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Joint Instability

Spectrum of joint instability across the shoulder, hip, elbow, and knee, focusing on traumatic vs atraumatic mechanisms and recurrence risk factors.

Overview

Glenohumeral instability management requires precise stratification based on presentation and bone status. Athletes with primary instability demonstrate lower rates of bone loss than those with recurrent instability or failed prior stabilization [2]. Patients presenting for stabilization with recurrent instability or following a failed procedure have higher rates of glenohumeral bone loss than those with primary instability [2]. Proper evaluation of bone loss best determines shoulder instability surgical indications and outcomes [21]. For patients meeting eligibility criteria for arthroscopic stabilization—those without significant bony lesions or deformity—there is no difference in postoperative recurrence of instability or radiographic outcomes between primary and revision arthroscopic anatomic glenoid reconstruction with distal tibial allograft [3]. These patients can expect equivalent rates of recurrence, better functional outcomes, and less morbidity compared to open methods [22].

Surgical intervention is indicated in the acute setting for physically active patients with knee dislocations and patellar fractures [24]. Surgery is indicated in the chronic setting for knee dislocations and patellar fractures when instability is present without significant arthrosis [24]. Surgical soft-tissue stabilization might be more aggressively indicated in cases of primary shoulder dislocation [28]. Recurrent instability with bone loss should be referred to experienced high-volume specialists [28]. There is no one procedure that fits all patients with anterior instability [74]. Surgeons should individualize their approach for anterior instability based on patients' bone changes, soft tissue quality, activity requirements, and surgical experience to maximize success and reduce complications [74]. Surgical intervention should be considered for skeletally immature patients with recurrent instability [75].

Arthroscopic Bankart repair has evolved to offer decreased pain, improved functional outcomes, and little recurrence of instability [76]. Arthroscopic Bankart repair results approach those of open repair when appropriate patient selection and technical considerations are applied [76]. Multidirectional instability should be initially treated with conservative treatment [11]. Newer arthroscopic techniques for multidirectional instability may now approach the success rates of traditional open treatments [11]. Arthroscopic stabilization of multidirectional instability yields excellent results and is a viable alternative to an open approach, with 95.6% of patients achieving full function and stability [23]. Surgical reconstruction of the sternoclavicular (SC) joint is a viable treatment option for chronic anterior instability with low complication rates and good patient outcomes [12].

Anatomy & Pathophysiology

Shoulder instability results from an imbalance between static and dynamic stabilizers [9]. The functional anatomy and biomechanics of shoulder stability involve complex interactions between these restraints [55]. A thorough understanding of normal anatomy and anatomic variations is critical to differentiate them from pathologic findings [9]. The biomechanical shoulder model is consistent with clinical observations [33].

Osseous Morphology: Patients with shoulder instability have constitutional biomechanically relevant glenoid concavity shape differences [58]. Glenoid concavity is a crucial factor for the stability ratio [67]. Labral morphology does not compensate for reduced bony glenoid concavity in clinically stable shoulders [73]. Current glenoid bone loss measurements are unable to provide an adequate estimation on the actual biomechanical effect of glenoid defects because the relation between the glenoid defect size and its biomechanical effect is nonlinear [58]. Current glenoid defect extent measurements are precise but not accurate because they do not account for the 3-dimensional shape of the glenoid concavity or the native glenoid shape [63]. The computable bony shoulder stability ratio (BSSR) is a precise biomechanical estimate of measured stability independent of defect size [67]. A glenoid classification scheme that relies more upon glenoid morphology and less upon humeral head position may demonstrate greater observer agreement [79].

Kinematics and Biomechanics: Capsular repair significantly alters normal glenohumeral kinematics [43]. Biomechanical changes of passive glenohumeral joint motion occur in the glenohumeral joint with as little as 5% GIRD [44]. Multiple anterior shoulder dislocations lead to abnormal translational kinematics and result in increased superior translation of the humerus [54]. Time-zero biomechanical shoulder instability studies do not replicate clinical dynamics [52]. Observed results in time-zero biomechanical studies do not confirm that the surgical approach would provide sufficient long-term noncontractile shoulder stability to withstand repetitive soft-tissue loading in a dynamic, clinical situation [52]. Open surgery stabilizes the shoulder but does not necessarily restore normal movement quality [50]. The modified position of the scapula was maintained during the entire range of motion after the Latarjet procedure, suggesting a shoulder-stabilizing kinematic effect in addition to the bony, sling and bumper effects [51].

Clinical Implications: Tissue pathology, pain, and sensorimotor alterations directly affect outcome following shoulder injury [68]. Recent advances in shoulder instability emphasize individualized strategies based on bone loss, patient risk profile, and dynamic stabilizing techniques [71].

Classification

FEDS: The frequency, etiology, direction, and severity (FEDS) system has content validity and is highly reliable for classifying glenohumeral instability [45].

WARPS/STAID: The WARPS/STAID classification system was introduced for patients with patellofemoral instability, establishing both validity and reliability in this population [57].

