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Shoulder Instability

Traumatic unidirectional and atraumatic multidirectional instability — pathomechanics, structural failure patterns, and clinical differentiation for treatment planning.

Overview

The MOON Shoulder Instability Study represents the largest cohort enrolled to date for shoulder stabilization [1]. Proper evaluation of bone loss is the primary determinant for surgical indications and outcomes [3]. Management must be guided by clinical indication rather than prophylactic intent to enhance performance or increase future games played in National Football League athletes [18]. Surgical soft-tissue stabilization may be indicated more aggressively in primary dislocation cases, while recurrent instability with bone loss requires referral to experienced high-volume specialists [25].

Tailored treatment strategies should account for pathology, patient age, activity demands, and surgeon skills [5]. While the Latarjet procedure is a viable and reliable option for anterior glenohumeral instability with durable long-term benefits [23], modern arthroscopic management offers reliable, lasting recovery and durable protection against recurrent posterior instability [4]. Emerging data support sustained athletic participation in arthroscopically managed posterior instability [4]. Despite well-performed randomized controlled trials, reporting remains poor [17], and substantial variability exists in outcome tools for high-impact anterior literature [24].

Standardized outcome reporting is essential, particularly for adolescents following arthroscopic anterior surgery [78]. Although numerous patient-reported outcome measures exist, clinically significant thresholds such as MCID and PASS remain limited [77]. Consensus statements aim to unify diagnosis and treatment through universal agreement on measurement tools [5], while recent studies provide specific thresholds to interpret outcomes and detect recurrent posterior instability earlier [15].

Anatomy & Pathophysiology

Osseous and Scapular Kinematics

Clavicle shortening significantly alters shoulder girdle kinematics, with reductions exceeding 10% causing profound effects on in vivo scapular motion [34, 57]. Distinct biomechanical properties between the hip and shoulder joints likely drive epidemiological differences between osteonecrosis of the humeral head and osteonecrosis of the femoral head [44]. While the biomechanical shoulder model aligns with clinical observations [29], evaluating altered shoulder kinematics remains complicated [30].

Kinematics and Pathomechanics

Abnormal kinematics and glenohumeral motion paths throughout a rotational range of motion are evident in thrower's models compared with intact shoulders [49]. Glenohumeral decentering is significantly associated with diminished function and active range of motion in all planes [61]. Biomechanical changes in passive glenohumeral joint motion occur with as little as 5% glenohumeral internal rotation deficit (GIRD) [51]. Findings suggest a plausible mechanical progression of kinematic and strength changes associated with rotator cuff pathology development [45]. Although open surgery stabilizes the shoulder, arm kinematic analyses indicate it does not necessarily restore normal movement quality [63]. Integrating digital dynamic radiography into clinical workflows allows dynamic, noninvasive examination of shoulder kinematics, providing an inexpensive method to objectively quantify disease severity with low radiation dosage [58].

Ligamentous and Capsular Integrity

Tears of the subscapularis carry greater biomechanical consequences than tears of the infraspinatus [52]. Simulated anterosuperior rotator cuff tears involving the superior half of the subscapularis significantly alter shoulder biomechanics, leading to increased anterosuperior and superior glenohumeral translation under higher loads [54]. Capsular repair significantly alters normal glenohumeral kinematics [50]. In the setting of shoulder instability without a labral tear, the capsulolabral advancement technique may be considered biomechanically superior [59]. While each reconstruction technique restores different elements of joint kinematics, no strategy completely restores the shoulder girdle to its preinjured state [56].

Clinical Implications for Throwing Athletes

Updates on the thrower's shoulder, encompassing anatomy, mechanics, pathomechanics, and treatment, are essential for clinicians and researchers investigating or treating the shoulder [31]. Advances in understanding shoulder biomechanics, pathophysiology, and diagnostic techniques, alongside improvements in surgical methods like arthroscopy, are necessary to properly prevent and treat common shoulder injuries in throwing athletes [43].

Classification

MOON Shoulder Instability Study: This initiative has enrolled the largest cohort of patients undergoing shoulder stabilization to date [1].

FEDS Classification: This system demonstrates content validity and high reliability for classifying glenohumeral instability [70]. It is particularly useful for identifying patients with a higher likelihood of undergoing surgical treatment based on the frequency and etiology of their shoulder instability [10, 14].

Snyder Classification: For experienced shoulder surgeons, this system serves as a reliable method for identifying SLAP lesions [69].

Glenoid Bone Loss Classification: A proposed classification system acts as a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty [68].

