences like recurrent instability, loss of function, arthritis, neruopraxia, vascular compromise, and bone loss. Prompt reduction followed by a period of immobilization is imperative to minimize these potential complications. Most patients require rehabilitation to restore range of motion and strength. Surgical stabilization may be warranted for young patients or those with high functional demands. Regular follow up is important to monitor for residual issues after a shoulder dislocation.

Nonoperative Treatment of Shoulder Dislocation: Adults vs Pediatrics

While the principles of initial management are similar, there are some key differences in the nonoperative treatment approach for shoulder dislocation between adults and pediatric patients.


  • Prompt closed reduction of the dislocated shoulder is performed in both populations.
  • Pediatric patients may require sedation with nitrous oxide or ketamine to achieve muscular relaxation.
  • Adults usually require procedural sedation and analgesia for successful reduction.


  • Immobilization in a sling or shoulder immobilizer is utilized to protect the healing capsulolabral complex.
  • Pediatrics are often immobilized for shorter duration of 2-3 weeks.
  • Adult guidelines generally recommend 4 weeks of immobilization due to increased risk of recurrence.

Physical Therapy

  • Early physical therapy is initiated to restore range of motion and prevent stiffness.
  • Gentle pendulum exercises and passive stretching begin after 2 weeks for pediatrics.
  • Adult protocols tend to delay passive range of motion until after 4 weeks.
  • Strengthening begins around 6 weeks in both populations.

Activity Modification

  • Sports are restricted until adequate healing, range of motion, and strength.
  • Pediatrics may return to non-contact sports by 4 weeks with shoulder padding.
  • Adult guidelines restrict sports for at least 8-12 weeks due to higher demands.

Recurrence Prevention

  • Instruction in proper exercise techniques and shoulder mechanics is key.
  • Pediatric programs focus on neuromuscular control and proprioception.
  • Adult programs emphasize rotator cuff and scapular stabilizer strength.
  • Open growth plates in pediatrics allow for remodeling after injury.

Return to Sport Clearance

  • Full recovery of strength, range of motion and shoulder stability should be demonstrated.
  • Functional testing like single leg plyometrics essential for pediatric athletes.
  • Adult criteria also include ability to tolerate sport-specific exertion.
  • Higher thresholds for clinical clearance typically used for adult athletes.

Surgical Indications

  • Surgery generally avoided until skeletal maturity is reached around age 14-16.
  • Earlier surgical stabilization considered in pediatric athletes with high recurrence risk.
  • Lower threshold for surgery in young adult athletes after initial dislocation.


While immobilization, physical therapy, activity modification, and return to sport criteria share similarities between pediatrics and adults, there are also important differences in nonoperative treatment approaches that recognize age-related factors. Understanding these nuanced distinctions can optimize rehabilitation and outcomes for each population after shoulder dislocation.

Operative Treatment of Shoulder Anterior Labral Repair

The anterior labrum in the shoulder is commonly torn or detached during traumatic dislocations resulting in instability. When nonoperative treatment fails, surgical repair of the labrum may be warranted.


  • Recurrent anterior instability after an initial shoulder dislocation
  • Dislocation during overhead athletic activities
  • Bankart lesion seen on MRI
  • Failed conservative management with persistent subluxations


  • Advanced glenohumeral arthritis
  • Multidirectional instability
  • Significant muscle-tendon tears
  • Medical comorbidities precluding surgery/anesthesia

Preoperative Planning

  • Physical exam to assess range of motion and stability
  • Imaging studies: MRI for soft tissue, CT for bony anatomy
  • Medical clearance and anesthesia consultation
  • Patient education on postoperative rehabilitation


  • Open Bankart repair
  • Detached labrum reattached to the glenoid rim with suture anchors
  • Arthroscopic Bankart repair
  • Less invasive with faster recovery but higher recurrence rate
  • Latarjet procedure
  • Transfer of coracoid process to reinforce anterior glenoid bone

Postoperative Care

  • Immobilization in sling for 4-6 weeks
  • Early passive range of motion exercises when pain allows
  • Progressive physical therapy program
  • Gentle strengthening at 12 weeks
  • Sport-specific drills at 4-6 months
  • Time to return to sports
  • 3-4 months for non-contact sports
  • 6+ months for contact/overhead sports


  • Up to 90% return to pre-injury sports participation
  • Recurrence rate around 10-15% at 2-5 years
  • Range of motion typically returns to normal
  • Minimal residual instability or apprehension
  • Arthritis risk remains elevated compared to normal shoulders

Arthroscopic Bankart Repair for Shoulder Instability

Arthroscopic Bankart repair has become a common procedure to treat recurrent anterior shoulder instability. This minimally invasive technique aims to restore function and prevent recurrence.


