Hill Sachs Lesion: Symptoms, Types, Causes and Treatment

The shoulder is one of the most mobile and complex joints in the human body—and, as a result, it’s prone to injury. Among the injuries affecting shoulder stability, the Hill Sachs lesion stands out as a critical factor in recurrent dislocations and functional impairment. In this comprehensive guide, we’ll explore the symptoms, types, causes, and modern treatment strategies for Hill Sachs lesions, drawing on the latest research and evolving clinical concepts.

Symptoms of Hill Sachs Lesion

Understanding the symptoms of a Hill Sachs lesion is essential for timely diagnosis and effective intervention. While some patients may not immediately realize the extent of their injury, others experience pronounced instability and pain—especially after shoulder trauma.

Symptom	Description	Frequency/Context	Source(s)
Instability	Sensation of shoulder “giving way”	Common in recurrent dislocations	4 6
Pain	Discomfort with movement or at rest	Especially after injury or instability	4 6
Decreased ROM	Limited range of motion	More pronounced in severe lesions	8
Apprehension	Fear of shoulder dislocation	During specific arm positions	4 8

Table 1: Key Symptoms

Instability and Recurrent Dislocation

One of the hallmark symptoms is a persistent feeling of instability in the shoulder joint. Patients often describe a sensation that the shoulder could "pop out" or "give way," especially during activities involving overhead movements or abduction and external rotation 4 6. This instability is more pronounced in individuals who have suffered multiple dislocations.

Pain and Discomfort

Pain is another frequent complaint, particularly after an episode of dislocation or trauma. The discomfort can be sharp during movement or a constant ache at rest, depending on the severity of the lesion and associated injuries 4 6.

Decreased Range of Motion

Some patients notice a reduction in their shoulder’s range of motion, especially in external rotation and abduction. This limitation is often more significant in cases where the lesion is large or has engaged with the glenoid rim, potentially leading to fear of further dislocation (the “apprehension sign”) 8.

Apprehension and Activity Limitation

Patients may avoid certain activities or movements due to apprehension about re-injuring their shoulder. This psychological symptom can significantly impact quality of life and participation in sports or daily tasks 4 8.

Types of Hill Sachs Lesion

Recent advances in imaging and biomechanical understanding have led to a more nuanced classification of Hill Sachs lesions. These types are important for predicting the risk of recurrent instability and guiding treatment.

Type	Definition/Location	Clinical Relevance	Source(s)
On-track	Does not engage glenoid rim	Lower recurrence risk	1 3 5
Off-track	Engages glenoid rim	High recurrence risk	1 3 9
Wide/Large	Expansive and deep humeral defect	Often with glenoid bone loss	2 4
Narrow/Medial	Smaller but medially located defect	Still may engage and cause issues	2 5

Table 2: Types of Hill Sachs Lesion

On-Track vs. Off-Track Lesions

A pivotal advancement in classifying these injuries is the "glenoid track" concept. An on-track Hill Sachs lesion is contained within the glenoid arc during shoulder motion and does not engage the glenoid rim, making recurrence of dislocation less likely 1 3 5. In contrast, an off-track lesion extends medially beyond the glenoid track, making it prone to engagement and a much higher risk of recurrent instability 1 3 9.

Wide/Large and Narrow/Medial Lesions

Hill Sachs lesions can also be described by their size and position:

• Wide/Large Lesions: These involve a broad and deep defect on the humeral head. They commonly coexist with substantial glenoid bone loss and are more likely to be clinically significant 2 4.
• Narrow/Medial Lesions: Though less extensive in width, these lesions are located more medially and can still engage the glenoid rim, especially if the glenoid is deficient 2 5.

Peripheral-Track and Central-Track Lesions

Some researchers further classify on-track lesions based on their percentage occupancy of the glenoid track:

• Peripheral-track lesions (≥75% occupancy): Worse patient-reported outcomes, even without recurrent instability.
• Central-track lesions (<75% occupancy): Generally better outcomes 5.

Causes of Hill Sachs Lesion

The development of a Hill Sachs lesion is closely linked to the mechanics of shoulder dislocation, particularly in young, active individuals. Understanding the causes not only informs prevention but also highlights the importance of early and effective management.

Cause	Mechanism/Trigger	Risk Factors	Source(s)
Anterior Dislocation	Humeral head compresses glenoid rim	Trauma, sports injuries	4 6
Recurrent Instability	Multiple dislocations worsen defect	Young age, contact sports	4 2 6
Bipolar Lesions	Combined glenoid and humeral bone loss	Severe or chronic instability	1 2 4
Posterior Dislocation (Reverse Hill Sachs)	Humeral head impacts posterior glenoid	Less common, seizures, trauma	4

Table 3: Major Causes

Traumatic Anterior Shoulder Dislocation

The classic mechanism for a Hill Sachs lesion is a traumatic anterior shoulder dislocation. When the humeral head is forced out of the socket, it impacts against the edge of the glenoid, resulting in a compression fracture or indentation on the posterolateral aspect of the humeral head 4 6.

