Age‐ and time‐specific management of traumatic anterior shoulder instability: The 2024 ESSKA–ESA Formal Consensus. Part 2: Treatment and return to sports

Abstract

Purpose

To establish age‐ and time‐specific recommendations for the treatment of traumatic anterior shoulder instability (TASI) and for return‐to‐sport (RTS) decision‐making through a formal consensus process among European experts.

Methods

The European Society of Sports Medicine, Knee Surgery and Arthroscopy–European Shoulder Associates (ESSKA–ESA) formal consensus methodology was followed. A steering group formulated 35 clinically relevant questions, 23 of which addressed treatment and RTS and are reported in Part 2. A structured literature review was conducted. Statements were drafted and graded based on the level of scientific support. Then, the rating group reviewed and refined the statements, followed by validation from the reader group for cultural adaptability. Recommendations were tailored by age group (adolescents, young adults and older adults) and timing of instability (first‐time vs. recurrent).

Results

The final global median (range) of the 23 questions was 9 (8–9). Eleven questions achieved strong agreement, 11 relative agreement and 1 uncertain agreement. The grades of recommendations were: A in 0 (0%) statements, B in 30 (35.3%) statements, C in 24 (28.2%) statements and D in 31 (36.5%) statements (each statement could have more than one grade of recommendation). Bone loss and soft tissue lesions were key factors in decision‐making. The consensus emphasized individualized thresholds for surgical versus conservative management, highlighting the role of bone augmentation in subcritical (bone loss 10%–15%) (especially in bipolar bone loss) and critical defects (bone loss >20%), lesion‐specific soft tissue repair and the limited role of immobilization. RTS criteria included pain‐free full range of motion, shoulder stability, strength and sport‐specific readiness, typically achieved between 4 and 6 months depending on the procedure and sport demands.

Conclusions

This ESSKA–ESA European Formal Consensus delivers practical, evidence‐ and experience‐based recommendations for treatment and RTS following TASI according to age‐ and time‐specific (first time and recurrent) scenarios. By integrating recurrence status, bone loss, soft tissue injury and sport type, the consensus provides a clinically valuable framework for individualized decision‐making.

Level of Evidence

Level II.

Abbreviations

ALSPA

anterior labral periosteal sleeve avulsion

ASA

arthroscopic subscapular augmentation

ASES

American Shoulder and Elbow Society

DAS

dynamic anterior stabilization

ESA

European Shoulder Associates

ESSKA

European Society of Sports Medicine, Knee Surgery and Arthroscopy

HAGHL

humeral avulsion of the glenohumeral ligament

ISAKOS

International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

RTS

return to sports

SLAP

superior labrum anterior–posterior

TASI

traumatic anterior shoulder instability

INTRODUCTION

Anterior shoulder dislocation or instability is one of the most frequent injuries encountered in sports medicine and orthopaedic practice, and it presents a particular challenge in terms of treatment and return‐to‐sport (RTS) decisions [1, 3, 5, 13, 15, 16, 20]. While most episodes occur in adolescents and young adults, the condition affects patients across all age groups, including recreational athletes and older adults [13, 14, 17, 18, 19]. The heterogeneity in patient profiles, ranging from contact and overhead athletes to middle‐aged workers and elderly individuals, makes clinical decision‐making complex. Furthermore, treatment strategies must consider not only age and recurrence status, but also the extent of bone loss, the presence of soft‐tissue lesions, the demands of the patient's sport or occupation and the timing within the competitive season [1, 4, 5, 6, 9, 10, 12, 20, 21].

Despite decades of research, the optimal treatment pathway for traumatic anterior shoulder instability (TASI) remains debated. Ongoing controversies include the role of early surgical intervention after first‐time dislocation, thresholds for bony procedures in cases of glenoid and humeral bone loss, indications for soft‐tissue repair and the value of immobilization and rehabilitation protocols. In addition, criteria for safe and effective RTS also vary widely across regions and specialities.

Several consensus initiatives, such as the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee consensus in 2010 [5], the American Shoulder and Elbow Surgeons (ASES) Neer Circle consensus in 2020 [20] and the Anterior Shoulder Instability International Consensus Group in 2022 [4], have provided essential guidance. However, none have systematically integrated age‐specific (a paramount parameter for a tailored management) considerations or sport‐related factors into treatment and RTS recommendations.

The present article constitutes the second part of the European Society of Sports Traumatology, Knee Surgery and Arthroscopy—European Shoulder Associates (ESSKA–ESA) Formal Consensus on TASI, developed through a structured methodology based on iterative rounds of discussion and voting among European experts. Part 1 addressed diagnosis, including history‐taking, physical examination and imaging [2]. The current Part 2 focuses on treatment strategies—both surgical and conservative—and on RTS criteria across three age groups: adolescents, young adults and older adults.

The full text, including the detailed literature summaries and complete reference list, is available at: https://esskaeducation.org/esska-consensus-projects.

