The True Recurrence Rate and Factors Predicting Recurrent Instability After Nonsurgical Management of Traumatic Primary Anterior Shoulder Dislocation: A Systematic Review


      To (1) define the cumulative recurrence rate after primary anterior shoulder dislocation in Level I and II comparative studies and (2) to pool risk ratios for common risk factors to provide a clinically practical hierarchy of modifiable and nonmodifiable risk factors for recurrence.


      Level I and II prognostic studies were identified using the electronic databases CINAHL, Embase, and MEDLINE from inception to December 2014. Included studies (n = 15) had recurrent dislocation as the main outcome, and a minimum 2-year follow-up. The cumulative odds ratio of prognostic factors was calculated where appropriate. Bias was assessed in each study using the Quality in Prognosis Studies (QUIPS) tool.


      The reported rate of recurrence ranged from 19% to 88% (pooled overall = 21%; pooled Level I only = 47%). The pooled time to recurrence was 10.8 months (standard deviation 0.42). Male sex (n = 6 studies) conferred a 2.68 (1.66-4.31; P < .001) and patient age <20 years (n = 4 studies) conferred a 12.76 (5.77-28.2; P < .001; vs >20 years) increased odds of recurrence. An associated greater tuberosity fracture (n = 7 studies) decreased the odds of recurrence by 3.8 times (2.94-5.00; P < .001). The quality of evidence was moderate for age, low for sex, and very low for all other prognostic variables.


      The pooled rate of recurrence after primary anterior shoulder instability was found to be 21% among moderate- to high-quality prognostic studies. Male sex and younger age predicted a significantly higher risk of recurrent instability (approaching 80%), whereas concurrent fracture of the greater tuberosity significantly decreased the risk of subsequent recurrent dislocation. However, considering the quality of available evidence for these predictors, there remains a clear need for further high-quality prospective studies.