Other Considerations: Shoulder instability results from an imbalance between static and dynamic stabilizers, and a thorough understanding of normal anatomy and anatomic variations is critical to differentiate them from pathologic findings [9]. Patients with shoulder instability should be thoroughly evaluated to identify the etiology of instability before considering operative treatment [1]. Surgical intervention for recurrent posterior shoulder instability is indicated when conservative treatment fails, requiring accurate definition of the instability pattern and addressing all soft-tissue and bony injuries [4]. A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit [27]. Multidirectional instability should be initially treated with conservative treatment [11]. Discrepancies in the definition and classification of multidirectional instability can make diagnosis and treatment selection challenging [7]. Variations in the criteria used for the diagnosis of multidirectional instability significantly affect the distribution of patients with that diagnosis [8]. The Instability Severity Index Score (ISIS) failed to predict recurrent instability in a cohort where ISIS scores were not significantly different between successful and failed repairs [6]. The Instability Severity Index (ISI) scoring system should not be condemned but complemented with preoperative advanced imaging studies (CT or MRI) to assess the severity of bone lesions more accurately [25]. Shoulder instability cannot reliably be classified using the ICD-9 coding system [49]. Recognition and classification of sternoclavicular (SC) joint injuries are critical to proper management to minimize long-term sequelae [53].

Clinical Presentation

Anterior instability is the most common presentation among shoulder instability patients, who are typically in their early 20s or younger [35]. Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability [2]. Conversely, athletes with primary glenohumeral instability demonstrate lower rates of bone loss than those with recurrent instability and failed prior stabilization [2]. Shoulder instability results from an imbalance between static and dynamic stabilizers [9]. A thorough understanding of normal anatomy and anatomic variations is critical to differentiate them from pathologic findings in shoulder instability [9].

Careful history and examination may reveal a constellation of musculoskeletal conditions associated with generalized joint laxity [5]. Subtle findings on radiographs or MRI can impact decision-making in patients with generalized joint laxity [5]. There are discrepancies in the definition and classification of multidirectional instability, which can make diagnosis and treatment selection challenging [7]. Variations in the criteria used for the diagnosis of multidirectional instability significantly affect the distribution of patients with that diagnosis [8].

Many different diagnostic examinations for assessing shoulder instability are used and a high variety is seen in the use of diagnostic tools [19]. In patients with suspected posterior glenohumeral instability, imaging of the affected shoulder can show abnormalities of the bone, labrum, and joint capsule [20]. Patients with posterior instability tend to have baseline dysplasia and/or glenoid bone loss [41]. Glenoid dysplasia is a developmental anomaly that may be underdiagnosed and is associated with instability and premature glenohumeral arthritis [38]. Recognizing HAGL lesions is important to manage patients with glenohumeral instability [36].

Microinstability is diagnostically challenging and can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability [39]. Microinstability can be characterized by small and easily overlooked anterior labral or Hill–Sachs lesions [39].

Instability of the proximal tibiofibular joint is rarely reported and often missed [16]. Understanding the etiology, symptoms, and anatomic variations of proximal tibiofibular joint instability is essential for evaluating symptomatic patients [16].

Patients who present with multiple recurrences, more than 2 preoperative dislocations, a duration of instability symptoms of more than 6 months, and identified off-track Hill-Sachs lesions may not be ideal candidates for arthroscopic instability repair due to higher failure rates [10]. It is critical to evaluate for clinical signs of instability in addition to radiographic parameters to avoid iatrogenic instability in the setting of a borderline dysplastic hip [18].

Investigations

Patients with shoulder instability require thorough evaluation to identify the etiology of instability before considering operative treatment [1]. Nonsurgical treatment is successful in most cases of recurrent posterior shoulder instability, but surgical intervention is indicated when conservative treatment fails, requiring accurate definition of the instability pattern and addressing all soft-tissue and bony injuries [4]. Careful history and examination may reveal a constellation of musculoskeletal conditions associated with generalized joint laxity, and subtle findings on radiographs or MRI can impact decision-making [5]. Discrepancies in the definition and classification of multidirectional instability can make diagnosis and treatment selection challenging [7], and variations in the criteria used for the diagnosis of multidirectional instability significantly affect the distribution of patients with that diagnosis [8].

Plain radiography: Conventional radiography remains the initial imaging study for evaluating patients with persistent shoulder pain and instability [69].

MRI: Magnetic resonance arthrography has been firmly established as the imaging modality of choice for demonstrating specific soft tissue abnormalities associated with glenohumeral instability [69]. In patients with suspected posterior glenohumeral instability, imaging of the affected shoulder can show abnormalities of the bone, labrum, and joint capsule [20]. Capsular injury is commonly seen in magnetic resonance imaging of patients with anterior shoulder instability [86]. MRI is able to reliably diagnose and is a good predictor of the structural soft tissue damage associated with chronic traumatic sternoclavicular joint (SCJ) instability [85]. Patients who undergo MRI greater than 6 months from the time of primary or initial shoulder dislocation had significantly more recurrent shoulder instability events and demonstrated a greater incidence and severity of intra-articular abnormalities, including SLAP tears, posterior labral tears, and anterior glenoid cartilage damage [87]. In patients that underwent 6-months of nonoperative management for isolated posterior glenohumeral instability, failure occurred approximately 47% of the time and was associated with a greater posterior humeral head subluxation ratio on index MRI than those who did not fail [89]. Undertaking an augmented capsular plication on patients with symptomatic atraumatic SCJ instability confirmed by MRI imaging that have failed appropriate nonoperative treatment provides a satisfactory result with regard to clinical outcomes and joint stability [90].

CT: The Instability Severity Index (ISI) scoring system should be complemented with preoperative advanced imaging studies (CT or MRI) to assess the severity of bone lesions more accurately [25]. Future studies on recurrent shoulder instability after primary arthroscopic Bankart repair should use advanced imaging for glenoid bone loss measurements [88].