Other Considerations: Universal agreement on outcome measurement tools and tailored treatment based on pathology, patient age, activity demands, and surgeon skills aims to improve diagnosis and treatment of shoulder instability [5]. Failure of primary shoulder stabilization procedures is often related to uncorrected anatomic pathology [6]. The instability severity index score permits precise identification of patients at risk for failure of primary shoulder stabilization procedures [6]. Shoulder laxity does not imply a pathologic process and must be differentiated from instability [13]. Substantial variability was observed in the scoring of important elements in the radiological report for the evaluation of anterior shoulder instability, regardless of modality [8]. Shoulder instability cannot reliably be classified using the ICD-9 coding system [40]. There are discrepancies in the definition and classification of multidirectional instability, which can make diagnosis and treatment selection challenging [65]. Objective and subjective scoring systems correlate significantly with the clinical condition of patients with recurrent shoulder instability and associated bony defects [71]. The formation of clusters based on glenoid morphology indicates that patterns exist in the types of glenoid defects [73]. Patterns in glenoid defect types highlight a need to further investigate a three-dimensional classification system and potentially new standardized revision implant component designs [73].

Clinical Presentation

The MOON Shoulder Instability Study has enrolled the largest cohort of patients undergoing shoulder stabilization to date [1]. A thorough clinical exam is the most important factor when determining indication for shoulder instability surgery [7]. Proper evaluation of bone loss best determines shoulder instability surgical indications and outcomes [3]. The instability severity index score permits precise identification of patients at risk for failure of primary shoulder stabilization procedures [6]. Failure of primary shoulder stabilization procedures is often related to uncorrected anatomic pathology [6]. Detailed and specific information about prognosis is critical in the management of a first-time anterior shoulder dislocation [11].

Imaging modalities can determine whether Hill-Sachs lesions will cause persistent anterior shoulder instability [12]. The current literature supports a variety of different imaging modalities that provide clinically acceptable accuracy in diagnosing and quantifying Hill-Sachs lesions [12]. Substantial variability was observed in the scoring of important elements in the radiological report for the evaluation of anterior shoulder instability, regardless of modality [8]. Shoulder laxity does not imply a pathologic process and must be differentiated from instability [13]. Pain can serve as a clinical indicator of larger labral pathology in patients presenting with shoulder instability [32].

Microinstability: This condition is diagnostically challenging [41] but can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability [41]. Minor shoulder instability is an intra-articular pathology presenting with extra-articular subacromial impingement symptoms [39]. PHAGL Lesion: This lesion is challenging to diagnose clinically [38] and can be the cause of posterior instability or a component of the spectrum of shoulder instability [38]. Coracoid Impingement: This is a rare finding [46], yet identification and proper management can yield excellent pain relief and functional outcomes in the patient with ongoing anterior shoulder pain [46].

Recurrent posterior instability of the shoulder is difficult to diagnose [48] and technically challenging to treat [48]. Over the past several centuries, a number of procedures have been developed to address posterior shoulder instability, particularly as this pathology has become better understood [47]. Improved understanding of anatomy, biomechanics, and advanced arthroscopic techniques have allowed for relatively reliable surgical results for recurrent posterior instability of the shoulder [48].

Non-traumatic shoulder instability's aetiologies and clinical manifestations are multifactorial [2]. The consensus statement aims to improve diagnosis and treatment of shoulder instability through universal agreement on outcome measurement tools and tailored treatment based on pathology, patient age, activity demands, and surgeon skills [5]. This review provides an overview of anterior shoulder instability, discusses the implications of bone deficiency in recurrent instability, and reviews prevailing treatment options for diagnosis, quantification, and surgical management [33]. Shoulder and spine surgeons should be wary and vigilant of accurately diagnosing the etiology of the presenting symptoms to ensure proper management and optimize prognosis [36]. The purpose of this article is to review the current literature concerning shoulder anatomy/pathology related to shoulder stability/instability to improve clinical diagnosis and surgical treatment of our patients [37].

Investigations

Plain radiography: Conventional radiography remains the initial imaging study for evaluating patients with persistent shoulder pain and instability [66]. It can be used for screening patients for significant glenoid bone loss [94], though radiographs are inferior to CT scans for assessing osseous lesions, especially at the glenoid rim [101]. Bone defects seen in preoperative plain radiographs are less important, and more accurate imaging is needed to reveal their true role for recurrence of instability after arthroscopic Bankart repair [99]. Posterior HAGL lesions identified on radiographic imaging are not clinically significant unless the patient has symptoms and a history specific for posterior instability [98]. Simultaneous bilateral posterior shoulder dislocation is a rare entity that requires careful clinical and radiological evaluation, often necessitating CT scans for diagnosis [100].

