Overview
The shoulder has more motion and less inherent stability than any other joint. The ball of the humerus sits on a small, shallow socket, held in place by the labrum around the rim, the capsule and ligaments attached to it, and the rotator cuff muscles that pull the ball into the center. A first anterior dislocation nearly always tears the labrum off the front of the socket (the Bankart lesion) and often dents the back of the humeral head where it hit the rim (the Hill-Sachs lesion). Instability is a shoulder that dislocates repeatedly, whether fully or as a subluxation that slips and returns on its own.
The decision that matters most is made after the first dislocation, and it depends on age and on bone loss. A first dislocation in a 19-year-old contact athlete has a high chance of recurring with rehabilitation alone, and each recurrence wears more bone from the socket rim; the same injury in a 55-year-old rarely recurs but frequently tears the rotator cuff. How much bone has been lost decides whether the labrum alone can be repaired or the socket has to be rebuilt.
Common Symptoms
- A dislocation: the shoulder visibly out of place after a fall or tackle, with severe pain, requiring reduction
- Subluxation: the shoulder slips partly out and clunks back, often with a moment of dead-arm numbness
- Apprehension, the sense that the shoulder is about to dislocate, with the arm out to the side and rotated back, as in a throwing position
- In posterior instability, pain and slipping with the arm forward under load, such as bench press or blocking
Deep pain and catching in a thrower without any sense of slipping is more often a SLAP tear at the top of the socket. Pain over the end of the collarbone after a fall is an AC joint separation. Weakness lifting the arm after a dislocation in a patient over 40 is a rotator cuff tear until proven otherwise.
Causes & Risk Factors
Anterior dislocation accounts for more than nine in ten cases. The mechanism is the arm forced back while out to the side and rotated outward: a tackle with the arm raised, a fall onto the outstretched arm skiing or cycling, a wave taking a surfer's arm. Posterior instability follows a blow to the front of the shoulder or repetitive pushing in linemen and lifters. The strongest risk factor for recurrence is age at the first dislocation: under 20, most patients dislocate again; over 40, few do. Contact sport, generalized ligament laxity, and bone loss from the socket or head raise the recurrence rate further.
How It Is Diagnosed
After a first dislocation Dr. O'Donnell confirms the reduction, checks the axillary nerve and examines the rotator cuff. Once the acute pain has settled, he tests stability directly: the apprehension and relocation tests for anterior instability, the load-and-shift test to grade how far the ball translates, the jerk and Kim tests for posterior instability, and the sulcus sign and Beighton score for generalized laxity, which is treated differently from a structural tear.
X-rays are taken after every dislocation, including an axillary view that confirms the ball is in the socket and a West Point view that shows the front rim for a bony Bankart fragment. MRI, ideally an MR arthrogram, shows the labral tear, the ligaments and the cuff, and is ordered once surgery is being considered. CT measures how much of the socket rim has been lost and the size of the Hill-Sachs lesion, and that measurement decides between a labral repair and a bone-block procedure. Visiting athletes can upload existing imaging through mymedicalimages.com for review before travel.
Treatment Options
Non-operative care
After a first dislocation the arm rests in a sling for one to two weeks for comfort, then a rehabilitation program restores motion, strengthens the rotator cuff and shoulder-blade stabilizers that hold the ball centered, and trains the shoulder to control the positions that provoke apprehension. This is the right treatment for patients over about 30 with a first dislocation and no significant bone loss, for instability from generalized laxity rather than a tear, and for anyone who does not want surgery; it takes six to twelve weeks. Athletes in mid-season can sometimes finish the season in a brace, with stabilization at season's end. Dr. O'Donnell is clear with young contact athletes that rehabilitation alone leaves most of them with a shoulder that will dislocate again.