METHODS

Definitions

The definitions of TASI, shoulder hypermobility, generalized joint hypermobility and related terms, the different age groups and timing of dislocation have been precisely defined in the Part‐1 article [2]. For clarification purposes, the differentiation between dislocation and instability is provided in this section.

The present study will cover the TASI. Instability does not equal dislocation. Anterior shoulder dislocation occurs when the humeral head displaces anteriorly or anterior‐inferiorly past the rim of the glenoid (the humeral head is completely out of the glenoid), regardless of its ability to self‐reduce or not. In some instances, the humeral head can moves up to the rim of the glenoid and then come back in a centred position quickly, a phenomenon defined as subluxation.

Shoulder instability is that condition in which the joint (the glenohumeral joint) is unable to function appropriately because of damaged static and/or dynamic stabilizers (labrum, capsule, ligaments, cartilage, bones and tendon/muscles) leading to either dislocation or subluxations. The mechanism of injury is defined as traumatic when there is a specific moderate‐ or high‐energy force applied directly (to the posterior shoulder and directed anteriorly) or indirectly (generally in an abducted and externally rotated shoulder position) into the shoulder (glenohumeral joint) causing the dislocation or subluxation.

Traumatic dislocations or subluxations generally occur during sports activity but can also occur in heavy labour conditions or after any accidental fall.

Episodes of complete dislocation or subluxations may occur as first‐time or recurrent situations, although traumatic subluxations may be more common in the latter scenario.

The present consensus covers both dislocation and subluxations situations, provided they are traumatic in origin.

Methodology

The consensus followed the formal consensus methodology developed by the French National Healthcare Institution (Haute Autorité de Sante) [11] and adopted by ESSKA [7, 8]. A comprehensive description of the methodology followed in the present consensus project has been reported in Part 1 [2].

The present article (Part 2) included 23 of the 35 questions. Those questions were related to the treatment and RTS. Questions #11, #12, #14, #15, #17 and #18 (classified in the Associated injuries section of Imaging studies—Section C) were included here as they pertain directly to treatment indications.

RESULTS

Eleven questions‐statements received consensus approval after the first round (strong agreement without the need for a second round). No questions were excluded (inappropriate). After the second round, the final global median (range) of the 23 questions was 9 (8–9). There were 11 questions with strong agreement, 11 questions with relative agreement and 1 with uncertain agreement. The grades of recommendations were A in 0 (0%) statements, B in 30 (35.3%) statements, C in 24 (28.2%) statements and D in 31 (36.5%) statements (some statements included several grades).

Finally, the reader group confirmed the applicability of the recommendations across 13 European countries.

Questions and answers

Imaging studies:

Associated injuries

Question #11:

What is the glenoid bone defect cut‐off to indicate a bony procedure (bone block or Latarjet) in first‐time anterior dislocation according to each specific age subgroup?

Displaced acute glenoid fractures should be fixed, particularly in adolescents and young adults (Grade C).

In cases of glenoid bone resorption from a previous fracture seen a long time after the first‐time dislocation, the percentage of bone defect should be quantified. A bony procedure is recommended in cases of a glenoid bone defect, with a cut‐off of 20% in adolescents and young adults (Grade B).

Patients with subcritical bone loss (10%–15%) may require a bony procedure, especially in cases of significant bipolar bony injuries or other risk factors (Grade C).

Some surgeons would recommend a bony procedure even in the absence of measurable glenoid bone loss (Grade D).

Older adults

There is no clear cut‐off value for older adults, as glenoid bone defects are generally better tolerated in this group and associated with lower recurrence rates (Grade D).

Median (Range): 8 (5–9). Relative agreement.

Question #12:

What is the glenoid bone defect cut‐off to indicate a bony procedure (bone block or Latarjet) in recurrent anterior dislocation?

A glenoid bone defect of 15%–20% is generally accepted as a cut‐off to indicate bony procedures across all age groups in recurrent dislocations. However, the cut‐off might be decreased in the youngest (adolescent) patients with other risk factors or increased in older adult patients without other risk factors (high‐level contact or collision sports, high number of instability episodes and/or associated Hill–Sachs lesion (Grade B).

Some surgeons may recommend a bony procedure (bone block or Latarjet) even in the absence of measurable bone loss (Grade D).

Median (Range): 9 (6–9). Relative agreement.

Question #14:

What is the Hill–Sachs lesion size cut‐off to indicate an associated procedure (i.e., remplissage or bony procedure) in first‐time anterior dislocation?

Hill–Sachs lesions should be evaluated using the glenoid track concept. In the absence of glenoid bone loss, off‐track Hill–Sachs lesions indicate the necessity for an associated procedure (Grade B).

The consensus group cannot propose any cut‐off value to indicate an associated surgical procedure for first‐time dislocations. Most off‐track Hill–Sachs lesions are converted to an on‐track lesion after bony procedures of the glenoid (Grade B).