Other Considerations: Many different diagnostic examinations for assessing shoulder instability are used, and a high variety is seen in the use of diagnostic tools [19]. Instability of the proximal tibiofibular joint is rarely reported and often missed; understanding its etiology, symptoms, and anatomic variations is essential for evaluating symptomatic patients [16]. It is critical to evaluate for clinical signs of instability in addition to radiographic parameters to avoid iatrogenic instability in the setting of borderline dysplastic hip [18]. The Instability Severity Index Score (ISIS) is a useful clinical tool when used in conjunction with computed tomography [91].

Treatment

Non-Operative Management

Patients with multidirectional shoulder instability should initially be treated with conservative management [11]. Nonsurgical treatment is successful in most cases of recurrent posterior shoulder instability, but surgical intervention is indicated when conservative treatment fails [4]. Among athletes receiving nonoperative treatment, those with anterior instability have significantly greater initial disability and change in disability than those with posterior instability during the course of care [70].

Nonoperative management of anterior shoulder instability can result in high rates of recurrent instability and pain at long-term follow-up [14]. At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability [14]. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management for anterior shoulder instability [15].

Conservative treatment for posterosuperior shoulder dislocation due to deltoid posterior fiber rupture may result in continuing instability that requires surgical treatment [59]. Nonsurgical management of perilunate fracture-dislocations results in progressive arthritis and poor long-term outcomes [77]. Nonsurgical management is acceptable for Hill-Sachs lesions that are small bony defects and nonengaging [80].

Operative Management

Indications: Patients should be thoroughly evaluated to identify the etiology of instability before considering operative treatment [1]. Proper evaluation of bone loss best determines shoulder instability surgical indications and outcomes [21]. Surgery is indicated in the acute setting for physically active patients with knee dislocations and in the chronic setting for instability without significant arthrosis [24]. Early operative stabilization of Bankart lesions in young patients offers a significant reduction in the risk of recurrent instability compared to non-operative management [46].

Surgical Approach / Technique: Surgical intervention for recurrent posterior shoulder instability requires accurate definition of the instability pattern and addressing all soft-tissue and bony injuries [4]. Surgical soft-tissue stabilization might be more aggressively indicated in cases of primary shoulder dislocation, whereas recurrent instability with bone loss should be referred to experienced high-volume specialists [28]. The success of treating anterior glenohumeral instability relies on multiple factors, including glenoid bone loss [34].

Arthroscopic vs. Open Techniques: Current data suggest that patients meeting eligibility criteria for arthroscopic stabilization (those without significant bony lesions or deformity) can expect equivalent rates of recurrence, better functional outcomes, and less morbidity compared to open methods [22]. Sizable glenohumeral bone defects remain the only absolute contraindication to an all-arthroscopic approach, while other complicating issues such as attenuated capsule, HAGL lesions, revision surgery, and collision athletes warrant close attention but are not true contraindications [64]. Arthroscopic stabilization of multidirectional instability yields excellent results and is a viable alternative to an open approach, with 95.6% of patients achieving full function and stability [23]. Newer arthroscopic techniques for multidirectional instability may now approach the success rates of traditional open treatments [11]. Results demonstrate the efficacy and durability of a modified capsular shift procedure for the treatment of atraumatic anterior-inferior shoulder instability [47]. For patients with posterior capsular contracture who fail nonsurgical management, arthroscopic posterior capsule release can result in improved motion and pain relief [65]. Asymptomatic non-unions after the "purse string" technique for anterior glenohumeral instability should not be considered failures as they are related to satisfactory outcomes, and no additional surgery should be performed [81].

Bone Loss and Reconstruction: Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability [2]. Athletes with primary glenohumeral instability demonstrate lower rates of bone loss than those with recurrent instability and failed prior stabilization [2]. Successful results were obtained in patients younger than 40 years with both primary and recurrent anterior shoulder instability after arthroscopic treatment [56]. There were no differences in postoperative recurrence of instability or radiographic outcomes between primary and revision arthroscopic anatomic glenoid reconstruction with distal tibial allograft for anterior shoulder instability with bone loss [3]. Both free bone graft transfer and the Latarjet procedure showed comparable success in joint stabilization for anterior shoulder instability with glenoid bone loss, but neither could prevent the progression of instability arthropathy [13]. Surgical reconstruction of the sternoclavicular (SC) joint is a viable treatment option for chronic anterior instability with low complication rates and good patient outcomes [12].

Other Considerations: The Instability Severity Index Score (ISIS) failed to predict recurrent instability in a cohort of patients with humeral head defects, as ISIS scores were not significantly different between successful and failed repairs [6].

Complications

Instability: Nonoperative management of anterior shoulder instability is associated with high rates of recurrent instability and pain at long-term follow-up [14]. At 17 years, this approach yields a high rate of poor outcomes [14]. Multiple instability events at initial presentation are the major predictor of failure for nonoperative treatment [15]. Patients with multiple instability events before or after consultation are more likely to require conversion to surgery after initial nonoperative management [15].

Arthroscopic shoulder stabilization using suture anchors carries a risk of recurrence, with approximately one third of stabilized shoulders experiencing at least one redislocation after 8 to 10 years [26]. Instability-related complications occur exclusively in the capsulabral group following surgery for traumatic anterior shoulder instability, and their incidence increases with time [48]. Recurrent instability requiring capsular reconstruction appears more prevalent in patients with a previous history of shoulder dislocation [84].

