Shoulder Instability / Dislocations

Age at first dislocation is the single biggest predictor. Hovelius's 25-year follow-up published in JBJS (2008) tracked 255 primary anterior dislocations treated non-operatively and found roughly half of shoulders in the 12 to 25 year age group eventually required stabilisation surgery or remained recurrent, 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 had a large bony Bankart lesion on imaging, 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 clean traumatic dislocation and a Bankart lesion on MRI, early surgical stabilisation is increasingly supported by the literature. For an older patient, a lower-demand individual, or someone with 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, responds well to structured rehabilitation in most cases. The Derby Shoulder Instability Programme led by Bateman and colleagues, and the Watson MDI programme, both report meaningful improvements in pain, function, and perceived stability with progressive scapular and rotator cuff retraining. Surgery is reserved for those who do not respond to an adequate rehabilitation trial, typically six months or more.

For conservative management of atraumatic instability, a realistic window is three to six months of progressive rehabilitation before unrestricted return to collision or overhead sport. Recent data in athletes show that roughly three-quarters return to play after conservative rehab, though recurrence rates are substantial, especially in collision athletes. Post-surgical timelines after Bankart repair typically run four to six months. Psychological readiness matters. Published work using the Shoulder Instability Return to Sport After Injury scale shows athletes scoring below 55 have significantly higher re-injury rates.

For many people, yes. Rebuilding the rotator cuff, periscapular muscles, and the kinetic chain from the core down improves dynamic stability meaningfully. This works well for atraumatic and multidirectional instability, and as part of post-operative rehab. It is less reliable when a large structural defect, such as a significant bony Bankart or engaging Hill-Sachs lesion, is driving mechanical dislocation.

Subluxation, where the ball partially slips then reduces, and pure functional apprehension are both common. A labral tear, capsular redundancy, or altered neuromuscular control can all present this way. On examination I am looking for a positive apprehension and relocation test, signs of generalised ligamentous laxity, and scapular 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 late cocking in the throwing motion can extend these tears posteriorly. SLAP lesions can cause deep clicking, pain with overhead loading, and a sense of microinstability, but they are a distinct entity from the frank dislocation pattern most people mean by shoulder instability. Management is usually conservative first.

Early work is isometric, position-safe loading of the rotator cuff with the arm at the side, plus scapular control drills to rebuild the platform the glenohumeral joint needs. From there I progress to dynamic rotator cuff work, closed-chain stability exercises, and proprioceptive challenges. Later phases reintroduce end-range loading, plyometrics, and sport-specific demands in a controlled way. The whole programme is built on the Derby and Watson frameworks with adjustments for your specific pattern.