Adolescents

The threshold for recommending an additional procedure (i.e., a remplissage) is lower in adolescents compared to older age groups (Grade D).

Median (Range): 8 (6–9). Relative agreement.

Question #15:

What is the Hill–Sachs lesion size cut‐off to indicate an associated procedure (i.e., remplissage or bony procedure) in recurrent anterior dislocation?

Although a cut‐off value of 20%–25% of Hill–Sachs lesions has been suggested, this number is not adequately supported in the existing literature (Grade C).

The consensus group cannot provide a cut‐off value of Hill–Sachs lesions upon which an associated procedure is recommended. Because of the recurrent nature of the instability, a lower threshold should be applied to indicate an additional procedure (i.e., a remplissage or bony procedure), particularly in the adolescent and young adult groups (Grade D). Therefore, the glenoid track, individual patient factors (including age, sports and activity levels) and associated injuries other than the Hill–Sachs lesions (bipolar bone loss) must be evaluated when considering an additional procedure (Grade B).

Median (Range): 9 (6–9). Relative agreement.

Question #17:

What soft tissue injuries are indications for surgical treatment in first‐time anterior shoulder dislocation according to each specific age subgroup?

Adolescents and young adults

Humeral avulsion of the glenohumeral ligament (HAGL lesion) should be considered an indication for surgical treatment in first‐time dislocations. In addition, other labral injuries (Bankart, anterior labrolitamentous periosteal sleeve avulsion [ALPSA], Perthes, glenolabral articular disruption) could be considered for surgical treatment in patients with high risk of recurrence, particularly in adolescents (Grade C).

If soft tissue surgery is performed in the context of instability, any additional superior labrum anterior to posterior (SLAP) tear type equal to or more than II may be addressed (Grade D). Concomitant full‐thickness rotator cuff tears should be repaired in younger age groups (Grade B).

Older adults

After a first‐time dislocation in this age group, surgical treatment is strongly recommended in case of a concomitant acute or acute‐on‐chronic full‐thickness rotator cuff tear (Grade B).

If the cuff can be successfully repaired, no stabilizing or functional benefit seems to be added by performing a labral repair. The consensus group cannot recommend surgical treatment of an isolated anterior capsulolabral tear after a first‐time shoulder dislocation in this age group (Grade C). Median (Range): 9 (7–9). Strong agreement.

Question #18:

What soft tissue injuries are indications for surgical treatment in recurrent shoulder dislocation according to each specific age group?

Adolescents and young adults

Recurrent anterior shoulder dislocation is an indication for surgery if an evident soft tissue injury can be identified (Grade B).

If soft tissue surgery is performed in the context of instability, any additional SLAP tear types equal to or more than two may be addressed (Grade D).

Concomitant full‐thickness rotator cuff tears, particularly in the young adult population, should be repaired in association with labral injuries (Grade B).

Older adults

In the setting of recurrent anterior instability and concomitant full‐thickness rotator cuff tear, if the cuff can be successfully repaired, no stabilizing or functional benefit seems to be added by performing a labral repair (Grade C).

Median (Range): 9 (5–9). Relative agreement.

Treatment:

Conservative treatment:

Question 19:

Is immobilization recommended after first‐time anterior shoulder dislocation (yes/no, type, position and timing)?

Adolescents and young adults

Immobilization in a sling is recommended for pain management. However, early mobilization within the first week may yield similar results to using a sling for 3 weeks.

The preferred type of immobilization is internal rotation. Evidence in the literature on the effectiveness of immobilization in external rotation remains inconclusive (Grade C).

Older adults

No comparative studies on this subject have been published for older people. Immobilization is recommended for pain management until concomitant injuries have been excluded (Grade C).

Median (Range): 9 (5–9). Relative agreement.

Question #20:

Is immobilization recommended after recurrent anterior shoulder dislocation (yes/no, type, position and timing)?

Most patients with recurrent anterior shoulder dislocation should be offered surgical treatment.

There is no evidence in favour of immobilization after recurrent anterior shoulder dislocation. A simple sling should be recommended for short‐term (1–2 weeks) pain management (Grade C).

Median (Range): 9 (6–9). Relative agreement.

Question #21:

Is rehabilitation recommended after first‐time anterior shoulder dislocation (yes/no, timing and goal)?

There is a lack of evidence supporting any specific answer to this question. Rehabilitation is recommended after first‐time dislocation, regardless of whether surgery is planned (Grade D). Following the period of immobilization, a pain‐controlled passive range of motion is started with gradual progress to active‐assisted exercises. When pain allows, periscapular and rotator cuff muscle strengthening can begin. Concomitant injuries must be ruled out at this phase (Grade D).

Median (Range): 9 (7–9). Strong agreement.

Question #22:

Is rehabilitation recommended after recurrent anterior shoulder dislocation (yes/no, timing and goal)?

Surgical treatment is generally recommended for recurrent anterior shoulder dislocation.

