Recurrent shoulder dislocation: what happens after the first dislocation, and when does surgery come up?

What should and should not be done at the first dislocation?

Safety first: A dislocated shoulder should not be forced back into place at home or on the field. Uninformed "pull-twist" maneuvers can increase fracture, vessel–nerve damage, and cartilage damage. The correct thing is to support the arm in the position it is in and go to emergency assessment as soon as possible. Reduction (putting it back in place) should be done in experienced hands, accompanied by circulation and nerve examination and appropriate imaging (an X-ray showing any accompanying fracture), and after the procedure the examination and film should be repeated. Two pitfalls should be kept in mind especially: over the age of 40, a first dislocation is often accompanied by a rotator cuff tear (the muscle group that rotates the shoulder) and is easily missed; at any age, damage to the axillary nerve, which supplies sensation to the outer surface of the shoulder and works the deltoid muscle, must be ruled out.

What happens after the first dislocation? The strongest factor determining risk: age

In the classic study in Sweden where patients who had a first shoulder dislocation were followed for 25 years (Hovelius et al.), the picture is clear:

• In those who had their first dislocation between ages 12–22, the dislocation recurred in about 70%,
• In the 23–29 age group this rate was 56%,
• Over the age of 30 it was 27%.

Systematic reviews point the same way: the strongest predictors of recurrence risk are young age (especially under 20), male sex, and participation in contact/collision sport. In young male athletes the recurrence rate exceeds 80% in some series. By contrast, there is another interesting finding: a portion of shoulders with recurrent dislocation can spontaneously become stable again over the years. So neither the sentence "once it dislocated, it will always dislocate" nor "it's nothing, it will pass" is correct on its own; risk must be calculated per person.

Why does it recur? During the first dislocation, the cartilage lip (labrum) at the front of the shoulder socket detaches from the socket in most patients (Bankart lesion), and a notch fracture can form on the head of the upper arm bone (Hill-Sachs lesion). This structural damage may not heal back to its former integrity on its own; each time the shoulder re-dislocates, the damage (especially bone loss) grows a little more.

Surgery or conservative at the first dislocation? The two sides of the evidence

Evidence for surgery: In meta-analyses of randomized trials comparing early arthroscopic Bankart repair with conservative treatment in young patients after a first dislocation, the re-instability rate is about 10% in the surgical group and 50–70% in the conservative group; return to the pre-injury level in sport and shoulder function scores were also better in the surgical group. Three caveats matter when reading these numbers: the participants are selected young and overwhelmingly male (soldier/athlete) groups; follow-up durations vary from study to study; and in many studies "recurrence" counts not only full dislocation but dislocation + subluxation events together. For this reason the rates should not be carried over to the general adult population as they are.

Evidence for conservative: The same literature has important limits. Most of the studies are small, the participants are predominantly young men (soldier/athlete) groups; the "conservative" arm is often not modern, structured rehabilitation but simple sling treatment. In long-term follow-up, about half of patients started conservatively could be managed without needing stabilization surgery; if everyone had been operated on early, these patients would have had unnecessary surgery. Still, to be honest: "not having surgery" and "a problem-free shoulder" are not the same thing — a portion of this group has accepted living with occasionally recurring dislocation/subluxation or limited function. Also, early surgery has not been shown to prevent shoulder arthritis (arthropathy) that can develop at older ages; an assessment at the network meta-analysis level emphasizes that the long-term evidence is generally of low quality.

The practical framework can be summarized like this:

If the conservative path is chosen, this is not "doing nothing": a program including scapular control, rotator cuff (the muscle group that rotates the shoulder) strengthening, and sport-specific gradual loading is applied; the patient is informed about signs of re-dislocation and is followed.

Bankart and Latarjet: a plain account of the two operations

• Bankart repair: The cartilage lip (labrum) and joint capsule that detached from the socket are fixed back in place, mostly by an arthroscopic (keyhole) method with small suture anchors. It repairs the anatomy "as it was"; it is the standard option in patients with little bone loss.
• Latarjet operation: The beak-like prominence of the shoulder blade (coracoid) is taken along with the muscles attached to it and screwed to the front-lower edge of the shoulder socket. This both widens the bony surface of the socket and creates a dynamic sling effect in which the transferred muscles brake forward escape when the arm rotates up and out. It is preferred in marked bone loss and in high-risk athletes.

Comparative studies and meta-analyses show that the re-dislocation rate after Latarjet is lower than after Bankart repair; on the other hand, Latarjet is technically more demanding and its complications, such as nerve injury and screw/graft problems, are seen a little more. So it is a balance decision between "more robust" and "simpler and anatomical," solved by choosing the right operation for the right patient.

Why is bone loss so important?

The shoulder socket is like the tee under a golf ball: as bone is lost from its edge, the ball (arm bone head) slides much more easily. Each recurrent dislocation wears the front edge of the socket a little more; for this reason as the number of dislocations rises, both bone loss grows and the chance of success of a simple repair falls.

