Shoulder Dislocation Is Not a One-Size-Fits-All Problem.
Your Treatment Shouldn't Be Either.
More variables go into the decision of how to treat a dislocating shoulder than almost any other condition in sports medicine. The patient's age, sex, and dominant side. Whether this is a first dislocation or the fifteenth. Whether they play contact or non-contact sports. Whether they are an overhead athlete. How much bone has been lost from the glenoid socket or the humeral head. Whether the shoulder comes out during sleep. Whether the lesion is on-track or off-track. Whether the patient has generalized ligamentous laxity. Where they are in their season. None of these variables can be fed into a formula. They require judgment — the kind of judgment that only comes from 25 years of experience, deep involvement in the academic shoulder surgery community, and the ability to offer every surgical option that exists rather than defaulting to the one technique a surgeon knows best.
Every surgeon has a favorite technique for shoulder instability. The best surgeons have several.
And here is something every patient, parent, coach, and agent needs to understand before making a surgical decision: the wrong surgery for a dislocating shoulder doesn't just fail — it makes the next surgery harder. Bone loss accelerates with each dislocation. Soft tissue stretches further with every failed repair. A Bankart repair performed on a patient who needed a bone block procedure does not just produce a poor outcome — it leaves the patient in a worse position than before, with less tissue to work with, more bone loss to address, and a revision surgery that is exponentially more complex than the index procedure would have been.
Dr. Raffy Mirzayan is one of a small number of surgeons in the United States who is experienced and proficient in the full spectrum of procedures for shoulder instability — from arthroscopic labrum repair to open bone block reconstruction. He is an active member of the American Shoulder and Elbow Surgeons, co-founder of Shoulder360™ — one of the largest shoulder surgery courses in the country — and an Arthrex consultant currently developing new instability techniques that are not yet available anywhere else. Every treatment plan he designs is custom-tailored to the individual patient. Because what works for one patient will not work for another.
Call (310) 746-5918 to schedule a consultation. Virtual consultations are available for patients traveling from out of state.
Why Shoulder Instability Is the Most Complex Decision in Sports Medicine
Of all the conditions Dr. Mirzayan treats and all the surgeries he performs, shoulder instability is the one where individual patient variables matter most — and where the consequences of getting the decision wrong are most severe.
Consider just a few of the factors that change the treatment recommendation entirely:
Age at first dislocation — A 14-year-old who dislocates for the first time has a dramatically higher recurrence rate than a 40-year-old. The younger the patient at first dislocation, the more aggressive the treatment consideration needs to be.
Contact versus non-contact sport — A college football linebacker and a recreational tennis player with identical MRIs may need completely different operations. The mechanical demands of their sport, the risk of re-injury, and the consequences of failure are entirely different.
Bone loss — Every dislocation chips away at the bony rim of the glenoid socket and can create a dent in the humeral head called a Hill-Sachs lesion. When bone loss reaches a critical threshold, soft tissue repair alone will fail regardless of how well it is performed. The surgeon who does not measure bone loss carefully — or who does not have the skills to address it surgically — will produce a failed repair.
On-track versus off-track lesions — This is one of the most important and most commonly overlooked concepts in shoulder instability surgery. A Hill-Sachs lesion that engages the front of the glenoid during normal shoulder motion — an off-track lesion — will cause a Bankart repair to fail even when the repair itself is technically perfect. Identifying this requires specific imaging analysis and the surgical experience to address it appropriately.
Hyperlaxity — Patients with generalized ligamentous laxity — joints that are naturally loose throughout the body — require a fundamentally different surgical approach than patients with normal tissue tension. Standard repair techniques in hyperlax patients produce consistently poor results.
Time of season — For a competitive athlete, the question is not just what surgery to perform but when. A pitcher in the middle of a season, a football player at the start of a recruitment year, a college athlete on scholarship — the timing of surgery, the expected recovery, and the acceptable level of risk all shift based on where the patient is in their athletic career.
No computer program weighs all of these variables correctly. No algorithm replaces the judgment of a surgeon who has seen every permutation of this injury across 25 years and thousands of cases.
The Procedures: A Full Spectrum of Options
Most surgeons who treat shoulder instability perform one or two techniques well. Dr. Mirzayan is proficient and experienced in the full range of procedures currently available — which means the treatment he recommends is determined by what is right for the patient, not by what he is most comfortable performing.
Arthroscopic Bankart Repair For patients with soft tissue Bankart lesions — tears of the labrum at the front of the shoulder socket — without significant bone loss, arthroscopic repair is the appropriate procedure. The torn labrum is reattached to the glenoid rim using suture anchors, restoring the soft tissue bumper that keeps the humeral head in the socket. This is the most commonly performed procedure for shoulder instability, and in the right patient it produces excellent results. In the wrong patient — one with significant bone loss or an off-track Hill-Sachs lesion — it will fail.
