Treating Anterior Shoulder Instability

This page covers how anterior shoulder instability is treated. For what the condition is, what tears, and how bone loss is assessed, see Anterior Shoulder Instability.

The short version: rehabilitation and surgery address different parts of the problem. Muscles can compensate for a stretched or detached ligament, and in many patients they compensate well enough. What a strengthening program cannot do is reattach a labrum or restore lost bone - so where those changes are present, the two are addressing different things rather than competing.

Non-Surgical Management

Best suited for:

• A first-time dislocation in an older or lower-demand patient
• Minimal bone loss and low recurrence risk
• Anyone unwilling or unable to have surgery

The sling. Practice varies on how long it is worn and in what position, and comparative studies have not shown one approach clearly better for preventing recurrence. Its main role is comfort during the early painful phase, and how long a patient needs it varies.

Rehabilitation targets the rotator cuff, the deltoid, and the scapular stabilizers - the muscles providing the dynamic control the torn ligaments no longer supply. It is valuable in every form of instability, is the mainstay for multidirectional and atraumatic instability, and remains part of the plan before and after any operation.

For structured home exercise alongside a therapy program, the AAOS shoulder conditioning program is a reasonable general resource.

The In-Season Athlete

This is a common question, and the answer varies from patient to patient. It rests on three things: the sport and position, how much of the season is left, and how much bone has already been lost.

A quarterback and an offensive lineman with the same MRI are not in the same situation. An athlete with a first dislocation and no bone loss has more room to finish a season than one on their fourth episode with a defect visible on CT.

Returning to play in a stabilizing brace is a reasonable option when the sport allows a brace, bone loss is minimal, and the recurrence risk is understood. It works poorly for overhead athletes, where the brace restricts exactly the motion the sport requires.

One factor to weigh: if the shoulder dislocates again during the season, further bone loss can occur, and that may change which operation is appropriate later.

When Surgery Is Considered

Several factors influence which operation is appropriate - age, sport and position, occupation, laxity, the number of previous episodes, and whether a previous stabilization has failed. Bone loss is the most important of them: how much remains on the socket, and whether the Hill-Sachs lesion sits within the glenoid track. (Both explained on the main instability page.)

Published recurrence rates after Bankart repair range from 7 to 42 percent, pooling at about 15 percent. The spread is not noise - it reflects who was operated on. These are the factors that move a patient toward the higher end:

Two of these compound. In one study of patients with near-track lesions - on-track, but close to the edge - those with hyperlaxity failed at roughly twice the rate of those without. In that same group of 173 patients, all with off-track lesions and bone loss above 20 percent excluded, recurrent instability still occurred in 23 percent.

A note on what “recurrence” means: studies count it differently - some only a further dislocation, others any return to the operating room or any subluxation. Subluxations should be mentioned at a follow-up visit; it is easy to assume an episode does not count because the shoulder went back on its own.

The Operations

Arthroscopic Bankart Repair

The workhorse, and the operation most patients with anterior instability will be offered. Through small incisions, the torn labrum and capsule are reattached to the rim with suture anchors, restoring both the bumper effect of the labrum and the tension of the ligaments.

Best suited for:

• Little or no glenoid bone loss - generally under about 13.5 percent
• An on-track Hill-Sachs lesion, with reasonable margin rather than sitting near the edge
• No significant hyperlaxity
• A first or second dislocation rather than many

Recurrence in that group is low. The published range across all patients is wide - 7 to 42 percent, pooling near 15 percent - but the higher figures come from series including the risk factors in the table above. Where those are absent, results are durable, and this is the least invasive of the stabilizing operations, with no bone transferred and no change to the anatomy.

Where one or more of those factors is present, an isolated repair is less predictable, and adding remplissage or choosing a bone procedure enters the discussion. That decision is made before surgery, from the examination and the imaging - which is why the assessment matters as much as the repair itself.

Bankart Repair With Remplissage

Remplissage - French for “filling” - secures the posterior capsule and infraspinatus tendon into the Hill-Sachs defect so it can no longer engage the front rim.

Remplissage is an addition to a stabilization procedure, not a stabilization procedure on its own. It addresses the defect on the back of the humeral head; it does nothing for the torn labrum and capsule at the front. It is therefore performed alongside a Bankart repair - or, less commonly, alongside a bone procedure - rather than in isolation.

Best suited for:

• Engaging or off-track Hill-Sachs lesions
• Very high-risk patients without significant glenoid-side bone loss - hyperlaxity, a near-track lesion, more than one prior instability episode, young age, subcritical bone loss, or collision-sport demands

A randomized trial found fewer redislocations with remplissage than with Bankart repair alone at medium-term follow-up.

Compared with a Latarjet, which is the more useful question for many patients: a systematic review of eight studies found recurrence broadly similar between the two, with no individual study showing a significant difference, where the Hill-Sachs lesion is less than 10 mm deep. That matters, because remplissage is the less invasive option and does not alter the anatomy at the front of the shoulder.