Recurrent Shoulder Instability

Each subsequent episode of instability can enlarge an existing Hill Sachs lesion or create new defects, especially in younger patients or those participating in contact sports. This repetitive trauma increases the risk of the lesion becoming clinically significant and symptomatic 4 2 6.

Bipolar Bone Loss

A particularly concerning scenario is the presence of both a Hill Sachs lesion and a glenoid bone defect—a "bipolar" injury. This combination greatly increases the risk of instability and recurrence, complicating both diagnosis and treatment 1 2 4.

Reverse Hill Sachs Lesion

Although much less common, a reverse Hill Sachs lesion can occur with posterior shoulder dislocations, where the anteromedial humeral head is compressed against the posterior glenoid rim. This is typically associated with seizures, electric shocks, or traumatic events 4.

Treatment of Hill Sachs Lesion

Treatment strategies for Hill Sachs lesions have evolved dramatically, moving from a “one-size-fits-all” approach to personalized interventions based on lesion type, size, and associated glenoid bone loss.

Treatment	Indication/Approach	Outcome/Considerations	Source(s)
Non-surgical	Small, stable, non-engaging lesions	Rehab, good outcomes in select cases	4 6
Remplissage	Large/engaging Hill Sachs lesions	Arthroscopic, fills defect, stable	7 8
Bankart Repair	Labral/capsular injuries, minor lesions	Often combined with remplissage	8
Latarjet	Off-track lesions, glenoid bone loss	Restores stability, prevents recurrence	1 9

Table 4: Treatment Approaches

Non-Surgical Management

For small, non-engaging Hill Sachs lesions that do not compromise overall shoulder stability, conservative treatment is often effective. This includes:

• Focused physical therapy to strengthen the rotator cuff and periscapular muscles
• Activity modification
• Close monitoring for signs of recurrent instability

Such cases usually have a favorable prognosis, especially if the patient’s functional demands are not excessive 4 6.

Arthroscopic Remplissage

For larger or engaging lesions, especially those at risk of engaging the glenoid rim, the remplissage procedure is a minimally invasive technique. This involves filling the defect by tenodesing (anchoring) the infraspinatus tendon and posterior capsule into the Hill Sachs lesion. The procedure can be performed in conjunction with an arthroscopic Bankart repair 7 8.

• Advantages: Reduces risk of recurrence, preserves range of motion
• Outcomes: High rates of restored stability, low recurrence (failure rate ~8%) 8
• Consideration: Slight decrease in external rotation may occur, but functional outcomes remain strong 8

Bankart Repair

A Bankart repair addresses injuries to the anterior labrum and capsule, which often accompany Hill Sachs lesions. In many cases, especially with minor humeral head defects, this repair alone may suffice. However, in the presence of an engaging lesion, it is typically combined with remplissage 8.

Latarjet Procedure

For off-track lesions or those with significant glenoid bone loss, the Latarjet procedure is the preferred solution. This surgery transfers a portion of the coracoid process to the anterior glenoid, effectively enlarging the glenoid track and preventing the Hill Sachs lesion from engaging 1 9.

• Effectiveness: Converts off-track lesions to on-track, reduces recurrence risk dramatically
• Surgical Considerations: Technically demanding, but highly effective in restoring stability even with glenoid remodeling 9

Other Considerations

• The choice of treatment must be individualized, based on lesion size, patient activity level, and concomitant pathologies.
• Accurate imaging and assessment (often 3D CT or MRI) are essential for classifying the lesion and guiding surgical planning 1 6.

Conclusion

The Hill Sachs lesion is a complex bony injury of the shoulder that plays a pivotal role in recurrent anterior instability. Advances in our understanding—especially the glenoid track concept—have shifted treatment toward more nuanced, personalized care. Key takeaways include:

• Symptoms range from instability and pain to decreased range of motion and apprehension.
• Types are best understood as on-track/off-track (engagement risk) and by size/location (wide/large, narrow/medial).
• Causes are primarily traumatic anterior dislocation and recurrent instability; bipolar bone loss is especially problematic.
• Treatment options include non-surgical rehab, arthroscopic remplissage, Bankart repair, and the Latarjet procedure—each tailored to lesion characteristics and patient needs.

In summary:

• Hill Sachs lesions are almost universal in recurrent anterior shoulder instability 4.
• The risk of recurrence and choice of treatment depend on whether the lesion is on-track or off-track 1 3 9.
• Engaging lesions and those with glenoid bone loss require advanced surgical techniques for optimal outcomes 8 9.
• Early recognition and individualized management can restore stability and function for most patients.

Understanding and appropriately addressing Hill Sachs lesions is essential for anyone involved in the care of shoulder instability—ensuring patients regain confidence, function, and quality of life.