When Do Shoulder Dislocations Require Surgery?

A shoulder dislocation can be a frightening and painful injury. Fortunately, not every shoulder dislocation requires surgery. Many people can be successfully treated with a period of rest followed by physiotherapy.

However, some patients have a significant risk of further dislocations or ongoing instability. In these situations, surgery may provide a more reliable way of restoring stability to the shoulder.

The decision depends on several factors, particularly your age, activity level, the number of dislocations you have experienced and the amount of damage to the shoulder.

What happens when a shoulder dislocates?

The shoulder is a ball-and-socket joint. The socket is relatively shallow, which gives the shoulder its exceptional range of movement but also makes it more vulnerable to instability.

When the shoulder dislocates, the ball (humeral head) comes completely out of the socket (glenoid).

Most shoulder dislocations occur when the ball comes out towards the front of the shoulder. This is known as an anterior shoulder dislocation.

During a dislocation, structures that normally stabilise the shoulder can be damaged. These may include:

• The labrum, which is the cartilage around the edge of the socket
• The ligaments and joint capsule
• The bone at the front of the socket
• The humeral head
• The rotator cuff

The type and extent of this damage can influence the likelihood of the shoulder dislocating again.

Does a first shoulder dislocation require surgery?

Not necessarily.

For many patients, particularly older or less physically active patients, a first-time shoulder dislocation can be treated without surgery.

After the shoulder has been put back into position, treatment usually involves a short period of relative rest followed by rehabilitation. Physiotherapy focuses on restoring movement and strengthening the muscles that help stabilise the shoulder.

However, younger and highly active patients have a considerably greater risk of recurrent instability.

For a young athlete participating in contact or collision sports, for example, surgery may sometimes be considered even after a first dislocation.

When should surgery be considered?

1. You have had more than one dislocation

Repeated dislocations are one of the clearest reasons to consider surgery.

Once a shoulder has dislocated several times, the structures responsible for stabilising the joint may no longer function normally.

Some patients also begin to experience subluxations, where the shoulder partially slips out and then back into position.

Others develop a persistent feeling that the shoulder is unstable or about to dislocate when the arm is placed in certain positions.

If instability is preventing you from confidently using your arm, surgery may be appropriate even if every episode has not required a trip to hospital.

2. You are young and very active

Age at the time of the first dislocation is an important predictor of recurrence.

In general, the younger you are when the shoulder first dislocates, the greater the chance that it will happen again.

This is particularly relevant for people participating in sports that repeatedly place the shoulder at risk, including:

• Australian Rules football
• Rugby
• Basketball
• Martial arts
• Surfing
• Contact and collision sports
• Overhead sports
• Weight training

For some young athletes, the risk of recurrent instability may be high enough that surgery is discussed following the first dislocation.

3. Your shoulder continues to feel unstable

A shoulder does not necessarily have to completely dislocate again for treatment to have failed.

You may notice that the shoulder feels as though it is going to “come out” when reaching overhead or placing the arm behind you.

This feeling is called apprehension.

Recurrent apprehension, subluxation or avoidance of certain arm positions can significantly interfere with sport, work and everyday activities.

Persistent symptomatic instability despite appropriate rehabilitation is an important reason to consider surgery.

What damage occurs with repeated dislocations?

One of the reasons we take recurrent instability seriously is that each dislocation can potentially cause further damage to the joint.

A common injury is a Bankart lesion, where the labrum and associated ligaments are torn away from the front of the socket.

The humeral head can also strike the edge of the socket during a dislocation, creating an indentation in the bone known as a Hill-Sachs lesion.

Repeated dislocations can also cause progressive loss of bone from the front of the glenoid.

This bone loss is important because it can make the shoulder increasingly unstable and may change the type of surgery required.

For this reason, repeated dislocations should not simply be considered harmless events because the shoulder can be put back into position.

What investigations will I need?

X-rays are usually performed after a shoulder dislocation to confirm that the joint has been reduced and to look for fractures or other bony injuries.

If surgery is being considered, additional imaging may include:

MRI – to assess the labrum, ligaments, rotator cuff and other soft tissues.

CT scan – particularly useful for accurately assessing bone loss from the socket and damage to the humeral head.

Understanding both the soft-tissue and bony injuries helps determine which operation is most appropriate.

What surgery is performed for shoulder instability?

There is no single operation that is appropriate for every unstable shoulder.

The procedure is selected according to the pattern of damage, the amount of bone loss and the patient’s risk of recurrent instability.

Arthroscopic Bankart repair

For many patients, the torn labrum and ligaments can be repaired back to the edge of the socket using small anchors.

This is usually performed arthroscopically through several small incisions.

The aim is to restore the normal soft-tissue restraints at the front of the shoulder.

Bankart repair with remplissage

Some patients also have a significant Hill-Sachs lesion in the humeral head.

In selected cases, a procedure called remplissage can be performed at the same time as a Bankart repair.

This involves attaching tissue at the back of the shoulder into the Hill-Sachs defect, reducing the chance that the defect can engage with the edge of the socket and cause another dislocation.

Latarjet procedure

When there is significant bone loss from the front of the socket, a soft-tissue repair alone may not provide enough stability.

A Latarjet procedure transfers a small piece of bone from another part of the shoulder to the front of the socket.

This reconstructs the missing bone and provides additional stability.

Latarjet surgery may also be considered in some high-risk patients or following failure of previous instability surgery.

What about shoulder dislocations in older patients?

Shoulder dislocations can cause different problems in older patients.

While recurrent instability tends to be less common than in younger patients, a first-time dislocation in an older person has a greater association with rotator cuff tears.

Persistent weakness, difficulty lifting the arm or ongoing pain following a dislocation should therefore be investigated.

Occasionally the rotator cuff injury rather than the instability itself becomes the main reason surgery is required.

Can physiotherapy prevent another dislocation?

Physiotherapy is an important part of treatment and can improve strength, coordination and control around the shoulder.

It is particularly valuable after a first dislocation and for patients with relatively low recurrence risk.

However, physiotherapy cannot repair significant bone loss or completely restore a labrum that has detached from the socket.

For patients with recurrent traumatic instability or significant structural damage, rehabilitation alone may therefore be insufficient.

So, when is surgery the right choice?

There is no single rule that applies to every patient.

Surgery becomes more likely when:

• You have had recurrent shoulder dislocations
• You experience repeated subluxations or ongoing apprehension
• You are young and participate in high-risk sports
• Instability prevents you from returning to work or sport
• Imaging demonstrates significant structural damage
• There is bone loss from the socket or a significant Hill-Sachs lesion
• Appropriate rehabilitation has failed to provide sufficient stability

Importantly, the operation needs to match the underlying problem.

For some patients, an arthroscopic Bankart repair is appropriate. Others may benefit from additional remplissage, while significant bone loss may require a procedure such as a Latarjet.

A shoulder instability assessment therefore involves more than simply counting the number of times the shoulder has dislocated. Your age, sporting demands, examination findings and the pattern of structural damage all contribute to deciding whether surgery is required and which operation is most likely to provide a stable, reliable shoulder.

‍