• Loss of 20–25% and above in the socket is considered "critical"; at this level, soft-tissue repair alone (Bankart) fails at a high rate and a bone-adding operation (Latarjet, etc.) comes up.
• There is also the concept of "subcritical" loss: in an observational study in an active military group, patient-reported shoulder scores (WOSI) worsened markedly after Bankart repair alone at losses of about 13.5% and above. However, this figure is not a definite decision threshold: it varies with the measurement method, the sport played, and evaluation together with loss on the arm bone head (bilateral/bipolar), and it does not on its own mean a bone operation like Latarjet is required.
• Evaluation does not look at one side: loss in the socket and the Hill-Sachs notch on the arm bone head are considered together (the "glenoid track / on-track–off-track" concept). If the notch is in a position where it can catch on the edge of the socket during movement ("off-track"), the risk is high and the surgical plan changes accordingly.

For this reason, in recurrent dislocation a bone map is usually made with CT or MRI; the question "how much bone is left" is as central to the decision as "how many times it dislocated." A critical practical message: if surgery is needed, waiting for many dislocations can increase bone loss and raise the need for a larger operation.

Sling duration and position: what does the evidence say?

• Duration: Keeping the arm in a sling for a long time has not been shown to be protective. Systematic reviews have shown that immobilization for more than 1 week in the classic position does not reduce recurrence risk; the 25-year Swedish follow-up also showed that sling duration did not change the long-term outcome. Current practice is a sling until the pain settles (usually 1–3 weeks), followed by early, controlled movement.
• Position: Slinging in an externally rotated position instead of resting the arm classically against the belly (internal rotation) was shown to seat the detached labrum better in its bed, and the first randomized trial reported that it reduced recurrence risk. However, subsequent studies could not consistently confirm this benefit; some meta-analyses found borderline benefit while others found no significant difference. In summary: the external-rotation sling is a reasonable option but its evidence is conflicting and it has not become a routine standard; the difficulty of compliance (walking around with the arm turned out) is also an important obstacle in practice.

Return to sport: not the calendar, criteria

• Return without surgery (in-season): After pain and movement improve and strength-control tests are passed, an athlete can sometimes return to play within the same season; however, the risk of a re-instability episode during the season is high. This is not a "wrong" option but can be a deferral strategy with the risks openly discussed; the permanent solution is reassessed at the end of the season in most young athletes.
• Return after surgery: In meta-analyses, the great majority (about 80–90%) of athletes return to sport after stabilization surgery; the rate of return to the pre-injury level is lower (about two-thirds). Return time averages around 6 months; in contact and overhead sports one is usually more cautious.
• The return decision should be made not by the calendar but by criteria: painless full movement, strength symmetry between the two sides, confidence in sport-specific movements (the apprehension test turning negative), and tolerating gradual training loading. Early return with criteria skipped is a leading cause of re-dislocation.

For clinicians

At the first dislocation the decision is shared and rests on risk stratification: age <20, male sex, contact/collision and overhead sport, hyperlaxity, and bone defect are the main predictors. The ISIS (Instability Severity Index Score) is a helpful tool in risk stratification; however, its external validation is inconsistent — the >6 threshold could not be validated in some independent series, and lower thresholds (e.g. ≥4; Phadnis et al.) have been proposed in some studies. For this reason ISIS should not on its own dictate the type of operation; it should be interpreted together with bone-loss measurement by 3D CT and on-track/off-track assessment. On imaging, the glenoid defect percentage (best by 3D CT) and on-track/off-track analysis with Hill-Sachs interval measurement should be done; the finding that WOSI scores worsen after isolated Bankart in "subcritical" loss above 13.5% (Shaha et al.) should be kept in mind, but it should be known that this is a threshold defined observationally in an active military population, may vary with measurement method, sport, and bipolar loss, and is not a Latarjet indication line. In bipolar loss, Bankart with added remplissage can, in selected cases, offer recurrence rates close to Latarjet with a lower complication profile; with Latarjet recurrence is lower but neurovascular injury and hardware problems are relatively more common. RCT meta-analyses favoring early surgery at the first dislocation are consistent in short-to-medium-term recurrence and patient-reported outcomes; however, the samples are selected young, predominantly male populations, follow-up durations are heterogeneous, and the definition of "recurrence" (dislocation only, or dislocation+subluxation) varies between studies — the rates should not be extrapolated to the general adult population. Also, a protective effect on arthropathy in the long term has not been shown, and structured rehabilitation is not standardized in most conservative arms — this limitation should be stated clearly when translating the evidence to the patient. At an acute first dislocation, neurovascular examination (especially the axillary nerve) and radiography before and after reduction are standard; over the age of 40 an accompanying rotator cuff tear should be actively sought. There is no evidence that a classic sling beyond 1 week reduces recurrence; the meta-analysis results for the external-rotation sling are heterogeneous and it is not at the level of a routine recommendation. Return to sport should be planned on a criteria basis; in-season conservative return can be offered as a valid option once the recurrence risk is discussed.

Frequently asked questions

Related articles

• Rotator cuff tear: surgery or exercise?
• Shoulder impingement syndrome: why the name is changing, and why exercise comes first
• Return to sport after injury: not the calendar, but the tests

Scientific references

This information is for general guidance only; it does not replace an examination, a diagnosis, or your physician's individual advice. Please consult a physician for your symptoms. About the author: Doç. Dr. Oğuz Yüksel — Academic Profile.