Hill-Sachs lesion

What is a Hill-Sachs lesion?

In an anterior shoulder dislocation, the head of the upper arm (humeral head) protrudes forward from the socket (glenoid). When sliding back, the posterior-superior articular surface of the humeral head can hit the anterior edge of the socket. This creates a bony dent (indentation fracture) – the Hill-Sachs lesion.

Small dents often cause little discomfort. However, if the defect size and position are unfavorable, the defect can “snap” back into the socket edge in the risk position (abduction/external rotation) (engaging or off-track). This increases the risk of further dislocations and a feeling of instability.

• Typical accompanying injury: Bankart lesion (avulsion of the anterior labral capsule complex).
• The larger the defect in the joint portion of the humeral head, the higher the risk of instability.
• Rare special case: “Reverse Hill-Sachs” in the case of posterior dislocation (defect on the front side).

Anatomy and biomechanics of the shoulder

The shoulder joint is the most mobile joint in the body. It is not stabilized primarily by bony form-fitting, but rather by an interaction between the lip of the socket (labrum), the joint capsule with ligaments and the muscles of the rotator cuff as well as the shoulder blade guidance (scapula kinetics).

The Hill-Sachs lesion affects the articular cartilage-bone surface of the humeral head. When moving in abduction and external rotation, a specific contact strip of the humeral head runs over the socket - the so-called “glenoid track”. If the defect is partially outside this track (off-track), it can get caught on the anterior edge of the socket and provoke instability.

• Labrum: enlarges the socket and serves as an attachment for the capsule.
• Capsule/ligaments: limit extreme movements.
• Rotator cuff: muscular centering of the humeral head.
• Glenoid Track concept: helps to objectively determine indications for surgery.

Causes and risk factors

The most common cause is a fall or impact with the arm in the abduction and external rotation position, e.g. B. in contact and ball sports, cycling or skiing accidents. Everyday falls can also cause a dislocation with a Hill-Sachs lesion.

• Contact and throwing sports (handball, rugby, American football).
• Hypermobility/hyperextensibility of the capsule.
• Previous dislocations: increased risk of new instability.
• Bone loss at the socket (glenoid): exacerbates the problem.
• Inadequate rehabilitation after initial dislocation.

Symptoms: How can I recognize a Hill-Sachs lesion?

The Hill-Sachs lesion itself does not always cause pain. Complaints often arise from the accompanying capsule/labrum injury or from recurring instability.

• Feeling of “slipping away” or unsteadiness in certain arm positions.
• Pain with abduction and external rotation (e.g. when throwing, overhead movements).
• Snap, click or block.
• Shoulder pain at night, protective posture.
• Repeated (partial) dislocations, often on seemingly minor occasions.

Warning signs after a recent dislocation: numbness, cold or circulatory problems, persistent changes in the shape of the shoulder - prompt medical evaluation is important here.

Diagnosis: How is the Hill-Sachs lesion diagnosed?

Diagnostics combines anamnesis, clinical tests and imaging. In addition to the size of the defect on the humeral head, any bony losses in the socket as well as the condition of the labrum and capsule are important.

• Clinic: Apprehension test (feeling of insecurity in abduction/AR), relocation test (improvement through counter support), strength and mobility test, neurovascular status.
• X-ray: AP view, axial/Y view; special projection (e.g. Stryker notch) for better representation of the defect.
• MRI/MR arthrography: assessment of labrum, capsule, rotator cuff and cartilage; Defect characterization.
• CT (often 3D): exact quantification of bony defects on the humeral head and glenoid; helpful for surgery planning.
• “on-track/off-track” concept: ratio of humeral head defect to glenoid width; supports the treatment decision.

As a rough guide, defects are often classified according to the proportion of the articular surface: small (< approx. 20%), medium (approx. 20–40%), large (> approx. 40%). The individual assessment is always carried out in the overall context of stability, accompanying lesions and activity level.

Conservative therapy: Always check first

For small, non-engaging (on-track) Hill-Sachs lesions and after the first dislocation, conservative treatment is the priority. The aim is pain-free mobility, muscular centering and secure shoulder control in everyday life and sports.

