ANTERIOR SHOULDER STABILITY IN ELITE ATHLETES

– Written by Eui Hwan Cho, Hyung Jun Koo, and Sae Hoon Kim, Republic of Korea

INTRODUCTION

In sports medicine, shoulder instability is a prevalent yet difficult issue, especially for professional players. The glenohumeral joint’s exceptional range of motion predisposes it to instability, as bony congruence provides limited inherent stability. Rather, joint stability is dependent on the coordinated action of dynamic stabilizers like the rotator cuff and periscapular muscles as well as static stabilizers like the labrum, capsule, and glenohumeral ligaments.

Traumatic anterior dislocation, in which the humeral head moves anteriorly out of the glenoid, accounts for over 90 percent of shoulder dislocations. These injuries typically occur when the arm is forcefully placed in abduction and external rotation. If treatment is not received, a first-time dislocation in young contact athletes often results in ongoing instability. Because repeated instability can impair performance and career longevity, professional athletes are increasingly having early surgical stabilization.

Although anterior instability is characterized by the Bankart lesion, which is defined as the detachment of the anteroinferior labrum, recent understanding emphasizes the importance of addressing additional structural contributors. Glenoid bone loss and Hill-Sachs lesions of the humeral head are major risk factors for recurrence and are commonly associated with treatment failure when left unaddressed. In a widely cited study, Burkhart and De Beer reported a 67 percent failure rate of Bankart repair in the presence of uncorrected glenoid bone loss, compared to only 4 percent when the glenoid rim was intact.

Modern treatment strategies now prioritize comprehensive evaluation and correction of both soft-tissue and osseous lesions. Individualized strategies are crucial for successful results since elite athletes have particular functional demands.

MECHANISM OF INJURY IN ELITE ATHLETES

Anterior shoulder instability in elite athletes typically arises from two mechanisms: acute trauma and repetitive microtrauma. The classic acute injury occurs when the arm is forcibly placed in abduction and external rotation during contact or a fall, causing the humeral head to dislocate anteriorly. This pattern is common in contact sports such as rugby and American football, as well as in overhead sports when an athlete lands on an outstretched arm. These injuries often involve a Bankart lesion of the labrum and a Hill-Sachs compression fracture of the humeral head. In throwing athletes, dislocations can also occur during the extreme external rotation during the cocking phase, sometimes accompanied by biceps pulley injury or partial rotator cuff tear.

On the other hand, athletes who participate in repetitive shoulder-loading sports like tennis, gymnastics, or swimming may eventually get atraumatic instability. Repeated stress stretches the capsule, wears the labrum, and attenuates the glenohumeral ligaments. Athletes who have generalized laxity, in which normal flexibility turns pathologic, frequently go through this phase.

When the shoulder is both externally rotated and abducted, it is most susceptible to anterior dislocation. In wrestling, this position frequently happens when throwing, spiking, or posting an arm. In sports involving flexibility or endurance, instability may arise from cumulative microtrauma rather than from a single traumatic incident.

SHOULDER INSTABILITY: ANATOMY AND BIOMECHANICS

Shoulder stability depends on the interplay of bone morphology, static stabilizers, and dynamic muscular control. The glenoid is a shallow socket, offering minimal coverage of the humeral head. The labrum deepens the glenoid concavity and serves as the anchor for the joint capsule and glenohumeral ligaments. Among these, the inferior glenohumeral ligament complex is especially important in preventing anterior translation of the humeral head when the arm is abducted and externally rotated. A Bankart lesion, involving detachment of the anteroinferior labrum, weakens this restraint and predisposes the shoulder to recurrent instability. The risk of dislocation increases as the contact surface diminishes by glenoid bone loss.

Dynamic stabilizers, including the rotator cuff muscles and scapular stabilizers, center the humeral head within the glenoid through balanced compressive forces. The subscapularis and anterior deltoid contribute to resisting anterior displacement, while coordinated scapulothoracic motion optimizes glenoid positioning. The long head of the biceps tendon also supports anterior stability, particularly when the arm is elevated and externally rotated.

