Should I Have Surgery After a Shoulder Dislocation?

If you've dislocated your shoulder for the first time, one of the questions you may be asking is:

"Do I need surgery?"

This is a question I have spent a large part of my research career trying to understand.

My PhD investigated whether we could predict who would develop recurrent shoulder instability after a first-time traumatic anterior shoulder dislocation.

The reason I became interested in prediction was quite simple:

Not everyone who dislocates their shoulder will dislocate it again.

For some people, early stabilisation surgery may be a very reasonable option. For others, rehabilitation without surgery may be entirely appropriate.

The difficult bit is working out which person is which.

And even with the best research available today, we cannot predict that perfectly.

So rather than asking simply:

"Does this injury need surgery?"

I think there is a better question:

"Given my risk of recurrence, my shoulder, the activities I want to return to, and what matters to me — which option is right for me?"

That is where shared decision making becomes really important.

Does everyone need surgery after their first shoulder dislocation?

No.

A first-time traumatic anterior shoulder dislocation does not automatically mean you need shoulder stabilisation surgery.

The problem is that the risk of having another episode of instability varies considerably between individuals.

Some people recover with rehabilitation and never experience another dislocation.

Others develop recurrent instability, repeated subluxations or persistent apprehension, particularly when returning to demanding sport or activity.

That means the first part of the decision is understanding:

How likely is this shoulder to become unstable again?

Can we predict who will dislocate again?

This was the central question of my PhD.

I started by looking at the existing research to understand which factors were associated with recurrent instability. We then followed people prospectively after a first-time traumatic anterior shoulder dislocation and developed the Predict Recurrent Instability of the Shoulder — PRIS — model.

What became clear — and remains clear today — is that prediction is difficult.

Some factors consistently influence recurrence risk.

Age is particularly important.

Younger people are much more likely to experience recurrent shoulder instability than older people after a first traumatic anterior shoulder dislocation.

Sex also influences risk at a population level.

Our systematic review found that males had greater odds of recurrent instability than females.

Joint hypermobility can also increase risk.

But none of these factors can tell us with certainty what will happen to an individual person.

You aren't an odds ratio.

That is why simply saying:

"You're young, therefore you need surgery"

isn't enough.

The PRIS tool: estimating your individual risk

As part of my PhD research, we developed the Predict Recurrent Instability of the Shoulder — PRIS — tool.

PRIS was developed specifically for people following a first-time traumatic anterior shoulder dislocation.

Rather than looking at one factor alone, it considers several characteristics together, including:

• age
• whether the injured shoulder is the dominant arm
• immobilisation following the initial injury
• the presence of a bony Bankart lesion
• shoulder pain and disability
• fear of movement and reinjury

The important thing to understand is that PRIS does not tell you whether you should have surgery.

It also cannot tell you with certainty whether your shoulder will dislocate again.

It gives us another piece of information that can help make the conversation about treatment better informed.

What does recent UK research tell us?

Nearly a decade after we published our systematic review, Makaram and colleagues at the Royal Infirmary of Edinburgh looked at this question again in a much larger UK cohort.

Their 2024 study followed 1,293 people aged between 15 and 35 years who had experienced a primary traumatic anterior shoulder dislocation and were initially managed without surgery.

Overall, 62.8% experienced recurrent instability during follow-up.

Of those who developed recurrent instability, 81% experienced their first recurrence within two years of the original dislocation.

The factors independently associated with greater recurrence risk included:

• younger age
• male sex
• participation in contact sport
• the presence of a bony Bankart lesion

A greater tuberosity fracture was associated with a lower risk of recurrent instability.

There is another part of this study that I think is particularly important.

Makaram and colleagues combined multiple risk factors to try to predict recurrence in an individual patient.

Despite having almost 1,300 patients and examining multiple predictors, their model still had only modest predictive ability.

At its best-performing threshold, the model correctly classified approximately 63% of patients.

The authors concluded that a substantial amount of the variation in recurrence risk remains unexplained.

In other words:

Even with a large cohort and increasingly sophisticated prediction models, we still cannot perfectly predict the future of an individual shoulder.

I think that matters enormously when we're talking to someone about surgery.

We can estimate risk.

We cannot predict your future with certainty.

Does a high risk of recurrence mean I should have surgery?

Not automatically.

Risk is important, but risk is only one part of the decision.

Two people could have a similar predicted risk of recurrent instability and make completely different — but entirely reasonable — treatment decisions.

Imagine two people with similar injuries.

One is a recreational runner who doesn't participate in contact or overhead sport.

The other is a 19-year-old rugby player who wants to return to tackling and competitive contact sport several times each week.

Their shoulders might look similar on imaging.

But the demands they intend to expose those shoulders to are completely different.

The consequences of another instability episode may also be very different.

This is why recurrence risk shouldn't be interpreted in isolation.

How I think this decision should be made

Because we cannot perfectly predict what will happen to an individual shoulder, I don't think the decision should be reduced to:

"You're young and you play rugby — you need surgery."

Nor should it be:

"It's only your first dislocation — just do physio first."

Both are too simplistic.

In my clinical practice, I prefer to think about this using the Three-Talk Model of Shared Decision Making.

It has three stages:

TEAM TALK → OPTION TALK → DECISION TALK

I like this model because it stops us moving too quickly from diagnosis straight to recommendation.

