top of page
  • Writer's picturePaul Monaro

Shoulder - Instability

The vast majority of shoulder dislocations are anterior (or antero-inferior). The mechanism of injury is usually excessive abduction combined with external rotation. The injury results in tearing of the inferior glenohumeral ligament complex. Likely accompanying injuries include:

- Bankart lesion: this is an avulsion of the anterior-inferior glenoid labrum. If this includes a fracture of the anterior glenoid rim it is known as a bony Bankart lesion.

- Hills-Sachs lesion. As the head of humerus dislocates, strong muscular action drives it forcefully back into the anterior glenoid rim. This often causes a compression fracture of the posterior-supirior humeral head.

Less common injuries are:

- Rotator cuff tear. In older patients (over 40) there will be a high risk of tearing of rotator cuff tendons - subscapularis, supraspinatus &/or infraspinatus.

- Axillary nerve traction injury, resulting in deltoid weakness & impaired lateral shoulder sensation.

Acute management:

While an X-ray prior to relocation is desirable, it is also advisable to have the shoulder reduced as soon as possible. If it is possible to lay the patient prone on a plinth with the arm hanging over the side, gentle sustained traction can lead to spontaneous relocation with minimal discomfort. This is known as Stimson’s method, and is easier & less traumatic than some of the other methods described.

The patient is then placed in a sling in internal rotation, and this should be worn for a minimum of two weeks. Exercises can be commenced during this time including:

- Scapular stabilisation exercises. The patient can be taught a range of dynamic & isometric scapular stabilisation exercises to maintain strength & neuromuscular control.

- Elbow range of motion exercises and stretching.

- Wrist and hand stretching & strengthening including maintaining grip strength.

Longer-term management

This is controversial. In the young patient, there is a high risk for recurrent instability & re-dislocation. Under 20 years of age, the recurrence rate is 72-95%, but only 20-30% for those aged 25-40 years, & 10-15% in those over 40. For this reason, many specialists advise stabilisation for the young first-time dislocator, particularly those in high risk sports. The risk of re-dislocation after surgical stabilisation drops to 3-15% in young athletes.

Surgical procedures:

The Putty-Platt procedure, which involved transference of the subscapularis tendon to reinforce the ligament complex, has been out of favor for 2-3 decades. It was associated with significant loss of external rotation and a high rate of subsequent osteoarthritis. Common procedures used today are:

1. Arthroscopic glenohumeral ligament & Bankart repair. This is the most common procedure used, and allows the patient to return to sport in as little as 3-4 months.

2. The open Bankart repair is considered the gold-standard in anatomic repair procedures, and is reported to provide better results in higher-risk patients. Return to sport is 6-8 months.

3. Laterjet (or Bristow-Laterjet) procedure. This involves attaching a bone graft (the coracoid with its attached muscles) to the anterior glenoid. This is advantageous after a bony Bankart lesion, chronic erosion of the anterior glenoid, or for high risk (contact) sportspeople. The reported re-dislocation rate is as low as 1%-10%. It is popular in France, and favored in Melbourne at some AFL clubs. It was traditionally an open procedure but can now be performed arthroscopically. Disadvantages include it being non-anatomic, requiring longer rehab (8-9 months), and resulting in a tighter shoulder. This increases the risk of developing glenohumeral osteoarthritis.

In the older low-risk patient with a rotator cuff tear, the specialist may advise cuff repair without shoulder stabilization.

Related article: also see ‘Conservative management of anterior shoulder dislocation’.


  1. Brukner, P & Khan, K (2012). Clinical Sports Medicine (4th ed). McGraw Hill, Syd., 362-364.

  2. Orchard, J (2010). The trade-off between stability & mobility in reconstructive surgery. Sport Health, 28, 3, 13-18.

  3. Wang, R et al (2009). Management of the first-time shoulder dislocation in the athlete. In Wilk, K et al (eds) The Athletes Shoulder, 2nd ed, Churchill Livingstone, Phil. 239-256.

Please contact us if you would like a printable copy of this document.

For information for doctors on physiotherapy management of all types of injuries visit:

Information for patients is at:

Concord Sport & Spine Physiotherapy

202 Concord Road

Concord West, NSW 2138

Sydney, Australia.

Ph (02) 9736 1092



Copyright © 2012 Paul Monaro. All Rights Reserved

3 views0 comments

Recent Posts

See All

Physical Hazards of Working from Home - Update

As I predicted in my April blog, many people are feeling the effects of working from home, where workplace setups are often inadequate, they work longer hours, and sit for longer periods before taking


Concord Sport & Spine Physiotherapy
bottom of page