  • Recurrent traumatic anterior instability or subluxations despite rehabilitation1
  • Detached anteroinferior labrum (Bankart lesion) on MRI
  • Young active patients engaged in overhead activities or collision sports


  • Multidirectional instability or generalized ligamentous laxity
  • Significant glenoid bone loss (>25%)
  • Engaging Hill-Sachs lesion
  • Advanced glenohumeral arthritis

Surgical Technique

  • General anesthesia, beach chair or lateral decubitus position
  • Anterior, anterosuperior, and posterior portals
  • Bankart lesion identified and mobilized
  • Glenoid rim prepared with rasp or burr
  • Suture anchors placed into glenoid (2-4 anchors)
  • Sutures passed through capsulolabral complex
  • Bankart lesion reapproximated and secured to glenoid

Postoperative Protocol

  • Sling immobilization for 4-6 weeks
  • Early passive range of motion when pain allows
  • Active assisted range of motion at 4-6 weeks
  • Begin strengthening at 12 weeks
  • Return to sports between 5-7 months


  • Up to 94% return to prior activity level
  • Failure rate around 12% at 2-5 years
  • Significant improvement in functional scores
  • High patient satisfaction scores (>9/10)


Arthroscopic Bankart repair is an effective and minimally invasive technique to treat recurrent shoulder instability, with high patient outcomes and return to play rates. Appropriate patient selection is key.

Open Bankart Repair for Shoulder Instability

Open Bankart repair involves surgical reattachment of the torn anteroinferior labrum to treat recurrent shoulder dislocations.


  • Recurrent traumatic anterior instability despite rehabilitation
  • Bankart lesion seen on MRI or arthroscopy
  • Young active patients engaged in overhead/collision sports


  • Multidirectional laxity or hyperlaxity syndromes
  • Significant glenoid bone defects (>25%)
  • Advanced glenohumeral arthritis

Surgical Technique

  • Deltopectoral approach to shoulder
  • Subscapularis split and capsule incised
  • Bankart lesion identified and mobilized
  • Glenoid rim abraded
  • Suture anchors inserted into glenoid
  • Capsulolabral complex repaired and reattached to glenoid
  • Subscapularis and capsule closed

Postoperative Rehabilitation

  • Immobilization in sling or brace for 4-6 weeks
  • Early passive range of motion exercises
  • Progressive physical therapy program
  • Active motion and strengthening after 6 weeks
  • Sport specific drills after 4 months
  • Time to return to sports: 6-9 months


  • Up to 95% return to prior sport participation
  • Recurrence rate around 5-15% at 2-5 years
  • Significant improvement in shoulder scores
  • Range of motion and strength expected to return to normal


Open Bankart repair is an effective treatment for recurrent anterior shoulder instability, allowing predictable restoration of function and return to athletics with low recurrence rates.

Arthroscopic Anterior Labral Repair With vs Without Remplissage

Both isolated labral repair and labral repair combined with remplissage can effectively treat anterior shoulder instability. The addition of the remplissage procedure aims to augment stability in certain situations.


  • Symptomatic anterior glenohumeral instability
  • Bankart lesion amenable to repair
  • Remplissage additionally indicated for:
  • Engaging large Hill-Sachs lesions (>25% humeral head)
  • Glenoid bone loss of up to 25%

Surgical Technique

  • Standard anterior portals established
  • Bankart repair performed with suture anchors
  • For remplissage, anchor inserted into posterolateral humeral head defect
  • Sutures passed through infraspinatus tendon and tied down

Isolated Bankart Repair

  • Failure rate around 12%
  • 94% return to prior activity level
  • Significant improvement in functional scores

Bankart Repair + Remplissage

  • Failure rate 0-9%
  • 90% return to sports
  • Better outcomes with larger Hill-Sachs lesions (>25%)
  • May have more limitation in external rotation


  • Stiffness or restricted external rotation
  • Anchor loosening, suture cut-through
  • Persistent posterior pain if overtightened
  • Risk of arthritis unchanged from Bankart repair alone


Adding remplissage to a Bankart repair is a viable option for anterior instability with coexisting Hill-Sachs lesions or mild glenoid bone loss. Outcomes are comparable or superior to isolated Bankart repair alone when appropriately indicated.

