Approach to Treating Patients after First-time Anterior Shoulder Instability: What Does the Evidence Say?

Management of first-time anterior shoulder instability (ASI) is an extensively studied yet controversial topic. Successful treatment requires incorporation of a wide range of factors including patient demographics, varying presenting pathology, functional demands, and sport specific considerations. The purpose of this review is to provide an up-to-date summary of the current literature and trends regarding management of first time ASI events.

For non-operative treatment of first-time ASI events, shorter times for immobilization and consideration of positioning in external rotation may be more beneficial. Operative intervention may be favored for patients at high risk of recurrence (young, male, collision sports, and/or overhead athlete). Historically, open soft tissue stabilization was a primary treatment option for ASI. More recently, there has been an increased emphasis on arthroscopic Bankart repair (ABR) especially in the United States. The remplissage has become a useful adjunct to ABR to manage cases with Hill-Sachs lesions or sub-critical bone loss. Latarjet (coracoid transfer) remains a well-studied and common option for cases of critical glenoid bone loss. When directly compared both ABR with Remplissage and Latarjet improve outcomes and reduce the risk of recurrence in athletes with first-time ASI. Currently, there is no uniform approach to managing first-time ASI events. Therefore, an individualized approach is required with consideration of the individuals demographic, presence of bone loss, functional demands, and sport specific considerations. In young, male, collision athletes early surgical intervention may be beneficial to prevent recurrence. When faced with minimal (< 13.5%) or subcritical bone loss (13.5% to 20%), ABR with Remplissage may reduce rates of instability compared to ABR alone.