Recurrent Anterior Shoulder Instability in a Collegiate Volleyball Player
A 22-year-old female collegiate volleyball player has had three anterior shoulder dislocations in 18 months, all during overhead play. Her Instability Severity Index Score (ISIS) is 5. Examination shows positive apprehension and relocation tests, Beighton score 2/9, and full strength. MRI shows a Bankart lesion with 5% glenoid bone loss and a small Hill-Sachs lesion. She wants to avoid surgery and return for the conference tournament in 8 weeks. She is otherwise healthy and has completed 4 weeks of physical therapy with persistent apprehension at 90/90.
1. Would you recommend nonoperative management or surgical stabilization? Explain the reasoning.
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Her ISIS of 5 and age under 25 predict a high recurrence rate with nonoperative care-roughly 50% or higher in young overhead athletes. With three dislocations in 18 months and persistent apprehension at 90/90 after 4 weeks of therapy, nonoperative management is unlikely to allow reliable return to competitive overhead volleyball.
I would recommend arthroscopic Bankart repair, with the caveat that 5% glenoid bone loss does not mandate a bony procedure. If she declines surgery, she needs a clear discussion of recurrence risk and a structured, criteria-based return-to-play plan rather than a fixed 8-week deadline.
2. If she chooses nonoperative care, what return-to-play criteria would you use, and how realistic is an 8-week timeline?
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Nonoperative return-to-play should not be calendar-driven. Criteria include pain-free full range of motion, symmetric strength (external rotation and scapular stabilizers), negative apprehension in provocative positions, and sport-specific overhead testing. A player with recurrent instability rarely meets these in 8 weeks; rushing back risks another dislocation and further bone loss.
If she chooses nonoperative care, emphasize scapular mechanics, rotator cuff endurance, and avoidance of the abducted externally rotated position early, with incremental throwing and hitting progression.
3. How would your recommendation change if glenoid bone loss were 20%?
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Glenoid bone loss of 20% or more, especially with an engaging Hill-Sachs lesion, shifts the decision toward an open or arthroscopic bony augmentation such as a Latarjet procedure rather than soft-tissue Bankart repair, because soft-tissue repair alone has higher failure rates with substantial bone loss. This would also change return-to-play timelines and counseling.