Open modified inferior capsular shift procedures do not eliminate long-term risk; recurrent instability may result from new trauma even after a long interval [31]. Consequently, follow-up should be continued as long as possible after this surgery due to the risk of recurrent instability from new trauma [31]. For traumatic anterior glenohumeral instability with large bony defects, arthroscopic conjoined tendon transfer has been associated with recurrent instability in one patient [72]. Furthermore, neither free bone graft transfer nor the Latarjet procedure can prevent the progression of instability arthropathy in anterior shoulder instability with glenoid bone loss [13].

Other Considerations: The natural history of scapholunate ligament injuries remains poorly understood, and it is currently unknown which specific injuries lead to wrist arthritis [83].

Recovery

Light activity (weeks): Evidence does not provide specific week ranges for light activity or desk work return.

Full activity (months): Evidence does not provide specific month ranges for full activity, manual work, or sport return.

Complete recovery / outcome plateau (months): Evidence does not provide specific month ranges for complete recovery or outcome plateau.

Rehabilitation protocol: Evidence does not specify immobilisation duration, weight-bearing/ROM progression, or sling/brace removal timing.

Functional milestones: The Instability Severity Index Score (ISIS) failed to predict recurrent instability, as ISIS scores were not significantly different between successful and failed repairs [6].

Other Considerations: Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability [2]. Glenoid bone loss of 6.8% was observed after a first-time anterior instability event, and total calculated glenoid bone loss was 22.8% in the setting of recurrent instability [29]. Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss [93]. The age of the patient at the time of the initial dislocation is the most consistent and significant factor influencing prognosis, with recurrence rates of 83% in patients under twenty years and 12% in patients over fifty years [92]. Patients who present with multiple recurrences, more than 2 preoperative dislocations, a duration of instability symptoms of more than 6 months, and identified off-track Hill-Sachs lesions may not be ideal candidates for arthroscopic instability repair due to higher failure rates [10].

There were no differences in postoperative recurrence of instability or radiographic outcomes between primary and revision arthroscopic anatomic glenoid reconstruction with distal tibial allograft for anterior shoulder instability with bone loss [3]. Both free bone graft transfer and Latarjet procedure cohorts showed comparable success in joint stabilization, but neither could prevent the progression of instability arthropathy [13]. Progression to glenohumeral arthritis after anterior stabilization occurred in 8% of a young patient population [94].

At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability [14]. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management [15]. 39% of patients reported instability symptoms at two years following arthroscopic stabilisation of atraumatic shoulder instability, with 8.5% requiring further stabilisation surgery [17]. About one third of stabilized shoulders experienced at least one redislocation after 8 to 10 years following arthroscopic shoulder stabilization using suture anchors [26]. The outcomes at 3 years' follow-up for revision of failed Latarjet with the Eden-Hybinette surgical technique were satisfactory in 80% of patients and 86% had stable shoulders [78]. The early and midterm results of arthroscopic stabilization of the shoulder for posterior instability are promising [82].

The sole assessment of recurrent dislocation to define natural history and treatment rationale is inadequate, and conclusions regarding treatment recommendations cannot be made from a study that did not compare treatment methods [30]. Recurrent instability might result from new trauma even if a long time has passed since the open modified inferior capsular shift procedure, so follow-up should be continued as long as possible after surgery [31].

