Shoulder Instability

For a detailed illustration of the relevant anatomy involved in a shoulder dislocation, the below video is quite helpful.

Bankart lesion seen during arthroscopic surgery of a right shoulder. Humeral head (ball) is above, and glenoid (socket) is below. Note the detachment and redness of the labrum as it is separated from the glenoid rim.

In more severe cases or with multiple dislocations, injury to the bony structures can also occur. On the humeral head (ball) side, as it dislocates over the rim of the glenoid (socket), the humeral head can be impacted against the glenoid rim, thus creating a divot in the humeral head surface. This defect is called a “Hill-Sachs lesion”. On the glenoid (socket) side, bony injury to the lip of the glenoid rim can also occur with shoulder dislocation. Sometimes this is referred to as a “bony Bankart lesion”. In more severe cases, this is referred to as “glenoid bone loss”, and any loss of bone in this critical area significantly reduces the stability of the shoulder joint.

In a young athlete with shoulder instability and dislocation, the treatment decision-making hinges entirely around the risk of additional dislocations and instability events. The goal of treatment is to avoid repeated dislocations, as the high amount of shear stresses on the cartilage surface during dislocation may predispose the shoulder to developing early arthritis in the future.

Thankfully, there is a large amount of high-quality published data to inform our decision-making process. We know that there are a number of risk factors associated with re-dislocation, including younger age, participation in contact sports, and overall ligamentous laxity. In fact, in a young athlete with the above risk factors, even after just a single shoulder dislocation, the risk of the shoulder dislocating again can be as high as 90% without surgery. Conversely, in an older patient that does not participate in contact sports, the risk of re-dislocation can be quite low.

Treatment of Shoulder Instability / Labrum Tear

As you have likely intuited based on the information thus far, treatment of shoulder instability is highly specific and personalized to each individual patient. For a high school football player that wants to continue playing football, perhaps at the collegiate level in the future, we may recommend surgery after a single first-time shoulder dislocation. Meanwhile, for a 33-year-old accountant who dislocated their shoulder while water-skiing for the first time (and who is not particularly interested in water-skiing again after this experience), we would likely recommend non-operative treatment and rehabilitation with physical therapy.

For patients planning to undergo surgical stabilization of the shoulder, the procedure itself can vary tremendously from patient to patient as well. For a first-time shoulder dislocation with an isolated soft tissue injury (Bankart lesion) and no associated bone loss, surgical stabilization would likely entail minimally-invasive arthroscopic repair of the injured capsule and labrum. On the other end of the spectrum, to surgically stabilize a shoulder with significant bone loss in addition to soft tissue injury, surgery would likely involve reconstructing the bony defect through transferring the nearby coracoid bone (Latarjet procedure), transferring bone from elsewhere in the body, or a bone transplant from a cadaveric donor (allograft).

Arthroscopic shoulder stabilization with labral repair

Again, we believe that treatment for shoulder instability must be customized for each individual patient based on your unique injury severity, risk factor(s), age, activity level, occupation, and expectations. As a sports-focused practice, we are equipped to provide whichever treatment is the best for you. At your consultation, Dr. Koscso will carefully review your injury history, symptoms, physical examination, and imaging to arrive at a treatment plan with you.

Recovery After Shoulder Stabilization / Labrum Repair

For a comprehensive reading of the expected post-operative recovery, including restrictions, physical therapy progressions, and return to work/sport guidelines after shoulder stabilization surgery, please see our corresponding protocol on our physical therapy protocols page.