MRI: Magnetic resonance arthrography has been firmly established as the imaging modality of choice for demonstrating specific soft tissue abnormalities associated with glenohumeral instability [66]. It is an accurate method to assess accompanying lesions in first-time and recurrent anterior dislocation of the shoulder [83]. Capsular injury is commonly seen on magnetic resonance imaging of patients with anterior shoulder instability [80]. Current literature supports a variety of different imaging modalities that provide clinically acceptable accuracy in diagnosing and quantifying Hill-Sachs lesions [12] and determining whether Hill-Sachs lesions will cause persistent anterior shoulder instability [12]. Zero echo time (ZTE) MRI demonstrated high reproducibility for the evaluation of glenoid bone defect in shoulders with anterior instability [95]. Patients with multidirectional instability demonstrated quantifiable dynamic instability on cine MRI with significantly greater humeral head deviation than healthy controls [97] and faster deviation velocity than healthy controls [97]. Posterior labral tears should be considered in patients with posterior shoulder pain during daily activities or sports even when MRI or MRA findings are ambiguous and without posterior instability complaints [93].

CT: Three-dimensional MRI (FRACTURE) is equivalent to 3D CT in quantifying bone loss in patients with shoulder dislocation [103] and equivalent to 3D CT in measuring shoulder morphologic parameters in patients with shoulder dislocation [103].

Other Considerations: Non-traumatic shoulder instability has multifactorial aetiologies and clinical manifestations [2]. Proper evaluation of bone loss best determines shoulder instability surgical indications and outcomes [3]. A thorough clinical exam is the most important factor when determining indication for shoulder instability surgery [7]. Substantial variability exists in the scoring of important elements in the radiological report for the evaluation of anterior shoulder instability, regardless of modality [8]. An increased Glenoid Index may help identify patients at risk for primary or recurrent anterior glenohumeral instability events [84]. Glenoid bone loss is a significant factor in recurrent anterior shoulder instability, present in up to 90% of cases [104]. Glenoid bone loss requires careful diagnosis and quantification to guide treatment selection ranging from soft-tissue repair to bony reconstitution [104].

Treatment

Non-Operative

Nonoperative treatment may be the preferred strategy when the likelihood of recurrent instability is low after conservative care or when an informed patient has an aversion to surgery [89]. While nonoperative treatment is associated with a faster return to play, operative management yields fewer recurrent instability events, greater time between events, and greater career longevity [92]. However, nonoperative treatment of shoulder instability carries substantial societal costs [67], and nonoperative treatments appear unreliable for posterior shoulder instability, though current studies have methodological limitations and a lack of clinical data [91].

Operative

Indications: Surgical treatment of primary, traumatic, anterior shoulder instability results in reduced recurrence rates compared with nonsurgical treatment at 10-year follow-up [9]. Surgical options are more effective than conservative measures in preventing recurrent instability in adolescents and young adults under 40 years of age with a first-time anterior shoulder dislocation [87]. Arthroscopic stabilization is now the treatment of choice for traumatic anterior shoulder dislocation in the 17- to 25-year age group, with increased use of MRI and bioabsorbable anchors [88]. Management should be based on clinical indication, and surgical stabilization should not be performed prophylactically to increase future games played or enhance performance [18]. A thorough clinical exam is the most important factor when determining the indication for shoulder instability surgery [7], and proper evaluation of bone loss best determines surgical indications and outcomes [3]. The success of treating anterior glenohumeral instability relies on multiple factors, including glenoid bone loss [53]. 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 [25].

Surgical Approach / Technique: Arthroscopic stabilization for recurrent anterior shoulder instability can be performed safely, with clinical outcomes comparable to those after traditional open stabilization [60]. Arthroscopic lavage reduced the recurrence rate and produced a better functional outcome at 1-year follow-up than non-operative treatment in young individuals with traumatic primary anterior shoulder dislocation [86]. Successful treatment of anterior instability requires a balance between restoring joint stability and minimizing loss of glenohumeral motion [62]. Arthroscopic treatment of posterior shoulder instability is an effective means to improve symptoms associated with recurrent posterior subluxation [64]. With modern arthroscopic management, posterior shoulder instability represents a condition where reliable and lasting recovery may be achievable, supported by emerging data suggesting durable protection against recurrent instability and sustained athletic participation [4]. The presence of a posterior glenoid fracture (bony Bankart lesion) did not represent a contraindication to arthroscopic shoulder stabilization [81]. Surgical stabilization results in resolution of primary minor shoulder instability and secondary impingement [90].

Implant Selection: The results demonstrate the efficacy and durability of the inferior capsular shift procedure for the treatment of shoulders with multidirectional instability [35]. The Latarjet is a safe and effective procedure for patients with shoulder instability [55].

Other Considerations: To assess the effectiveness of an arthroscopic stabilization procedure for anterior shoulder instability using the Rowe score, a difference of at least 9.7 in the score is clinically relevant [42]. The thresholds defined in this study can provide a guideline for interpreting patient outcomes following arthroscopic stabilization for posterior shoulder instability, allowing for earlier detection of recurrent posterior instability [15].