There is a lack of evidence supporting any specific answer to this question. In cases of recurrent anterior shoulder dislocation, particularly among contact and collision athletes, a rehabilitation programme is unlikely to be sufficient to achieve shoulder stability. As a preoperative management, rehabilitation may be useful to achieve pain‐free shoulder function for daily activities. The patient should start passive and active‐assisted exercises as soon as pain is tolerated, followed by proprioceptive and strengthening exercises for the rotator cuff, deltoid and periscapular muscles. Rehabilitation is also helpful to prepare patients for rehabilitation after surgery (Grade C).

Median (Range): 9 (6–9). Relative agreement.

Question #23:

What are the criteria to return to sports after anterior shoulder dislocation treated conservatively?

The main criteria to define the return of a patient suffering from an anterior shoulder dislocation treated conservatively to sporting activity (recreational or competitive) are the following:

‐ Obtaining a full pain‐free range of motion.

‐ Clinically stable shoulder with negative apprehension test.

‐ Adequate muscular strength and endurance.

The patient's return to sport is advised when all these criteria are met. In most cases, this is achieved after 6–16 weeks post‐traumatic (Grade C). In individual cases, return to sport might be allowed even with minor loss of external rotation or residual apprehension (Grade D).

Median (Range): 9 (7–9). Strong agreement.

Surgical treatment:

Question #24:

What are the indications/contraindications for soft tissue procedure after first‐time anterior shoulder dislocation?

When surgery is indicated after a first‐time anterior shoulder dislocation, the surgical technique might be either a soft tissue procedure or a bony procedure. Acute surgical stabilization of first‐time anterior shoulder dislocation in young, active patients is more effective than conservative treatment at long‐term follow‐up, based on lower recurrence rate, better return to sports and higher patient‐perceived improvement. The literature does not specify clear indications and contraindications for soft tissue procedures following first‐time anterior shoulder dislocation in older adult patients.

Some surgeons would recommend systematic bony procedures and have no indications for soft‐tissue procedures (Grade D).

Indications for soft tissue procedures in first‐time anterior shoulder dislocation are:

‐ Injury of the capsulolabral complex, including the anterior inferior glenohumeral ligament without critical (>15%) glenoid bone loss, requires a Bankart procedure. Bony Bankart fractures of a size that cause acute instability and new dislocations after the reduction should be reduced and fixed in the acute phase if unstable post‐reduction (Grade B).

‐ HAGL lesions require repair at the humeral insertion (Grade B).

‐ Additional remplissage procedure is recommended in cases of an off‐track Hill–Sachs lesion (Grade B).

‐ Posterior labral tears may be addressed concurrently (Grade D).

‐ ALPSA lesion must be released and mobilized to the glenoid rim before fixation, as they represent an increased risk of recurrence compared to a Bankart lesion (Grade B).

‐ Arthroscopic subscapular augmentation (ASA) may be considered in hyperlax patients (Grade C).

‐ Dynamic anterior stabilization (DAS) may be considered in cases of subcritical glenoid bone loss (Grade D).

‐ Patients with a full‐thickness rotator cuff tear as a consequence of an anterior shoulder dislocation needs a rotator cuff repair to stabilize the joint and prevent degenerative changes. This is the main indication for a soft tissue procedure in the older adult group, and the most performed procedure is rotator cuff repair and not labral repair (Grade B).

Contraindications for soft tissue procedures in first‐time anterior shoulder dislocation:

‐ Severe humeral, glenoid or bipolar bone loss (Grade B).

‐ Advanced osteoarthritis (Grade B).

Special attention is needed in patients with collagen disorders (e.g., Marfans, Ehlers–Danlos, Down Syndrome).

Median (range): 9 (5–9). Relative agreement.

Question #25:

What are the indications/contraindications for soft tissue procedures after recurrent traumatic anterior shoulder dislocation?

Surgical stabilization is indicated in most patients suffering from recurrent anterior shoulder instability. The surgical technique might be either a soft tissue procedure or a bony procedure. An increasing number of dislocations will lower the threshold for additional soft tissue procedures or bony procedures. Soft tissue procedures such as open and arthroscopic Bankart repair have proven to reduce the recurrence rate in anterior shoulder dislocation.

Some surgeons would recommend systematically bony procedures and have no indications for soft‐tissue procedures (Grade D).

Indications for soft tissue procedures in recurrent anterior shoulder dislocation:

‐ Injury of the capsulolabral complex, including the anterior inferior glenohumeral ligament without critical glenoid bone loss, requires a Bankart procedure. Bony Bankart fractures of a size that cause acute instability and new dislocations after the reduction should be repositioned and fixated in the acute phase (Grade B).

‐ In cases of a HAGL, the ligament has to be repaired at the humeral side (Grade B).

‐ Additional remplissage procedure is recommended in cases of an off‐track Hill–Sachs lesion (Grade B).

‐ When a concomitant posterior labral lesion is present, this can be addressed at the same time (Grade C).