Arthroscopic stabilization (Bankart and labral repair)
Dr. O'Donnell recommends arthroscopic shoulder stabilization after a first dislocation in patients under about 25 who play contact or overhead sport, after a second dislocation at any age, for recurrent subluxation despite rehabilitation, and for posterior instability with a confirmed labral tear. Through small portals the torn labrum is reattached to the socket rim with suture anchors, the stretched capsule is tightened, and a large Hill-Sachs dent can be filled by stitching the infraspinatus tendon into it (remplissage). The operation is performed under a nerve block and general anesthesia as an outpatient at Bayside Surgery Center.
Latarjet and bone-block procedures
When CT shows that roughly a fifth or more of the front of the socket has been lost, when a Hill-Sachs lesion is large enough to engage the rim, or when a previous labral repair has failed, a soft-tissue repair alone will not hold. The Latarjet procedure transfers the coracoid with its attached tendons to the front of the socket, restoring the bony rim and adding a muscular sling across the front of the joint. It is the reliable choice for the shoulder that has dislocated many times.
Recovery & What to Expect
After an anterior labral repair, the early weeks protect the repair from the one position that stresses it, the arm out to the side and rotated back.
| Phase | Timing | What happens |
|---|---|---|
| Protected motion | Weeks 0–4 | Sling at all times except exercise and hygiene. Pendulums; passive flexion to 90–120°; external rotation limited to 30° at the side; no abduction-external rotation position, no extension behind the body, no weight through the arm. |
| Progressive motion | Weeks 4–8 | Sling discontinued at 4 to 6 weeks. Flexion to full; external rotation progressed to 45° and then full by 8 to 10 weeks; light cuff and scapular strengthening. Apprehension position avoided until 8 weeks. |
| Strengthening | Weeks 8–16 | Progressive resistive cuff and scapular strengthening, rhythmic stabilization and proprioception; full external rotation stretching once cleared. Advance on full symmetric motion and 80% strength. |
| Return to sport | Months 4–6 | Plyometrics, interval throwing or sport-specific progression, then contact drills as cleared. Contact sport typically at about 6 months. |
Desk work is possible within a week, driving once the sling is off at 4 to 6 weeks, non-contact training at about 4 months, and contact sport, surfing and throwing at about 6 months. Posterior repairs follow a similar timeline with the restrictions reversed, avoiding internal rotation and pushing for six weeks. Both protocols are available as PDFs: Bankart repair, anterior stabilization and posterior labral repair.
Frequently Asked Questions
Can a dislocated shoulder heal on its own?
The pain will pass, but the labrum torn from the socket rim rarely heals back in place. Whether that matters depends on age. Over 40, the shoulder usually does not dislocate again and the bigger concern is a rotator cuff tear sustained at the same time. Under 25, most patients treated with rehabilitation alone dislocate again.
Should I have surgery after my first shoulder dislocation?
If you are under about 25 and play contact or overhead sport, Dr. O'Donnell usually recommends it, because the recurrence rate with rehabilitation alone is high and each further dislocation wears bone from the socket. Over 30, with no bone loss and no contact sport, rehabilitation is the first choice. A second dislocation at any age is an indication for stabilization.
What is the difference between a Bankart repair and a Latarjet?
A Bankart repair reattaches the torn labrum and tightens the capsule arthroscopically and is the standard operation when the socket bone is intact. A Latarjet moves a piece of bone from the shoulder blade to the front of the socket to rebuild a rim that has been worn away, and is chosen when CT shows significant bone loss, a large Hill-Sachs lesion, or a failed previous repair.
How long will I be in a sling after shoulder stabilization?
Four to six weeks, including at night, removed only for exercises and hygiene. External rotation is limited to 30 degrees for the first 4 weeks and the arm is kept out of the throwing position so the repaired labrum is not stressed. Full rotation is reached by about 8 to 10 weeks.
When can I return to contact sport after shoulder surgery?
Typically about 6 months after a Bankart repair, once motion is full, strength matches the other side, there is no apprehension on testing, and sport-specific drills are complete. Non-contact training resumes at about 4 months. Returning earlier risks re-dislocating and tearing the repair.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.