Key Evidence

  • [L4] Therefore, patients should be thoroughly evaluated to identify the etiology of instability before considering operative treatment. (10.2106/00004623-199274060-00010)
  • [L3] Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability. (10.1016/j.jse.2021.10.002)
  • [L3] There were no differences in postoperative recurrence of instability or radiographic outcomes. (10.1016/j.jse.2024.04.005)
  • [L5] Nonsurgical treatment is successful in most cases, but surgical intervention is indicated when conservative treatment fails, requiring accurate definition of the instability pattern and addressing all soft-tissue and bony injuries. (10.5435/00124635-200608000-00004)
  • [L5] Careful history and examination may reveal a constellation of musculoskeletal conditions associated with generalized joint laxity, and subtle findings on radiographs or MRI can impact decision-making. (10.2106/jbjs.18.00458)
  • [L3] The Instability Severity Index Score (ISIS) failed to predict recurrent instability in this cohort, as ISIS scores were not significantly different between successful and failed repairs. (10.1016/j.jse.2014.06.007)
  • [L5] There are discrepancies in the definition and classification of multidirectional instability, which can make diagnosis and treatment selection challenging. (10.1016/j.jht.2017.03.005)
  • [L3] Variations in the criteria used for the diagnosis of multidirectional instability significantly affect the distribution of patients with that diagnosis. (10.2106/00004623-200311000-00011)
  • [L5] Shoulder instability results from an imbalance between static and dynamic stabilizers, and a thorough understanding of normal anatomy and anatomic variations is critical to differentiate them from pathologic findings. (10.1177/03635465000280062501)
  • [L5] Patients who present with multiple recurrences, more than 2 preoperative dislocations, a duration of instability symptoms of more than 6 months, and identified off-track Hill-Sachs lesions may not be ideal candidates for arthroscopic instability repair due to higher failure rates. (10.1016/j.arthro.2018.06.021)
  • [Paper] Multidirectional instability should be initially treated with conservative treatment, and newer arthroscopic techniques may now approach the success rates of traditional open treatments. (10.1016/j.csm.2013.07.010)
  • [L4] Surgical reconstruction of the SC joint is a viable treatment option for chronic anterior instability with low complication rates and good patient outcomes. (10.5435/jaaos-d-19-00611)
  • [L2] Both cohorts showed comparable success in joint stabilization, but neither could prevent the progression of instability arthropathy. (10.1016/j.jse.2025.01.017)
  • [L4] At long-term follow-up of 17 years, a high rate of poor outcomes was observed following nonoperative management of anterior shoulder instability. (10.1016/j.jse.2021.07.016)
  • [L3] Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. (10.1016/j.arthro.2021.03.047)
  • [L5] Instability of the proximal tibiofibular joint is rarely reported and often missed; understanding its etiology, symptoms, and anatomic variations is essential for evaluating symptomatic patients. (10.5435/00124635-200303000-00006)
  • [L4] However, 39% of patients reported instability symptoms at two years, with 8.5% requiring further stabilisation surgery. (10.1016/j.jse.2021.03.039)
  • [Commentary] It is critical to evaluate for clinical signs of instability in addition to radiographic parameters to avoid this potentially devastating complication. (10.1016/j.arthro.2021.04.025)
  • [L4] Many different diagnostic examinations for assessing shoulder instability are used and a high variety is seen in the use of diagnostic tools. (10.1007/s00402-016-2443-7)
  • [L5] In patients with suspected posterior glenohumeral instability, imaging of the affected shoulder can show abnormalities of the bone, labrum, and joint capsule. (10.2214/ajr.07.3849)
  • [L5] Proper evaluation of bone loss best determines shoulder instability surgical indications and outcomes. (10.1016/j.arthro.2021.01.004)
  • [L4] Current data suggest that patients meeting eligibility criteria for arthroscopic stabilization (those without significant bony lesions or deformity) can expect equivalent rates of recurrence, better functional outcomes, and less morbidity compared to open methods. (10.1016/j.arthro.2011.06.006)
  • [L4] Arthroscopic stabilization of multidirectional instability yields excellent results and is a viable alternative to an open approach, with 95.6% of patients achieving full function and stability. (10.1016/j.arthro.2012.04.069)
  • [Commentary] The Instability Severity Index (ISI) scoring system should not be condemned but complemented with preoperative advanced imaging studies (CT or MRI) to assess the severity of bone lesions more accurately. (10.1016/j.arthro.2021.02.008)
  • [L4] With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years. (10.1177/0363546511415657)
  • [L5] The essential statements on which the experts reached consensus included the following: A history of multiple dislocations and failed soft-tissue surgery should make surgeons consider the possibility of an associated bone deficit. (10.1016/j.arthro.2020.12.237)
  • [L5] In the interim, surgical soft-tissue stabilization might be more aggressively indicated in cases of primary shoulder dislocation, whereas recurrent instability with bone loss should be referred to experienced high-volume specialists. (10.1016/j.arthro.2016.06.032)
  • [L2] Glenoid bone loss of 6.8% was observed after a first-time anterior instability event, and total calculated glenoid bone loss was 22.8% in the setting of recurrent instability. (10.1177/0363546519831286)
  • [Letter] The sole assessment of recurrent dislocation to define natural history and treatment rationale is inadequate, and conclusions regarding treatment recommendations cannot be made from a study that did not compare treatment methods. (10.1177/0363546510379343)
  • [L4] Recurrent instability might result from new trauma even if a long time has passed since the open modified inferior capsular shift procedure, so follow-up should be continued as long as possible after surgery. (10.1016/j.jse.2021.07.021)
  • [L5] The biomechanical shoulder model is consistent with clinical observations. (10.1016/j.jse.2016.05.031)
  • [L5] The success of treating anterior glenohumeral instability relies on multiple factors, including glenoid bone loss. (10.1016/j.arthro.2021.09.002)
  • [L4] Anterior instability is most common among shoulder instability patients, and most patients undergoing shoulder stabilization are in their early 20s or younger. (10.1177/0363546518755752)
  • [L4] Recognizing HAGL lesions is important to manage patients with glenohumeral instability. (10.1016/j.arthro.2016.03.009)
  • [L5] Glenoid dysplasia is a developmental anomaly that may be underdiagnosed and is associated with instability and premature glenohumeral arthritis. (10.5435/jaaos-d-15-00032)
  • [L3] Microinstability is diagnostically challenging and can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability. (10.1007/s00167-022-06941-4)
  • [L2] Patients with posterior instability tend to have baseline dysplasia and/or glenoid bone loss. (10.1177/2325967121s00238)
  • [L5] Capsular repair also significantly alters normal glenohumeral kinematics. (10.1007/s00167-015-3915-y)
  • [L5] Biomechanical changes of passive glenohumeral joint motion occur in the glenohumeral joint with as little as 5% GIRD. (10.1177/0363546512462012)
  • [L2] The FEDS system has content validity and is highly reliable for classifying glenohumeral instability. (10.1016/j.jse.2010.10.027)
  • [L1] Early operative stabilization of Bankart lesions in young patients offers a significant reduction in the risk of recurrent instability compared to non-operative management. (10.1111/j.1758-5740.2010.00083.x)
  • [L4] Results in this series demonstrate the efficacy and durability of a modified capsular shift procedure for the treatment of atraumatic anterior-inferior shoulder instability. (10.1177/0363546504272685)
  • [L3] Instability-related complications occurred only in the capsulabral group, and the incidence increased with time. (10.1177/03635465211029022)
  • [L1] Shoulder instability cannot reliably be classified using the ICD-9 coding system. (10.1016/j.jse.2008.10.005)
  • [L3] Arm kinematic analyses suggest that open surgery stabilizes the shoulder but does not necessarily restore normal movement quality. (10.1016/j.jse.2013.09.021)
