Every Shoulder Dislocation Does More Damage Than the Last

Why Waiting Is the Costliest Decision You Can Make After a Shoulder Dislocation

After a second shoulder dislocation, 86% of patients have already developed significant bone damage requiring a more complex surgery than a simple Bankart repair. Research I co-authored with Dr. Stephen Burkhart — one of the world's most decorated shoulder surgeons — shows that every dislocation makes the problem worse and the treatment harder. Acting early is not overly aggressive. It is the most protective thing you can do.

The "Wait and See" Approach Has a Hidden Cost

Shoulder dislocation is one of the most common joint injuries, particularly in young, active people under 40. The ball of the shoulder joint pops out of the socket — usually toward the front — and has to be put back in place, either by a medical professional or, in repeat dislocators, sometimes by the patient themselves.

After the initial pain settles and the arm is back in position, many patients are told to rest, do some physical therapy, and see how it goes. This "wait and see" approach sounds reasonable. But my research — conducted with Dr. Stephen Burkhart, one of the most influential shoulder surgeons of the past three decades — shows that this approach carries a significant hidden cost: every dislocation progressively damages the bony architecture of the shoulder, and that damage changes what kind of surgery is required to fix it.

The message from our data is clear: the sooner shoulder instability is addressed surgically, the simpler and safer the operation — and the less damage the patient has to live with or overcome.

What Actually Happens Inside the Shoulder With Each Dislocation

When the shoulder dislocates anteriorly, two structures are damaged by the impact and separation:

• The labrum — the soft tissue rim that deepens the shoulder socket and keeps the ball centered — tears away from the front of the glenoid. This is the Bankart lesion.
• The glenoid (socket) — repeated impacts chip away at the front edge of the bone, creating glenoid bone loss.
• The humeral head (ball) — the impact of the ball striking the rim of the socket creates a dent on the back of the ball called a Hill-Sachs lesion.

A single dislocation creates a Bankart tear but usually produces only minimal bone damage. At that point, a straightforward arthroscopic Bankart repair — the simplest of the stabilization procedures — is often sufficient.

The problem is what happens with each subsequent dislocation. Each time the ball comes out, it scrapes across the glenoid rim, eroding more bone. Each impact deepens the Hill-Sachs dent. The damage is cumulative and irreversible. And once bone loss crosses critical thresholds, a simple soft tissue repair is no longer enough — more complex bone-based procedures become necessary.

The Study: My Research With Dr. Burkhart

This study, published in the International Journal of Shoulder Surgery and co-authored with Dr. Stephen Burkhart of the San Antonio Orthopedic Group — a surgeon widely regarded as one of the founders of modern arthroscopic shoulder surgery — examined the relationship between the number of preoperative dislocations, total dislocation time, and the complexity of surgery required.

We reviewed primary stabilization surgeries performed using a consistent decision-making algorithm: patients with minimal bone loss received an isolated Bankart repair; those with a significant Hill-Sachs lesion received Bankart repair plus remplissage; and those with more than 25% glenoid bone loss received an open Latarjet reconstruction. The Latarjet is a more invasive open procedure that transfers a piece of the coracoid bone to the front of the socket to rebuild it — effective, but with a complication rate as high as 25%.

We then looked at how the number of dislocations and total time spent dislocated before surgery correlated with which operation the patient ended up needing.

The Results: The Numbers Are Striking

64%  of patients with only 1 dislocation needed just a simple Bankart repair

86%  of patients with 2 or more dislocations already needed a bone loss procedure

6.1  average dislocations in patients who required Latarjet reconstruction

5+ hrs  total dislocation time strongly predicted the need for Latarjet reconstruction

The pattern was unambiguous and statistically significant. As the number of dislocations increased, so did the likelihood of needing remplissage (to address the Hill-Sachs dent) or Latarjet reconstruction (to address glenoid bone loss). The groups progressed systematically: Bankart-only patients averaged 2.0 dislocations, remplissage patients averaged 3.4, and Latarjet patients averaged 6.1.

Total dislocation time followed the same pattern. The more total hours the shoulder had spent dislocated — the cumulative time the ball was out of the socket before being reduced — the greater the bone damage. Patients who had spent 5 or more total hours dislocated were significantly more likely to require a Latarjet reconstruction.

This finding about total dislocation time was novel. To our knowledge, this was the first study to examine total dislocation time as a variable in surgical decision-making. It adds an important dimension to the patient history: not just how many times has the shoulder come out, but how long did it stay out each time?