What about a Bankart lesion?

This is an area where people can understandably become confused.

You may have been told that an MRI or other scan shows a Bankart lesion.

A Bankart lesion involves injury to the front of the labrum associated with anterior shoulder dislocation.

It is important information.

Makaram and colleagues found that the presence of a bony Bankart lesion was associated with a greater risk of recurrent instability in their young UK cohort.

But: Having a Bankart lesion does not automatically mean that you need surgery.

Imaging needs to be interpreted alongside factors such as age, bone loss, symptoms, previous instability, sport and activity demands, clinical examination, recurrence risk, and your goals and preferences.

The scan informs the decision. It shouldn't make the decision for you.

Your sport, work and lifestyle change the decision

One of the things that gets lost when we talk about recurrence percentages is Demand.

What are you actually asking this shoulder to return to?

A shoulder returning to recreational running faces very different demands from a shoulder returning to rugby, goalkeeping, combat sport, mountain biking, overhead competition, or manual work.

The decision is therefore not just about the shoulder you have today. It is also about what you want that shoulder to do next.

Five questions I think you should ask before deciding on surgery

1. What is my individual risk of recurrent instability?

Not simply the average recurrence rate from a research paper. Your risk. Prediction tools such as PRIS may help inform this conversation, but they should be interpreted alongside the clinical assessment and imaging.

2. What exactly am I trying to return to?

"Return to sport" is too vague. Are you returning to swimming? Goalkeeping? Rugby? Mountain biking? Contact training four nights per week? The Demand matters.

3. What are the benefits and downsides of each option for me?

Ask about recurrence, rehabilitation, time away from work and sport. And importantly: Ask about uncertainty. A good consultation shouldn't make either pathway sound risk-free.

4. What matters most to me?

Avoiding another dislocation? Avoiding surgery? Returning to competition? Getting back to work? Long-term confidence in the shoulder? There isn't one correct priority.

5. Am I ready to decide?

You don't always have to make this decision immediately. Sometimes an entirely reasonable response is: "I need more information." Or: "I'd like to see how rehabilitation goes first." That is still part of shared decision making.

What would I do?

Patients sometimes ask me: "But what would you do if it was your shoulder?"

It's a completely reasonable question. But I'm not you. I don't have your shoulder, your sport, your job, your tolerance of risk or your feelings about surgery.

What I can do is help you understand the evidence, your likely recurrence risk, the advantages and disadvantages of the different options, and the uncertainty around them. Then we can work out what matters most to you.

If it were my decision, I would want an estimate of my individual recurrence risk, an explanation of what the imaging actually means, an honest discussion about what rehabilitation can and cannot achieve, and a clear understanding of what each pathway means for the activities I want to return to.

That is a much better basis for a decision than: "You're young — get it fixed." Neither tells the whole story.

Surgery or rehabilitation? There isn't one right answer

The important point is that the decision shouldn't be based on one recurrence statistic, one risk factor, one MRI finding, your age alone, or your clinician's treatment preference alone.

Instead, I think it should bring together four things:

What if I choose rehabilitation?

Choosing non-operative management doesn't mean simply waiting to see whether your shoulder dislocates again. Rehabilitation should progressively restore the qualities required for the activities you want to return to.

At Flawless Motion, we think about this as:

CONTROL • CAPACITY • CONFIDENCE • DEMAND

The aim isn't simply to make the shoulder stronger. It is to prepare the shoulder — and the person — for the demands they want to return to.

Can a shoulder brace be useful if I don't have surgery?

For some people, a shoulder instability brace may form part of a non-operative or return-to-sport strategy.

A brace does not make an unstable shoulder stable and it does not replace rehabilitation. It may, however, help some athletes limit exposure to vulnerable shoulder positions or provide additional external support while they progressively return to higher-risk activities.

Whether bracing is appropriate depends on the direction of instability, the activity you're returning to and your individual rehabilitation plan.

Learn when a shoulder instability brace may help →

About the author

Dr Margie Olds, PhD

I am a shoulder physiotherapist and researcher specialising in shoulder instability, rehabilitation and return to sport.

My PhD investigated prediction of recurrent shoulder instability following first-time traumatic anterior shoulder dislocation. My research included a systematic review of recurrence risk and prospective cohort research that led to development of the Predict Recurrent Instability of the Shoulder — PRIS — tool.

I continue to work clinically with people following shoulder instability, from the initial dislocation through rehabilitation and return to sport.

Research discussed in this article

Olds MK, Ellis R, Donaldson K, Parmar P, Kersten P. Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis. British Journal of Sports Medicine. 2015;49:913–922.

Olds MK, Ellis R, Parmar P, Kersten P. Who will redislocate his/her shoulder? Predicting recurrent instability following a first traumatic anterior shoulder dislocation. BMJ Open Sport & Exercise Medicine. 2019;5:e000447.

Makaram NS, Becher H, Oag E, et al. Predicting recurrence of instability after a primary traumatic anterior shoulder dislocation. Bone & Joint Journal. 2024;106-B(10):1111–1117.

Elwyn G, Durand MA, Song J, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359:j4891.

This article provides general educational information and should not be used to decide whether you personally require surgery. Treatment following shoulder dislocation should be discussed with an appropriately qualified healthcare professional who can assess your individual injury, imaging, recurrence risk, goals and circumstances.