Hill-Sachs Lesions are posterosuperolateral defect that results from the Head of Humerus compressing into the Glenoid Cavity. As they are most often the result of Anterior Glenohumeral Dislocation s, Hill-Sachs Lesions often occur concomitantly with Bankart Lesions or other Glenoid Labrum Tears . Hill-Sachs Lesions may predispose pathology of The Shoulder Girdle through a Glenohumeral Instability -related sequelae.
Hill-Sachs Lesions are the most common form of bony lesion, with a higher proportion associated with recurrent Glenohumeral Dislocations when compared to first time Dislocations (SOURCE-4). The mechanism most often involve an anteriorly forced Head of Humerus in a position of GH Joint - Abduction and GH Joint - External Rotation (SOURCE-8). This not only compromises the anterior capsulolabral structures but in the case of Hill-Sachs Lesions, compresses the posterosuperolateral aspect of the Humeral Head into the anterior Glenoid (SOURCE-8). Concomitant bone defect to the both the Humerus and Glenoid, known as a “Bipolar-Lesion” is observed in up to 81% of Anterior Glenohumeral Instability instances (SOURCE-7). When roughly 25% or more of the Glenoid Cavity is compromised it begins to resemble an inverse pear-shape, a morphology which is associated with instability related pathology (SOURCE-7). Intuitively, the precise position of the Hill-Sachs Lesion also influences the extent of injury. Where the lesion interferes with the smooth motion/ articulation of the Glenohumeral Joint it is described to “engage” which predisposes further injury (SOURCE-7). Larger or more medially lesions are particularly prone to engaging (SOURCE-7). A more recent “on-track” (not engaging) and “off-track” terminology has been adapted which quantifies the distance from the medial margin of the Humeral defect to the Glenoid’s articular surface (SOURCE-7). This framework more accurately predicts recurrence and provides guidance for surgical intervention (SOURCE-7).
Hill-Sachs lesions are complex injuries that rarely occur in isolation. The following pathologies are commonly associated with them, often serving as predisposing factors or occurring concomitantly:
Glenohumeral Instability - like many Glenoid Labrum and Rim disturbances, Hill-Sachs lesions share a bidirectional relationship with instability. Traumatic Glenohumeral Dislocation is often the driving force behind a Hill-Sachs lesion with a higher proportion of lesions found in those with recurrent Dislocation events (SOURCE-4+8). As Hill-Sachs lesions may disturb joint articulation, they are highly associated with further instability, particularly when the lesion engaging/ “off-track” (SOURCE-7). One study found impression Fractures of the Head of the Humerus to be associated with 65-71% Glenohumeral Dislocations and 100% of recurrent Glenohumeral Instability (SOURCE-1).
Bankart Lesion - following a first Glenohumeral Dislocation , 64% of patients with a Bankark Lesion also had a concomitant Hill-Sachs lesion (SOURCE-1). This number increased to 79% with recurrence (SOURCE-1).
Rotator Cuff Tear - while less common in the young, Rotator Cuff Tears become increasingly prevalent with Glenohumeral Dislocation beyond 35 years of age (SOURCE-11-12). As Hill-Sachs lesions are highly associated with this mechanism of injury the two pathologies often occur concomitantly.
If the Glenoid remains intact Hill-Sachs lesions may be “clinically silent”; however, with concomitant injury catching and events of Glenohumeral Instability may ensue (SOURCE-8). The following observations are often made with Hill-Sachs lesions (SOURCE-8+13):
Deep Pain in The Shoulder Girdle
Traumatic Instability event
Recurrent Instability - that possibly gets easier and more frequent
Mechanical Symptoms - such as crepitus, clicking and catching
Range of Motion of The Shoulder Girdle may be performed as tolerated by the patient and compared to the asymptomatic side (SOURCE-8). Establishing whether or not the Hill-Sachs lesion is “engaging” is typically done in 90º GH Joint - Abduction and 0-135º of GH Joint - External Rotation , with engagement often accompanied by a palpable clunk (SOURCE-3+13). In advanced cases crepitus may experienced throughout range of motion.
The following Shoulder - Special Tests may be relevant in the evaluation of a Hill-Sachs Lesion (SOURCE-8):
Apprehension Test - “mid-range” variation in lower degrees of GH Joint - Abduction
Jobe Relocation Test - assess for laxity
Additionally, special tests to rule out common concomitant conditions may be conducted, including those for Rotator Cuff Tears and SLAP Lesions (SOURCE-13).
The following imaging modalities may be relevant in the evaluation of Hill-Sachs Lesions and common concomitant injury:
Computed Tomography (CT Scan)- in particular 3D-CT is superior for the evaluation of Bone -loss, providing a clear image of the orientation of the Humeral defect or accurately quantifying disturbance of the Glenoid Rim (SOURCE-8). This modality is therefore useful for preoperative planning (SOURCE-8).