Latarjet Procedure for Revision Shoulder Stabilization

The Latarjet procedure involves transferring the coracoid process to the anterior glenoid to augment bony defects in revision settings of recurrent shoulder instability.


  • Failed prior stabilization surgery (Bankart repair or capsulorrhaphy) with recurrence
  • Glenoid bone loss >20-25%
  • Engaging Hill-Sachs lesions
  • Patients with connective tissue disorders or hyperlaxity


  • Intact, non-engaging glenoid rim
  • Advanced glenohumeral arthritis
  • Multidirectional instability patterns

Surgical Technique

  • Deltopectoral approach to shoulder
  • Coracoid tip osteotomized and transferred to anterior glenoid defect
  • Fixed with two screws below equator of glenoid
  • Conjoined tendon repaired to lateral capsule

Postoperative Rehabilitation

  • Immobilization in sling or brace x 6 weeks
  • Early passive range of motion exercises
  • Progressive physical therapy program
  • Active motion after 6 weeks
  • Strengthening at 12 weeks
  • Time to return to sports: 9-12 months


  • Recurrence rates of 0-15% at 2+ years
  • Up to 90% return to prior sports participation
  • Significant improvement in outcome scores
  • 10-15% loss of external rotation commonly seen


The Latarjet procedure is an effective revision option for treating recurrent anterior shoulder instability even in high-risk patients, albeit with some range of motion limitations.

Shoulder Glenoid Bone Loss

Glenoid bone loss is a common complication of anterior shoulder dislocation and instability. It can lead to recurrent instability after arthroscopic Bankart repair. Operative treatment options aim to restore the native glenoid anatomy and provide a stable glenohumeral articulation.

Assessment of Glenoid Bone Loss

Accurate assessment of glenoid bone loss is critical for surgical planning and decision making. The glenoid bare spot method, inverted pear glenoid method, and CT scan with 3D reconstruction are commonly used assessment techniques. CT scan provides the most accurate evaluation of location and magnitude of bone loss. Greater than 25% glenoid bone loss as measured on CT scan is considered significant and may require bone augmentation procedures.

Indications for Operative Treatment

In patients with recurrent anterior instability and significant glenoid bone loss (>20-25%), isolated arthroscopic Bankart repair results in high failure rates up to 67%. Operative treatment is indicated in these patients to restore glenoid concavity and treat bone loss.

Surgical Options

1. Bone grafting
Autologous iliac crest bone graft has been the historical method to reconstruct anterior glenoid bone loss. The Latarjet procedure uses an iliac crest bone block along with the attached coracoidProcess to stabilize anterior glenohumeral dislocations. The Bristow procedure uses only the coracoid tip. Potential drawbacks include graft resorption, graft fracture, and graft nonunion.

2. Allograft reconstruction
Tricortical iliac crest allograft reconstruction avoids donor site morbidity of autologous grafts. Union rates over 90% have been reported. Precise graft contouring and placement are critical to success.

3. Anatomic glenoid reconstruction
Anatomic glenoid reconstruction with distal tibial osteoarticular allograft transplantation is an emerging technique. It provides anatomic restoration of the glenoid arcs and curvature. Long-term outcomes are still forthcoming.

4. Bone augmentation with arthroscopic stabilization
Remplissage adds posterior Hill-Sachs bone grafting to arthroscopic Bankart repair to limit engagement. Relative over-constraint of the shoulder is a potential risk.


