Shoulder Lesions: Understanding and Managing Shoulder Lesions, especially Hill-Sachs/Bankart lesions.

What are Shoulder Lesions? 

Shoulder lesions are injuries or abnormalities in the structures of the shoulder joint. These lesions can affect bones, tendons, ligaments, and other soft tissues, leading to pain, instability, and limited function. The term “lesion” broadly encompasses various types of damage within the shoulder.

Types of Shoulder Lesions

There are various conditions referred to as Shoulder lesions. These include:

  • Labral Tears:
    • Bankart Lesion: A tear of the anterior-inferior part of the glenoid labrum, often associated with anterior shoulder dislocations.
    • SLAP Lesion: Abbreviation for Superior Labral Anterior to Posterior tear, involving the top part of the labrum where the biceps tendon attaches. It is common in overhead athletes.
  • Hill-Sachs Lesion:
    • A Hill-Sachs Lesion is a compression fracture on the posterolateral aspect of the humeral head often occurs with anterior shoulder dislocations.
  • Rotator Cuff Tears:
    • Damage to one or more of the rotator cuff tendons (supraspinatus, infraspinatus, teres minor, subscapularis). They can be partial or full-thickness tears.
  • Bursitis:
    • When the small fluid-filled sac, known as the bursa, that reduces friction between bones and soft tissues, becomes inflammed. It commonly affects the subacromial bursa.
  • Shoulder Impingement Syndrome:
    • When the rotator cuff tendons are compressed or “impinged” under the acromion (part of the shoulder blade), causing pain and inflammation.
  • Fractures:
    • Clavicle Fracture: Break of the collarbone.
    • Humeral Head Fracture: Break of the top part of the arm bone.
    • Glenoid Fracture: Break of the socket part of the shoulder blade.
  • Capsular Injuries:
    • Damage to the shoulder capsule, which is the fibrous tissue surrounding the joint.
  • Instability:
    • General term for various conditions where the shoulder feels loose or dislocates easily, often due to labral tears or ligament injuries.
Shoulder Lesion
Shoulder Injury

Prevalence of Hill-Sachs and Bankart Lesions 

The prevalence of Hill-Sachs and Bankart lesions varies depending on the population and the specific circumstances of shoulder dislocations. Here are some general statistics:

Hill-Sachs Lesion

  • Prevalence: Hill-Sachs lesions are found in approximately 35% to 40% of first-time anterior shoulder dislocations. In cases of recurrent dislocations, the prevalence can be much higher, with some studies reporting rates of 80% to 100%.

Bankart Lesion

  • Prevalence: Bankart lesions are present in about 85% to 90% of first-time anterior shoulder dislocations. The prevalence of Bankart lesions in individuals with recurrent shoulder instability is similarly high.

These statistics underscore the commonality of these lesions in shoulder dislocations and highlight the importance of proper diagnosis and treatment to manage shoulder stability effectively.

Symptoms and Causes of Hill-Sachs and Bankart Shoulder Lesions 

Hill-Sachs Lesion

Symptoms:

  • Pain: Often occurs immediately after the shoulder dislocation and may persist as a dull ache or sharp pain with certain movements.
  • Reduced Range of Motion: Difficulty moving the shoulder, particularly with external rotation and overhead activities.
  • Instability: Feeling that the shoulder might “slip” or dislocate again.
  • Crepitus: A grinding or popping sensation during shoulder movements.

Causes:

  • Traumatic Shoulder Dislocation: Usually occurs when the shoulder is forced out of its socket, commonly due to falls, sports injuries, or accidents.
  • Recurrent Dislocations: Once a Hill-Sachs lesion is present, it increases the likelihood of future dislocations, which can further exacerbate the lesion.

Bankart Lesion

Symptoms:

  • Pain: This is often felt deep in the shoulder, especially with overhead movements or when the arm is placed in certain positions.
  • Instability: A noticeable feeling of looseness in the shoulder, particularly during activities that involve lifting the arm.
  • Weakness: Reduced shoulder strength makes it difficult to perform everyday tasks.
  • Catching or Locking: Sensation of the shoulder catching or locking up during movement.