      Level of Evidence

      Level II, systematic review of Level I and II prognostic studies.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Leroux T.
        • Wasserstein D.
        • Veillette C.
        • et al.
        Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada.
        Am J Sports Med. 2014; 42: 442-450
        • Zacchilli M.A.
        • Owens B.D.
        Epidemiology of shoulder dislocations presenting to emergency departments in the United States.
        J Bone Joint Surg Am. 2010; 92: 542-549
        • Cox C.L.
        • Kuhn J.E.
        Operative versus nonoperative treatment of acute shoulder dislocation in the athlete.
        Curr Sports Med Rep. 2008; 7: 263-268
        • Hovelius L.
        • Lind B.
        • Thorling J.
        Primary dislocation of the shoulder. Factors affecting the two-year prognosis.
        Clin Orthop Relat Res. 1983; 176: 181-185
        • Hovelius L.
        • Olofsson A.
        • Sandstrom 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. 2008; 90: 945-952
        • Kralinger F.S.
        • Golser K.
        • Wischatta R.
        • Wambacher M.
        • Sperner G.
        Predicting recurrence after primary anterior shoulder dislocation.
        Am J Sports Med. 2002; 30: 116-120
        • Murthi A.M.
        • Ramirez M.A.
        Shoulder dislocation in the older patient.
        J Am Acad Orthop Surg. 2012; 20: 615-622
        • Robinson C.M.
        • Dobson R.J.
        Anterior instability of the shoulder after trauma.
        J Bone Joint Surg Br. 2004; 86: 469-479
        • Sachs R.A.
        • Lin D.
        • Stone M.L.
        • Paxton E.
        • Kuney M.
        Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted?.
        J Bone Joint Surg Am. 2007; 89: 1665-1674
        • te Slaa R.L.
        • Wijffels M.P.
        • Brand R.
        • Marti R.K.
        The prognosis following acute primary glenohumeral dislocation.
        J Bone Joint Surg Br. 2004; 86: 58-64
        • Hovelius L.
        • Augustini B.G.
        • Fredin H.
        • Johansson O.
        • Norlin R.
        • Thorling J.
        Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study.
        J Bone Joint Surg Am. 1996; 78: 1677-1684
        • Vavken P.
        • Sadoghi P.
        • Quidde J.
        • et al.
        Immobilization in internal or external rotation does not change recurrence rates after traumatic anterior shoulder dislocation.
        J Shoulder Elbow Surg. 2014; 23: 13-19
        • Hanchard N.C.
        • Goodchild L.M.
        • Kottam L.
        Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.
        Cochrane Database Syst Rev. 2014; 4: CD004962
        • Chahal J.
        • Marks P.H.
        • Macdonald P.B.
        • et al.
        Anatomic Bankart repair compared with nonoperative treatment and/or arthroscopic lavage for first-time traumatic shoulder dislocation.
        Arthroscopy. 2012; 28: 565-575
        • Longo U.G.
        • Loppini M.
        • Rizzello G.
        • Ciuffreda M.
        • Maffulli N.
        • Denaro V.
        Management of primary acute anterior shoulder dislocation: Systematic review and quantitative synthesis of the literature.
        Arthroscopy. 2014; 30: 506-522
        • Wright J.G.
        • Swiontkowski M.F.
        • Heckman J.D.
        Introducing levels of evidence to the journal.
        J Bone Joint Surg Am. 2003; 85: 1-3
        • Leroux T.
        • Ogilvie-Harris D.
        • Veillette C.
        • et al.
        The epidemiology of primary anterior shoulder dislocations in patients aged 10 to 16 years.
        Am J Sports Med. 2015; 43: 2111-2117
        • Hayden J.A.
        • Cote P.
        • Bombardier C.
        Evaluation of the quality of prognosis studies in systematic reviews.
        Ann Intern Med. 2006; 144: 427-437
        • Huguet A.
        • Hayden J.A.
        • Stinson J.
        • et al.
        Judging the quality of evidence in reviews of prognostic factor research: adapting the GRADE framework.
        Syst Rev. 2013; 2: 71
        • Hayden J.A.
        • van der Windt D.A.
        • Cartwright J.L.
        • Cote P.
        • Bombardier C.
        Assessing bias in studies of prognostic factors.
        Ann Intern Med. 2013; 158: 280-286
        • Higgins J.
        • Thompson S.G.
        Quantifying heterogeneity in a meta-analysis.
        Stat Med. 2002; 21: 1539-1558
        • Higgins J.
        • Deeks J.
        Chapter 7: Selecting studies and collecting data.
        in: Higgins J. Green S. Cochrane handbook for systematic reviews of interventions. The Cochrane Collaboration, 2011
        • Hozo S.P.
        • Djulbegovic B.
        • Hozo I.
        Estimating the mean and variance from the median, range, and the size of a sample.
        BMC Med Research Methodol. 2005; 5: 13
        • Henry J.H.
        • Genung J.A.
        Natural history of glenohumeral dislocation—Revisited.
        Am J Sports Med. 1982; 10: 135-137
        • Hoelen M.A.
        • Burgers A.M.J.
        • Rozing P.M.
        Prognosis of primary anterior shoulder dislocation in young adults.
        Arch Orthop Trauma Surg. 1990; 110: 51-54
        • Lill H.
        • Korner J.
        • Hepp P.
        • Verheyden P.
        • Josten C.
        Age-dependent prognosis following conservative treatment of traumatic anterior shoulder dislocation.
        Eur J Trauma. 2001; 27: 29-33
        • McLaughlin H.
        • Cavallaro W.U.
        Primary anterior dislocation of the shoulder.
        Am J Surg. 1950; 80 (passim): 615-621
        • Robinson C.M.
        • Howes J.
        • Murdoch H.
        • Will E.
        • Graham C.
        Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients.
        J Bone Joint Surg Am. 2006; 88: 2326-2336
        • Rowe C.R.
        • Sakellarides H.T.
        Factors related to recurrences of anterior dislocations of the shoulder.
        Clin Orthop. 1960; 20: 40-48
        • Safran O.
        • Milgrom C.
        • Radeva-Petrova D.R.
        • Jaber S.
        • Finestone A.
        Accuracy of the anterior apprehension test as a predictor of risk for redislocation after a first traumatic shoulder dislocation.
        Am J Sports Med. 2010; 38: 972-975
        • Salomonsson B.
        • von Heine A.
        • Dahlborn M.
        • et al.
        Bony Bankart is a positive predictive factor after primary shoulder dislocation.
        Knee Surg Sports Traumatol Arthrosc. 2010; 18: 1425-1431
        • Simonet W.T.
        • Cofield R.H.
        Prognosis in anterior shoulder dislocation.
        Am J Sports Med. 1984; 12: 19-24
        • Vermeiren J.
        • Handelberg F.
        • Casteleyn P.P.
        • Opdecam P.
        The rate of recurrence of traumatic anterior dislocation of the shoulder: A study of 154 cases and a review of the literature.
        Int Orthop. 1993; 17: 337-341
        • Hovelius L.
        The natural history of primary anterior dislocation of the shoulder in the young.
        J Orthop Sci. 1999; 4: 307-317
        • Randelli P.
        • Taverna E.
        Primary anterior shoulder dislocation in young athletes: Fix them!.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 1404-1405
        • Mather 3rd, R.C.
        • Orlando L.A.
        • Henderson R.A.
        • Lawrence J.T.
        • Taylor D.C.
        A predictive model of shoulder instability after a first-time anterior shoulder dislocation.
        J Shoulder Elbow Surg. 2011; 20: 259-266
        • Brophy R.H.
        Results of shoulder stabilization surgery in athletes.
        Clin Sports Med. 2013; 32: 825-832