Shoulder instability and labral tears

The shoulder trades stability for motion. A shallow socket lets the arm move in almost every direction, and the joint stays centred through a rim of cartilage called the labrum, the capsule and ligaments attached to it, and the muscles of the rotator cuff and shoulder blade. Instability means one or more of those restraints is no longer holding the ball centred in the socket.

That can look like a full dislocation requiring a reduction in the emergency department, a subluxation where the shoulder slips and relocates on its own, or a shoulder that simply feels unsafe overhead or behind the body. A traumatic dislocation usually tears the labrum off the front of the socket — a Bankart lesion — and can chip bone from the socket or the back of the humeral head.

SLAP tears involve the labrum at the top of the socket where the biceps tendon anchors, and are more typical of throwing athletes and overhead workers than of frank dislocation.

Symptoms vary with the pattern of instability, but patients commonly describe some combination of the following.

Most instability is traumatic: a tackle, a fall on an outstretched arm, a wrestling or hockey collision, or a ski injury that forces the arm into an extreme position. Once the labrum and capsule are torn, the shoulder is more likely to dislocate again with less force, and each episode can remove a little more bone from the socket.

A second group of patients has instability without a single injury. Naturally loose connective tissue, repetitive overhead loading in swimmers, throwers and volleyball players, or repeated microtrauma can stretch the capsule until the shoulder becomes unstable in more than one direction. These cases are usually treated very differently from a traumatic dislocation.

General guidance rather than individual medical advice: a shoulder that has fully dislocated should be evaluated, even after a successful reduction, because the injury pattern is what determines the risk of recurrence. So should a shoulder that repeatedly slips, one that has become weak or numb after an episode, and one that keeps an athlete out of a sport or a worker out of overhead tasks.

Prompt evaluation matters most for younger contact athletes, where recurrence rates after a first dislocation are high, and for anyone whose shoulder has dislocated more than once — because progressive bone loss changes which operations remain available.

The visit starts with the story of the injury: the position the arm was in, whether the shoulder needed to be put back in, how many episodes there have been and what provokes them. Examination assesses range of motion, rotator cuff and scapular strength, generalized laxity, and the direction in which the shoulder is unstable.

X-rays document the joint and any bone injury. MRI, often with contrast in the joint, shows the labrum, capsule and rotator cuff. When repeated dislocations or a bony injury on x-ray raise the question of socket bone loss, a CT scan is used to measure it, because that measurement directly influences the choice of operation.

Non-operative care is the first step for many patients, and the definitive treatment for many others. A period of relative rest lets the initial injury settle, followed by a physical therapy program focused on rotator cuff strength, scapular control and, in athletes, the mechanics of the trunk and hips that feed the throwing or overhead motion.

This is the primary treatment for atraumatic and multidirectional instability, where the evidence supports a prolonged, well-executed strengthening program before surgery is considered. It is also reasonable for a first-time traumatic dislocation in an older or lower-demand patient, whose risk of recurrence is far lower.

Bracing and activity modification are used selectively, including for athletes finishing a season. That decision is made openly, with the risk of another episode discussed rather than glossed over.

Surgery is discussed when instability recurs despite rehabilitation, when a young contact or collision athlete sustains a traumatic dislocation with a clear labral tear, when there is significant bone loss from the socket or humeral head, or when instability continues to limit work, sport or daily confidence in the arm.

The purpose is to restore the anatomy holding the shoulder centred so that it stops dislocating. No operation can promise a shoulder will never dislocate again, and that is stated plainly during the discussion rather than implied otherwise.

The right procedure depends on the direction of instability, the quality of the tissue and — most importantly — how much bone remains on the socket.

After arthroscopic stabilization, the arm is protected in a sling for roughly four to six weeks while the repair heals to bone. Therapy begins with protected motion, adds active motion as the repair consolidates, then progresses to strengthening at around three months.

Return to non-contact activity generally comes earlier than return to contact or overhead sport, which is usually considered around five to six months and is based on strength symmetry, motion and sport-specific testing rather than time alone. Recovery after a Latarjet follows a similar arc, with the added consideration of bone healing.

Timelines here are typical ranges for education. Your own plan is set in the office, in coordination with your therapist and, for athletes, your trainer and coaching staff.

Nolan Horner, MD is a board-certified orthopedic surgeon whose fellowship training at Rush University Medical Center was in sports medicine and shoulder surgery.

He has cared for professional athletes with the Chicago Bulls, Chicago White Sox and Chicago Fire, and has published extensively in peer-reviewed orthopedic literature. In the office that translates into a straightforward conversation: what your imaging actually shows, what the realistic options are, and what each one asks of you.

This page is general educational information and is not individualized medical advice. A diagnosis and treatment plan require an in-person evaluation.