From a biomechanical perspective, shoulder stability is achieved by maintaining the humeral head within a functional arc of motion. This is accomplished through tensioning of capsuloligamentous structures and synchronous muscle activation. If any component is compromised, the humeral head may shift excessively, resulting in micro-instability and progressive capsular damage. Therefore, to guarantee long-term joint stability, effective therapy must both restore structural integrity and reestablish neuromuscular control.

PATHOLOGY AND INJURY PATTERNS

Beyond the labral Bankart lesion, anterior shoulder instability often involves additional bony and capsuloligamentous injuries. Glenoid bone loss (bony Bankart lesions) and Hill-Sachs humeral head defects commonly occur together as a “bipolar” pattern. Bony Bankart fractures or erosions of the anterior glenoid are present in up to ~50% of recurrent cases, and bone loss beyond a critical threshold (~20% of glenoid width) renders the joint highly prone to recurrent instability despite soft-tissue repair. Most traumatic dislocations result in Hill-Sachs lesions, which are compression indentations of the posterolateral humeral head.

Although small Hill-Sachs defects may be incidental, a large engaging Hill-Sachs that contacts the glenoid rim greatly increases redislocation risk.

The glenoid track concept links these bony lesions by defining the glenoid contact zone on the humeral head during shoulder motion. If a Hill-Sachs stays within this zone (on-track), it will not engage the glenoid; if it extends beyond (off-track), it can engage the anterior glenoid rim (Figure 1). Engaging off-track lesions strongly correlate with Bankart repair failure. Therefore, quantifying glenoid and Hill-Sachs bone loss is critical to determine track status and guide management.

The on-track/off-track principle directly informs surgical decision-making. The objective is to correct the bone insufficiency in order to bring an off-track lesion back on track. For on-track lesions with minimal bone loss, a standard arthroscopic Bankart repair is usually sufficient. By contrast, off-track lesions require additional augmentation to prevent engagement. Two primary options are utilized: remplissage, which fills the Hill-Sachs cavity with posterior capsule and infraspinatus tendon to eliminate engagement; and the Latarjet procedure, which restores glenoid width, provides a dynamic sling effect through the conjoined tendon, and reinforces the capsule for a combined stabilizing effect. While thresholds may vary, off-track lesions with glenoid bone loss under 20 percent are often treated with Bankart repair and remplissage. When bone loss approaches or exceeds 20 to 25 percent, a Latarjet or bone graft is generally considered.

Other injury patterns beyond the labrum also contribute to instability. Anterior labroligamentous periosteal sleeve avulsions (ALPSA lesions) are essentially a medially displaced Bankart variety and are linked to increased failure rates if left untreated. Avulsion of the glenohumeral ligament (HAGL) is another, less common, cause of anterior instability. Superior labral (SLAP) tears may co-occur (particularly type V extending into the anterior labrum), but adding SLAP repair to Bankart has not significantly improved stability outcomes.

CLINICAL EVALUATION AND IMAGING

A thorough clinical history and focused physical examination are crucial when evaluating an elite athlete with suspected anterior shoulder instability. Important history details include any previous shoulder subluxations or dislocations, as well as the mechanism of injury, which is frequently forceful abduction and external rotation. The examination should assess the shoulder’s range of motion and strength while specifically checking for signs of instability.

Several provocation maneuvers help confirm anterior instability, including the Apprehension, Relocation, and Load-and-Shift tests. In the Apprehension test, the abducted, externally rotated arm often causes fear of imminent dislocation. Applying a posterior force (Relocation test) relieves the apprehension; together, these signs are highly specific for true anterior instability. The anterior and posterior translation of the humeral head in the glenoid is measured by the Load-and-Shift test. Since generalized ligamentous laxity predisposes athletes to recurrent instability, the examination should also evaluate generalized ligamentous laxity (e.g., elbow hyperextension or a positive sulcus sign).

Anteroposterior, Grashey, scapular Y, axillary, West Point, or Bernageau views are among the plain radiographs that can be used to detect fractures, glenoid rim injuries, or a Hill-Sachs lesion (Figure 2). Following the initial evaluation, advanced imaging is utilized to completely describe osseous and soft tissue injuries. Soft-tissue lesions (Bankart, SLAP, HAGL) and any related rotator cuff rupture can be seen on magnetic resonance imaging (MRI), frequently with contrast. After the acute phase is over and the pain and swelling have subsided, an MRI is usually conducted. The gold standard for measuring the loss of glenoid bone is computed tomography (CT). For surgical planning, 3D CT reconstructions aid in visualizing bone abnormalities.

