To Fix or Rehabilitate? First-Time Shoulder Dislocation in a High School Athlete

Introduction
First-time anterior shoulder dislocations are among the most common injuries encountered in young athletes, particularly those participating in collision sports such as football. While many can return to play after nonoperative management, the high risk of recurrent instability in adolescent athletes makes treatment decisions far more straightforward. Factors including age, sport, level of competition, imaging findings, and long-term athletic goals all influence whether early surgical stabilization or conservative treatment offers the best path forward.

The following case highlights the evaluation and management considerations for a highly competitive high school football player following a first-time traumatic anterior shoulder dislocation.

The Patient
A 16-year-old high school football player presents to your office for evaluation of a right shoulder injury. He plays wide receiver and reports during the first game of the season he sustained an acute injury, in which he was tackled to the ground during a catch attempt. While going to the ground he braced himself with his right shoulder and felt his shoulder dislocate anteriorly. His athletic trainer was experienced in shoulder reduction maneuvers and was able to reduce his shoulder on the field. He has been wearing a sling since the injury. He denies any previous instability history or injuries to his right shoulder. He is a junior, has ambitions of playing college football, and has generated significant Division 1 scouting interest during his prior seasons.

On examination, he has full symmetric range of motion in all planes compared to his contralateral side, with some discomfort at end ranges of motion. His strength is full in all domains. He has positive apprehension and relocation testing supine with a 2+ anterior load and shift and 1+ posterior load and shift. He is fully neurovascularly intact in the upper extremity. He has no signs of hyperlaxity.

His obtained magnetic resonance imaging (MRI) demonstrated an anteroinferior labral tear and a Hill Sachs impaction lesion, which is on track. He has no glenoid bone loss and no injury to his rotator cuff.

Point: Fix It

Simply put, this is a high-risk patient—a young male athlete competing in a collision sport. It is well established that recurrent instability rates are high after first-time shoulder dislocation.^1-2 Recently published Level 1 outcome data with 6-year follow up, in which first-time dislocators under 25 years old with subcritical bone loss were randomized to arthroscopic versus nonsurgical management, found recurrence rates of 89.5% with nonsurgical treatment compared to 27.8% in those treated surgically.³ Pooled analysis has shown that arthroscopic Bankart repair carries a seven-fold reduction in recurrence risk.⁴ This is a staggering difference, which is likely even more exaggerated in this patient who possesses multiple additional risk factors for recurrent instability.

Redislocation is an extremely consequential complication in this young athlete. A shoulder dislocation is a destructive force that can cause significant injury to the osseous, cartilage, and soft tissue structures of the shoulder joint. With each subsequent dislocation, cumulative damage to the shoulder can occur. Patients with a history of multiple instability episodes have been found to have increased glenoid bone loss, increasing the risk for failure of a soft tissue repair.^5-6 Prompt surgical management can prevent this cascade of injury and reduce the likelihood of requiring more aggressive surgical intervention, such as Latarjet or allograft bone block porocedure⁷.

This repeat cycle of injury can lead to significant time missed from the sport season. Even with nonsurgical management, athletes often miss multiple weeks of play before being cleared to return to sport.⁸ Delay in definitive management subsequently leads to further time missed from sport if redislocation does occur. Athletes undergoing surgical stabilization are 5.8 times more likely to complete the following season without further instability compared with those managed nonsurgically. This further tilts the decision towards surgical management in a young football player with collegiate prospects. The true cost of redislocation has been quantified in recent literature. Li et al performed a cost-effectiveness analysis comparing arthroscopic Bankart repair to nonsurgical treatment and found that surgery was the favorable financial decision in 100% of simulations.¹⁰

The treatment of choice is clear: Fix it the first time and don’t wait for disaster.

Counterpoint: Rehab It

While this is a high-risk individual for repeat dislocation, the decision is not so simple. This is an elite player who is going through the college recruiting process. Surgery would abruptly end his season, potentially putting his chances at a scholarship at jeopardy. Given that his MRI does not show glenoid bone loss, and his small Hill-Sachs is on track, there is no need to jump to a season-ending surgery just yet. Treat the patient as a whole, not just the MRI.