Bankart Repair with Remplissage When a Hill-Sachs lesion is present and is determined to be off-track — meaning it engages the front of the glenoid during normal motion — the repair must address both the labrum and the Hill-Sachs defect. Remplissage fills the Hill-Sachs lesion with the posterior capsule and infraspinatus tendon, preventing it from engaging and causing re-dislocation. This procedure is performed arthroscopically in combination with the Bankart repair and adds meaningful stability in appropriately selected patients.
Open Bankart Repair with Subscapularis-Sparing Approach In some patients — particularly those with previous failed arthroscopic repair or significant capsular redundancy — open Bankart repair provides more robust soft tissue reconstruction than arthroscopic techniques can achieve. Dr. Mirzayan performs this procedure using a subscapularis-sparing approach that avoids splitting or detaching the subscapularis muscle — a meaningful advantage that preserves internal rotation strength and reduces the morbidity associated with traditional open approaches.
Open Capsular Shift For patients with multidirectional instability or significant capsular redundancy — particularly those with hyperlaxity — a capsular shift tightens the entire capsular envelope of the shoulder rather than simply reattaching the labrum. This is a procedure that requires a nuanced understanding of capsular anatomy and the ability to precisely balance tension in the repair.
Latarjet and Bristow Procedures When bone loss from the glenoid reaches a critical threshold — typically 20 to 25 percent of the glenoid surface — soft tissue repair alone will fail. The Latarjet and Bristow procedures address this by transferring the coracoid process of the scapula to the front of the glenoid, simultaneously restoring the bony arc of the socket and adding a dynamic sling effect from the conjoined tendon. These are technically demanding procedures with important neurovascular considerations, and they require a surgeon with extensive experience to perform safely and reliably.
Distal Tibial Allograft For patients who require glenoid bone augmentation but are not candidates for a Latarjet — or in whom the coracoid is insufficient — distal tibial allograft provides an alternative source of bone graft that can restore glenoid anatomy without harvesting the patient's own coracoid. This is a more recently developed technique that requires specialized expertise and is available at very few centers.
Arthroscopic Free Bone Block The arthroscopic free bone block procedure achieves the same glenoid augmentation as the Latarjet — using either autograft or allograft bone — through an entirely arthroscopic approach. This represents the current frontier of shoulder instability surgery, combining the anatomic restoration of a bone block procedure with the reduced morbidity of arthroscopic technique. Dr. Mirzayan is among the surgeons at the leading edge of this approach.
Techniques in Development As an Arthrex consultant, Dr. Mirzayan is currently involved in developing new surgical techniques for shoulder instability that are not yet available to other surgeons. For patients with complex or revision instability who have exhausted standard options, this pipeline of innovation may offer solutions that do not yet exist anywhere else.
Published Evidence
Dr. Mirzayan has contributed to the peer-reviewed literature on shoulder instability across multiple publications:
Shoulder Instability Publication 1
Shoulder Instability Publication 2
Shoulder Instability Publication 3
Shoulder Instability Publication 4
Dr. Mirzayan has also presented on shoulder instability in surgical education settings. A case-based learning presentation on shoulder instability is available here: Shoulder Instability Case-Based Learning — Orthopaedic Principles
And a surgical video from a shoulder instability course is available here: Shoulder Instability Surgical Course Video
What to Expect: Evaluation and Treatment
Every shoulder instability evaluation with Dr. Mirzayan begins with a detailed conversation — not imaging. How did the first dislocation happen? How many times has it dislocated since? What sports does the patient play, at what level, and at what point in their season or career? What treatments have been tried? These questions are not formalities. They determine the entire treatment plan.
Imaging follows the history. Standard X-rays, including specialized views to assess glenoid bone loss, are obtained in every case. MRI with arthrogram provides the most accurate assessment of the labrum, capsule, and soft tissue structures. CT scanning is used when precise quantification of bone loss — from the glenoid or the humeral head — is required to determine whether a bone block procedure is necessary.
Surgery, when indicated, is planned individually for each patient based on the complete clinical picture. Recovery timelines vary depending on the procedure performed, the demands of the patient's sport, and where they are in their athletic career. Dr. Mirzayan will give you a personalized assessment of what surgery is appropriate, what recovery looks like, and what a realistic return to sport timeline is for your specific situation.
Coming from Las Vegas, Phoenix, or Out of State?
Shoulder instability is a condition where the breadth of your surgeon's experience and technique repertoire matters more than almost anywhere else in orthopedic surgery. A surgeon who offers only one or two techniques will fit your problem to their solution. A surgeon who offers the full spectrum of options will fit the solution to your problem.
Dr. Mirzayan regularly treats patients from Las Vegas, Henderson, Phoenix, Scottsdale, and across the country. If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have out-of-network benefits that cover a substantial portion of the cost of surgery. His office will verify your coverage before you commit to anything.
