Management of anterior shoulder instability in patients aged 40 and older: a systematic review

Anterior shoulder instability (ASI) is a common shoulder condition that primarily affects adolescents and young adults. In older adults this represents a distinct condition with a distinct pathomechanism and complication profile. This review synthesizes the literature on ASI in patients 40 years or older, focusing on injury characteristics, treatment modalities, and clinical outcomes.

Three databases (PubMed, MEDLINE, Embase) were searched on October 18, 2025. Primary studies investigating operative or non-operative management of ASI in patients with onset of instability at ≥ 40 years old were included. Methodological quality was assessed using MINORS criteria. Data were collated utilizing descriptive statistics.

Ten studies were included with 541 patients, of which 315 were non-operative and 226 were operative. The most common concomitant injuries included rotator cuff tears (n = 219 of 409, 53.5%), Hills-Sachs lesions (n = 208 of 445, 46.7%), and glenoid bone defects (n = 20 of 249, 8.0%). The most common operative procedures were rotator cuff repair (80.5%, n = 182), Bankart repair (12.8%, n = 29), and reverse shoulder arthroplasty (4.4%, n = 10). Recurrent instability occurred in 5.5% of operative patients (n = 21 of 380) and 15.0% of non-operative patients (23 of 153) among studies reporting rates. Both non-operative and operative management yielded favourable outcomes, with low recurrence and complication rates, and satisfactory range of motion.

ASI in patients ≥ 40 years old is commonly associated with concomitant injuries and can be managed operatively or non-operatively depending on injuries and instability severity. Further prospective, comparative studies using standardized outcomes are needed to better define optimal management in this population.

IV, systematic review.