The trade-off: the same review found external rotation better after Latarjet. Filling the defect places the posterior structures under some tension. Most patients do not find the difference limiting in daily activity, but it belongs in the conversation for anyone whose sport depends on end-range external rotation.

Open Bankart Repair and Capsular Shift

The same objective as the arthroscopic repair, but the exposure allows a more substantial capsular shift where the capsule has stretched and become slack. I perform these as well.

Best suited for:

• Subcritical glenoid bone loss - not large enough to require grafting, but enough to make an isolated arthroscopic repair less predictable
• Recurrent instability without an engaging Hill-Sachs lesion, where the problem is in the capsulolabral tissue
• HAGL lesion - humeral avulsion of the glenohumeral ligament, where the capsule has detached from the humeral side. Arthroscopic repair is well described; I prefer an open approach, which gives direct access to the humeral-side detachment
• Selected younger contact athletes and manual laborers

Performed less frequently than it once was, as arthroscopic repair has become more common. Its track record for reducing recurrent instability is excellent.

The trade-offs are the same ones that apply to the Latarjet. It requires a larger incision than an arthroscopic repair, and the approach passes through the subscapularis - so where the tendon is taken down rather than split, that repair site remains a point of relative vulnerability, and a later significant injury or dislocation carries some risk of the subscapularis rupturing there. This is a consideration in patients likely to sustain further high-energy injuries, which is much of the group the operation is chosen for.

Open Latarjet

Best suited for:

• Significant glenoid bone loss
• Revision after a failed prior stabilization
• Selected high-risk collision athletes

I perform this through an open approach.

A portion of the coracoid, with the conjoint tendon left attached, is transferred to the anterior glenoid and secured - most commonly with screws, though cortical buttons are also used. It works through three mechanisms at once:

• Restores bone to a deficient socket
• The transferred tendon acts as a dynamic sling across the front of the joint as the arm elevates
• The repaired capsule adds a static restraint

Recurrence rates are low. It is a more extensive procedure with its own complication profile, including graft malposition, hardware failure such as screw breakage, nerve injury, and rotator cuff injury, particularly to the subscapularis.

It also alters the anatomy permanently. The coracoid and its tendon are moved from their native position, which can make later operations on that shoulder more technically demanding, since the landmarks are no longer where a surgeon expects. Not a reason to avoid it where indicated - a reason it is reserved for shoulders that need it rather than used first-line.

Distal Tibial Allograft

Donor bone from the distal tibia is shaped to match the missing portion of the socket. I perform this both open and arthroscopically assisted.

Best suited for:

• Severe glenoid bone loss
• Revision after a failed Latarjet, where the coracoid has already been used
• Cases where restoring the joint surface itself matters

Its advantage is that it brings its own cartilage - the distal tibia has a curved articular surface closely matching the glenoid, so the reconstruction restores a cartilage-bearing socket rather than a bone-only ledge. Comparative studies show recurrence and outcomes similar to the Latarjet, with complication rates in the same range. Some graft resorption is commonly reported on follow-up imaging; whether it is clinically significant, and whether it affects outcomes, is not yet clear.

The Subscapularis

Both the open Bankart and the Latarjet pass through the subscapularis, the muscle across the front of the shoulder.

• I most often use a split, working between the fibers through the muscle belly. The tendon stays attached to bone, so nothing is reattached at the end and the attachment is never disturbed
• The alternative is a takedown, detaching the tendon and repairing it at the end. That repair heals, but the site remains a point of relative vulnerability if the shoulder is significantly injured again - part of the reason I favor the split

Recovery and Return to Sport

My general recommendation is return to sport at six months, subject to formal return-to-sport testing. The date is a guide; performance on testing determines readiness.

The full protocols are on this site, and the one that applies depends on the operation:

• Anterior Stabilization Protocol - for arthroscopic and open Bankart repair, with or without remplissage
• Latarjet and Distal Tibial Allograft Protocol - for the bone transfer procedures

(Both are also listed on the post-operative physical therapy protocols page, along with the protocols for other procedures.)

After a Latarjet or bone graft procedure the timeline differs, because bone has to heal to bone. Return to contact is generally governed by radiographic evidence of union rather than the calendar.

Criteria assessed at testing: restored motion, symmetric strength, sport-specific readiness, and - the one most often underweighted - the absence of apprehension in the position that caused the injury. Where those are not met at six months, return is deferred.

Confidence and Fear of Re-Injury

Fear of re-injury is a well-documented barrier to returning to sport, and it commonly persists after the shoulder has met every physical criterion.

The mechanism is straightforward: a dislocation is a distinct and painful event, and the memory becomes associated with the arm position in which it occurred. Returning to sport requires moving into that position under competitive conditions.

Strengthening alone may not address this, but reconditioning that includes graded exposure to the position of apprehension - controlled, progressing as tolerance improves - is effective. Athletes do not always raise this on their own, so asking directly is part of the evaluation.

Frequently Asked Questions

Do I need surgery after my first shoulder dislocation?