• Short-term immobilization after acute dislocation, followed by early functional mobilization.
• Pain therapy and anti-inflammatory measures (e.g. cooling, medication after individual consideration).
• Physiotherapy: Strengthening the rotator cuff and scapula stabilization, proprioception, targeted capsule balance.
• Technical training for sports (avoiding throwing/contact in risk positions).
• Temporary sports adaptation; If necessary, orthoses in contact sports for the transition phase.

Injections are not routinely used for this bone impaction injury. Regenerative procedures (e.g. PRP) have no established evidence here. Consistent, individually guided rehabilitation is crucial.

Surgical options: For persistent instability or large defects

Surgery may be considered in cases of repeated instability, “off-track” or involving defects, major bony losses, or if conservative therapy does not lead to stable function despite good implementation. The choice of procedure depends on the size of the defect, involvement of the socket, tissue quality and sporting/professional requirements.

• Arthroscopic Bankart repair: Refixation of the labrum and capsule to restore anterior stability.
• Remplissage: “filling” of the Hill-Sachs defect by tenodesis/attachment of the infraspinatus and posterior capsule; Reduces the risk of snapping, with a slight possible reduction in external rotation.
• Bone construction/defect filling: e.g. B. autologous/allogeneic bone transplants for larger defects.
• Glenoid addressing for socket loss (e.g. bony procedures such as Latarjet) – v. a. with significant glenoid deficiency.
• Rare special cases: Partial replacement/resurfacing of the humeral head in the case of very large defects and accompanying degenerative findings (especially in older patients).

A serious indication includes imaging, functional analysis and an honest assessment of benefits and risks. A general “immediate operation” after the initial dislocation is not indicated; The goal is an individually tailored, secure solution.

Rehabilitation, healing process and return to sport

The duration of rehabilitation depends on the extent of the injury and, if necessary, the surgical procedure chosen. Principles: pain-adapted mobilization, early functional stability, progressive strengthening and sport-specific structure.

• After conservative treatment: everyday stress often after a few weeks, sport-specific training, depending on stability, usually after 8-12 weeks.
• After arthroscopic stabilization/remplissage: protection with a sling initially, controlled release of movement from week 2-4, strength building from week 6-8, contact/throwing sports typically after 4-6 months - varies individually.
• Return-to-play criteria: full pain-free mobility, symmetrical strength/coordination, no feeling of instability, passed functional tests.

Regular follow-up checks ensure that increases in load occur safely. Returning to risky situations too early increases the risk of recurrence.

Prevention and everyday tips

• Avoid risky position (maximum external rotation/abduction) initially; practice axial control.
• Scapula and rotator cuff training as an integral part of your program.
• have sports technique checked; If necessary, adjustment for throwing/overhead sports.
• Gradual increase in workload with clear intermediate goals.
• Pay attention to good posture and shoulder blade guidance in everyday life (screen height, carrying behavior).

Frequent accompanying injuries

After shoulder dislocations, accompanying injuries often occur together. These should always be assessed and – if clinically relevant – treated specifically.

• Bankart lesion (anterior labrum/capsule): most important cause of anterior instability.
• Cartilage damage to the glenoid (socket) or humeral head.
• SLAP lesion (superior labrum) – v. a. in overhead athletes.
• Capsular overstretching with generalized laxity.
• Reactive synovitis/irritable effusion after trauma.
• Less common: injuries to the rotator cuff (especially in older patients).

When should I see a doctor?

• After any shoulder dislocation or severe shoulder contusion.
• For repeated feelings of instability, “folding” of the shoulder or recurring (partial) dislocations.
• For persistent pain, blockage or snapping phenomena.
• If there is numbness, tingling, a feeling of cold or a change in color of the arm/hand - suspected nerve/vascular involvement.

An early, structured diagnosis helps to avoid consequential damage such as recurring dislocations or premature osteoarthritis.

Your appointment in Hamburg

We would be happy to clarify your shoulder problems in our orthopedic practice in Hamburg - from the initial diagnosis to individual therapy planning. You can find us at Dorotheenstraße 48, 22301 Hamburg. You can easily make appointments online via Doctolib or contact us by email.