Causes:

  • Traumatic Shoulder Dislocation: Typically caused by a significant force that displaces the shoulder, tearing the labrum from the glenoid rim.
  • Repetitive Overhead Activities: For example throwing or swimming can contribute to labrum tears over time.
  • Falls: Impact from falling onto an outstretched arm or directly on the shoulder.
  • Direct Blows: A strong impact to the shoulder, often seen in contact sports.

What is the Relationship Between Hill-Sachs and Bankart Lesions?

Hill-Sachs and Bankart lesions are closely related and often occur together due to the nature of shoulder dislocations, particularly anterior dislocations. Here’s how they are connected:

Common Cause:

Both lesions typically result from a traumatic anterior shoulder dislocation. During this type of dislocation, the humeral head is forced out of the glenoid (socket of the shoulder blade).

  • Mechanism of Injury:
    • Hill-Sachs Lesion: Occurs when the humeral head impacts against the anterior edge of the glenoid during dislocation, causing a compression fracture on the posterolateral aspect of the humeral head.
    • Bankart Lesion: Happens when the dislocating force causes a tear of the anterior-inferior part of the glenoid labrum, where the labrum is pulled away from the glenoid.
  • Combined Occurrence:
    • High prevalence Together: 
    • Studies have shown that a significant percentage of patients with anterior shoulder dislocations have both lesions. It is estimated that up to 90% of individuals with recurrent anterior shoulder dislocations have a Bankart lesion, and many of these also have a Hill-Sachs lesion.
    • Functional Impact: The presence of both lesions complicates the shoulder’s stability. The Hill-Sachs lesion represents a defect in the humeral head that can engage with the glenoid 
    • rim, while the Bankart lesion involves a loss of the labral bumper effect, leading to an increased risk of recurrent dislocations.
  • Treatment Considerations:
    • When both lesions are present, treatment plans often must address both issues to restore shoulder stability. This may involve surgical repair of the Bankart lesion (reattaching the labrum to the glenoid) and procedures to address the Hill-Sachs lesion (e.g., filling the defect or bone grafting).

 Their combined presence exacerbates shoulder instability, necessitating comprehensive treatment strategies to manage both lesions and prevent recurrent dislocations. Access Ortho offers urgent care for acute shoulder injuries. 

Potential Complications of Hill-Sachs and Bankart Lesions

The potential complications of Hill-Sachs and Bankart lesions depend on whether the injury occurs in isolation or in combination with the other.  

Hill-Sachs Lesion Complications:

  • Recurrent Shoulder Dislocations: Increased likelihood due to persistent instability.
  • Engaging Lesion: Severe cases may cause the shoulder to lock or subluxate.
  • Chronic Shoulder Pain: Ongoing pain, especially with overhead movements.
  • Reduced Range of Motion: Stiffness and difficulty with daily activities.

Bankart Lesion Complications:

  • Recurrent Shoulder Instability: Frequent dislocations or subluxations.
  • Glenoid Labrum Damage: Further damage with repeated dislocations.
  • Glenohumeral Arthritis: Risk of arthritis from chronic instability.
  • Muscle Atrophy and Weakness: Reduced shoulder function due to muscle disuse.

Combined Complications:

  • Increased Risk of Recurrent Dislocations: Higher likelihood with both lesions.
  • Complex Surgical Repairs: More complicated treatment is required.
  • Prolonged Recovery: Longer rehabilitation process.
  • Higher Risk of Chronic Pain and Dysfunction: Persistent pain and functional limitations.

Both Hill-Sachs and Bankart lesions can severely impact shoulder stability and function, with compounded effects when both are present. Proper management is essential to mitigate these complications.

Diagnosing Shoulder Lesions, including Diagnostic Methods for Shoulder Lesions

Diagnosis of Shoulder Lesion is through a combination of the following: 

Clinical Evaluation:

  • Patient History:
    • Details about the injury mechanism, frequency of dislocations, and any previous shoulder problems.
    • Symptoms such as pain, instability, weakness, and range of motion issues.
  • Physical Examination:
    • Inspection: Checking for visible deformity, swelling, or muscle atrophy.
    • Palpation: Feeling for tenderness around the shoulder.
    • Range of Motion Tests: Assessing active and passive movements.
    • Stability Tests:
      • Apprehension Test: Evaluating the patient’s reaction to placing the arm in a position that might cause dislocation.
      • Relocation Test: Applying pressure to the shoulder to see if it relieves symptoms of instability.

