First Time Shoulder Dislocation: When to Consider Surgery

First Time Shoulder Dislocation: When to Consider Surgery

A first-time shoulder dislocation can be a painful and unsettling experience, but it’s also a fairly common injury, especially among active individuals. While some people recover well with non-surgical management, others may face a higher risk of recurrence. For these individuals, surgical intervention may be recommended—even after the first dislocation. Understanding the risks of recurrence based on age, activity level, and the extent of structural damage can help guide treatment decisions.

Why Do Shoulder Dislocations Happen?

The shoulder is an incredible joint, offering the widest range of motion in the body. This mobility allows us to perform activities like throwing, reaching overhead, and rotating our arms with ease. However, this flexibility comes at a cost: the shoulder sacrifices stability to achieve its motion. The shoulder joint is a ball-and-socket structure where the rounded head of the humerus (upper arm bone) fits into a shallow socket on the scapula (shoulder blade). Its stability relies heavily on soft tissues, including the labrum, ligaments, and muscles. Trauma is the most common cause of shoulder dislocations. A forceful injury—such as a direct blow to the shoulder, a fall on an outstretched arm, or an awkward landing during sports—can overwhelm these stabilizing structures, causing the ball of the humerus to pop out of the socket.

Structures Typically Damaged in a Shoulder Dislocation

A traumatic dislocation often results in damage to one or more of the following structures:

1. Labrum: The labrum is a ring of cartilage that deepens the socket and stabilizes the joint. A tear in the labrum, often referred to as a Bankart lesion, is a common injury after a dislocation.
2. Ligaments: The glenohumeral ligaments help hold the humeral head in place. A dislocation can stretch or tear these ligaments, compromising joint stability.
3. Bone: In some cases, a dislocation can cause bony injuries, such as:
   • Hill-Sachs Lesion: A compression fracture on the back of the humeral head caused by its impact with the socket.
   • Bony Bankart Lesion: A fracture of the glenoid rim (the edge of the socket) that occurs alongside labral tears.
4. Rotator Cuff Muscles and Tendons: In older patients, a dislocation can result in rotator cuff injuries, further impairing shoulder function.
   These injuries often determine the severity of the dislocation, the likelihood of recurrence, and the best treatment options. Prompt evaluation and imaging are essential to assess the extent of damage and guide management.

Why Do Shoulder Dislocations Recur?

After a first-time dislocation, the damaged soft tissues and bony structures may not heal completely, leaving the shoulder prone to instability. Recurrence is particularly common in certain groups, such as younger patients and athletes. Key factors contributing to recurrence include:

1. Age: Younger patients, particularly those under 25, are at the highest risk of recurrence. Studies show that recurrence rates can exceed 70% in this group after a first dislocation[^1].
2. Activity Level: Athletes participating in high-impact or overhead sports, such as football, rugby, or basketball, are at a greater risk of redislocation due to the demands placed on their shoulders[^2].
3. Extent of Initial Damage: Associated injuries such as large Hill-Sachs lesions, significant labral tears, or bony Bankart lesions further destabilize the joint, making recurrence more likely.

Non-Surgical vs. Surgical Management

Treatment for first-time shoulder dislocations typically involves one of two approaches: non-surgical management or surgical intervention. The choice depends on the patient’s risk factors, activity level, and the severity of the injury.
Non-Surgical Management: Non-surgical treatment usually involves sling immobilization followed by physical therapy to restore strength and stability. This approach avoids surgical risks and often allows for a quicker return to activities. However, non-surgical management may leave the shoulder prone to recurrence, especially in younger, active patients. Recurring dislocations can worsen structural damage, making future treatment more complex.
Surgical Management: For high-risk patients—such as young athletes or those with significant structural damage—early surgical stabilization can be a proactive solution. Surgery restores stability, reduces the risk of recurrence, and prevents further joint damage. Arthroscopic procedures are often sufficient, but in cases of severe damage, open surgery may be required.

When to Consider Surgery After a First Dislocation

While surgery is commonly recommended after recurrent dislocations, specific risk profiles may warrant surgical intervention even after a first-time dislocation. Early surgical stabilization can significantly reduce the risk of future instability and joint damage, particularly for individuals at high risk of recurrence. Situations where surgery may be considered after the first dislocation include:

1. Young Age and Active Lifestyle: Patients under 25 years old, especially those with an active lifestyle, are at a much higher risk of recurrent dislocations due to increased physical demands. Early surgical stabilization in these cases can prevent long-term joint damage, reduce the likelihood of repeated dislocations, and preserve shoulder function for future activities.
2. Participation in High-Risk Activities: Individuals engaged in high-impact or overhead sports (e.g., football, rugby, basketball) or physically demanding occupations that involve repetitive shoulder strain are particularly vulnerable to redislocation. Surgical intervention in these cases can restore joint stability and allow a safe return to their sport or work environment.
3. Evidence of Significant Structural Damage: Imaging studies that reveal significant bone loss (Hill-Sachs or bony Bankart lesions) or severe ligament damage (e.g., humeral avulsion of the glenohumeral ligament) often indicate a need for surgery. These injuries signify very severe trauma with a high likelihood of failure with non-operative treatment. Addressing these injuries promptly through surgical repair minimizes further joint degradation and increases the likelihood of a successful recovery.

Conclusion

First-time shoulder dislocations should be evaluated on a case-by-case basis, with careful consideration of the patient’s age, activity level, and the extent of joint damage. While non-surgical management may be appropriate for some, others may benefit from early surgical intervention to prevent recurrent dislocations and protect the long-term health of their shoulder.

For more information on Shoulder Instability, please click here.

References

1. De Carli, Angelo, et al. “Early Surgical Treatment of First-Time Anterior Glenohumeral Dislocation in a Young, Active Population Is Superior to Conservative Management at Long-Term Follow-Up.” International Orthopaedics, vol. 43, no. 12, 2019, pp. 2799–2805. https://doi.org/10.1007/s00264-019-04382-2.
2. Nazzala, Ehab M., et al. “First-Time Traumatic Anterior Shoulder Dislocation: Current Concepts.” Journal of ISAKOS, vol. 8, no. 2, April 2023, pp. 101–107. Open access.