Traumatic anterior dislocation of the shoulder is a relatively common injury in the young, active population. Most of the interest regarding these injuries has focused on recurrence as the primary complication. Recurrence is not typically a problem in the older population; prolonged morbidity secondary to associated rotator cuff injury is more common. In older individuals, the dynamic stabilizers are more likely to fail (rotator cuff), whereas in young individuals, it is more often the static restraints that fail (labrum). Additionally, with increasing age, the incidence of pre-existing, degenerative tears of the rotator cuff is increasing.

When evaluating a patient who cannot abduct the arm after reduction of an anterior dislocation, the physician tends to assume that this inability is caused by an axillary nerve palsy. This assumption frequently results in an unnecessary delay in establishing the correct diagnosis of a ruptured rotator cuff, and the delay can result in a challenging reconstruction.

The association of a rotator cuff tear and dislocation in the older population is well documented. Ribbans et al. [1] reported a 63% rotator cuff tear rate in primary traumatic dislocation in a small number of patients older than 50 years. Hawkins and Mohtadi [2] reported a 90% rotator cuff tear rate in a similar patient population. Toolanen et al. [3] reported a 38% tear rate, and 47% of the patients still complained of shoulder dysfunction at 3 years postinjury. However, 65% of their patients had electromyogram-confirmed axillary nerve or brachial plexus injury, which may have contributed to their poor results. Neviaser et al. [4] reported a 100% rate of rotator cuff tears in patients older than 40 years with a primary traumatic anterior dislocation. However, this was a preselected group of patients, making the true incidence impossible to determine. In their study, most rotator cuff tears were initially misdiagnosed as axillary nerve injuries. They also reported a 30% recurrence rate and emphasized the importance of the rotator cuff to glenohumeral stability. This is consistent with Itoi et al. [5] who used a cadaver model to describe the importance of the rotator cuff muscles and the long head of the biceps, as dynamic stabilizers of the shoulder. Pevny et al. [6] studied 52 patients older than 40 years with a shoulder dislocation. Between these group of patients, 42 showed excellent or good outcomes, and 11 showed fair and poor outcomes. 18 patients out of a total of 52 showed a rotator cuff tear (35%), and only 11 (61%) of these patients obtained an excellent or good outcome. Of the 11 patients with a fair or poor result, seven (64%) had a rotator cuff tear. Of the patients with isolated cuff tears, 84% had an excellent or good result when treated surgically, compared with 50% when treated nonsurgically. These findings indicate that recurrence is not a frequent complication of traumatic anterior shoulder dislocation in this age group (4%). However, prolonged morbidity secondary to rotator cuff tear is more prevalent than in a younger population.

The most important concerns regarding this topic are related to the treatment. The dispute is about the type of treatment, conservative or surgical, open or arthroscopic. And finally on what to repair labral tear, cuff tear or both.

Pevny et al. [6] showed that patients treated surgically had 84% excellent/good results, compared with 50% excellent/good results when treated nonoperatively. In this series, most of the patients had open cuff repairs. Bassett and Coffield [7] also reported better results after surgical cuff repair in terms of functional outcome and pain relief following acute dislocations. In all studies available, the cuff repair was combined with an acromioplasty. Voos et al. [8] showed good clinical outcomes, restoration of motion, and high degree of patient satisfaction in patients treated arthroscopically with rotator cuff and Bankart lesion.