In patients with significant glenoid bone loss, operative management provides reliable restoration of glenoid anatomy and shoulder stability. Accurate preoperative assessment of bone loss is essential to guide appropriate treatment. Both bone grafting and allograft reconstructions have shown good short and mid-term outcomes. Anatomic reconstruction techniques aim to fully restore native glenoid anatomy and curvature. Further research is needed on long-term patient outcomes and comparison between different surgical options. Surgeon experience and careful patient selection remain critical factors for success.

Shoulder Humeral Head Hill-Sachs Lesions Introduction

Hill-Sachs lesions are bony defects of the posterolateral humeral head that occur in association with anterior shoulder dislocations. They can engage the anterior glenoid rim leading to recurrent instability. Operative treatment aims to prevent engagement and glenohumeral joint locking.

Assessment of Hill-Sachs Lesions

The size, orientation and location of Hill-Sachs lesions significantly affect the risk of engagement with the glenoid. Lesions oriented parallel with the glenoid equator are more likely to engage. Lesions involving 20-40% of the humeral head diameter have the highest risk of engagement. Accurate sizing of Hill-Sachs lesions is critical to guide management decisions.

Indications for Operative Management

Hill-Sachs lesions involving more than 25% of the humeral head are less likely to remain reduced after arthroscopic Bankart repair alone. Engaging lesions with significant bone loss often require operative stabilization to prevent recurrent instability.

Operative Options

1. Remplissage
Posterior capsulodesis and infraspinatus tenodesis converts the Hill-Sachs lesion into an extra-articular defect. Good clinical outcomes have been reported, but modest loss of external rotation commonly occurs.

2. Humeral head bone grafting
Autograft or allograft reconstruction of large Hill-Sachs lesions prevents engagement. Graft integration and postoperative outcomes are less predictable than remplissage.

3. Osteochondral allograft transplantation
Osteochondral allografts can anatomically reconstruct large Hill-Sachs defects. Donor-site morbidity is avoided, but graft availability and long-term graft survival are concerns.

4. Humeral head rotational osteotomy
Rotational osteotomy of the proximal humerus increases the intact articular arc and eliminates engagement. Appropriate osteotomy position can be difficult to determine preoperatively.

5. Partial humeral head resurfacing
Prosthetic humeral head resurfacing provides another option for large engaging lesions. The intact articular surface is preserved, but partial humeral head replacements may have higher failure rates.


The optimal surgical approach depends on Hill-Sachs lesion size, engagement risk, and other patient factors. Good outcomes have been achieved with both remplissage and bone grafting techniques. Anatomic Hill-Sachs reconstruction and prosthetic solutions are emerging options. Further comparative studies are needed to determine best practices. Careful patient selection and technical execution remain paramount for successful outcomes.

Postoperative Physical Therapy After Shoulder Anterior Labral Repair

Physical therapy is a critical component of recovery after arthroscopic anterior labral repair. Controlled rehabilitation protects the repair while restoring range of motion and strength. Optimal physical therapy protocols continue to evolve as surgical techniques and implants improve.

Early Postoperative Phase

The early phase focuses on maintaining the integrity of the labral repair. Sling immobilization is commonly used for 3-6 weeks along with gentle pendulum and passive range of motion (ROM) exercises.[1] Elbow, wrist and hand ROM is encouraged to reduce stiffness. Submaximal isometrics help minimize muscle atrophy.

Intermediate Phase

Gradual active assisted and active ROM exercises commence around 6 weeks postoperatively.[2] Motion progresses to restore functional ROM while avoiding excessive translation and rotation. Strengthening targets the rotator cuff, deltoid and scapular stabilizers. Low load, high repetition rotator cuff and scapular exercises are beneficial.

Advanced Strengthening Phase

Resisted rotator cuff strengthening continues, incorporating therabands and light free weights.[3] Higher intensity strengthening begins around 12 weeks, progressing gradually to avoid overloading healing tissues. Sport or activity-specific programs are designed around the patient’s functional goals.

Return to Activity Phase

Intervals or highly repetitive actions are generally avoided for 4-6 months after labral repair.[4] Contact and collision sports may require an even longer recovery period before full clearance. Functional testing helps confirm sport readiness along with patient-reported outcomes.

Rehabilitation Principles

Controlled tension and graded progression are key principles during all phases of recovery and return to activity. Frequent assessment ensures therapies target current impairments while avoiding overstressing healing tissues. Patients must be an active participant in the rehabilitation process.


