Bankart Repair & Shoulder Instability

The shoulder trades stability for motion. The ball of the humerus sits against a socket, the glenoid, that is shallow by design, closer to a golf tee than a cup. What keeps the ball centered is soft tissue: the labrum, a fibrocartilage rim that deepens the socket; the capsule and its ligaments, which tighten at the ends of motion; and the rotator cuff, which presses the ball into the socket as you move.

The front and bottom of that ring take the load when the arm is out to the side and rotated back, the position of a throw, a tackle, or a fall onto an outstretched hand. That is where most shoulders fail.

When the shoulder dislocates forward, the ball is driven over the front rim of the socket, and the labrum and its attached ligaments usually tear away from the bone. That detachment is a Bankart tear. Once the labrum is off the rim, the front of the socket has lost its bumper and its ligament anchor, and the shoulder can slide out again with far less force.

Two other injuries often travel with it:

• Bony Bankart. A piece of the socket rim breaks off with the labrum, or the rim wears away over repeated dislocations.
• Hill-Sachs lesion. A dent in the back of the ball where it was pressed against the socket rim while dislocated.

Not all instability is a full dislocation. A subluxation is a partial slip that goes back on its own, and it can tear the labrum just as a dislocation can. Instability can also run backward (posterior instability, common in football linemen and weightlifters) or in several directions in naturally loose shoulders. Each is evaluated and treated differently.

Each dislocation stretches the capsule and can chip away bone from the socket rim and the back of the ball, making the next one easier. That is why instability tends to be a progressive problem, especially in young athletes in contact and overhead sports. Age at the first dislocation is the strongest predictor: teenagers and athletes in their early twenties re-dislocate far more often than patients over forty.

Older patients have a different risk. After forty, a dislocation is more likely to tear the rotator cuff than to cause repeated instability, so new weakness after a dislocation deserves an MRI. The rotator cuff repair guide covers that injury.

• A dislocation that needed to be put back in, in an emergency room or on the field.
• A shoulder that slips, shifts, or clunks with throwing, reaching overhead, or reaching behind you.
• Apprehension: a sense the shoulder is about to come out when the arm is cocked back, and avoiding that position.
• A dead-arm feeling or a flash of pain after a hit or a hard throw.
• Dislocations that happen with less and less force, sometimes in sleep.

Numbness over the outside of the shoulder, or weakness lifting the arm after a dislocation, should be checked promptly. They point to a stretched nerve or a torn rotator cuff.

The story does most of the work: how the shoulder came out, how many times, and what it takes now. On examination, apprehension and relocation maneuvers reproduce the instability and show its direction, and the rest of the exam checks for general looseness and rotator cuff strength.

X-rays show the bone: rim fractures, rim wear, and the Hill-Sachs dent. MRI, often with contrast in the joint, shows the labrum and capsule. When bone loss may change the operation, usually after several dislocations, a CT scan measures how much of the socket is missing. That single measurement often decides which procedure is right.

Many shoulders do not need an operation. A first dislocation in a lower-risk patient is usually treated with a short period in a sling for comfort, then physical therapy aimed at rotator cuff and shoulder blade strength and control. Older patients without a cuff tear, and athletes in non-contact sports, often do well this way.

In-season athletes sometimes return to play in a brace and plan surgery for the off-season. That is a reasonable choice in the right athlete, made with eyes open: each further dislocation can add damage, and a second event in season usually ends the experiment.

Stabilization is recommended when the shoulder keeps coming out, or when the risk that it will is high enough that waiting costs more than operating. In practice that means:

• Recurrent dislocations or subluxations despite a genuine course of therapy.
• A first dislocation in a young athlete in a contact, collision, or overhead sport. That athlete has a high chance of dislocating again, and each recurrence costs bone and cartilage, which is why stabilization is often recommended earlier in that group.
• A bony Bankart or meaningful bone loss on imaging.
• Instability that interferes with work, sleep, or daily life.

The second decision is which operation. That depends mostly on bone.

