Shoulder Dislocation – Instability

What are shoulder dislocation and instability?

The stability of the shoulder is provided by a combination of structures: the glenoid, the labrum (a fibrous ring that deepens the socket), the ligaments, the joint capsule and the rotator cuff muscles. As the glenoid is relatively shallow – which is what allows the great mobility – the shoulder relies on these structures to remain stable.

Dislocation is the complete displacement of the humeral head out of the glenoid. Subluxation is a partial, transient displacement. Instability is the chronic condition in which the shoulder repeatedly “comes out” or gives the feeling that it is about to dislocate, due to damage to the stabilising structures.

Traumatic and atraumatic instability

Shoulder instability falls into two main categories, which are treated differently:

• Traumatic instability: It usually begins with a first, distinct traumatic dislocation – a fall or a violent movement, often in a sporting setting. During the dislocation, the labrum is injured (the classic Bankart lesion), along with other structures. After the first episode, particularly in young people, there is an increased risk of recurrence, as the injured structures do not always heal properly.
• Atraumatic instability: It occurs without a distinct injury, often in people with generalised ligamentous laxity (hyperlaxity). Here, the instability may involve more than one direction and is often treated conservatively at first.

This distinction is important, as traumatic instability often needs surgical repair, whereas atraumatic instability often responds to physiotherapy.

Clinical presentation – Symptoms

In an acute dislocation, the patient has severe pain, deformity of the shoulder and inability to move it, with the arm “locked” in a particular position. The dislocation is reduced (put back in place) by a doctor, often on an emergency basis.

In chronic instability, the symptoms include:

• Recurrent episodes of dislocation or subluxation.
• A feeling that the shoulder is “coming out” or is about to, particularly in certain movements (e.g. when the arm is raised and rotated backwards).
• Pain and a feeling of “insecurity” in the joint.
• Avoidance of certain movements or activities, for fear of a new dislocation.

Diagnosis

Diagnosis is based on the history (particularly the mechanism and the number of episodes), the clinical examination with special instability tests, and imaging studies. X-rays show the dislocation and any associated fractures. Magnetic resonance imaging (MRI) – ideally with contrast medium injected into the joint – is the examination of choice for demonstrating soft-tissue lesions, such as a labral tear (Bankart). Computed tomography (CT) is used to assess any bone loss.

Treatment

Treatment is tailored to the type of instability, the patient’s age and level of activity, the number of episodes and the extent of the lesions.

Conservative treatment

After a first dislocation, reduction is followed by a brief period of immobilisation and then by a structured physiotherapy programme to strengthen the muscles that stabilise the shoulder. Conservative treatment is often the first choice, particularly in atraumatic instability and in older patients.

Surgical treatment

In young, active patients with traumatic instability and recurrent dislocations, surgical repair is often necessary. The operation – as a rule arthroscopic – repairs the damaged structures: most commonly, by suturing the labrum (Bankart repair) with special anchors. In cases with significant bone loss, more complex techniques may be required. Surgical repair aims to restore stability and to prevent new dislocations, which progressively damage the joint.

The role of physiotherapy and prevention

Physiotherapy plays a central role in the management of shoulder instability – both as the main treatment (particularly in atraumatic instability) and as part of rehabilitation after a dislocation or surgery. A targeted programme strengthens the rotator cuff muscles and the scapular stabilisers, which act as “dynamic stabilisers” of the joint, compensating – where possible – for the laxity of the structures.

To prevent new episodes, particularly in athletes, it is important to avoid the “at-risk” positions of the arm during rehabilitation, to return to activity gradually and in a controlled manner, and to maintain good muscle condition. A hasty return to sport, before rehabilitation is complete, increases the risk of a new dislocation.

Why proper treatment matters

Each new dislocation is not simply painful – it causes additional damage to the labrum, the cartilage and the bone. Recurrent instability can, over time, lead to wear of the joint and early arthritis. This is why, particularly in young patients with traumatic instability, timely and proper treatment matters beyond immediate relief.

Bone loss and complex cases

In some cases of instability – particularly after multiple dislocations – the damage is not confined to the soft tissues but extends to the bone as well. Recurrent dislocations can cause bone loss either in the glenoid or in the humeral head (the so-called Hill-Sachs lesion). When there is significant bone loss, simple repair of the labrum is not enough, as it does not address the bony problem.

In these complex cases, more specialised techniques that also restore the bony deficiency are required in order to ensure stability. Accurate preoperative assessment – often with a CT scan to quantify the bone loss – is decisive here for choosing the appropriate technique, which is why specialist treatment is so important.

Cost of treatment

The cost depends on the type of treatment (conservative or surgical), the complexity of the operation, the materials (e.g. suture anchors), the hospital and the class of room, as well as insurance cover. In most cases of surgical treatment, private insurance policies and insurance funds cover a significant part of the expense.

Precise information is given on an individual basis, after the clinical assessment. The clinic is at your disposal for any relevant information.

More about the factors that determine the cost and about cover by insurance funds: Cost of surgery.

Before and after treatment

Before treatment, a patient with chronic instability lives with the constant feeling of insecurity that their shoulder “will come out”, avoiding activities and movements for fear of a new dislocation. Each new episode is painful and adds further damage to the joint.

After proper treatment – conservative or surgical – and completion of rehabilitation, the great majority of patients regain a stable, reliable joint and return to their activities safely. Particularly in young athletes, restoring stability means returning to their sport without the constant fear of dislocation.

Frequently asked questions

What is a Bankart lesion?

It is a tear of the labrum at the anterior-inferior part of the glenoid, which classically occurs during a traumatic dislocation of the shoulder. Its repair (suturing) is the basic surgical procedure for traumatic instability.

After the first dislocation, will it happen again?

In young, active patients, the risk of recurrence after a traumatic dislocation is significant. At older ages the risk is lower. Proper treatment reduces the risk of new episodes.

Is surgery always necessary?

No. Atraumatic instability and certain other cases are treated conservatively with physiotherapy. Surgery is indicated mainly in traumatic instability with recurrent dislocations in young, active patients.

How is the surgical repair performed?

As a rule arthroscopically, by suturing the labrum (Bankart repair) with special anchors. In cases with bone loss, more complex techniques may be required.

Is the cost covered by insurance?

In most cases of surgical treatment, private insurance policies and insurance funds cover part or all of the expense. The clinic can give you detailed information.

Are young athletes more prone?

Yes. Young, active patients – particularly athletes in contact sports or in sports with overhead movements – have a significantly higher risk of recurrence after a traumatic dislocation, which is why they often benefit from surgical stabilisation.

Can I put the dislocated shoulder back in place myself?

No. Reduction must be performed by a doctor, as an incorrect attempt can cause additional damage to bones, nerves or blood vessels. An acute dislocation is an emergency.