Radiographs often first line of assessment following Dislocation which may reveal osseous injury including Fracture s, Avulsion Fractures and defects of the Glenoid Rim or Head of Humerus (SOURCE-9+10). While the AP, Lateral and Axillary views are typically obtained, other views may provide more relevance (SOURCE-8):
modified West Point Axillary View - used to evaluated Glenoid bone loss
Stryker Notch View - specific for Hill-Sachs Lesions as the GH Joint - Internal Rotation of the Humerus brings the posterolateral defect into direct view
Magnetic Resonance Imaging (MRI)- with the capacity for Bone and Soft-Tissue to be implicated in Humeral Head pathology, MRIs may be preferable due to their ability to produce clear images of both. Although for Bone specifically it is difficult to accurately quantify the location and size of Hill-Sachs lesions and Glenoid bone loss using MRI’s (SOURCE-8). High sensitivity for the detection of edema does however allow MRIs to recognise pathologies in their early phase (SOURCE-2).
Proton Density Weighted Images (PD)- localise bone and soft-tissue pathology at the same time. The high water content in inflamed tissue causes this tissue to appear white. Damage is somewhat proportional signs of edema and may serve as a predictor for concomitant conditions. This imaging technique is preferred by many clinicians for a suspected Hill-Sachs Lesion (SOURCE-2).
Conservative management of Hill-Sachs Lesions may be indicated for those with small, non-engaging/ “on-track” lesions or poor surgical candidates (SOURCE-8). Generally post-operative management follows a similar course to conservative rehabilitation, though with different time-frames and slight variation between procedures (SOURCE-6). Range of Motion , Strength and functional capacity should be progressed as tolerated by the patient and their recovery. Following surgical intervention the shoulder is typically immobilised for 3-6 weeks in neutral rotation which protects the repair site, although immobilisation in GH Joint - External Rotation has been described to minimise tension of the Glenohumeral Joint Capsule and consequent Contracture formation (SOURCE-6). Return to sport should be delayed for 6 months and ideally meeting the following criteria (SOURCE-6):
Diminished Pain / Sensitivity
Shoulder Strength >90% of the asymptomatic side
There is a paucity of literature regarding Stretching techniques for the treatment of Hill-Sachs lesions or following surgical repair. Irrespective of the procedure, there appears a consensus that shoulder motion should be restricted postoperatively for roughly a 4 week period and full Range of Motion should be possible by roughly 12 weeks (SOURCE-6+14). This provides an approximate guide as to when rudimentary stretches may be commenced and how aggressively they should be progressed. Following most surgeries related to Hill-Sachs lesions, particular caution should be given to GH Joint - External Rotation and GH Joint - Abduction to ensure tissues of focus are not further compromised. The following lists stretches that may be relevant in the treatment of Hill-Sachs lesions:Initial Phase
Quadruped Thoracic Rotation - reduce the need for the shoulder to compensate for a lack of Thoracic Spine Mobility
Seated Thoracic Rotation with Breathing - large lateral flexion and rotation range coupled with breathing
Rotator Cuff Pendulums - oscillatory motion that afford a distracting glide to the Humeral Head
Forward Elevation Stretch - rudimentary passive stretch with moderate GH Joint - Flexion range
Mid-Phase
Passive Ranges of Motion for Shoulder - progressed as tolerated by patient
Genie Stretch - rudimentary horizontal adduction stretch
Late Phase
Door Frame Shoulder Stretch - self-guided anterior shoulder stretch with large Horizontal GH Joint - Abduction range
Sleeper Stretch - greater emphasis on GH Joint - Internal Rotation
Dowel External Rotation Stretch - self-guided GH Joint - External Rotation stretch with overpressure
Banded Capsule Rolls - split stance biceps variation that emphasises shoulder rotation
Bent Over Lat Stretch - accessible active stretch with large GH Joint - Flexion or Horizontal GH Joint - Adduction range
Shoulder Dislocates - mobility exercise that emphasises the greatest circumduction range possible
While rudimentary Range of Motion exercises may be may be commenced as early as the following day, Strength -based training is typically delayed for 9-12 weeks post-surgery (SOURCE-6). Emphasis should be placed on prime movers and key stabilisers of The Shoulder Girdle such as the Deltoid , Rotator Cuff , Serratus Anterior , Trapezius and Rhomboids (SOURCE-8).Initial Phase - passive or active assisted movement is commenced anywhere between 2 and 12 weeks post-surgery, with some recommending conservative motions the day after intervention (SOURCE-6). Range of Motion is often restricted for 4-8 weeks, in particular arm rotation and elevation (SOURCE-6).