Imaging Studies:

  • X-rays:
    • Hill-Sachs Lesion: Often visible as a dent or compression fracture. It occurs on the posterolateral aspect of the humeral head.
    • Bankart Lesion: This may show displacement of the humeral head or associated bone fragment (bony Bankart lesion).
  • Magnetic Resonance Imaging (MRI):
    • Hill-Sachs Lesion: Provides detailed images of the bone defect and associated soft tissue injuries.
    • Bankart Lesion: Clearly shows the tear or detachment of the glenoid labrum and any associated damage to the surrounding structures.
  • Computed Tomography (CT) Scan:
    • Offers a more detailed view of the bone structure and is particularly useful for assessing the extent of a Hill-Sachs lesion.
  • Arthroscopy:
    • Diagnostic Arthroscopy: An invasive procedure in which a small camera is used to directly visualise and assess the extent of the lesions. The camera is inserted through the skin into the shoulder joint. This can be particularly useful if imaging studies are inconclusive.

These methods help determine the presence and extent of the lesions, guiding appropriate treatment strategies.

Shoulder Lesion

Managing and Treating Hill-Sachs and Bankart Lesions

The management and treatment of Hill-Sachs and Bankart Lesions varies depending on the type and extent of the injury. 

Hill-Sachs Lesion

Non-Surgical Treatment:

  • Physiotherapy:
    • Focus on strengthening the rotator cuff stabilising muscles to enhance shoulder stability.
    • Exercises to prevent stiffness and improve flexibility.
    • Proprioceptive training to improve shoulder joint awareness and control.
  • Activity Modification:
    • Avoiding activities that place the shoulder in vulnerable positions, particularly overhead or contact sports, until stability is restored.

Surgical Treatment:

  • Arthroscopic Remplissage:
    • Filling the Hill-Sachs defect with the infraspinatus tendon and posterior capsule to prevent engagement with the glenoid rim.
  • Bone Grafting:
    • Using bone grafts to fill large Hill-Sachs defects, restoring the contour of the humeral head.
  • Humeral Head Resurfacing:
    • Resurfacing or partial shoulder replacement for severe cases where the defect significantly affects joint function.

Bankart Lesion

Non-Surgical Treatment:

  • Immobilisation:
    • Using a sling for a few weeks post-injury to allow healing and reduce pain.
  • Physiotherapy:
    • Strengthening exercises for the surrounding muscles.
    • Gradual reintroduction of activities to improve range of motion and function.

Surgical Treatment:

  • Arthroscopic Bankart Repair:
    • Reattaching the torn labrum to the glenoid rim using suture anchors.
    • It is minimally invasive and allows for quicker recovery compared to open surgery.
  • Open Bankart Repair:
    • Traditional surgical approach for severe cases or when arthroscopy is not feasible.
    • Provides strong repair and stability but requires longer recovery time.
  • Latarjet Procedure:
    • Transfer of the coracoid process to the anterior glenoid to provide additional stability, often used for recurrent dislocations or when there is significant bone loss.

Combined Treatment Approach

When both Hill-Sachs and Bankart lesions are present, a combined approach may be necessary:

  • Comprehensive Surgical Repair:
    • Addressing both lesions in a single surgery to restore overall shoulder stability.
    • Combining techniques like arthroscopic Bankart repair with remplissage or bone grafting.
  • Rehabilitation:
    • Customised physiotherapy program focusing on both stability and range of motion.
    • Gradual progression from passive to active exercises, emphasising strengthening and proprioception.

A tailored rehabilitation program is essential for optimal recovery and preventing recurrence. Access Ortho will offer a comprehensive assessment and treatment plan for patients with these injuries.

Outlook and Prognosis for Hill-Sachs and Bankart Lesions, including recovery time

The outlook and recovery time for these injuries vary depending on the injury and management. 