TREATMENT STRATEGY

When treating elite athletes with anterior shoulder instability, the long-term risk of recurrence and joint degradation must be balanced against the urgency of returning to play. While nonoperative management may be reasonable for older or lower-demand individuals, early surgical stabilization is increasingly favored in young, high-demand athletes given the high recurrence after a single dislocation.

Making the decision to try rehabilitation or move forward with surgery is the first step. Contact athletes (such as those participating in football or rugby) have significantly higher recurrence rates with nonoperative care, making early surgery more appropriate. On the other hand, low-contact athletes may attempt bracing and rehabilitation to complete a season if the instability is mild and imaging shows no significant structural damage.

The results of imaging are crucial. The presence of a labral tear, bony Bankart fragment, or substantial glenoid bone loss strongly favors operative intervention. On the other hand, conservative management with careful observation may be used for minor soft tissue damage. While bracing during in-season play can lower the likelihood of recurrence, it doesn’t treat the underlying pathology.

Surgical timing is also important. Some sportsmen wait until the offseason to play, while others get surgery immediately if the risk of recurrence is unacceptable. No matter the timing, the decision must be individualized and informed by shared discussion, sport-specific demands, and a clear understanding that repeated instability events may result in cumulative harm, which could complicate future management. For elite athletes, a proactive treatment strategy is often preferred. Early surgical repair is generally the most reliable approach to preserve both short-term performance and long-term joint health.

SURGICAL TECHNIQUES

Arthroscopic Bankart Repair(ABR) and Remplissage

ABR is the first-line surgical stabilization for anterior shoulder instability in athletes without significant glenoid bone loss. This procedure reattaches the torn anteroinferior labrum to the glenoid rim, restoring labral tension and stability. However, recurrence rates after ABR are relatively high in elite contact athletes, particularly when significant bone loss or a large Hill-Sachs lesion is present. For an engaging (off-track) Hill-Sachs defect, a remplissage is often added. Remplissage fills the humeral head defect with posterior capsule and infraspinatus tendon, preventing engagement (Figure 3). This combined approach significantly reduces recurrence risk while preserving high return-to-sport rates. Importantly, adding remplissage does not compromise shoulder motion or performance, even in overhead athletes.

Latarjet Procedure and Glenoid Bone Grafting

For substantial glenoid bone loss (often >20% of the glenoid width) or recurrent instability after failed soft-tissue repair, a bony augmentation is indicated. In these situations, the most well-known bone-block technique is the Latarjet operation. It restores glenoid width by transferring the coracoid to the anterior glenoid, while the conjoined tendon that is linked offers a dynamic sling for stability (Figure 4). Latarjet has shown lower recurrence than Bankart repair when significant bone loss or off-track lesions are present. Among its disadvantages are that it is a non-anatomic, technically challenging, open surgery that carries risks (such as stiffness or nerve damage).

An alternative for glenoid reconstruction is the distal tibial allograft (DTA), which uses a cadaver distal tibia graft to replace deficient glenoid bone. DTA avoids autograft harvest (preserving the coracoid) and provides a graft with contour and cartilage matching the native glenoid, with early results suggesting it can restore stability comparable to Latarjet. Unlike Latarjet, DTA does not provide a muscular sling effect. When a Latarjet is impractical or there are significant flaws or revision instances, DTA can be used.
 

Dynamic Anterior Stabilization (DAS)

An emerging method for treating Anterior shoulder instability is arthroscopic DAS. This technique blends advantages of both soft tissue and bony procedures by creating a tendon sling effect of Latarjet procedure as the augmentation to the Bankart repair without the need for open procedures or bony fixation (Figure 5). Transferring the conjoined tendon or the long head of the biceps (LHB) onto the anterior glenoid rim via a subscapularis split are the two primary methods. Wu et al. observed comparable outcomes from both methods for patients with less than 15% bone loss, including >86% return to sport and 63 patients free of repeat dislocations.

3D-printed implant

Partial glenoid arthroplasty (PGA) using 3D-printed implants is another experimental approach under development by our team for large bone defects. This custom technique aims to precisely restore glenoid anatomy in severe bone loss, but it remains in development and is not yet part of standard practice.