The key fork in the road is bone. If the socket rim is intact, the torn labrum can be repaired arthroscopically. If repeated dislocations have worn away a meaningful portion of the rim, repairing soft tissue alone fails too often, and the deficient bone has to be addressed.

Arthroscopic Bankart repair

Through small portals, the labrum is freed from where it has scarred, the rim is prepared, and the labrum and ligaments are reattached to the socket with suture anchors, re-tensioning the stretched capsule at the same time. When the Hill-Sachs dent is large enough to catch on the rim, it can be filled with tendon and capsule in the same operation, a step called remplissage.

Latarjet procedure

The Latarjet transfers a small block of bone, the coracoid, with its attached tendon to the front of the socket through an open incision. It rebuilds the missing rim, and the tendon acts as a sling across the front of the joint when the arm is in the throwing position. It is chosen for significant bone loss, and often when a previous soft-tissue repair has failed.

Posterior and multidirectional instability

Shoulders that slip backward are treated with an arthroscopic repair of the back of the labrum and capsule. Shoulders that are loose in several directions are treated first and foremost with therapy, and with a capsular tightening procedure only when a long, well-run program has not held.

• Stop nicotine in every form. It impairs healing of the labrum to bone and of the Latarjet bone block.
• Hold anti-inflammatories and blood thinners as directed in your pre-op instructions.
• Set up physical therapy before surgery day; early protected motion is scheduled, not improvised.
• Arrange button-up or zip-front shirts, a recliner or wedge pillow for sleeping more upright, and a driver.
• Review our preparing for major shoulder surgery checklist for what to have at home and what to bring.

1. Anesthesia. General anesthesia with a regional nerve block that handles most of the first day's pain.
2. Arthroscopy and survey. Through small portals the whole joint is inspected: the labrum all the way around, the socket rim, the Hill-Sachs dent, the biceps anchor, and the rotator cuff.
3. Repair. For a Bankart repair, the labrum is mobilized, the rim is freshened to bleeding bone, and the labrum and ligaments are secured with suture anchors, working from the bottom of the socket upward and tightening the capsule as each anchor is placed. For a Latarjet, the coracoid is moved through a short incision at the front of the shoulder and fixed to the socket rim with two screws.
4. Closure. Portals or the incision are closed and the arm goes into a sling. Nearly all of this surgery is same-day; you go home within hours.

The repair has to heal to bone before it can be loaded, so the first weeks are about protection and the months after are about earning motion, then strength, then sport. The timelines below follow our published protocols. Your post-op instructions are the final word.

Weeks 0 to 6

A sling for about six weeks. Therapy starts within days with protected, passive motion. External rotation, the movement that stresses the repair, is deliberately limited for the first several weeks, and forward elevation is capped at shoulder height for the first three. Hand, wrist, and elbow motion start immediately.

Weeks 6 to 12

The sling comes off, full active motion begins, and driving resumes for most patients. Light strengthening for the rotator cuff and shoulder blade starts around week eight, along with lifting beyond a few pounds and working overhead.

Months 3 to 6

Progressive strengthening, then advanced work: push-up progressions, plyometrics, and sport-specific drills. A throwing progression and return to sports like skiing generally begin around four months after a Bankart repair and somewhat later after a Latarjet, and only with full pain-free motion and full rotator cuff strength. Contact and collision athletes commonly need five to six months.

The full schedules are in our Bankart repair protocol and Latarjet protocol, written for you and your physical therapist.

Possible complications include infection, bleeding, blood clot, stiffness, temporary numbness from the nerve block, and anesthesia risks. Specific to stabilization: instability can recur, particularly with early return to contact sport, in very young athletes, and when bone loss was underestimated. Some loss of external rotation is common and is usually small. The Latarjet carries additional, uncommon risks: nerve irritation and issues with the transferred bone or its screws.

No surgeon can guarantee an outcome. What you can expect is a candid assessment of which operation fits your shoulder, and whether one is needed at all.