Hill-Sachs Lesion

Outlook:

  • Mild Lesions: Many patients can achieve good shoulder stability and function without surgery with proper management.
  • Severe Lesions: Surgical intervention can significantly improve outcomes, but the prognosis depends on the extent of the lesion and the success of the repair.

Recovery Time:

  • Non-Surgical Treatment: Typically, 3-6 months of physiotherapy to regain strength and range of motion.
  • Surgical Treatment:
    • Remplissage/Bone Grafting: Approximately 6-12 months for full recovery.
    • Return to sports and high-demand activities can take 6-9 months or longer, depending on the individual’s progress.

Bankart Lesion

Outlook:

  • First-time Dislocations: Good prognosis with appropriate management, especially if surgical repair is performed for recurrent instability.
  • Recurrent Dislocations: Surgery often yields positive outcomes, reducing the risk of further dislocations and improving shoulder function.

Recovery Time:

  • Non-Surgical Treatment: Typically 3-6 months, focusing on strengthening and stability exercises.
  • Surgical Treatment:
    • Arthroscopic Bankart Repair: 4-6 months for full recovery.
    • Open Bankart Repair: 6-9 months due to a longer healing process and rehabilitation.
    • Return to sports usually takes 6-9 months, depending on the stability and strength achieved during rehabilitation.

Combined Treatment and Recovery

When both Hill-Sachs and Bankart lesions are present, the recovery process may be more complex:

Surgical Treatment:

  • Comprehensive Repair: Combining procedures like arthroscopic Bankart repair with remplissage or bone grafting.
  • Rehabilitation: A tailored program focusing on restoring range of motion, strength, and stability.

Recovery Time:

  • Typically ranges from 6-12 months for full recovery.
  • Return to sports and high-demand activities can take 9-12 months or longer, depending on the extent of the injuries and the success of the rehabilitation process.

The outlook for Hill-Sachs and Bankart lesions is generally positive with appropriate treatment. Non-surgical management may suffice for mild cases, while surgical intervention is often required for severe or recurrent injuries. Recovery times vary, with full recovery typically taking 6-12 months, and return to sports or high-demand activities can take longer. Patient compliance with rehabilitation is crucial for optimal outcomes. Access Ortho offers specialist orthopaedic care for patients with acute injuries.

Shoulder Lesion
Assessment of Shoulder

When to Seek Medical Attention for Shoulder Lesions and the Importance of Early Diagnosis

Situations Requiring Immediate Medical Attention:

  • Acute Shoulder Dislocation:
    • Immediate evaluation is crucial if you experience a shoulder dislocation. The shoulder needs to be relocated by a medical professional to prevent further damage.
    • Severe pain, deformity, and inability to move the shoulder are key signs that immediate medical attention is needed.
  • Severe Pain:
    • Intense, unrelenting shoulder pain that does not improve with rest or over-the-counter pain medication warrants prompt medical evaluation.
    • Pain associated with swelling, bruising, or a visible deformity also requires urgent attention.
  • Instability:
    • Frequent or recurrent episodes of the shoulder feeling like it is slipping out of place or actually dislocating should be evaluated by a healthcare provider.
    • Sensation of shoulder instability during everyday activities or sports indicates that you need medical advice.
  • Reduced Range of Motion:
    • Significant limitations in shoulder movement or stiffness that affects daily activities and does not improve with rest or basic exercises should be assessed by a medical professional.
    • Difficulty performing tasks that require reaching overhead or behind your back.
  • Weakness or Numbness:
    • Noticeable weakness in the shoulder or arm or numbness and tingling, especially after a shoulder injury, should prompt medical evaluation.
    • These symptoms could indicate nerve involvement or other complications requiring medical intervention.
  • Persistent Swelling or Bruising:
    • Ongoing swelling or bruising around the shoulder area that does not subside with conservative measures such as icing and rest.
    • Signs of infection, for example redness, warmth, or fever, in conjunction with shoulder pain or swelling.