‐ ALPSA lesion must be released and mobilized to the glenoid rim before fixation, as they represent an increased risk of recurrence compared to a Bankart lesion (Grade B).

‐ ASA may be considered in hyperlax patients (Grade C).

‐ DAS may be considered in cases of subcritical glenoid bone loss (Grade D).

‐ Patients with a full‐thickness rotator cuff tear as a consequence of an anterior shoulder dislocation needs a rotator cuff repair to stabilize the joint and prevent degenerative changes. This is the main indication for a soft tissue procedure in the older adult group, and the most performed procedure is rotator cuff repair and not labral repair (Grade B).

Contraindications for soft tissue procedures in first‐time anterior shoulder dislocation:

‐ Severe humeral, glenoid or bipolar bone loss (Grade B).

‐ Advanced osteoarthritis (Grade B).

Special attention is needed in patients with collagen disorders (e.g., Marfans, Ehlers–Danlos, Down Syndrome).

Median (Range): 8 (5–9). Relative agreement.

Question #26:

Is there an optimal method for labral fixation?

The literature regarding the optimal method for labral fixation across all age groups is scarce. The consensus group recommends:

‐ Arthroscopic approach is preferred over open repair (Grade C).

‐ Complete mobilization of labrum and capsule until subscapularis muscle fibres are visualized (Grade D).

‐ Debridement of glenoid rim and anterior bony surface to promote healing (Grade D).

‐ Create a bleeding bed into which the repaired tissue can better heal (Grade D).

‐ Three anchors or passage of at least four sutures through soft tissue (Grade C).

‐ Inclusion of small glenoid bony fragments in capsulolabral repair (Grade C).

‐ Restore height and width of the labral tissue to create a bumper effect (Grade D).

Median (Range): 8.5 (5–9). Relative agreement.

Question #27:

When should additional soft tissue procedures be added to the regular Bankart repair (remplissage/ASA/DAS or others)?

Both for a first‐time and a recurrent shoulder dislocation, the decision for additional soft tissue procedures is based on the size and location of the Hill–Sachs lesion, the anterior glenoid bone loss, the anterior glenoid soft tissue condition and on co‐existing joint injuries. The purpose of the additional soft tissue procedure is to lower the recurrence rate after Bankart repair in specific cases.

In the case of an off‐track Hill–Sachs lesion, it could be argued that a bony procedure is indicated; however, if Bankart repair is chosen, remplissage should be added to the regular Bankart repair (Grade B).

In patients with poor anterior soft tissue quality, an associated SLAP lesion or in overhead athletes, the DAS procedure could be considered. In patients with anterior soft tissue insufficiency and shoulder hyperlaxity, the ASA procedure as an augmentation of Bankart repair is a possible option. There is still limited evidence on both DAS and ASA procedures, so they are not recommended for widespread use (Grade C).

Some surgeons would recommend a systematic addition of soft‐tissue procedures to the regular Bankart repair (Grade D).

Older adults

The Bankart repair is secondary, and the focus should be placed on addressing the rotator cuff tear, whenever present (Grade C).

Median (Range): 8 (3–9). Uncertain agreement.

Question #28:

What are the indications/contraindications for bone augmentation/Latarjet procedures after a first‐time anterior shoulder dislocation?

A bony procedure is recommended in cases of a glenoid bone defect, with a cut‐off of 20% in adolescents and young adults (Grade B).

Patients with subcritical bone loss (10%–15%) may require a bony procedure, especially in cases of significant bipolar bony injuries or other risk factors (Grade C).

Some surgeons would recommend systematically a bony procedure and have no indications for soft‐tissue procedure (Grade D).

The practice of collision sports, particularly in younger age groups or those with hyperlaxity, can lower the threshold for a bone procedure even in patients with limited glenoid bone loss (Grade C).

Adolescents

The risk of bone loss, both on the glenoid and humeral side, is increased when compared to the adult population (Grade B).

The threshold for bone augmentation/Latarjet procedures after the first‐time dislocation in this group of patients should be high, apart from high‐risk contact sports (Grade D).

Older adults

Bone augmentation procedures after a first‐time anterior shoulder dislocation have never been explicitly investigated in this age group. The indication for a glenoid bone augmentation procedure in this age group after a first‐time anterior shoulder dislocation is rare but might be performed in selected cases (Grade D).

Median (Range): 8 (7–9). Strong agreement.

Question #29:

What are the indications/contraindications for bone augmentation/Latarjet procedure after recurrent anterior shoulder dislocation?

A bone augmentation procedure is indicated in patients with traumatic recurrent anterior shoulder dislocation and a critical glenoid bone loss (>20%) (Grade B).

It can also be an option in cases of subcritical (10%–15%) glenoid bone loss, especially with a concomitant off‐track Hill–Sachs lesion (Grade B). The practice of collision sports, younger age, hyperlaxity and failed previous soft tissue procedures can lower the threshold for a bone procedure, even in patients with limited glenoid bone loss (Grade C).