In a study of this patient’s exact cohort, school-aged athletes who were injured during a school-related event, more athletes treated nonoperatively than operatively were able to return to the same preinjury sport for at least one season (85% vs 72%).¹¹ There should be a thorough discussion with the athlete and the family regarding the potential for further dislocations, but also the possibility he may be able to return to play this season if he opts for rehabilitation.  For this elite athlete getting college looks, that matters.

While I agree that a recurrence rate of 89.5% with nonsurgical treatment compared with 27.8% after surgical treatment appears compelling, a closer look at the study protocols provides important context. The nonoperative cohort underwent three weeks of immobilization in internal rotation followed by physical therapy. However, it has been suggested that early strength training favors a lower recurrence rate than immobilization alone and thus the large discrepancy may not be as large as the study suggests with a different postoperative protocol.¹² While this patient is certainly at risk for recurrence, the risk itself is not an indication. An initial nonoperative trial of early mobilization, progressive rotator cuff and scapular strengthening, range-of-motion-limiting bracing, and objective return-to-sport criteria of full pain-free motion and strength is an appropriate first-line strategy for the elite high school football player, given his uncomplicated first-time anterior dislocation.

In sum, this is a high-level athlete with real college prospects, and immediately ending his junior season before it has even started has real consequences for his future. If the patient and his family understand the risks of recurrence and want to trial nonoperative treatment with an appropriate rehabilitation protocol to potentially save his season, then rehab is absolutely the way to go.

References

1. Wasserstein DN, Sheth U, Colbenson K, et al. The true recurrence rate and factors predicting recurrent instability after nonsurgical management of traumatic primary anterior shoulder dislocation: A systematic review. Arthroscopy. 32: 2016; 2616-2625.
2. Hovelius L, Olofsson A, Sandström B, et al. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. a prospective twenty-five-year follow-up. J Bone Joint Surg Am. 90: 2008; 945-952.
3. Pougès C, Boutry M, Maynou C, et al. Arthroscopic Bankart Repair Versus Immobilization for a First Episode of an Anterior Shoulder Dislocation Before the Age of 25 Years: A Randomized Controlled Trial With 6-Year Follow-up. Am J Sports Med. 2025;53(10):2289-2297.
4. Hurley ET, Manjunath AK, Bloom DA, et al. Arthroscopic bankart repair versus conservative management for first-time traumatic anterior shoulder instability: A systematic review and meta-analysis. Arthroscopy. 36: 2020; 2526-2532.
5. Fox MA, Drain NP, Rai A, et al. Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes. Arthroscopy. 2023;39(3):682-688.
6. Vaswani R, Gasbarro G, Como C, et al. Labral morphology and number of preoperative dislocations are associated with recurrent instability after arthroscopic Bankart repair. Arthroscopy. 36: 2020; 993-999.
7. Rugg CM, Hettrich CM, Ortiz S, Wolf BR. MOON Shoulder Instability Group, Zhang AL. Surgical stabilization for first-time shoulder dislocators: a multicenter analysis. J Shoulder Elbow Surg. 27: 2018; 674-685. 
8. Watson S, Allen B, Grant JA. A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation. Sports Health. 2016;8(4):336-341.
9. Dickens JF, Rue JP, Cameron KL, et al. Successful return to sport after arthroscopic shoulder stabilization versus nonoperative management in contact athletes with anterior shoulder instability: A prospective multicenter study. Am J Sports Med. 45: 2017; 2540-2546.
10. Li ZI, Hurley ET, Garra S, et al. Arthroscopic Bankart repair versus nonoperative management for first-time anterior shoulder instability: A cost-effectiveness analysis. Shoulder Elbow. 2024;16(1):59-67.  
11. Shanley E, Thigpen C, Brooks J, Hawkins RJ, Momaya A, Kwapisz A, Kissenberth MJ, Tokish JM. Return to Sport as an Outcome Measure for Shoulder Instability: Surprising Findings in Nonoperative Management in a High School Athlete Population. Am J Sports Med. 2019;47(5):1062-1067.
12. Hanai H, Hirose T, Nakai H, et al. Early muscular training and immobilization in external rotation could reduce the recurrence rate in first-time shoulder dislocators among young rugby athletes. J Shoulder Elbow Surg. 2025;34(6):e446-e454.