Long-Term Symptoms Requiring Medical Attention:

  • Chronic Pain:
    • Shoulder pain lasting more than a few weeks should be evaluated, especially if it interferes with sleep, work, or recreational activities.
    • Pain that worsens with specific movements or activities.
  • Recurrent Dislocations:
    • Multiple shoulder dislocations or a feeling of the shoulder “giving way” repeatedly are strong indicators that you need to see a specialist.
    • History of shoulder dislocations leading to apprehension or fear of certain movements.
  • Impact on Quality of Life:
    • If shoulder issues significantly affect your quality of life, ability to perform daily activities, or participation in sports, seeking medical advice is important.

Seek rapid medical attention if you experience acute dislocation, severe pain, instability, reduced range of motion, weakness, numbness, persistent swelling, or signs of infection. This care should be provided by the Emergency Department if you cannot relocate the shoulder or if you have weakness or numbness. Access Ortho will offer rapid appointments for other acute concerns. 

If you have long-term chronic pain, you are best to see your GP first, and they can determine what care will be best for you. 

Early diagnosis and treatment is important to prevent further damage and improve outcomes.

Frequently Asked Questions About Shoulder Lesions

What’s the difference between a shoulder lesion and a rotator cuff tear?

Shoulder Lesion: Refers to any damage or injury to the shoulder structures, including the labrum (e.g., Bankart and SLAP lesions), the humeral head (e.g., Hill-Sachs lesion), or other soft tissues and bone structures.

Rotator Cuff Tear: Specifically involves the rotator cuff muscles and tendons (supraspinatus, infraspinatus, teres minor, and subscapularis). Rotator cuff tears can be partial or full-thickness and affect shoulder stability and function.

Can shoulder lesions be cancerous?

Most shoulder lesions are not cancerous and result from trauma or repetitive stress. However, in rare cases, bone lesions or masses in the shoulder area could be indicative of malignancy, such as bone tumours or metastatic cancer. A biopsy or further testing may be needed if a tumour is suspected.

How do SLAP lesions differ from other shoulder lesions?

SLAP Lesion: Stands for Superior Labral Anterior to Posterior lesion, which involves a tear of the labrum where it attaches to the biceps tendon. It is different from Bankart lesions, which affect the anterior-inferior part of the labrum. SLAP lesions are often associated with overhead activities and can cause pain, clicking, and shoulder instability.

What are the most common symptoms of shoulder lesions?
  • Pain: Often localised to the shoulder joint or surrounding areas.
  • Instability: A feeling that the shoulder might dislocate or slip out of place.
  • Reduced Range of Motion: Difficulty moving the shoulder through its full range.
  • Weakness: Decreased strength, particularly with overhead activities.
  • Clicking or Popping: Sensation or sound during shoulder movements.

Are shoulder lesions more common in athletes?

Yes: Athletes, especially those involved in overhead sports (e.g., baseball, swimming, volleyball) or contact sports, are at higher risk for shoulder lesions due to the repetitive stress and potential for trauma. However, these injuries can also occur in non-athletes.

How are shoulder lesions treated without surgery?
  • Rest and Activity Modification: Avoiding activities that exacerbate symptoms.
  • Physiotherapy: Strengthening exercises, range-of-motion exercises, and proprioceptive training.
  • Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation.
  • Ice and Heat Therapy: To minimise swelling and relieve pain.
  • Injections: Corticosteroid or hyaluronic acid injections for pain relief and inflammation control.

Can shoulder lesions heal on their own?

Depends on the Lesion: Some mild shoulder lesions, like minor labral tears or strains, may improve with conservative treatment. However, more significant lesions, such as severe tears or recurrent dislocations, typically require medical intervention to fully heal and restore function.

How do shoulder lesions affect the range of motion?

Restricted Motion: Lesions often lead to pain, swelling, and instability, limiting the shoulder’s range of motion. For example, a torn labrum or rotator cuff can restrict the ability to move the shoulder freely and perform overhead or rotational movements.

What is the recovery process like after shoulder lesion surgery?
  • Immediate Post-Surgery: Includes immobilisation with a sling and pain management.
  • Rehabilitation: A structured physiotherapy program starts with passive range-of-motion exercises and progresses to active strengthening and functional exercises.
  • Timeline: Recovery typically ranges from 6-12 months, depending on the severity of the lesion and type of surgery. Full return to high-demand activities or sports may take longer.