Anterior Shoulder Instability Part I—Diagnosis, Nonoperative Management, and Bankart Repair—An International Consensus Statement


      The purpose of this study was to establish consensus statements via a modified Delphi process on the diagnosis, nonoperative management, and Bankart repair for anterior shoulder instability.


      A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.


      The independent factors identified in the 2 statements that reached unanimous agreement in diagnosis and nonoperative management were age, gender, mechanism of injury, number of instability events, whether reduction was required, occupation, sport/position/level played, collision sport, glenoid or humeral bone-loss, and hyperlaxity. Of the 3 total statements reaching unanimous agreement in Bankart repair, additional factors included overhead sport participation, prior shoulder surgery, patient expectations, and ability to comply with postoperative rehabilitation. Additionally, there was unanimous agreement that complications are rare following Bankart repair and that recurrence rates can be diminished by a well-defined rehabilitation protocol, inferior anchor placement (5-8 mm apart), multiple small-anchor fixation points, treatment of concomitant pathologies, careful capsulolabral debridement/reattachment, and appropriate indications/assessment of risk factors.


      Overall, 77% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were the aspects of patient history that should be evaluated in those with acute instability, the prognostic factors for nonoperative management, and Bankart repair. Furthermore, there was unanimous consensus on the steps to minimize complications for Bankart repair, and the placement of anchors 5-8 mm apart. Finally, there was no consensus on the optimal position for shoulder immobilization.

      Level of Evidence

      Level V, expert opinion.

      Key Words

      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


        • White A.E.
        • Patel N.K.
        • Hadley C.J.
        • Dodson C.C.
        An algorithmic approach to the management of shoulder instability.
        J Am Acad Orthop Surg Glob Res Rev. 2019; 3
        • Provencher M.T.
        • Midtgaard K.S.
        • Owens B.D.
        • Tokish J.M.
        Diagnosis and management of traumatic anterior shoulder instability.
        J Am Acad Orthopaed Surg. 2020; 29: e51-e61
        • Glazebrook H.
        • Miller B.
        • Wong I.
        Anterior shoulder instability: A systematic review of the quality and quantity of the current literature for surgical treatment.
        Orthop J Sports Med. 2018; 6 (2325967118805983)
        • Friedman L.G.M.
        • Lafosse L.
        • Garrigues G.E.
        Global perspectives on management of shoulder instability: Decision making and treatment.
        Orthop Clin North Am. 2020; 51: 241-258
        • Bishop J.Y.
        • Hidden K.A.
        • Jones G.L.
        • Hettrich C.M.
        • Wolf B.R.
        • MOON Shoulder Group
        Factors influencing surgeon's choice of procedure for anterior shoulder instability: A multicenter prospective cohort study.
        Arthroscopy. 2019; 35: 2014-2025
        • Frank R.M.
        • Thon S.G.
        • Tokish J.M.
        • et al.
        Management of shoulder instability in 2020: What, when, and how.
        Instr Course Lect. 2021; 70: 3-22
        • Lizzio V.A.
        • Meta F.
        • Fidai M.
        • Makhni E.C.
        Clinical evaluation and physical exam findings in patients with anterior shoulder instability.
        Curr Rev Musculoskelet Med. 2017; 10: 434-441
        • Haley C.C.A.
        History and physical examination for shoulder instability.
        Sports Med Arthrosc Rev. 2017; 25: 150-155
        • Bencardino J.T.
        • Gyftopoulos S.
        • Palmer W.E.
        Imaging in anterior glenohumeral instability.
        Radiology. 2013; 269: 323-337
      1. Duethman NC, Bernard CD, Leland D, et al. Multiple instability events at initial presentation is the major predictor of failure of non-operative treatment for anterior shoulder instability. Arthroscopy In press.

