Hill-Sachs Lesion: Causes, Diagnosis, Treatment & Recovery Guide
A Hill-Sachs lesion is one of the most common bony injuries associated with anterior shoulder dislocation. Despite its high prevalence—occurring in up to 100% of recurrent dislocations—it is often underdiagnosed or overlooked in initial management. At BoneFractures.org, we provide a detailed, clinically accurate, and SEO-optimized review to help patients and healthcare providers understand this critical injury and its implications for shoulder stability and treatment planning.
What Is a Hill-Sachs Lesion?
A Hill-Sachs lesion is an impaction fracture (compression defect) on the posterolateral aspect of the humeral head. It occurs when the humeral head forcefully impacts the anterior glenoid rim during an anterior shoulder dislocation. First described in 1940 by radiologists Harold Hill and Maurice Sachs, this lesion is not just a dent—it’s a key predictor of recurrent instability.
Key Insight: The size and location of a Hill-Sachs lesion directly influence whether it becomes an “engaging” lesion—meaning it catches on the glenoid rim during movement, triggering recurrent dislocations.
Hill-Sachs and Bankart Lesion: The Dangerous Duo
Hill-Sachs lesions rarely occur in isolation. They are almost always paired with a Bankart lesion—a tear of the anteroinferior glenoid labrum. Together, they create a “double pathology” that significantly increases the risk of recurrent shoulder dislocation:
- Hill-Sachs: Defect on the humeral head (ball).
- Bankart: Loss of the labral “bumper” on the glenoid (socket).
Studies show that while Hill-Sachs lesions occur in 35–40% of first-time dislocations, this jumps to 80–100% in recurrent cases. Similarly, Bankart lesions are present in 85–90% of initial dislocations.
Symptoms of a Hill-Sachs Lesion
Many patients are unaware they have a Hill-Sachs lesion until they experience recurrent instability. Common signs include:
- Shoulder pain after dislocation (acute or chronic)
- Sensation of “slipping” or “giving way” during overhead or external rotation movements
- Reduced range of motion, especially external rotation
- Crepitus (grinding or popping) during shoulder movement
- Apprehension when placing the arm in abduction and external rotation
Diagnosis: Imaging & Clinical Tests
Accurate diagnosis requires a combination of clinical evaluation and advanced imaging:
Clinical Examination
- Apprehension Test: Patient feels fear of dislocation when arm is placed in 90° abduction + external rotation.
- Relocation Test (Jobe’s Test): Pain/apprehension decreases when posterior pressure is applied.
Imaging
- X-ray: Stryker notch view or AP internal rotation view can reveal the “dent.”
- MRI: Gold standard for soft tissue (e.g., Bankart tear) and bone marrow edema.
- CT Scan: Best for quantifying lesion size, depth, and glenoid bone loss—critical for surgical planning.
Classification & Treatment Guidelines
Treatment depends on lesion size, engagement risk, and presence of glenoid bone loss:
1. Small Lesions (<20 h3="" head="" humeral="" of="">
• Often non-engaging
• Managed conservatively with physical therapy
• Focus: rotator cuff strengthening, proprioception, scapular stabilization
2. Medium Lesions (20–30%)
• Risk of engagement if glenoid is intact
• Arthroscopic Remplissage: The gold-standard surgical option—fills the defect using the infraspinatus tendon and posterior capsule.
• Highly effective in preventing recurrence with minimal loss of external rotation.
3. Large/Engaging Lesions (>30% or “off-track”)
• High recurrence risk even after Bankart repair alone
• Requires combined approach:
– Latarjet procedure (coracoid transfer) if significant glenoid bone loss (>25%)
– Bone grafting (autograft/allograft) or humeral head resurfacing for massive defects
• Shoulder replacement is reserved for elderly patients with arthritis.
“On-Track” vs. “Off-Track” Concept: Modern treatment hinges on whether the Hill-Sachs lesion engages the glenoid. If the medial margin of the lesion is medial to the glenoid track, it’s “off-track”—and remplissage or bone grafting is essential.
Recovery & Prognosis
- Non-surgical: 3–6 months of structured physical therapy.
- Post-Remplissage: Full recovery in 6–9 months; return to sports at 6+ months.
- Post-Latarjet: 9–12 months for full recovery due to bone healing.
Success rates exceed 90% when treatment matches the lesion’s biomechanical risk.
When to See a Specialist
Seek orthopedic evaluation if you experience:
- First-time or recurrent shoulder dislocation
- Persistent instability or “apprehension”
- Failure to improve after 4–6 weeks of physical therapy
- Plans to return to contact or overhead sports
Frequently Asked Questions (FAQ)
Can a Hill-Sachs lesion heal on its own?
The bone defect itself does not “heal” or fill in. However, small, non-engaging lesions may not require intervention if shoulder stability is restored through muscle control.
Is surgery always needed?
No. Only engaging or large lesions in active patients typically require surgery. Many first-time dislocations in older adults are managed non-operatively.
How is Hill-Sachs different from a regular humeral fracture?
It’s a specific type of impaction fracture caused by dislocation—not a break from direct trauma. The bone is compressed, not shattered.
Can physical therapy prevent recurrence?
Yes—for small lesions and in low-demand patients. But it cannot eliminate the mechanical risk of an engaging defect.