What is the initial management for a small Hill-Sach (Hill-Sach lesion, a bony defect in the humeral head) lesion of the shoulder?

Initial Management of Small Hill-Sachs Lesion of the Shoulder

Conservative management is the initial approach for small Hill-Sachs lesions of the shoulder that are non-engaging and do not cause instability. 1, 2

Diagnostic Workup

• Initial evaluation should include standard shoulder radiographs with three views: anteroposterior (AP) views in internal and external rotation, and an axillary or scapula-Y view 1
• The Stryker notch view is specifically recommended to evaluate Hill-Sachs lesions 1
• Radiographs should be performed upright as malalignment can be underrepresented on supine imaging 1
• MR arthrography is the preferred advanced imaging for evaluating Hill-Sachs lesions when further characterization is needed, as it can assess both bony and cartilaginous components 1
• CT without contrast can be used to assess bony defects when MRI is contraindicated, though it has limitations in evaluating cartilaginous Hill-Sachs lesions 1

Treatment Algorithm

For Small, Non-engaging Hill-Sachs Lesions:

1. Initial Conservative Management:

   • Focused rehabilitation program targeting rotator cuff and scapular stabilizers 2
   • Activity modification to avoid positions that may provoke instability 2
   • Progressive return to activities as symptoms improve 2

2. Monitoring:

   • Regular clinical follow-up to assess for signs of instability 2
   • If symptoms of instability develop, reassess with advanced imaging 1

Factors That May Warrant Surgical Consideration:

• Presence of engaging Hill-Sachs lesion (lesion that engages the anterior glenoid with the shoulder in abduction and external rotation) 3
• Concomitant significant glenoid bone loss creating an "inverted-pear" glenoid 3
• Recurrent instability despite conservative management 2, 3
• High-demand athletes, especially contact sport participants 3

Important Considerations

• The incidence of Hill-Sachs lesions approaches 100% in patients with recurrent anterior shoulder instability 2
• Identification of concomitant glenoid bone loss is essential as this creates a bipolar injury pattern that may require different management 2
• Small, non-engaging Hill-Sachs lesions in stable shoulders have good outcomes with conservative management 2
• Surgical management should be considered when there is objective evidence of shoulder instability during desired activities 2

Common Pitfalls to Avoid

• Inadequate imaging leading to missed diagnosis or underestimation of lesion size 1
• Failure to assess for associated soft tissue injuries (Bankart tears, labral or capsular injuries) 2
• Overlooking the presence of glenoid bone loss, which significantly affects treatment decisions and outcomes 2, 3
• Inappropriate surgical intervention for small, non-engaging lesions that could be managed conservatively 2

Emerging Techniques

• Minimally invasive balloon reduction techniques are being investigated for acute Hill-Sachs lesions, though these remain experimental 4
• For larger or engaging lesions requiring surgery, the "remplissage" technique (arthroscopic capsulotenodesis of the posterior capsule and infraspinatus tendon to fill the Hill-Sachs lesion) may be considered 5