        • Begly J.P.
        • Alaia M.J.
        First-time traumatic anterior shoulder instability management in the young and active patient.
        Bull Hospital Joint Dis (2013). 2019; 77: 21-32
        • Monk A.P.
        • Garfjeld Roberts P.
        • Logishetty K.
        • et al.
        Evidence in managing traumatic anterior shoulder instability: a scoping review.
        Br J Sports Med. 2015; 49: 307-311
        • Itoi E.
        • Sashi R.
        • Minagawa H.
        • Shimizu T.
        • Wakabayashi I.
        • Sato K.
        Position of immobilization after dislocation of the glenohumeral joint. A study with use of magnetic resonance imaging.
        J Bone Joint Surg Am. 2001; 83: 661-667
        • Itoi E.
        • Hatakeyama Y.
        • Urayama M.
        • Pradhan R.L.
        • Kido T.
        • Sato K.
        Position of immobilization after dislocation of the shoulder. A cadaveric study.
        J Bone Joint Surg Am. 1999; 81: 385-390
        • Rashid M.S.
        • Arner J.W.
        • Millett P.J.
        • Sugaya H.
        • Emery R.
        The Bankart repair: Past, present, and future.
        J Shoulder Elbow Surg. 2020; 29: e491-e498
        • Barber F.A.
        Editorial Commentary: Open or arthroscopic surgery? Practice makes perfect...we do best what we do most often.
        Arthroscopy. 2020; 36: 872-874
        • Tokish J.M.
        • Kuhn J.E.
        • Ayers G.D.
        • et al.
        Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.
        J Shoulder Elbow Surg. 2020; 29: 2429-2445
        • Murawski C.D.
        • Hogan M.V.
        • Thordarson D.B.
        • Stone J.W.
        • Ferkel R.D.
        • Kennedy J.G.
        Editorial. Foot Ankle Int. 2018; 39: 1S-2S
        • Katz J.N.
        Editorial Commentary: Degenerative meniscal tear: Sojourn to the oracle.
        Arthroscopy. 2020; 36: 513-515
        • Hohmann E.
        • Angelo R.
        • Arciero R.
        • et al.
        Degenerative meniscus lesions: An expert consensus statement using the modified Delphi technique.
        Arthroscopy. 2020; 36: 501-512
        • Hohmann E.
        • Cote M.P.
        • Brand J.C.
        Research pearls: Expert consensus based evidence using the Delphi method.
        Arthroscopy. 2018; 34: 3278-3282
        • Angelo R.L.
        • Ryu R.K.
        • Pedowitz R.A.
        • Gallagher A.G.
        Metric development for an arthroscopic Bankart procedure: Assessment of face and content validity.
        Arthroscopy. 2015; 31: 1430-1440
        • Schumaier A.
        • Kovacevic D.
        • Schmidt C.
        • et al.
        Defining massive rotator cuff tears: A Delphi consensus study.
        J Shoulder Elbow Surg. 2020; 29: 674-680
        • Garrigues G.E.
        • Zmistowski B.
        • Cooper A.M.
        • Green A.
        • Group I.C.M.S.
        Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: The definition of periprosthetic shoulder infection.
        J Shoulder Elbow Surg. 2019; 28: S8-S12
        • Di Giacomo G.
        • Peebles L.A.
        • Midtgaard K.S.
        • de Gasperis N.
        • Scarso P.
        • Provencher C.M.T.
        Risk factors for recurrent anterior glenohumeral instability and clinical failure following primary Latarjet procedures: An analysis of 344 patients.
        J Bone Joint Surg Am. 2020; 102: 1665-1671
        • Dekker T.J.
        • Peebles L.A.
        • Bernhardson A.S.
        • et al.
        Risk factors for recurrence after arthroscopic instability repair—The importance of glenoid bone loss >15%, patient age, and duration of symptoms: A matched cohort analysis.
        Am J Sports Med. 2020; 48: 3036-3041
        • Tokish J.M.
        • Thigpen C.A.
        • Kissenberth M.J.
        • et al.
        The Nonoperative Instability Severity Index Score (NISIS): A simple tool to guide operative versus nonoperative treatment of the unstable shoulder.