Some surgeons would recommend a bony procedure systematically and have no indications for soft‐tissue procedure (Grade D).

Older adults

There is limited evidence on indications/contraindications for bone augmentation procedures after recurrent anterior shoulder dislocation in this age group. It is mainly performed in the setting of subcritical/critical glenoid defects. Osteoarthritis represents the main contraindication (Grade D).

Median (Range): 9 (7–9). Strong agreement.

Question #30:

What type of immobilization is recommended after soft tissue procedures (position and timing)?

There are no high‐level studies providing the answer. The consensus group recommends the use of a simple sling for a period of 3–4 weeks after soft tissue procedures. Exercises usually start a few days after surgery. The range of motion should be limited to maximum shoulder height in forward flexion and abduction, and 20° of external rotation for the first 4 weeks after surgery. From 4 weeks on, the range of motion increases as tolerated. Strengthening exercises are recommended from 8 to 12 weeks after surgery (Grade D).

Median (Range): 9 (7–9). Strong agreement.

Question #31:

What type of immobilization is recommended after bone augmentation/Latarjet procedure (position and timing)?

There are no high‐level studies providing the answer. The consensus group recommends the use of a simple sling for a period of 2–4 weeks after bony procedures (Grade D). Exercises usually start a few days after surgery. The range of motion should be limited to maximum shoulder height in forward flexion/abduction and 20° of external rotation for the first 4 weeks after surgery. From 4 weeks on, the range of motion increases as tolerated. Strengthening exercises are recommended from 8 to 12 weeks after surgery (Grade D).

Median (Range): 8 (7–9). Strong agreement.

Question #32:

What type of rehabilitation and when is recommended after soft tissue procedures?

To date, no universal or specific postoperative rehabilitation guideline exists, with limited scientific evidence available for all age groups.

The consensus group recommends a period of motion limited to passive exercises only for 2 weeks, extendable to a maximum of 3–4 weeks in the youngest and hyperlax patients. During this period, passive shoulder external rotation up to neutral, and active non‐resisted active elbow and hand/wrist exercises are encouraged. Afterwards, rehabilitation supervised by a physical therapist is recommended to improve active range of motion (from Weeks 2–4 to 8 postoperatively), gain general strength (from Weeks 10 to 14 postoperatively) and perform sport‐specific exercises (generally after Week 16 postoperatively) (Grade D).

Median (Range): 8 (7–9). Strong agreement.

Question #33:

What type of rehabilitation and when is recommended after bone augmentation/Latarjet procedure?

There is a lack of evidence regarding specific rehabilitation recommendations following bone augmentation/Latarjet procedures. In general, the rehabilitation after a Latarjet procedure can be faster than after a soft tissue procedure without limitation of external rotation.

The consensus group recommends a period of motion limited to passive exercises only for 2 weeks. Active motion can be allowed after 2 weeks from surgery. In case of the Latarjet procedure, resisted elbow flexion and supination should be avoided for the first 6 weeks. After 2–4 weeks, rehabilitation supervised by a physical therapist is recommended to improve active range of motion (from Weeks 2–4 to 8 postoperatively), gain general strength (from Weeks 10 to 14 postoperatively) and perform sport‐specific exercises (generally after Week 16 postoperatively) (Grade D).

Median (Range): 8 (7–9). Strong agreement.

Question #34:

What are the criteria to return to sports after surgical treatment of anterior shoulder instability (yes/no, timing and goal)?

No specific criteria are defined for RTS after surgical treatment of anterior shoulder instability. The RTS must be individualized based on the patient's demands and the type and level of sport practised (Grade C).

The patient should have a stable shoulder with a negative apprehension test, be pain‐free, have a full active range of motion, restored scapulothoracic rhythm and appropriate strength compared to the contralateral shoulder. In addition, the patient should meet their sport's specific functional, proprioceptive and physical demands. Psychological readiness of the patient remains mandatory. Patients undergoing a soft tissue procedure will usually resume activities without restriction at six months. For patients undergoing a bony procedure, this usually happens at four months. However, these time intervals may be altered (increased or decreased) based on the patient's progression. In individual cases, return to sport might be allowed even with minor loss of external rotation or residual apprehension (Grade D).

Older adults

In this age group, if a rotator cuff repair has been performed, the rehabilitation programme should follow the rules of such a repair (Grade C).

Median (Range): 9 (8–9). Strong agreement.

Outcomes:

Question #35:

Which measurement tools are validated for evaluating outcomes in the treatment of anterior shoulder instability?

The Western Ontario Shoulder Instability Index score, Walch&Duplay score and general shoulder outcome scores (Constant, ASES and Disabilities of the Arm, Shoulder and Hand) are validated for patients with shoulder instability (Grade B).

There's a high variability in the outcome measurement tools used in the literature. Recurrence rate (redislocation, subluxation or residual apprehension) is the most used outcome evaluation tool. A combination of recurrence rate, a general shoulder score (Constant, ASES or Disabilities of the Arm, Shoulder and Hand) and an instability‐specific score (Western Ontario Shoulder instability Index score, numerical scale Western Ontario Shoulder instability Index score, Walch&Duplay score, Rowe) is recommended (Grade D).

