I recently saw two professional athletes with shoulder instability. The first was a rugby league forward who had dislocated his dominant shoulder. His priority was clear, he wanted the shoulder to be as stable, strong and powerful as possible. He tackles for a living and wants the lowest possible chance of ever dislocating it again. The second was a professional cricketer (and opening batter) who had injured his non-dominant shoulder. He also wanted his shoulder to never dislocate again, but his sporting demands are different. Stability is important, but so is maintaining excellent shoulder function for batting, throwing and fielding.

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The diagnosis may be the same, but should they have the same operation? The answer is probably not.

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Matching the Operation to the Athlete

Anterior shoulder instability is a good example of why treating an athlete requires more than treating their MRI scan. The anatomy matters, but so do the sport, position, level of competition and consequences of recurrent instability. For most athletes requiring surgery, the discussion includes two broad approaches. A Bankart repair attempts to restore the damaged labrum and capsuloligamentous structures to their normal anatomy. In contrast a Latarjet procedure in a non-anatomic procedure which involves the transfer of part of the coracoid to the front of the glenoid, providing both additional bone and a dynamic sling that makes the shoulder more resistant to anterior instability.

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Both operations work well. The question is which option is the best one for the athlete in front of you?

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Recent evidence in contact athletes illustrates some of the important consideration. Systematic review data suggests recurrent instability is significantly lower following Latarjet than arthroscopic Bankart repair, but at the expense of a higher complication rate. Return to sport rates and functional outcomes are generally high following both procedures. That makes the rugby league player's decision relatively straightforward. Contact athletes have a much higher risk of recurrent instability, and a professional forward repeatedly places his shoulder into high-force collision situations. The consequences of another dislocation are substantial. In this setting, accepting the greater surgical intervention and complication risk of a Latarjet in return for greater stability makes sense.

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The cricketer has different needs. He is not repeatedly tackling 110kg opponents, and the shoulder is not his dominant shoulder. He does, however, need excellent function for batting and fielding. If his underlying anatomy is favourable, an arthroscopic Bankart repair becomes an attractive option to restore the damaged anatomy and provide stability without undertaking a bone-block procedure that may be more than he requires.

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Balancing Stability, Movement and Risk

One of the traditional concerns about Latarjet has been a potential loss of shoulder range, particularly external rotation. This is also something I have observed in clinical practice and is an important consideration in athletes for whom shoulder movement matters. Interestingly, contemporary evidence challenges that perception. A 2025 systematic review and meta-analysis comparing Bankart repari, Bankart with remplissage and Latarjet found no significant difference in loss of external rotation between the procedures. Some comparative studies have even reporte4d better external rotation following Latarjet.

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An important consideration is that while there may be no difference between the procedures this does not mean that athletes necessarily regain completely normal shoulder movement after either operation. Some postoperative stiffness and loss of external rotation can occur following any shoulder stabilisation. For most athletes a small deficit is unlikely to be functionally important, but it may matter considerably more to an overhead athlete, where relatively small changes in shoulder movement can affect sporting performance. This is probably important for our cricketer.

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The argument fort a Bankart repair shouldn't simply be that it will preserve more movement. Rather, if his anatomy is favourable and his risk of recurrence is lower, an anatomical soft-tissue repair may provide all the stability he requires without exposing him to the additional surgical morbidity of a bone-block procedure.

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The additional morbidity associated with a Latarjet procedure is worth acknowledging. Complications are still relatively uncommon, but include graft non-union or fracture, graft or screw-related problems, infection and nerve injury, with some patients requiring further surgery for symptomatic hardware. Systematic reviews suggest graft-related problems are among the most frequent short-term complications, while hardware problems are also an important cause of subsequent intervention.

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For these reasons for this cricket athlete, I would probably recommend a Bankart repair.

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Why Bone Loss Matters

One of the most important considerations when choosing surgical treatment is bone loss. During a shoulder dislocation, bone may be lost from the anterior glenoid and an impaction defect, the Hills-Sachs lesion, may develop in the humeral head. These lesions need to be considered together. The glenoid-track concept helps determine whether this combination is likely to make the shoulder vulnerable to further instability.

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Our thinking about how much bone loss matters has also changed. Historically, bone-block procedures such as Latarjet were generally considered when glenoid loss approached 20 to 25%. We now recognise that smaller amounts, often described as subcritical bone loss, can affect the success of a soft-tissue repair, particularly in a young athlete exposed to high-risk sport.

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Age, previous dislocations, hyperlaxity, the size and position of the Hill-Sachs lesion and previous surgery all also impact our management decisions. These factors need to be considered alongside the athlete's sport, position, performance requirements and tolerance for recurrent instability. This is why two athletes with apparently similar shoulder injuries may appropriately end up having different treatment.

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Rehabilitation Should Be Athlete-Specific Too

Ultimately, there is no universally superior operation. Both soft-tissue stabilisation and bone-block procedures produce high rates of return to sport. The aim is to match the operation to both the injury and the athlete.

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The same principle should apple to rehabilitation. Whichever operation is chosen, rehabilitation needs to be bespoke to the athlete and the demands they are returning to. Movement, strength, proprioception and confidence all need to be restored, but the end poiint should not simply be normal clinic-based measures or reaching apredertermined date after surgery.

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Return to sport should be based on functional milestones that reflect what that shoulder actually needs to do. For our league forward, that means restoring strength and power, but also progressively developing the capacity and confidence to tolerate repeated contact and vulnerable shoulder positions. For the cricketer, rehabilitation needs to reflect batting, throwing and fielding, with particular attention to the movement, control and endurance required for those tasks.

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Two professional atheletes. Two unstable shoulders. Potentially two different operations and two different rehabilitation pathways.