Shoulder Instability and Dislocation

Age at first dislocation is one of the strongest predictors. Hovelius's 25-year follow-up published in JBJS (2008) tracked 255 first-time forward dislocations treated without surgery and found roughly half of shoulders in the 12 to 25 year age group eventually needed surgery to stabilise them or kept dislocating, while outcomes in patients 26 to 40 years were noticeably better. Data from the West Point and US military cohorts show similarly high re-dislocation rates in young contact athletes. If you are under 25, in-season in a collision sport, or a scan showed a large piece of bone broken off the front of the socket (bony Bankart lesion), the odds of re-dislocation without surgery are genuinely high and worth discussing with an orthopaedic surgeon early.

It depends on who you are and what you do. For a young contact or overhead athlete with a dislocation from a clear injury and a tear of the front of the socket rim on MRI (Bankart lesion), early surgical stabilisation is increasingly supported by the literature. For an older person, someone with lower demands on the shoulder, or someone whose instability began without an injury or goes in several directions (atraumatic or multidirectional instability), a structured rehabilitation trial is the appropriate first step. I talk through these factors honestly rather than defaulting to either camp.

Atraumatic instability, including multidirectional instability, often responds well to structured rehabilitation. The Derby Shoulder Instability Program led by Bateman and colleagues, and the Watson MDI program, both report meaningful improvements in pain, function, and perceived stability with progressive shoulder blade and rotator cuff retraining. Surgery is reserved for those who do not respond to an adequate rehabilitation trial, typically six months or more.

For atraumatic instability managed without surgery, three to six months of progressive rehabilitation before unrestricted return to collision or overhead sport is a realistic window. The shoulder can still slip or dislocate again after returning, especially in collision sports. After surgery to repair the socket rim (Bankart repair), return usually takes four to six months or longer, following your surgeon's protocol. Confidence matters too: in athletes after stabilisation surgery, those who were not psychologically ready at six months, measured with the SIRSI questionnaire, had more recurrences (Pasqualini and colleagues, 2024). That study did not include people managed without surgery.

For many people, yes. Rebuilding the rotator cuff, the muscles around the shoulder blade, and the chain of muscles from the trunk down meaningfully improves how well the muscles hold the shoulder steady. This works well for atraumatic and multidirectional instability, and as part of rehab after surgery. It is less reliable when a large structural defect is causing the dislocations, such as a significant piece of bone missing from the socket rim (bony Bankart) or a dent in the ball that catches on the socket (engaging Hill-Sachs lesion).

Subluxation, where the ball partly slips out and then goes back in, and simply feeling that it might slip (apprehension) are both common. A labral tear, a loose, stretched joint capsule, or changed muscle control can all cause this. On examination I check whether placing the arm in the at-risk position brings on that worry and whether pressing the ball back eases it (apprehension and relocation tests), look for general looseness in the joints (generalised ligamentous laxity), and check shoulder blade control under load. Imaging is useful when the pattern does not fit, but the clinical picture usually drives the plan.

A SLAP tear is a tear of the superior labrum, the rim of cartilage at the top of the socket where the biceps tendon anchors. Burkhart and Morgan's 'peel-back' work described how the arm's position when it is cocked back to throw can extend these tears toward the back. SLAP lesions can cause deep clicking, pain with overhead loading, and a feeling of slight looseness (microinstability), but they are a distinct problem from the full dislocation pattern most people mean by shoulder instability. Treatment is usually non-surgical first.

Early work is static holds for the rotator cuff (isometrics) in safe positions with the arm at the side, plus shoulder blade control drills to rebuild the base the ball-and-socket joint needs. From there I progress to moving rotator cuff exercises, stability exercises with the hand on a wall or the floor (closed-chain), and position-sense challenges. Later phases bring back loading at the end of the range, jumping and throwing-type drills (plyometrics), and sport-specific demands in a controlled way. The whole program is built on the Derby and Watson frameworks with adjustments for your specific pattern.