After just one recurrent dislocation — a total of two dislocations — 86% of patients had bone damage significant enough to require a more complex surgical procedure. The window for the simplest, safest repair closes faster than most people realize.

The Bigger Picture: What Recurrent Instability Does to Your Shoulder Over Time

The damage from recurrent shoulder instability is not limited to what happens on the operating table. Left untreated, it has long-term consequences that extend well beyond the dislocations themselves.

Recurrent instability dramatically increases the risk of glenohumeral arthritis. One long-term study following patients for 25 years found that patients with even a single recurrent subluxation or dislocation had moderate or severe glenohumeral arthritis in 35% of cases — compared to just 17% in patients who did not have recurrent instability. Another study found a 2.3 times increased risk of arthritis with increasing number of preoperative dislocations.

Recurrent instability also progressively damages the labrum, capsule, and ligaments — the soft-tissue restraints that, when intact, provide the foundation for a successful repair. Patients with more than one dislocation are significantly more likely to have posterior labral tears and SLAP lesions alongside the primary Bankart lesion, each requiring additional repair and increasing operative complexity.

The trajectory of untreated shoulder instability is, in most cases, progressive deterioration: more dislocations, more bone loss, more soft tissue damage, more arthritis. Acting early interrupts that trajectory.

Who Should Consider Early Surgical Stabilization?

This research specifically supports the case for primary arthroscopic stabilization in young patients at high risk for recurrence — defined as those under 40 years old who are active and have already dislocated once or are at elevated risk of redislocation.

The recurrence rate after a first-time anterior shoulder dislocation in patients under 40 is approximately 67%. That means the majority of young patients who dislocate once will dislocate again. Waiting for a second dislocation to "confirm" the need for surgery means waiting for the bone damage to accumulate.

Factors that support considering early surgical stabilization after a first-time dislocation:

• Age under 25 — the highest risk group for recurrence
• Active participation in contact sports or overhead athletics
• Significant Hill-Sachs lesion or any glenoid bone loss on first imaging
• Desire to return to high-demand activity or sport without the ongoing risk of redislocation
• Occupation or lifestyle where a sudden unexpected dislocation creates safety risk

For patients who have already experienced two or more dislocations, the data from this study underscore the urgency of evaluation. Bone damage is almost certainly present at that point, and continued delay only allows further erosion of the surgical options available.

The Operations — From Simplest to Most Complex

Understanding the spectrum of procedures helps illustrate what is at stake with delayed treatment:

• Arthroscopic Bankart repair — the simplest operation. Done entirely through small incisions with a camera. Reattaches the torn labrum to the front of the socket. Recovery is typically 4 to 6 months to return to sport. Complication rate is low.
• Bankart repair with remplissage — adds a step to fill in the Hill-Sachs dent on the back of the ball with tendon and capsule, preventing it from catching on the glenoid rim. Still arthroscopic, but somewhat longer and more technically demanding.
• Latarjet reconstruction — an open procedure that transfers a piece of the coracoid bone to the front of the socket to rebuild lost glenoid bone. Highly effective for significant bone loss, but more invasive, with longer recovery and a complication rate as high as 25%.

The goal of early intervention is simple: keep the patient in the Bankart repair column. Every dislocation that is allowed to occur before surgery is another step toward remplissage, and eventually toward Latarjet.

The Bottom Line

Shoulder dislocations are not a "wait and see" injury — at least not for young, active patients. Each episode does measurable, progressive damage to the bone and soft tissues of the shoulder. That damage accumulates, it does not reverse, and it changes what kind of surgery is needed to fix the problem.

Research I conducted with Dr. Burkhart shows that after just two dislocations, 86% of patients already have bone loss significant enough to require procedures beyond a simple labral repair. The sooner instability is addressed, the simpler the surgery, the lower the complication risk, and the better the long-term preservation of shoulder health.

If you have had a shoulder dislocation — especially if you are young, active, and have already had more than one — the most important thing you can do is get a thorough surgical evaluation before the next one happens.

Patrick J. Denard, MD is a fellowship-trained orthopedic surgeon specializing in shoulder surgery at the Oregon Shoulder Institute in Medford, Oregon. He is the lead author of "Increasing Preoperative Dislocations and Total Time of Dislocation Affect Surgical Management of Anterior Shoulder Instability," published in the International Journal of Shoulder Surgery (2015), co-authored with Dr. Stephen S. Burkhart.

If you have experienced a shoulder dislocation and want to understand your options before further damage occurs, request an appointment at Oregon Shoulder Institute.

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