Hill-Sachs Lesion Injury and Deformity

Damage to the Shoulder Joint as a Result of Dislocation

A Hill-Sachs injury to the shoulder can occur due to a shoulder dislocation, resulting in a Hill-Sachs lesion or a Hill-Sachs deformity of the head of the humerus bone (the upper arm bone)

As the bones in the shoulder joint dislocate, the round humeral head (the ball on the top of the arm bone) can strike the edge of the glenoid bone (the socket) with force. This creates a compression fracture in the humeral head. A small divot in the bone is often seen on MRI, and larger Hill-Sachs injuries may also be seen on an X-ray.

Sometimes this condition doesn't require intervention, but it can cause symptoms and may require surgical repair.

Football player being tackled and suffering shoulder injury
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Hill Sachs Defect

The Hill-Sachs defect occurs when there is an injury to the bone and cartilage of the humeral head.

The shoulder joint is made up of the humeral head and the glenoid bone (the socket). Ligaments, cartilage, and tendons help hold these bones in place.

A shoulder dislocation occurs when the ball of the ball-and-socket shoulder joint comes out of position. The structures that hold the ball inside the shoulder socket are damaged from a shoulder dislocation.

Damage to the shoulder is mostly dependent on the age of the person who sustained the injury. The usual damage is either to the shoulder ligaments, called a Bankart tear, which occurs in younger people, or to the rotator cuff tendons, which usually occur in older people.

In addition to ligament or tendon damage, the bone and cartilage can also be damaged; the most common type of damage from a shoulder dislocation is a Hill-Sachs defect.

A shoulder dislocation is often confused with a separated shoulder, but these are very different injuries.

A Hill-Sachs defect does not occur in isolation. There is always damage that allowed the shoulder to dislocate. If you have a Hill-Sachs defect, this confirms that your shoulder completely came out of the socket and that it's not just partially dislocated, as occurs in subluxation.

A Hill-Sachs defect occurs in about half of first-time shoulder dislocations and is almost always seen in people who have recurrent shoulder instability from multiple previous dislocations.

Your doctor may look to see if you have a Hill-Sachs defect to confirm whether you've had a shoulder dislocation injury, and identifying this injury is critical to ensure proper treatment of your shoulder dislocation.

Shoulder Dislocation Treatment

Usually, after a first time Hill-Sachs injury, the shoulder joint must be repositioned, often in a hospital or emergency department. If the Hill-Sachs defect is large and left untreated, recurrent shoulder instability could occur.

You and your surgeon need to discuss the treatment options if you have a Hill-Sachs injury. The best treatment for you may depend on a number of factors, including the appearance of the injury on imaging studies, physical examination findings, and expectations for future athletics participation.

Criteria for Surgery

A Hill-Sachs injury that involves less than 20% of the humeral head can almost always be left alone without needing further treatment. That means the usual treatment of the shoulder dislocation (which may or may not include surgery) can proceed without factoring in the Hill-Sachs defect.

Injuries that involve more than 40% of the humeral head almost always require treatment. In situations where the Hill-Sachs defect involves between 20% and 40% of the humeral head, your surgeon will determine if the defect is contributing to shoulder instability.

A Hill-Sachs defect that causes the ball to move abnormally within the socket is said to be "engaging," and these engaging Hill-Sachs injuries usually require surgical treatment.

Treatment options to manage a Hill-Sachs defect include:

  • Doing nothing: Observation is the most common treatment, and usually successful when a Hill-Sachs injury involves less than 20% of the humeral head.
  • Capsular shift: Shifting the shoulder capsule is a surgical procedure that tightens the tissue in the area of the Hill-Sachs defect to prevent excessive rotation of the shoulder. By limiting rotation, the Hill-Sachs defect may become a non-engaging defect.
  • Bone grafting/tissue filling: When the defect is large, and tightening up the shoulder would be insufficient, the defect in the humeral head must be filled in. Your surgeon may use bone from your pelvis or other soft-tissue to fill the void.
  • Disimpaction: Disimpaction is a surgical procedure that lifts up the compressed bone to try to re-establish the normal shape of the humeral head.
  • Shoulder Replacement: In some rare situations, especially with large defects, the best option may be a shoulder replacement surgery. Because the shoulder replacement can wear out over time, this procedure is more common among older people and is usually reserved for the last resort in younger people.
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