Shoulder Dislocation and Instability

Traumatic instability follows a specific injury that tore the labrum or capsule. Atraumatic instability occurs in a shoulder that was always loose, often in both shoulders, without a clear injury. The two are treated differently: for atraumatic instability, exercise-based rehabilitation is the recommended first treatment, and surgery is generally kept for a shoulder that remains unstable after it 6.

Atraumatic instability is treated with a long, patient rehabilitation programme retraining the muscles that position the shoulder blade and control the joint, although no randomised trial has yet compared exercise with no treatment or usual care 7. It takes months, and the patients who do well are the ones told that honestly at the start.

Young athletes in contact sport have a high recurrence rate with rehabilitation alone, and early stabilisation surgery is a reasonable discussion rather than a last resort. Older patients rarely re-dislocate but frequently have a rotator cuff tear alongside, which is the thing actually limiting them.

Nerve injury at the time of dislocation, particularly the axillary nerve, is checked rather than assumed absent — it changes the rehabilitation timeline substantially.

Rotator cuff and scapular control first, then strength through range, then position sense at speed and under fatigue. Overhead and behind-the-body positions are reintroduced deliberately and late, because that is where the shoulder is least protected.

A traumatic first dislocation in someone under twenty carries a high rate of recurrence, and the risk falls substantially with age at first injury 1.

That age pattern drives the decision: early surgical stabilisation is discussed more readily in a young athlete than in someone older, where rehabilitation alone succeeds more often.

For young, active people, surgery lowers the chance of the shoulder coming out again. In randomised trials of first-time dislocation in young adults, with an average age in the early twenties, 6.3% of those who had surgical stabilisation had further instability, compared with 46.6% of those treated with a sling alone 2.

Rehabilitation alone is still a reasonable first choice for many people: a network meta-analysis of 22 randomised trials found moderate-quality evidence that about half of those managed with physiotherapy had no further dislocation, and that surgery can be considered if instability becomes chronic 3. Immobilising the arm in external rather than internal rotation showed no benefit, although that evidence is of low or very low quality 3.

Returning in the same season without surgery is possible, but another episode is common. In a prospective study of 45 college contact athletes treated with rapid rehabilitation and no immobilisation, 73% returned to play after a median of 5 days lost, yet only 27% completed the season without the shoulder becoming unstable again 4.

A European expert consensus bases the return-to-sport decision on pain-free full range of motion, a stable shoulder, restored strength and sport-specific readiness, criteria typically reached between four and six months, depending on the procedure and the demands of the sport 5.