  • [L3] The modified position of the scapula was maintained during the entire range of motion, suggesting a shoulder-stabilizing kinematic effect in addition to the bony, sling and bumper effects. (10.1016/j.jse.2024.02.022)
  • [L5] Time-zero biomechanical shoulder instability studies are valuable but limited because they do not replicate clinical dynamics, and the observed results do not confirm that the surgical approach would provide sufficient long-term noncontractile shoulder stability to withstand repetitive soft-tissue loading in a dynamic, clinical situation. (10.1016/j.arthro.2022.04.006)
  • [L1] Injuries to the SC joint are uncommon, and recognition and classification are critical to proper management to minimize long-term sequelae. (10.1177/0363546513498990)
  • [L5] Multiple anterior shoulder dislocations lead to abnormal translational kinematics and result in increased superior translation of the humerus. (10.1007/s00167-022-07257-z)
  • [Paper] This article reviews the functional anatomy and biomechanics of shoulder stability, outlining the bony and soft tissue lesions associated with shoulder instability in the athlete and highlighting the complex interactions between static and dynamic restraints. (10.1016/j.csm.2013.07.001)
  • [L3] Successful results were obtained in patients younger than 40 years with both primary and recurrent anterior shoulder instability after arthroscopic treatment. (10.1016/j.jse.2023.05.029)
  • [L2] This study introduced the WARPS/STAID classification system and established both validity and reliability in subjects with patellofemoral instability. (10.1007/s00167-013-2477-0)
  • [L5] Current glenoid bone loss measurements are unable to provide an adequate estimation on the actual biomechanical effect of glenoid defects because the relation between the glenoid defect size and its biomechanical effect is nonlinear and patients with shoulder instability have constitutional biomechanically relevant glenoid concavity shape differences. (10.1177/0363546518819102)
  • [Case_report] Conservative treatment may result in continuing instability which requires surgical treatment. (10.1186/s12891-019-2727-5)
  • [L5] Current glenoid defect extent measurements are precise but not accurate because they do not account for the 3-dimensional shape of the glenoid concavity or the native glenoid shape, which are critical for expressing the loss of biomechanical stability. (10.1016/j.arthro.2020.05.006)
  • [L5] Sizable glenohumeral bone defects remain the only absolute contraindication to an all-arthroscopic approach, while other complicating issues such as attenuated capsule, HAGL lesions, revision surgery, and collision athletes warrant close attention but are not true contraindications. (10.1016/j.arthro.2007.03.004)
  • [L5] For patients who fail nonsurgical management, arthroscopic posterior capsule release can result in improved motion and pain relief. (10.5435/00124635-200605000-00002)
  • [L5] Glenoid concavity is a crucial factor for the stability ratio, and the computable bony shoulder stability ratio (BSSR) is a precise biomechanical estimate of measured stability independent of defect size. (10.1007/s00167-021-06562-3)
  • [L5] Tissue pathology, pain, and sensorimotor alterations directly affect outcome following shoulder injury and must be addressed by clinicians to fully restore function. (10.1016/j.csm.2008.03.005)
  • [L5] Conventional radiography remains the initial imaging study for evaluating patients with persistent shoulder pain and instability, while magnetic resonance arthrography has been firmly established as the imaging modality of choice for demonstrating specific soft tissue abnormalities associated with glenohumeral instability. (10.1177/03635465000280032501)
  • [L4] Among those that receive nonoperative treatment, athletes with anterior instability have significantly greater initial disability and change in disability than those with posterior disability during the course of care. (10.1016/j.jse.2021.04.007)
  • [L5] Recent advances have reshaped the approach to shoulder instability, emphasizing individualized strategies based on bone loss, patient risk profile, and dynamic stabilizing techniques. (10.5397/cise.2025.00451)
  • [L4] Recurrent instability occurred in 1 patient who underwent the arthroscopic procedure. (10.1016/j.arthro.2017.06.044)
  • [L4] This study demonstrates that labral morphology does not compensate for reduced bony glenoid concavity in clinically stable shoulders. (10.1016/j.jseint.2025.101422)
  • [L5] There is no one procedure that fits all patients with anterior instability; surgeons should individualize their approach based on patients' bone changes, soft tissue quality, activity requirements, and surgical experience to maximize success and reduce complications. (10.1016/j.arthro.2017.09.028)
  • [L5] Surgical intervention should be considered for patients with recurrent instability. (10.5435/jaaos-21-09-529)
  • [L5] Arthroscopic Bankart repair has evolved to offer decreased pain, improved functional outcomes, and little recurrence of instability, with results approaching those of open repair when appropriate patient selection and technical considerations are applied. (10.5435/00124635-200511000-00008)
  • [L4] The outcomes at 3 years' follow-up were satisfactory in 80% of patients and 86% had stable shoulders. (10.1016/j.otsr.2019.12.009)
  • [L4] A glenoid classification scheme that relies more upon glenoid morphology and less upon humeral head position may demonstrate greater observer agreement. (10.1016/j.jse.2007.12.006)
  • [L5] Nonsurgical management is acceptable in cases of small bony defects and nonengaging lesions, while surgical options include arthroscopic and open techniques. (10.5435/jaaos-20-04-242)
  • [L4] Asymptomatic non-unions should not be considered as failures as they are related to satisfactory outcomes, and no additional surgery should be performed. (10.1016/j.jse.2021.03.066)
  • [L1] The early and midterm results of arthroscopic stabilization of the shoulder for posterior instability are promising. (10.1016/j.arthro.2014.11.009)
  • [L5] The natural history of scapholunate ligament injuries is poorly understood, and it is unknown which injuries lead to wrist arthritis. (10.1007/s11552-013-9499-4)
  • [L4] Recurrent instability requiring capsular reconstruction seems to be more prevalent in patients with a previous history of shoulder dislocation. (10.1016/j.jse.2009.07.062)
  • [L4] MRI is able to reliably diagnose and is a good predictor of the structural soft tissue damage associated with chronic traumatic SCJ instability. (10.1016/j.jse.2025.04.018)
  • [L1] Capsular injury is commonly seen in magnetic resonance imaging of patients with anterior shoulder instability. (10.1016/j.xrrt.2024.08.004)
  • [L3] Patients who undergo MRI greater than 6 months from the time of primary or initial shoulder dislocation had significantly more recurrent shoulder instability events and demonstrated a greater incidence and severity of intra-articular abnormalities, including SLAP tears, posterior labral tears, and anterior glenoid cartilage damage. (10.1177/2325967117728019)
  • [L4] Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score. (10.1177/03635465211038712)
  • [L3] In patients that underwent 6‐months of nonoperative management for isolated posterior glenohumeral instability, failure occurred approximately 47% of the time and was associated with a greater posterior humeral head subluxation ratio on index MRI than those who did not fail. (10.1177/2325967121s00570)
  • [L4] Undertaking an augmented capsular plication on patients with symptomatic atraumatic SCJ instability confirmed by MRI imaging that have failed appropriate nonoperative treatment provides a satisfactory result with regard to clinical outcomes and joint stability. (10.1016/j.jse.2025.06.003)
  • [Letter] The authors disagree with Bouliane et al.'s conclusions regarding the Instability Severity Index Score (ISIS), arguing that the score must be used as a whole and is a useful clinical tool when used in conjunction with computed tomography. (10.1111/sae.12038)
  • [L4] The age of the patient at the time of the initial dislocation is the most consistent and significant factor influencing prognosis, with recurrence rates of 83% in patients under twenty years and 12% in patients over fifty years. (10.2106/00004623-195638050-00001)
  • [L3] Early surgical stabilization before recurrence of instability may be the most effective method for preventing progression to clinically significant bone loss. (10.1177/03635465231160286)
  • [L3] Progression to glenohumeral arthritis after anterior stabilization occurred in 8% of a young patient population. (10.1177/03635465251390551)