Older adults

If the patients have undergone rotator cuff repair, the treatment outcomes are assessed accordingly (Grade B).

Median (Range): 9 (8–9). Strong agreement.

DISCUSSION

The most important contribution of this ESSKA European Formal Consensus is the provision of age‐ and time‐specific recommendations for the treatment (both surgical and conservative) and RTS management of TASI. By integrating anatomical, functional and demographic variables, the current work addresses key controversies and decision points in both first‐time and recurrent instability across different age groups.

Bone loss thresholds and the indication for bony procedures

The present consensus reiterates that bone loss is one of the most important determinants of surgical strategy. While previous studies have proposed absolute thresholds for ‘critical’ or ‘subcritical’ glenoid bone loss (ranging from 13.5% to 25%) [20], our group avoided rigid cut‐offs and emphasized individualized interpretation based on age, activity level and recurrence status. This nuanced view is particularly relevant in adolescents and young adults, where even subcritical bone loss may predispose to recurrence, especially in collision athletes.

Unlike previous international consensus (ISAKOS, ASES Neer Circle, Anterior Shoulder Instability International Consensus Group), this work provides age‐specific recommendations and stratifies first‐time versus recurrent dislocations, offering added detail for clinical decision‐making. The ISAKOS 2010 consensus [5] recognized the importance of bone loss but did not provide specific numeric cut‐offs. The ASES Neer Circle consensus [20] more recently incorporated bone loss into clinical decision‐making, identifying >13.5% of glenoid bone loss as meaningful. Our findings are aligned with these, but extend the discussion by underlining that the threshold for surgical intervention is lower in younger, high‐risk athletes. Moreover, while prior consensus documents generally emphasized recurrent instability, our recommendations also highlight the potential role of early bony procedures even after a first‐time dislocation in select young, high‐demand athletes.

Regarding Hill–Sachs lesions, our consensus supports the use of the on‐track/off‐track concept to guide the need for remplissage or bone augmentation. Previous consensus statements [5, 20] endorsed the clinical relevance of bipolar bone loss, but provided less detail on how to integrate the glenoid track concept into treatment algorithms. The Anterior Shoulder Instability International Consensus [4] recently reinforced the utility of this framework, and our work builds on this by providing age‐specific recommendations, particularly in adolescents with a high incidence of off‐track lesions.

Soft tissue injuries as indications for surgery

Soft tissue procedures (Bankart repair ± remplissage, ASA or DAS) remain first‐line for most on‐track lesions without significant bone loss. The consensus underscores that soft tissue lesions such as ALPSA, HAGHL, SLAP lesions and rotator cuff tears significantly influence treatment recommendations. In adolescents and young adults, these injuries are considered strong indications for surgical repair after first‐time dislocation. In older adults, full‐thickness rotator cuff tears are regarded as the main indication for early surgery, with labral repair offering little added benefit once cuff integrity is restored.

This position is consistent with prior consensus guidelines. The ISAKOS 2010 statement [5] identified Bankart and capsulolabral injuries as primary indications for stabilization but did not differentiate by age. The ASES Neer Circle consensus [20] highlighted that concomitant injuries such as HAGL or cuff tears should modify the treatment strategy. Our consensus provides more granularity by distinguishing the role of specific lesions across different age groups, which represents a step forward compared to earlier generalist approaches. Furthermore, the Anterior Shoulder Instability International Consensus [4] emphasized that overhead athletes may present with subtle instability and that associated SLAP lesions require special attention. Our consensus corroborates this view and suggests that combined Bankart and SLAP repair may optimize outcomes in this subgroup.

Conservative treatment, immobilization and rehabilitation

Immobilization after a first‐time anterior dislocation remains a matter of debate. Our consensus supports a period of immobilization in most cases but acknowledges the lack of evidence for clear superiority of external versus internal rotation bracing. This cautious stance reflects the heterogeneity of the literature. The ISAKOS consensus [5] and the Neer Circle consensus [20] did not recommend immobilization beyond patient comfort, whereas more recent randomized studies suggested that external rotation may reduce recurrence in some subgroups. Our group concluded that age and activity level are more important determinants than position of immobilization, aligning partially with prior statements but offering a more individualized interpretation.

Regarding rehabilitation, our consensus emphasizes early initiation of motion and progressive strengthening, with clear goals for functional recovery and sport‐specific conditioning. This mirrors the position of prior consensus papers, which recognized rehabilitation as essential but provided limited detail on progression [5, 20]. The novel contribution of our work is the inclusion of explicit timelines and goals across different age categories, thereby providing more actionable guidance for clinical practice.