        Sports Health. 2020; 12: 598-602
        • Thomazeau H.
        • Courage O.
        • Barth J.
        • et al.
        Can we improve the indication for Bankart arthroscopic repair? A preliminary clinical study using the ISIS score.
        Orthop Traumatol Surg Res. 2010; 96: S77-S83
        • Vopat M.L.
        • Peebles L.A.
        • McBride T.
        • Cirone I.
        • Rider D.
        • Provencher C.M.T.
        Accuracy and reliability of imaging modalities for the diagnosis and quantification of Hill-Sachs lesions: A systematic review.
        Arthroscopy. 2021; 37: 391-401
        • de Mello R.A.F.
        • Ma Y.J.
        • Ashir A.
        • et al.
        Three-dimensional zero echo time magnetic resonance imaging versus 3-dimensional computed tomography for glenoid bone assessment.
        Arthroscopy. 2020; 36: 2391-2400
        • Walter W.R.
        • Samim M.
        • LaPolla F.W.Z.
        • Gyftopoulos S.
        Imaging quantification of glenoid bone loss in patients with glenohumeral instability: A systematic review.
        AJR Am J Roentgenol. 2019; : 1-10
        • Kho J.
        • Kholinne E.
        • Lim S.
        • et al.
        Arthroscopic bare spot method underestimates true bone defect in bony Bankart lesion.
        Arch Orthop Trauma Surg. 2019; 139: 1269-1275
        • Wasserstein D.N.
        • 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. 2016; 32: 2616-2625
        • Hurley E.T.
        • Manjunath A.K.
        • Bloom D.A.
        • et al.
        Arthroscopic Bankart repair versus conservative management for first-time traumatic anterior shoulder instability: A systematic review and meta-analysis.
        Arthroscopy. 2020; 36: 2526-2532
        • Etoh T.
        • Yamamoto N.
        • Shinagawa K.
        • Hatta T.
        • Itoi E.
        Mechanism and patterns of bone loss in patients with anterior shoulder dislocation.
        J Shoulder Elbow Surg. 2020; 29: 1974-1980
        • Duchman K.R.
        • Hettrich C.M.
        • Glass N.A.
        • et al.
        The incidence of glenohumeral bone and cartilage lesions at the time of anterior shoulder stabilization surgery: A comparison of patients undergoing primary and revision surgery.
        Am J Sports Med. 2018; 46: 2449-2456
        • Dickens J.F.
        • Slaven S.E.
        • Cameron K.L.
        • et al.
        Prospective evaluation of glenoid bone loss after first-time and recurrent anterior glenohumeral instability events.
        Am J Sports Med. 2019; 47: 1082-1089
        • Nakagawa S.
        • Iuchi R.
        • Hanai H.
        • Hirose T.
        • Mae T.
        The development process of bipolar bone defects from primary to recurrent instability in shoulders with traumatic anterior instability.
        Am J Sports Med. 2019; 47: 695-703
        • Itoi E.
        • Hatakeyama Y.
        • Sato T.
        • et al.
        Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial.
        J Bone Joint Surg Am. 2007; 89: 2124-2131
        • Itoi E.
        • Hatakeyama Y.
        • Kido T.
        • et al.
        A new method of immobilization after traumatic anterior dislocation of the shoulder: A preliminary study.
        J Shoulder Elbow Surg. 2003; 12: 413-415
        • Whelan D.B.
        • Kletke S.N.
        • Schemitsch G.
        • Chahal J.
        Immobilization in external rotation versus internal rotation after primary anterior shoulder dislocation: A meta-analysis of randomized controlled trials.
        Am J Sports Med. 2016; 44: 521-532
        • 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; : CD004962
        • 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
        • Jordan R.W.
        • Saithna A.
        • Old J.
        • MacDonald P.
        Does external rotation bracing for anterior shoulder dislocation actually result in reduction of the labrum? A systematic review.
        Am J Sports Med. 2015; 43: 2328-2333