See Also

References

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[2] Athletes with primary glenohumeral instability demonstrate lower rates of bone loss than those with recurrent instability and failed prior stabilization. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.10.002

[3] Clinical and radiographic outcomes of primary vs. revision arthroscopic anatomic glenoid reconstruction with distal tibial allograft for anterior shoulder instability with bone loss. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.04.005

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[11] Pediatric and Adolescent Shoulder Instability. Clinics in Sports Medicine. 2013. DOI: 10.1016/j.csm.2013.07.010

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[15] Multiple Instability Events at Initial Presentation Are the Major Predictor of Failure of Nonoperative Treatment for Anterior Shoulder Instability. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.03.047

[16] Instability of the Proximal Tibiofibular Joint. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200303000-00006

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[18] Editorial Commentary: Psoas Tenotomy in the Setting of a Borderline Dysplastic Hip Risks Iatrogenic Instability: Be Extremely Cautious and Particularly in Athletes. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.04.025

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[20] Imaging Signs of Posterior Glenohumeral Instability. American Journal of Roentgenology. 2009. DOI: 10.2214/ajr.07.3849

[21] Proper Evaluation of Bone Loss Determines Shoulder Instability Indications and Outcomes. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.01.004

[22] The Rationale for an Arthroscopic Approach to Shoulder Stabilization. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.06.006

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[24] Chapter 101 Knee Dislocations and Patellar Fractures. 2019.

[25] Editorial Commentary: Should We Condemn the Shoulder Instability Severity Index Scoring System? Not at All!... Can We Improve Its Radiographic Component? Yes, We Can!. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.02.008

[26] Long-term Results After Arthroscopic Shoulder Stabilization Using Suture Anchors. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511415657

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[28] Editorial Commentary: Glenoid Bone Reconstruction for Recurrent Shoulder Instability—Risk or Benefit?. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.06.032

[29] Prospective Evaluation of Glenoid Bone Loss After First-time and Recurrent Anterior Glenohumeral Instability Events. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519831286

[30] Letter to the Editor. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510379343

[31] Long-term outcomes of open modified inferior capsular shift for traumatic anterior shoulder instability: over 20 years of follow-up. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.07.021

[33] Effects of glenoid inclination and acromion index on humeral head translation and glenoid articular cartilage strain. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.05.031

[34] Editorial Commentary: Recurrent Anterior Shoulder Instability With Glenoid Bone Loss Requires Restoring the Bone. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2021.09.002

[35] Descriptive Epidemiology of the MOON Shoulder Instability Cohort. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518755752