REHABILITATION AND RETURN TO SPORT

Rehabilitation Phases

Postoperative rehabilitation progresses through phases focused on healing, functional restoration, and protecting the repair. During the first 6 weeks after surgery, the shoulder is immobilized with limited motion to protect the restored tissues and promote recovery. By 6–12 weeks, therapy gradually restores range of motion and initiates gentle strengthening while avoiding excessive stress (e.g., limiting extreme external rotation). From 3–6 months, the focus shifts to regaining full shoulder strength, neuromuscular control, and power, approaching near-normal function while safeguarding the repair. Progression is guided by time and clinical milestones to ensure adequate healing.

Sport-Specific Retraining

Late-stage rehabilitation is tailored to the sport-specific demands of elite athletes. Overhead athletes need full range of motion and strong rotator cuff muscles. In particular, the strength of the external rotators should be at least 65 percent of the internal rotators to safely return to high-speed throwing. Collision athletes focus on maximal shoulder strength, power, and stability to tolerate high-impact contact. Advanced plyometric exercises help athletes practice sport movements safely before returning to full play.

Return-to-Play Criteria

Return-to-play decisions rely on stringent functional criteria rather than time alone. Before they are cleared to return, guidelines mandate pain-free full ROM, near-normal shoulder strength (≥80-90% of opposite side), and no instability (negative apprehension test). On average, athletes return to competition around 6 months post-surgery, though contact and overhead sports often necessitate longer rehab to meet these benchmarks. Final return to play is only allowed when the athlete can perform sport-specific tasks at full intensity without limitation.

SPORT-SPECIFIC FACTORS

Contact vs Non-Contact Sports

Contact sports like rugby and American football can cause traumatic instability and recurrence if treated nonoperatively. Thus, early surgical stabilization is often favored for contact athletes. Arthroscopic Bankart repair (with possible augmentation like remplissage) or open/bony procedures like Latarjet are commonly employed to restore stability and reduce recurrence. However, athletes in non-contact or low-impact sports may sometimes be managed conservatively, as some can fully recover with dedicated rehabilitation without surgery.

In-Season vs Off-Season Timing

In-season shoulder dislocations present a dilemma. Nonoperative therapy (rapid reduction, rehabilitation, and bracing) is the only way to return in the same season, despite the significant risk of recurrent instability. Studies report that most athletes who continue in-season without surgery experience recurrent instability. Functional shoulder bracing is frequently used in this scenario to limit abduction/external rotation and protect the shoulder. However, bracing and rehab do not address the labral tear or bony lesion, so definitive surgical repair is typically deferred to the off-season. If needed, off-season surgery allows enough healing time before the next season.

Overhead vs Non-Overhead Demands

Overhead athletes (throwers, swimmers, volleyball players) pose unique management challenges. They often present with repetitive subluxations or microinstability rather than acute dislocations, and their performance depends on extreme shoulder range of motion. Surgical technique must preserve rotational range; for example, an arthroscopic Bankart repair is tailored to avoid over-tightening, as postoperative external rotation deficits can impair return-to-play in overhead sports. Non-overhead athletes may tolerate slight motion loss if it yields more stability. Moreover, overhead athletes derive less benefit from bracing (which limits motion crucial for throwing), whereas non-overhead or contact athletes can sometimes compete with shoulder bracing that provides protection at the cost of some mobility.

Position-Specific Biomechanical Demands

Position-specific biomechanics further refine management decisions. An athlete’s field position determines the shoulder stresses: for example, a quarterback or pitcher (high-frequency overhead throwing) requires maximal shoulder mobility and fine control, whereas a linebacker or rugby forward (primarily contact-oriented) prioritizes stability and strength.

Career Stage Considerations

An athlete’s career stage alters the risk–benefit analysis for treatment. Young elite contact athletes have recurrence rates of 70–85% with nonoperative care after a first dislocation, and each recurrence may cause cumulative injury. Thus, early definitive surgical stabilization is advised to preserve shoulder function and career longevity. In contrast, a veteran athlete nearing the end of a career may be more willing to tolerate some instability risk in order to avoid a lengthy surgical rehabilitation, especially if the immediate goal is to finish a season. Ultimately, the management strategy is individualized, weighing sport-specific demands and career implications to select the optimal surgical technique, timing of intervention, or conservative approach for each athlete.

