Bankart repair for unstable dislocating shoulders: Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals.

Edited By: Frederick A. Matsen III, M.D., Winston J. Warme, MD
Last updated Tuesday, November 13, 2007

Figure 2 - Throwing may be difficult

Figure 3 - Traumatic anterior instability

Figure 4 - Exercises to strengthen the rotator cuff

Review of the condition

Characteristics of shoulder dislocations

Instability is a common cause of shoulder injury; shoulder function can usually be improved by a surgical repair. Individuals with shoulder instability usually notice that the shoulder feels unsteady or the ball may actually slip out of the joint in certain positions, such as when the arm is out to the side or across the body. People with anterior (frontward) instability of the shoulder, have difficulty throwing because this action depends on normal ligaments across the front of the joint, as shown in the figure and movie 5.

QuickTime movie

• Movie 5: Diagonal path (9.59 MB)

Types

The most common type of shoulder instability is traumatic anterior instability. In this type, the ligaments and the labrum at the lower front part of the shoulder are torn by an injury that occurred when the arm was out to the side.

The figure on the left shows in cross section the capsule and labrum torn from the edge of the glenoid socket. Note that the damaged socket resembles a golf tee with one of its edges broken away so that the golf ball will tend to roll off of it. The figure on the right shows the same injury looking at the socket with the ball removed. The gap between the glenoid and the torn capsule and labrum is where the ball dislocates. The tear of the labrum and capsule from the glenoid is called a "Bankart Lesion".

Common causes of this injury include a skiing fall with the arm out to the side, a clothesline tackle, or a blocked spike in volleyball. The shoulder may not pop back in the joint, but instead often needs to be put back in place by experienced assistance, such as in an emergency room. The dislocated shoulder is given a chance to heal; then the patient is started on a rehabilitation program.

Not infrequently, the labrum and the ligaments do not heal completely and the shoulder continues to feel unsteady (for example when the arm is moved out to the side and backward). These injuries seriously compromise the stability of the shoulder. An unhealed Bankart Lesion can result in recurrent anterior shoulder instability. When multiple dislocations have occurred, the chances of healing without surgery become small.

A similar type of injury can occur to the back of the joint (traumatic posterior shoulder instability), but it is much less common. Traumatic posterior instability arises from mechanisms such as a fall on the outstretched hand.

There is another type of instability which arises without an injury--atraumatic instability. In this condition the shoulder loses its normal ability to center the ball in the glenoid socket. Not infrequently, atraumatic instability may allow the shoulder to slip in different directions (multidirectional instability). In this condition there is usually nothing torn, but rather the stabilizing structures of the shoulder decompensate.

Diagnosis

Shoulder instability must be distinguished from other causes of shoulder dysfunction, such as arthritis, rotator cuff tear and snapping scapula. Arthritis usually results in shoulder stiffness and pain; X-rays show the loss of the joint space. Rotator cuff tear results in shoulder weakness. In snapping scapula, the shoulder pops when the shoulder blade is moved on the chest wall.

Shoulder dislocations are among the most common conditions of the shoulder. They are more likely to be found in people from 15 to 35 years of age. Individuals over the age of 40 who dislocate their shoulders are likely to also have a tear of the rotator cuff. Those who have instability of one shoulder are somewhat more likely to have instability of the opposite shoulder. People with loose joints are more likely to have atraumatic instability.

The experienced shoulder surgeon can make a diagnosis of shoulder instability from the patient's history and from the physical examination. In traumatic instability, X-rays may show damage to the humeral head (ball of the shoulder) or the glenoid (socket). Complex tests such as MRI or arthroscopy are rarely necessary to make the diagnosis.

It is essential that the surgeon establish the diagnosis of shoulder instability before surgical treatment is considered.

Medications

Exercises

Shoulder exercises to strengthen the rotator cuff, such as those shown in the figure above, may help control an unstable shoulder. Particularly in atraumatic instability, rotator cuff strengthening and training the shoulder for stability are the mainstays of treatment.

In traumatic instability, the repair of the labrum and the ligaments can usually restore stability to the joint. The restoration of stability often allows patients to return to their usual activities.

In atraumatic instability, there is no single lesion to repair. Thus, if exercises do not restore joint stability, careful consideration needs to be given to the advisability of any surgical procedure. While tightening or burning the ligaments and capsule of the joint have been used for this condition, it is recognized that these procedures may not specifically address the cause of the instability.

Possible benefits of surgical repair for shoulder dislocations

Surgery for shoulder dislocations at the University of Washington

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