Virtual consultations are available. You can submit your imaging in advance, meet Dr. Mirzayan on video, and get an honest, individualized assessment of your instability and your surgical options before committing to travel or time off sport.
Call (310) 746-5918 or contact us online to schedule your consultation.
Frequently Asked Questions
Do I need surgery after a first-time shoulder dislocation? Not necessarily — but it depends heavily on who you are. A 16-year-old contact sport athlete who dislocates for the first time has a recurrence rate approaching 90% without surgical intervention. A 45-year-old recreational golfer who dislocates for the first time has a much lower recurrence risk and may do well with conservative treatment. Age, sport, activity level, and the presence of bone loss all factor into this decision. Dr. Mirzayan will give you an honest, individualized assessment rather than a one-size-fits-all answer.
What is a Bankart lesion? A Bankart lesion is a tear of the labrum — the cartilage rim that deepens the shoulder socket — at its front-lower attachment. It is the most common structural injury associated with anterior shoulder dislocation and is present in the majority of patients who dislocate their shoulder. Not all Bankart lesions require the same treatment, and the presence of bone loss or an off-track Hill-Sachs lesion significantly changes what procedure is appropriate.
What is an off-track Hill-Sachs lesion and why does it matter? A Hill-Sachs lesion is a dent in the back of the humeral head created when the ball impacts the front rim of the socket during dislocation. An off-track lesion is one that is large enough — relative to the remaining glenoid bone — to engage the front of the socket during normal shoulder motion, causing the shoulder to re-dislocate even after a technically perfect Bankart repair. Identifying off-track lesions requires specific imaging analysis. Treating them requires either remplissage or a bone block procedure. Performing a Bankart repair alone on an off-track lesion will fail.
What is the Latarjet procedure and when is it needed? The Latarjet procedure transfers the coracoid process of the scapula to the front of the glenoid, restoring lost bone and adding a dynamic stabilizing effect from the attached conjoined tendon. It is indicated when glenoid bone loss has reached a threshold — typically 20 to 25 percent of the glenoid surface — at which soft tissue repair alone is insufficient. It is also used in some high-risk patients — contact sport athletes, patients with previous failed Bankart repair — even in the absence of critical bone loss. It is a technically demanding procedure that should be performed by surgeons with extensive experience.
What is the difference between arthroscopic and open shoulder instability surgery? Arthroscopic surgery uses small incisions and a camera to perform the repair with minimal tissue disruption. It is appropriate for most soft tissue Bankart repairs and remplissage procedures. Open surgery provides more direct access and allows more robust soft tissue reconstruction — it is used for patients with significant capsular redundancy, previous failed arthroscopic repair, or in conjunction with bone block procedures. Dr. Mirzayan performs both and selects the approach based on the individual patient's anatomy and injury pattern.
I had a Bankart repair that failed. What are my options? Revision shoulder instability surgery is more complex than index surgery — there is less tissue to work with, there may be additional bone loss from subsequent dislocations, and the previous repair must be addressed before a new reconstruction can be performed. Dr. Mirzayan evaluates revision instability cases individually and has experience with the full range of revision options, including bone block procedures, distal tibial allograft, and arthroscopic free bone block reconstruction. A detailed imaging workup — including CT scan for bone loss quantification — is essential before any revision plan is made.
Do you see patients from outside Los Angeles? Yes. Dr. Mirzayan regularly treats patients from Las Vegas, Henderson, Phoenix, Scottsdale, and from across the country. Virtual consultations are available. For a complex or recurrent instability case, a consultation with Dr. Mirzayan — in person or by video — is often the most important first step toward getting the right answer. Call (310) 746-5918.
Does being out-of-network mean I will pay full price out of pocket? Not necessarily. Many patients with commercial insurance — especially PPO plans and self-funded employer plans — have strong out-of-network benefits. Dr. Mirzayan's office will verify your coverage before your consultation so you have a clear picture of what to expect before making any decisions.
About Dr. Raffy Mirzayan
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon with 25 years of experience treating shoulder instability and dislocation at every level of complexity — from first-time dislocations in young athletes to revision bone block reconstructions in patients who have failed multiple prior surgeries. He is an active member of the American Shoulder and Elbow Surgeons, co-founder of Shoulder360™ — one of the largest shoulder surgery courses in the United States, training more than 350 surgeons annually — and an Arthrex consultant currently developing new instability techniques that are not yet available anywhere else. With four peer-reviewed publications on shoulder instability, 88 total peer-reviewed publications, and proficiency in the full spectrum of surgical techniques for this condition, Dr. Mirzayan brings a breadth of expertise that is genuinely rare. He does not have a favorite technique. He has the right technique for each patient. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, and Scottsdale, for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