[36] Humeral Avulsion of the Glenohumeral Ligaments: A Systematic Review. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2016.03.009

[38] Glenoid Dysplasia. Journal of the American Academy of Orthopaedic Surgeons. 2016. DOI: 10.5435/jaaos-d-15-00032

[39] Microinstability characterised by small and easily overlooked anterior labral or Hill–Sachs lesions can be managed with arthroscopic anterior labral repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06941-4

[41] Glenoid Bone Loss After First-Time Posterior Instability Events: A Prospective Cohort Study. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00238

[43] Biomechanical comparison of the modified Bristow procedure with and without capsular repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3915-y

[44] The Effect of Glenohumeral Internal Rotation Deficit Due to Posterior Capsular Contracture on Passive Glenohumeral Joint Motion. The American Journal of Sports Medicine. 2012. DOI: 10.1177/0363546512462012

[45] Development and reliability testing of the frequency, etiology, direction, and severity (FEDS) system for classifying glenohumeral instability. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.10.027

[46] The Management of Acute Traumatic Primary Anterior Shoulder Dislocation in Young Adults. Shoulder & Elbow. 2010. DOI: 10.1111/j.1758-5740.2010.00083.x

[47] A Modified Capsular Shift for Atraumatic Anterior-Inferior Shoulder Instability. The American Journal of Sports Medicine. 2005. DOI: 10.1177/0363546504272685

[48] Return to Professional Australian Rules Football After Surgery for Traumatic Anterior Shoulder Instability. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211029022

[49] Intraobserver and interobserver agreement of International Classification of Diseases, Ninth Revision codes in classifying shoulder instability. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.10.005

[50] Movement control in patients with shoulder instability: a comparison between patients after open surgery and nonoperated patients. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.09.021

[51] Kinematic stabilization after the Latarjet procedure: beyond the triple blocking effect. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.02.022

[52] Editorial Commentary : Time‐Zero Biomechanical Shoulder Instability Studies Are Valuable But Limited Because They Do Not Replicate Clinical Dynamics. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.04.006

[53] Instability and Degenerative Arthritis of the Sternoclavicular Joint. The American Journal of Sports Medicine. 2013. DOI: 10.1177/0363546513498990

[54] Increased superior translation following multiple simulated anterior dislocations of the shoulder. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07257-z

[55] Functional Anatomy and Biomechanics of Shoulder Stability in the Athlete. Clinics in Sports Medicine. 2013. DOI: 10.1016/j.csm.2013.07.001

[56] Lesion prevalence and patient outcome comparison between primary and recurrent anterior shoulder instability. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.05.029

[57] Introduction of a classification system for patients with patellofemoral instability (WARPS and STAID). Knee Surgery, Sports Traumatology, Arthroscopy. 2013. DOI: 10.1007/s00167-013-2477-0

[58] Challenging the Current Concept of Critical Glenoid Bone Loss in Shoulder Instability: Does the Size Measurement Really Tell It All?. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546518819102

[59] Posterosuperior shoulder dislocation due to the rupture of deltoid posterior fibers: a case report. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2727-5

[63] Editorial Commentary: Glenoid Bone Loss Measurements in Shoulder Instability—Precise but Not Accurate. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.05.006

[64] Arthroscopic Shoulder Stabilization: Is There Ever a Need to Open?. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.03.004

[65] Posterior Capsular Contracture of the Shoulder. Journal of the American Academy of Orthopaedic Surgeons. 2006. DOI: 10.5435/00124635-200605000-00002

[67] Glenoid concavity has a higher impact on shoulder stability than the size of a bony defect. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06562-3

[68] Sensorimotor Factors Affecting Outcome Following Shoulder Injury. Clinics in Sports Medicine. 2008. DOI: 10.1016/j.csm.2008.03.005

[69] Imaging Techniques for the Evaluation of Glenohumeral Instability. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280032501

[70] Athletes diagnosed with anterior and posterior shoulder instability display different chief complaints and disability. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.04.007

[71] Up-to-date concepts and procedures in shoulder instability: a comprehensive review. Clinics in Shoulder and Elbow. 2025. DOI: 10.5397/cise.2025.00451

[72] Conjoined Tendon Transfer for Traumatic Anterior Glenohumeral Instability in Patients With Large Bony Defects and Anterior Capsulolabral Deficiency. Arthroscopy. 2017. DOI: 10.1016/j.arthro.2017.06.044

[73] Labral morphology does not compensate for reduced bony glenoid concavity in stable shoulders. JSES International. 2026. DOI: 10.1016/j.jseint.2025.101422

[74] Editorial Commentary: We Need to Customize Surgical Treatment When Treating Patients With Recurrent Anterior Shoulder Instability. Arthroscopy. 2018. DOI: 10.1016/j.arthro.2017.09.028

[75] Management of Shoulder Instability in the Skeletally Immature Patient. Journal of the American Academy of Orthopaedic Surgeons. 2013. DOI: 10.5435/jaaos-21-09-529

[76] Arthroscopic Bankart Repair. Journal of the American Academy of Orthopaedic Surgeons. 2005. DOI: 10.5435/00124635-200511000-00008

[77] Chapter 24 Carpal Instability. 2019.

[78] Revision of failed Latarjet with the Eden-Hybinette surgical technique. Orthopaedics & Traumatology: Surgery & Research. 2020. DOI: 10.1016/j.otsr.2019.12.009

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a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.