Recurrent shoulder dislocation

Quick overview

The shoulder is the most mobile joint in the body - this freedom also makes it susceptible to instability. After an initial dislocation, repeated dislocations may occur depending on the tissue and bone involvement. The risk is increased with contact sports, overhead strain, capsular ligament loosening and certain accompanying bony injuries.

• Typical: feeling of insecurity, “apprehension” in the abduction/external rotation position, recurring dislocations
• Common direction: anterior (forward); less often posterior (backward) or inferior (downward)
• Treatment: Step-by-step plan – physiotherapy and training therapy as a basis, surgery for persistent instability or relevant defects

Anatomy and Mechanics of Instability

The shoulder joint (glenohumeral joint) consists of the head of the humerus and the relatively flat socket of the shoulder blade (glenoid). The labrum (joint lip), capsule and ligaments as well as the rotator cuff stabilize the joint dynamically and statically. In the event of a dislocation, these structures can be injured.

• Labrum/capsule damage: Frequent Bankart lesion (avulsion of the articular lip at the bottom) with loosening of the capsule
• Bone involvement: bone loss at the socket (glenoid defect) or impression on the head of the humerus (Hill-Sachs dent)
• Dynamic stability: The rotator cuff, biceps tendon and scapula muscles control centering and proprioception

The greater the tissue or bone injury and the greater the functional laxity, the higher the risk that the shoulder will become unstable again. The so-called “glenoid track” constellation (interplay of socket size and humeral head impression) also influences whether a defect becomes clinically relevant.

Symptoms

• Recurring shoulder protrusion or slipping (dislocation/subluxation)
• Feeling of insecurity in certain positions, especially a. Abduction and external rotation (“apprehension”)
• Pain, especially with rapid movements or overhead work
• Loss of strength, rapid fatigue, “dead arm” feeling
• Snapping, cracking or rubbing
• Uncommon numbness or tingling after dislocation (nerve irritation)

Causes and risk factors

It often starts with a traumatic event (fall, tackle). The younger those affected are when the first event occurs, the higher the risk of recurrence. Even without major individual damage, instability can occur due to repeated microtraumas, overhead sports or generalized connective tissue laxity.

• Trauma-related damage: Bankart lesion, Hill-Sachs dent, bony acetabular defect
• Hypermobility/Multidirectional Instability (MDI): congenital or acquired capsular ligament laxity
• Sports with contact/overhead load (handball, volleyball, climbing, rugby)
• Premature return to training or competition without sufficient stability
• Previous surgery or tendon lesions that impair dynamic centration
• Rare causes: seizures/electric shock (often posterior), neurological disorders

Diagnostics in our practice

A careful anamnesis and physical examination are crucial. We examine the direction, frequency and triggers of instability, accompanying symptoms and individual goals (everyday life, sport, work).

• Functional tests: apprehension/relocation test, load and shift, sulcus sign, jerk test (posterior), assessment of scapula kinematics
• Assessment of tissue laxity (e.g. Beighton score) and muscular control
• Imaging: X-ray (exclusion of fracture, bony defects), MRI (labrum/capsule/rotator cuff), if necessary MR arthrography
• If relevant bone loss is suspected: CT with 3D analysis for surgical planning

The decision for the optimal approach is based on the clinic, activity profile and the extent of soft tissue and bone damage. This creates an individual treatment plan – conservative if possible; operationally if necessary.

Conservative therapy: the basis of every treatment

The goal is to restore active stability through neuromuscular control, strengthening and coordination. In many cases, this can significantly improve the instability. A structured program usually lasts several months.

• Initial: pain control, inflammation management, if necessary brief immobilization after acute dislocation
• Early: scapular stabilization, isometric rotator exercises, closed chain, proprioception
• Structure: Strengthening the rotator cuff and periscapular muscles, plyometrics, sport-specific drills
• Technique and posture work: optimization of throwing/overhead movements, trunk and leg axis control
• Aids: Taping/shoulder orthoses temporarily during sports, activity modification
• Return-to-Activity: Step-by-step plan with functional criteria instead of pure time specifications

Injections or so-called “regenerative” procedures (e.g. PRP) currently have no proven indication for stabilization in the event of structural instability of the labrum-capsule complex and do not replace training. They can be discussed in individual cases for accompanying symptoms (e.g. irritation of the bursa), if used conservatively and carefully considered.

Operational options – when do they make sense?

Surgery may be considered if dislocations/subluxations continue to occur despite physiotherapy in line with guidelines, if there are relevant bony defects or if there is a high risk of recurrence in competitive sports. The choice of procedure depends on the direction of instability and the extent of the damage.

• Arthroscopic stabilization (Bankart repair) with capsular tightening/plication for anterior instability without major bone defects
• Additional remplissage for “engaging” Hill-Sachs dents to prevent pinching
• Bone augmentation procedures (e.g. Latarjet, iliac crest or distal clavicle replacement) with significant glenoid bone reduction
• Posterior/inferior stabilization in appropriate direction, capsular shift if necessary
• Concomitant treatments: Rotator cuff, SLAP/biceps tendon disorders, rotator interval closure in selected cases

Every operation has opportunities and risks. Potential complications include renewed instability, limitation of movement, stiffness, nerve irritation, infection and, in the long term, joint wear and tear. Individual information is mandatory.

Rehabilitation and everyday life

After a stabilization operation, a phase-oriented rehabilitation protocol follows. The exact periods vary depending on the procedure and individual healing and are controlled by doctors and physiotherapists.

• Office work: often possible after 1-2 weeks (depending on pain/sling)
• Manual activities/overhead: much later, to be determined individually
• Driving a car: only after the arm has been safely checked and released
• Self-exercises: consistent and technically correct, better regularly and briefly than rarely and intensively

Course and prognosis

Many patients benefit significantly from a consistent conservative program. Younger, contact or overhead-oriented athletes have a higher risk of recurrence - in this case, earlier surgical stabilization may be considered if certain findings are present. After adequate surgery and rehabilitation, it is often possible to return to sport/everyday life without being able to guarantee freedom from symptoms or complete resilience.

Prevention and personal contribution

• Balanced scapula and rotator program (centering before strength)
• Torso and leg axis stability for efficient power transmission
• Increase training volume and intensity gradually
• Technique training for throwing/overhead sports
• Avoiding risky final positions as long as uncertainty exists
• Clarify recurring complaints early instead of “holding on”

When should I seek medical attention?

• After each dislocation to examine nerve/vascular function and accompanying injuries
• Repeated tipping or dislocation moments despite training
• Persistent pain, numbness, signs of paralysis
• Increasing restriction of movement or significant fear of instability

If necessary, we quickly organize imaging and initiate a coordinated therapy program - conservative as the first step, surgical if there is a clear indication.

Your shoulder consultation in Hamburg

Our practice at Dorotheenstraße 48, 22301 Hamburg, specializes in conservative orthopedics and sports orthopedic diagnostics. Arrange your appointment conveniently online via Doctolib or by email – we will provide you with evidence-based and personal advice.