Rotator Cuff Pendulums - oscillatory motion that afford a distracting glide to the Humeral Head
Shoulder Sling - passive shoulder movement produced by asymptomatic side
Active-Assisted GH Joint - Flexion with arm in Elbow - Supination - assistance afforded by asymptomatic hand or practitioner
Isometric Rotator Cuff Exercises - GH Joint - External Rotation is often delayed until 6 weeks post-surgery, while discomfort through GH Joint - Internal Rotation should be avoided until 8 weeks (SOURCE-6):
Prone Shoulder External Rotations - adds gravity or light load to Apprehension Test position
Other Rotator Cuff Banded Rotations exercises sustained as an Isometric Muscle Contraction
Mid-Phase - Strength exercises are typically commenced from 9-12 weeks post-surgery with emphasis on the aforementioned prime movers and key stabilisers of the shoulder (SOURCE-6+8):
Prone Horizontal Abduction - rudimentary Scapulothoracic Joint - Retraction exercise
Pallof Press - low load horizontal push exercise that emphasises anti-rotation of Core
Side-Lying Shoulder External Rotations - maximises effect of gravity against External Rotation with upper arm fixed against torso
Standing Shoulder External Rotations - incorporates upright torso posture
Band Pull-Apart - basic isotonic exercise for Scapular Retractors
Banded Unilateral Lat Activations - activate lat, posteroinferior drawer on Humerus
Circumduction Row - isotonic exercise with variable load used to emphasise mid-to-lower Trapezius
Bottoms-Up Kettlebell Walk - typically isometric exercise for entire arm musculature with perturbation from walking
Face Pulls - bilateral isonotic horizontal pull exercise that emphasises GH Joint - External Rotation
Inverted Rows - rudimentary isotonic horizontal pull exercise that utilises bodyweight
One Arm Row - unilateral DB version of Seated Row
Lat Pulldown - rudimentary weighted isotonic vertical pull movement with a high range of motion
Farmers Carry - upperbody/ Core isometric exercise with perturbation of walking
Prone Lat Pulldown - Lat Pulldown variation that emphasises Thoracic - Extension
Suitcase Carry - unilateral farmers carry which emphasises crossbody functional patterns
Late Phase - exercise progression beyond the mid-phase should increasingly reflect the patients physical demands with the aims of a return to sport or full function within 6 months (SOURCE-6). Exercise selection should consider increasing loads, range of motion and incorporating relevant functional patterns:
Side Raises - isotonic GH Joint - Abduction exercise with many variations
Front Raises - isotonic GH Joint - Flexion exercise with many variations
Lu Raises - large GH Joint - Abduction range with no Humerus rotation to promote Scapulothoracic Joint - Upward Rotation
Push Press - explosive overhead movement with large range that incorporates entire body
Bird-Dog Row - One Arm Row variation that emphasises Posterior Sling
Pull-Up - bodyweight or greater load through large overhead motion
DB Hang Clean - unilateral clean progression, often performed explosively
Kneeling Landmine Press - explosive Vertical Push exercise with a large overhead range
Split Stance Landmine Press - explosive unilateral, whole-body Vertical Push exercise
DB Snatch - unilateral isotonic, explosive shoulder exercise with large overhead range
DB Snatch to Step-Up - wholebody DB Snatch variation that emphasises diagonal functional patterns
Rope Climb - pull-up variation with entire load bestowed on alternating arm
Medball Pullover Throw - plyometric Pullover variation
Irrespective of size, non-engaging Hill-Sachs lesions (typically evaluated in a position of 90º GH Joint - Abduction and 90º GH Joint - External Rotation ) are generally amendable to a Bankart repair alone (SOURCE-3). However, where there is concomitant Glenoid compromise, both “critical” (>25%) and “subcritical” (15%) lesions are at a substantially greater risk of recurrent instability following a standalone Bankart repair (SOURCE-3). Similarly, those with Hill-Sachs lesions had an 8.3x higher risk of arthroscopic Bankart repair failure (SOURCE-7). Engaging or Off-Track may therefore require additional procedures such as an open capsular shift or Bone -grafting (SOURCE-3). The addition ofRemplissagefor example decreases recurrence rates in those with Hill-Sachs defects by anywhere from 10% to 10x (SOURCE-6+7). Although an inconsistent finding, Remplissage may be associated with a loss of Range of Motion , particularly GH Joint - External Rotation (SOURCE-7). Where there is significant concomitant injury to the Glenoid, Glenoid bone augmentation may be necessary which may reduce engagement of a Hill-Sachs Lesion due to an increase in articular surface (SOURCE-7). Both arthroscopic and open Latarjet Procedures produce boast low re Dislocation rates for Hill-Sachs Lesions of moderate or smaller size (SOURCE-7). For larger Hill-Sachs Lesions the Latarjet alone may not be a sufficient stabiliser and may require additional bone-graft or Remplissage procedures (SOURCE-7).
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