Current physical therapy protocols allow early protected ROM while limiting stress on repaired labral tissue. Progressive strengthening restores muscle performance and dynamic stability. Criteria-based advancement provides individualized rehabilitation to safely achieve patient goals. Further research is warranted to optimize post-operative rehabilitation as surgical techniques continue to evolve.

Risk of Recurrent Shoulder Dislocation/instability in Adults Versus Pediatrics

Both adolescent and adult patients are at risk for recurrent instability after an initial anterior shoulder dislocation. However, the rates and risk factors for recurrence may differ between skeletally immature patients and adults.

Recurrence Rates

Pediatrics patients have a very high recurrence risk after first-time dislocation, with rates reported between 50-100%. The highest risk is seen in teenagers undergoing their adolescent growth spurt. Recurrence rates in adults are lower, averaging around 26% across multiple studies.

Risk Factors for Recurrence

1. Pediatric patients
Younger age, open physes, and joint hyperlaxity increase the risk of recurrent instability in pediatric patients. Hill-Sachs lesions are less important predictors as these patients can compensate well and remain stable despite humeral head defects.

2. Adult patients
Key risk factors for recurrence in adults include larger Hill-Sachs lesions, glenoid bone loss, activity level, and hyperlaxity/collisions sports. Non-operative management has a high failure rate in adults with these characteristics.

3. Age
Younger patient age at initial dislocation is the most significant risk factor for recurrence in all populations. The highest risk is seen in teenage athletes.

Management Strategies

Immobilization in a sling or brace can reduce recurrence risk in pediatrics, but surgical stabilization is frequently required. Prompt surgical treatment provides more reliable stabilization in high risk adults and adolescents.


Younger patients, especially teenagers, face the highest risk of recurrence after initial shoulder dislocation. Pediatric patients have different pathoanatomic risk factors compared to adults. Recognizing these differences can guide appropriate treatment algorithms to minimize instability recurrence for all age groups.

Open versus Arthroscopic Bankart Repair in Adults and Children


Shoulder instability is a common condition, especially among young athletes participating in contact sports. The Bankart lesion, an injury to the anterior labrum and glenoid, is the most frequent cause of recurrent shoulder instability.1 Surgical stabilization is often required after failed conservative management. The two most common surgical techniques are open Bankart repair and arthroscopic Bankart repair. This review will examine the evidence for these procedures in adults and children.

Open Bankart Repair

Open Bankart repair has been considered the gold standard treatment for shoulder instability. During an open procedure, an incision is made on the front of the shoulder to visualize the damaged labrum. The detached labrum is reattached to the glenoid rim using suture anchors.

Several studies have shown excellent outcomes with open Bankart repair in adults. Recurrence rates are generally less than 5%. Low recurrence rates are also achieved in adolescent patients. Open repair allows direct visualization and secure labral repair. However, disadvantages include increased surgical morbidity, longer recovery time, and stiffness compared to arthroscopic techniques.

Arthroscopic Bankart Repair

With advancements in arthroscopic shoulder surgery, arthroscopic Bankart repair has gained popularity. Small incisions allow placement of a camera and instruments inside the joint. The labrum is repaired to the glenoid using suture anchors similar to the open technique.

In adults, multiple randomized trials and meta-analyses have compared open versus arthroscopic Bankart repair. No significant differences were found in recurrence rates, return to sports, or functional outcomes. Arthroscopic repair results in less pain, faster recovery, and fewer complications compared to open repair.

However, in adolescents and children, open Bankart repair may result in lower recurrence rates compared to all-arthroscopic fixation techniques. The open procedure allows more secure labral repair in younger patients with ligamentous laxity. Further comparative studies are needed to define the optimal treatment by age group.


Both open and arthroscopic Bankart repair are effective procedures with low recurrence rates in adults. Arthroscopic repair offers advantages of minimally invasive surgery. In adolescents and children, open repair may result in lower recurrence rates compared to arthroscopic fixation. Patient age, ligamentous laxity, and surgeon experience should guide treatment decisions. Further randomized trials comparing these techniques are warranted.


© 2023 Dr. Robert Afra – San Diego Orthopedic Surgery Shoulder – Knee – Elbow