CONCLUSION

Effective management of anterior shoulder instability in elite athletes requires a comprehensive approach that addresses both soft-tissue and bony pathology. Treatment strategies must be tailored to the athlete’s sport, position, and season timing, ensuring long-term joint stability while optimizing athletic performance.

Eui Hwan Cho MD

Hyung Jun Koo, MD

Sae Hoon Kim MD, PhD

Department of Orthopedic Surgery

Seoul National University Hospital

101 Daehak ro, Jongno gu, 03080, Seoul, Republic of Korea

Contact: drjacobkim@gmail.com

References

1. Brinkman JC, Damitio E, Tokish JM. Arthroscopic management of the contact athlete with anterior instability. Clin Sports Med. 2024;43(4):601-615.
2. Longo UG, Loppini M, Rizzello G, et al. Management of primary acute anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy. 2024;30(4):506-522.
3. Boileau P, Villalba M, Hery JY, et al. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88(8):1755-1763.
4. Stambaugh JR, Bryan TP, Edmonds EW, et al. Arthroscopic shoulder stabilization in high school football players. Orthop J Sports Med. 2024;12(3):23259671241239334.
5. Marigi EM, Lamba A, Boos A, et al. Outcomes of shoulder instability surgery in competitive wrestlers: reoperations and return to play at 5 years’ mean follow-up. Am J Sports Med. 2024;52(3):586-593.
6. Murray IR, Goudie EB, Petrigliano FA, et al. Functional anatomy and biomechanics of shoulder stability in the athlete. Clin Sports Med. 2013;32(4):607-624.
7. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16(7):677-694.
8. Wilbur RR, Shirley MB, Nauert R, et al. Anterior shoulder instability in throwers and overhead athletes: long-term outcomes in a geographic cohort. Am J Sports Med. 2022;50(1):182-188.
9. Itoi E, Lee SB, Berglund LJ, et al. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Joint Surg Am. 2000;82(1):35-46.
10. Clarke CJ, Torrance E, Gibson J, et al. Diagnosing the direction of shoulder instability in rugby players. Shoulder Elbow. 2024;16(1):33-37.
11. Yamamoto N, Itoi E, Abe H, et al. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elbow Surg. 2007;16(5):649-656.
12. Hurley ET, Colasanti CA, Haskel JD, et al. Return to play after non-operative management of primary anterior shoulder instability: a systematic review. Bull Hosp Jt Dis (2013). 2023;81(2):118-124.
13. Dickens JF, Owens BD, Cameron KL, et al. Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study. Am J Sports Med. 2014;42(12):2842-2850.
14. Kwapisz A, Shanley E, Momaya AM, et al. Does functional bracing of the unstable shoulder improve return to play in scholastic athletes? Sports Health. 2021;13(1):45-48.
15. Christensen GV, O’Reilly OC, Wolf BR. Decision making of the in-season athlete with anterior shoulder instability. Clin Sports Med. 2024;43(4):585-599.
16. Shaha JS, Cook JB, Song DJ, et al. Redefining “critical” bone loss in shoulder instability: functional outcomes worsen with “subcritical” bone loss. Am J Sports Med. 2015;43(7):1719-1725.
17. Domos P, Ascione F, Wallace AL. Arthroscopic Bankart repair with remplissage for engaging Hill-Sachs lesions in professional collision athletes. Shoulder Elbow. 2019;11(1):17-25.
18. Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy. 2014;30(1):90-98.
19. Davis WH, DiPasquale JA, Patel R, et al. Arthroscopic remplissage combined with Bankart repair results in a higher rate of return to sport in athletes compared with Bankart repair alone or the Latarjet procedure: a systematic review and meta-analysis. Am J Sports Med. 2023;51(13):3304-3312.
20. Bitar IJ, Marangoni LD, Bustos DG, et al. Similar outcomes in collision athletes with subcritical glenoid bone loss and on-track Hill-Sachs lesion versus off-track Hill-Sachs lesion managed with open Bankart repair plus inferior capsular shift. Arch Orthop Trauma Surg. 2024;144(12):3197-3204.

Header Image by Matthew Tipple (Cropped)