RTS criteria

RTS after shoulder instability treatment is one of the most critical yet controversial aspects of management. Our consensus emphasizes that RTS decisions must consider both objective functional recovery (strength, range of motion, absence of apprehension) and contextual factors (type of sport, contact level, season timing). In general, non‐contact sports may be resumed earlier (3–4 months), while collision and overhead sports require at least 6 months and objective demonstration of stability.

Return to previous activity level expectations and timing for RTS should be considered during patient counselling. Compared to the Latarjet procedure, Bankart repair showed the highest RTS rate along with the highest return to the same preinjury level. In contrast, the Latarjet procedure demonstrated the shortest RTP rate [1].

The ISAKOS 2010 consensus [5] provided only general recommendations regarding RTS and did not stratify by sport type. The Neer Circle consensus [20] stressed that factors such as position played and timing within the season should influence decision‐making, but did not provide standardized criteria. The 2022 Anterior Shoulder Instability International Consensus [4] focused on overhead athletes, advocating a cautious approach and recognition of subtle instability symptoms. Our consensus incorporates these perspectives but adds a structured, age‐ and sport‐specific framework that can be more readily applied in clinical practice.

Strengths and limitations

As in Part 1 [2], the current consensus is limited by the heterogeneity and overall low level of evidence for many treatment‐related questions, reflecting the ongoing lack of high‐quality comparative studies in this field. Much of the available literature is not designed to address age‐specific considerations, and therefore, expert opinion, albeit structured, has influenced several recommendations. Another limitation is the variability in rehabilitation and RTS protocols across different institutions, which challenges the generalizability of standardized timelines. Nevertheless, this consensus followed the rules of the ESSKA Formal Consensus based on 6 basic pillars: pluralism, iterative process, literature review, independent oversight, face‐to‐face meetings and transparency. These pillars provide rigorous methodology and thus robustness and credibility to the recommendations. Further clinically relevant, high‐quality studies are needed for many of these questions in order to provide statements with a higher likelihood of strong agreement. In addition, consensus studies are needed for the management of recurrent dislocation/instability after surgical treatment.

CONCLUSION

This ESSKA–ESA Europeal Formal Consensus provides practical, age‐ and time‐specific recommendations for the management of TASI. By incorporating recurrence status, bone loss, soft tissue injury and sport‐specific demands, it offers a clinically applicable framework for personalized treatment and RTS decisions.

AUTHOR CONTRIBUTIONS

All authors whose names appear on the manuscript made substantial contributions to the conception/design of the work or the acquisition, analysis and/or interpretation of data, drafted the work or revised it critically for important intellectual content, approved the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

CONFLICT OF INTEREST STATEMENT

Ana Catalina Ângelo: Consultation fees and payment honoraria for lectures, presentations, speakers' bureaus, manuscript writing or educational events for: Conmed Corporation, Zimmer‐Biomet, and Enovis. Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: Deputy chair of the ISAKOS Communication Committee and Editorial board of The Hive—MSK Journal. Stock or stock options: Beemed. Emmanouil Brilakis: Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: ESA‐ESSKA Board (Vice‐Chair), JISAKOS Editorial Board, and Hellenic Association of Orthopaedic Surgery and Traumatology (treasurer). Berte Bøe: Payment of honoraria for lectures, presentations, speakers' bureaus, manuscript writing or educational events for: Smith & Nephew and Ortomedic. Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: ESSKA, ISAKOS, and AJSM. Miguel Ruíz‐Iban: All support for the present manuscript (e.g., funding, provision of study materials, medical writing, article processing charges, etc.): ESSKA. Grants or contracts from any entity: Smith & Nephew, Link, Acumed, and Skeletal Dynamics. Consultation fees, payment honoraria for lectures, presentations, speakers' bureaus, manuscript writing or educational events, and support for attending meetings and/or travel for: Smith & Nephew and Link. Maristella Francesca Saccomanno: Consultation fees and payment honoraria for lectures, presentations, speakers' bureaus, manuscript writing or educational events for: Zimmer‐Biomet. Giuseppe Milano: Grants or contracts from any entity: Medics and FGP‐medi. Consulting fees: Arthrex. Payment honoraria for lectures, presentations, speakers' bureaus, manuscript writing or educational events for: Rejoin. Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: ISAKOS Shoulder Committee Deputy Chair, ISAKOS Publication Committee, and ISAKOS Rotator Cuff Study Group Chair. Receipt of equipment, materials, drugs, medical writing, gifts or other services: FGP‐medi and Medacta. Philippe Beaufils: Grants or contracts from any entity: ESSKA Consensus Projects advisor. Eduard Alentorn‐Geli: Grants or contracts from any entity: Smith & Nephew and Arthrex. Payment honoraria for lectures, presentations, speakers' bureaus, manuscript writing or educational events for: Smith & Nephew and Arthrex. Support for attending meetings and/or travel: Smith & Nephew, Arthrex, and ConMed. The remaining authors declare no conflict of interest.

ETHICS STATEMENT

The authors have nothing to report.

Supporting information

Annex I. Literature summaries.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.