In the patient age 25–50 it is important to distiguish between the patients less than 40 and those over 40 years of age. First time dislocation in the patient over 40 years of age is often associated with significant rotator cuff and neurologic injury, and also may have a much higher risk of developing degenerative changes.

Traumatic supraspinatus tears in middle-age patients younger than 40 years are rare events, with few reports in the literature [1–4]. Posttraumatic shoulder pain in this patient population is routinely attributed to instability or fracture, and the diagnosis of a rotator cuff tear can often be overlooked due to the patient’s age.

When compared with the more mature shoulder, the young, healthy supraspinatus tendon is a robust tendon that is able to absorb a significant amount of energy before tendon failure. The weakest structural link in the shoulder in this patient population is often the bone as opposed to the tendon. As a result, shoulder trauma in younger patients likely results in more fractures than supraspinatus tears [5].

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 preexisting, degenerative tears of the rotator cuff is increasing.

Based on pathological findings seen during arthroscopy in young, first-time dislocators, it is now evident that both age and severity of labral detachment are important factors in determining the chance of recurrence [6–8]. Results from these studies suggest that early arthroscopic labral stabilization reduces the chance of recurrence in these select individuals [6, 9].

Unlike the younger population, older individuals typically have a different spectrum of intra-articular pathology associated with first-time traumatic dislocations [10–13]. This may explain the difference in recurrence rates between these two populations.

Unlike the younger population, the older individual is more at risk for rotator cuff injury during a first-time dislocation [7, 10–13]. McLaughlin [14] referred to this as a posterior mechanism of injury as opposed to an anterior mechanism seen in younger individuals. His point was that in the older individual, it is more likely for the dynamic stabilizers (e.g., rotator cuff) to fail, whereas in the younger individual, it is the static restraints (e.g., labrum and capsule) that typically fail.

Morbidity secondary to rotator cuff lesions can be as debilitating in these patients as recurrence is in the young.

There are no studies in literature regarding the association of Bankart and rotator cuff tear in patients aged less than 40 years. Neviaser et al. [10] 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. [15] 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.

Ribbans et al. [13] reported a 63% rotator cuff tear rate in primary traumatic dislocation in a small number of patients older than 50 years. Hawkins and Mohtadi [12] reported a 90% rotator cuff tear rate in a similar patient population.

McLaughlin and MacLellan [14] suggested that anterior dislocation of the shoulder occurs either by disruption of the glenohumeral ligament (anterior mechanism) or by rupture of the rotator cuff (posterior mechanism). They believed that failure of the posterior support was more likely in patients who are older than 40 years, because the tendinous structure usually degenerates and weakens with age. Rupture of the musculotendinous cuff, particularly of the supraspinatus, infraspinatus, and teres minor, can permit anterior dislocation of the humeral head on an intact anterior soft tissue hinge and thus may be termed the posterior mechanism of anterior dislocation [16].