A Hill-Sachs lesion is an impression fracture on the posterior-superior aspect of the humeral head that occurs during an anterior shoulder dislocation. As the humeral head exits the socket, its posterior rim contacts the anterior edge of the glenoid and is indented by the bony rim. The lesion is common in patients with anterior instability, and its size and location determine whether it contributes to recurrent dislocation.
What Is a Hill-Sachs Lesion?
The humeral head is the spherical upper end of the humerus that sits in the glenoid socket. When the shoulder dislocates anteriorly, the head is driven forward and downward out of the socket. On the way out, the posterior-superior part of the head compresses against the rigid anterior edge of the glenoid, creating an impression fracture in the softer cancellous bone of the humeral head.
A Hill-Sachs lesion is common in patients who have had even a single anterior dislocation. Small lesions have no clinical consequence. Larger lesions, particularly those oriented so that they engage the glenoid rim during normal shoulder motion, can contribute to recurrent instability. An engaging Hill-Sachs lesion creates a mechanical situation where the humeral head can re-dislocate more easily in the cocked position.
The size and orientation of the Hill-Sachs lesion, together with any glenoid bone loss (bipolar bone loss), drive surgical decision-making for recurrent anterior instability.
Causes and Risk Factors
- Anterior shoulder dislocation is the underlying cause of all Hill-Sachs lesions
- Risk factors for the dislocation itself (young age, contact sport, ligamentous laxity) apply to Hill-Sachs lesions
- Multiple dislocations increase Hill-Sachs size with each event
- Combined glenoid and humeral bone loss (bipolar loss) significantly raises the risk of recurrence
Symptoms
Hill-Sachs lesions do not produce symptoms directly. They contribute to the symptoms of the underlying instability:
- Apprehension with the arm abducted and externally rotated
- Recurrent partial or complete dislocations
- A sense of the shoulder catching or engaging in specific positions
- Pain and weakness following dislocation events
Diagnosis
Dr. Chudik’s evaluation includes the dislocation history, the specific positions that produce apprehension, and a physical examination focused on instability testing. X-rays, particularly the Stryker notch view and West Point view, demonstrate Hill-Sachs lesions. CT is the imaging study of choice for quantifying the size and orientation of the Hill-Sachs lesion and any accompanying glenoid bone loss. MRI characterizes the labrum and capsule. The Westmont office has on-site high-field MRI and X-ray.
Treatment
Treatment is driven by the instability pattern and bone loss rather than by the Hill-Sachs lesion alone. Small Hill-Sachs lesions that do not engage are usually addressed incidentally during routine arthroscopic Bankart repair.
For larger or engaging Hill-Sachs lesions, Dr. Chudik performs additional procedures to address the humeral head defect:
- Remplissage, an arthroscopic technique in which the infraspinatus tendon and capsule are sutured into the Hill-Sachs defect to prevent engagement with the glenoid
- Bone grafting of the Hill-Sachs defect in selected cases with very large lesions
- Combined bone-block procedures for bipolar bone loss, including glenoid augmentation with coracoid or iliac crest graft
Recovery and Outcomes
Recovery after remplissage added to a Bankart repair follows a similar timeline to Bankart repair alone with slight modifications: four to six weeks of sling protection, progressive range of motion over two to three months, and strengthening over three to four months. Return to contact sport is typically five to six months. External rotation can be mildly restricted after remplissage, which is usually well-tolerated.
Outcomes for addressing Hill-Sachs lesions in the context of instability surgery are good when the tissue is healthy and bone loss is appropriately quantified.
When to See Dr. Chudik
Schedule an evaluation after any shoulder dislocation, if recurrent instability has followed a prior dislocation, or if imaging has identified a Hill-Sachs lesion. Call 630-324-0402 or request an appointment online.