Not always. For a young contact athlete the evidence favors early stabilization - recurrence risk without surgery is high, and each additional dislocation risks further bone loss, which can turn a straightforward repair into a larger operation. For an older or lower-demand patient with no bone loss, non-surgical management is reasonable.

Can I strengthen my way out of shoulder instability?

Rehabilitation is central to treatment and very effective for atraumatic and multidirectional instability. For traumatic anterior instability with a torn labrum, strengthening improves dynamic control but cannot reattach detached tissue or replace lost bone, so it does not reliably prevent recurrence in high-risk patients.

Can I finish my season and have surgery afterward?

Sometimes. It depends on your sport and position, how much of the season remains, and how much bone has already been lost. Returning in a stabilizing brace is reasonable in sports that permit one, when bone loss is minimal and the recurrence risk is understood. It works less well for overhead athletes.

What is the difference between a Bankart repair and a Latarjet?

A Bankart repair reattaches the torn labrum and ligaments to the rim of the socket arthroscopically, and is used when there is little or no bone loss. A Latarjet transfers a piece of the coracoid bone, with its tendon attached, to the front of the socket, and is used when significant glenoid bone has been lost, after a failed previous repair, and in some high-risk collision athletes.

What is remplissage, and will it make my shoulder stiff?

Remplissage fills the dent on the back of the ball with the posterior capsule and infraspinatus tendon so it cannot catch on the front rim. It is always performed as an addition to a stabilization procedure rather than on its own, because it does not address the torn tissue at the front of the shoulder. It is added to a Bankart repair when the Hill-Sachs lesion is large or off-track, and may be added for patients at high risk of dislocating again. A systematic review found external rotation better after a Latarjet than after Bankart with remplissage, so there is a real difference - though most patients do not find it limiting in daily activity.

Does a Latarjet make future shoulder surgery harder?

It can. The coracoid and its tendon are moved to the front of the socket, so the anatomy is permanently changed and the landmarks are not where a surgeon would normally expect them. This is one reason the Latarjet is reserved for shoulders that need it rather than used as a first choice.

What does the operation involve for the muscle at the front of the shoulder?

Both the open Bankart and the Latarjet pass through the subscapularis. I most often work between the fibers through the muscle belly, leaving the tendon attached to bone - nothing needs reattaching afterward. The alternative is to detach the tendon and repair it, which heals but remains a point of relative vulnerability if the shoulder is significantly injured again.

How long until I can return to sport?

My general recommendation is six months, subject to formal return-to-sport testing assessing motion, symmetric strength, sport-specific performance, and the absence of apprehension. The six-month mark is a guide; clearance depends on the testing. After a bone graft procedure, recovery is additionally governed by evidence the graft has healed.

Considering stabilization surgery, or want a second opinion on a recommendation?

Dr. Gabriella Ode is a fellowship-trained sports medicine and shoulder surgeon at the HSS Sports Medicine Institute, head team orthopaedic surgeon for the New York Liberty, and assistant team orthopaedic surgeon for the Brooklyn Nets. Request an appointment or request a remote second opinion.

Financial disclosure. Dr. Ode is a paid consultant for Advita Ortho and ConMed, manufacturers of orthopaedic implants and surgical instrumentation. These relationships are reported publicly through the CMS Open Payments database. She receives no compensation for this website, and no compensation is tied to any individual patient’s treatment decision. Her complete financial disclosures are available here.

References

1. Zhang M, Liu J, Jia Y, et al. Risk factors for recurrence after Bankart repair: a systematic review and meta-analysis. J Orthop Surg Res. 2022.
2. Boden SA, Charles S, Hughes JD, et al. Recurrent instability after arthroscopic Bankart repair in patients with hyperlaxity and near-track lesions. Orthop J Sports Med. 2023.
3. MacDonald P, McRae S, Old J, et al. Arthroscopic Bankart repair with and without arthroscopic infraspinatus remplissage in anterior shoulder instability with a Hill-Sachs defect: a randomized controlled trial. J Shoulder Elbow Surg. 2021.
4. Woodmass JM, McRae S, Lapner P, et al. Arthroscopic Bankart repair with remplissage in anterior shoulder instability results in fewer redislocations than Bankart repair alone at medium-term follow-up of a randomized controlled trial. Am J Sports Med. 2024.
5. Schrouff CLJH, Verlaan L. Bankart repair with remplissage vs. Latarjet procedure on recurrence, postoperative pain scores, external rotation, and Rowe score in patients with a Hill-Sachs lesion. A systematic review. JSES Rev Rep Tech. 2023.
6. Frank RM, Romeo AA, Richardson C, et al. Outcomes of Latarjet versus distal tibia allograft for anterior shoulder instability repair: a matched cohort analysis. Am J Sports Med. 2018.

This article is for general education and is not a substitute for individual medical advice. Please consult a physician about your specific condition.

Written by Gabriella E. Ode, MD, FAAOS, FAOA

Sports Medicine and Shoulder Surgeon, HSS Sports Medicine Institute
Associate Professor of Orthopaedic Surgery, Weill Cornell Medical College
Head Team Physician, New York Liberty

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