        • Braun C.
        • McRobert C.J.
        Conservative management following closed reduction of traumatic anterior dislocation of the shoulder.
        Cochrane Database Syst Rev. 2019; 5: CD004962
        • Shinagawa K.
        • Sugawara Y.
        • Hatta T.
        • Yamamoto N.
        • Tsuji I.
        • Itoi E.
        Immobilization in external rotation reduces the risk of recurrence after primary anterior shoulder dislocation: A meta-analysis.
        Orthop J Sports Med. 2020; 8 (2325967120925694)
        • Hurley E.T.
        • Fried J.W.
        • Alaia M.J.
        • Strauss E.J.
        • Jazrawi L.M.
        • Matache B.A.
        Immobilisation in external rotation after first-time traumatic anterior shoulder instability reduces recurrent instability: A meta-analysis.
        J ISAKOS. 2021; 6: 22-27
        • Hurley E.T.
        • Montgomery C.
        • Jamal M.S.
        • et al.
        Return to play after the Latarjet procedure for anterior shoulder instability: A systematic review.
        Am J Sports Med. 2019; 47: 3002-3008
        • Ciccotti M.C.
        • Syed U.
        • Hoffman R.
        • Abboud J.A.
        • Ciccotti M.G.
        • Freedman K.B.
        Return to play criteria following surgical stabilization for traumatic anterior shoulder instability: A systematic review.
        Arthroscopy. 2018; 34: 903-913
        • Riff A.J.
        • Frank R.M.
        • Sumner S.
        • et al.
        Trends in shoulder stabilization techniques used in the United States based on a large private-payer database.
        Orthop J Sports Med. 2017; 5 (2325967117745511)
        • Mahure S.A.
        • Mollon B.
        • Capogna B.M.
        • Zuckerman J.D.
        • Kwon Y.W.
        • Rokito A.S.
        Risk factors for recurrent instability or revision surgery following arthroscopic Bankart repair.
        Bone Joint J. 2018; 100-B: 324-330
        • Dekker T.J.
        • Peebles L.A.
        • Bernhardson A.S.
        • et al.
        Limited predictive value of the Instability Severity Index Score: Evaluation of 217 consecutive cases of recurrent anterior shoulder instability.
        Arthroscopy. 2021; 37: 1381-1391
        • Bois A.J.
        • Mayer M.J.
        • Fening S.D.
        • Jones M.H.
        • Miniaci A.
        Management of bone loss in recurrent traumatic anterior shoulder instability: A survey of North American surgeons.
        JSES Int. 2020; 4: 574-583
        • Klemt C.
        • Toderita D.
        • Nolte D.
        • Di Federico E.
        • Reilly P.
        • Bull A.M.J.
        The critical size of a defect in the glenoid causing anterior instability of the shoulder after a Bankart repair, under physiological joint loading.
        Bone Joint J. 2019; 101-B: 68-74
        • Brown L.
        • Rothermel S.
        • Joshi R.
        • Dhawan A.
        Recurrent instability after arthroscopic Bankart reconstruction: A systematic review of surgical technical factors.
        Arthroscopy. 2017; 33: 2081-2092
        • Bokshan S.L.
        • DeFroda S.F.
        • Gil J.A.
        • Badida R.
        • Crisco J.J.
        • Owens B.D.
        The 6-O'clock anchor increases labral repair strength in a biomechanical shoulder instability Model.
        Arthroscopy. 2019; 35: 2795-2800
        • Coughlin R.P.
        • Bullock G.S.
        • Shanmugaraj A.
        • et al.
        Outcomes after arthroscopic rotator interval closure for shoulder instability: A systematic review.
        Arthroscopy. 2018; 34: 3098-3108, e3091
        • Provencher M.T.
        • Peebles L.A.
        Editorial Commentary: Rotator interval closure of the shoulder continues to be a challenge in consensus on treatment.
        Arthroscopy. 2018; 34: 3109-3111
        • Hohmann E.
        • Brand J.C.
        • Rossi M.J.
        • Lubowitz J.H.
        Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus.
        Arthroscopy. 2018; 34: 349-351