Complications

Instability: Failure of primary shoulder stabilization is frequently attributed to uncorrected anatomic pathology, a risk precisely identified by the instability severity index score [6]. While modern arthroscopic management offers durable protection against recurrent posterior instability [4], surgical treatment for primary traumatic anterior instability reduces recurrence rates compared to nonsurgical management at 10-year follow-up [9]. However, mid-term recurrence following primary arthroscopic anterior capsulolabral repair remains significant at 30% [16], and in patients under 40, the rate of recurrent anterior instability is roughly one-third after initial physician consultation [85]. Recurrent instability requiring capsular reconstruction is more prevalent in those with a prior history of dislocation [82], and while one- to 2-year follow-up may appear similar, longer-term data will likely show diminished outcomes as recurrence rates increase [76]. Long-term follow-up is essential to capture these trends, as demonstrated by the MOON Shoulder Instability Study, the largest cohort to date [1].

Other Considerations: Non-traumatic instability presents with multifactorial aetiologies and clinical manifestations [2], and the FEDS classification (frequency and etiology) aids in identifying patients likely to require surgery [10, 14]. Long-term benefits in stability and function are observed in high-risk patients undergoing ABR for first-time anterior dislocation [20], yet the natural history of first-time dislocations is intrinsically linked to arthropathy [22]. Arthropathy severity 33 to 35 years post-B-L repair follows this natural history of degeneration [27]. Shoulder arthroplasty in the setting of prior instability improves functional outcomes comparable to patients without instability history [28] and may improve outcomes for those with instability arthropathy [79], with midterm follow-up showing continued functional improvement after total shoulder arthroplasty [21]. Female patients undergoing the Latarjet procedure exhibit similar 90-day complication and 2-year secondary surgery rates to males [72]. Outcome reporting remains challenging due to substantial variability, with 28 different tools used in high-impact literature [24]. Finally, the efficacy of suture button fixation for glenoid allograft bone block remains unclear but promising, pending long-term data [26].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity or driving; however, management of first-time anterior dislocations requires detailed prognostic information to guide early decisions [11]. While variability in managing first-time dislocations persists, emerging trends suggest consensus on critical factors for consideration [96].

Full activity (months): Modern arthroscopic management of posterior shoulder instability allows for reliable and lasting recovery with sustained athletic participation [4]. Arthroscopic repair for posterior instability yields favorable mid-term outcomes with significant functional improvements at a mean follow-up of 10.6 years [74]. Surgical treatment of primary, traumatic, anterior shoulder instability reduces recurrence rates compared to nonsurgical treatment at 10-year follow-up [9]. For recurrent anterior instability with engaging Hill–Sachs lesions, the combination of arthroscopic remplissage and classic Bankart repair demonstrates long-term outcomes regarding recurrence rates without significantly influencing range of motion [75]. In cases of severe capsular deficiency, open anterior capsular reconstruction resulted in 45% of shoulders remaining completely stable at 3.8 years [102].

Complete recovery / outcome plateau (months): Long-term follow-up studies are essential for unidirectional, posttraumatic, anterior shoulder instability [19]. The Latarjet procedure offers durable benefits and is a viable, reliable treatment option for anterior glenohumeral instability [23]. Long-term data indicate that the benefits of the Latarjet procedure are durable [23]. The degree of arthropathy 33 to 35 years after Bristow-Latarjet repair follows the natural history of shoulder dislocation regarding joint degeneration [27]. Patients with a history of anterior instability undergoing total shoulder arthroplasty can expect continued functional improvement compared to preoperative values at midterm follow-up [21]. Shoulder arthroplasty in the setting of prior anterior instability yields subjective and functional outcomes comparable to patients without instability history [28]. A long-term benefit in overall stability and functional outcome exists in high-risk patients undergoing arthroscopic Bankart repair for first-time anterior dislocation [20].

Rehabilitation protocol: The FEDS classification, particularly frequency and etiology, may help identify patients with a higher likelihood of requiring surgical treatment [10]. There is significant variability in surgical procedure selection driven by time alone [105]. A substantial proportion of respondents, particularly those over 55 years old, continue to base practices on personal experience rather than standardized protocols for first-time shoulder dislocations [96]. The answer regarding whether suture button fixation is the latest trend in glenoid allograft bone block fixation that is here to stay remains unclear but promising [26]. Long-term data will be crucial in the surgical evolution to solve the exceedingly difficult problem of shoulder instability [26].

Functional milestones: Non-traumatic shoulder instability's aetiologies and clinical manifestations are multifactorial [2]. The MOON Shoulder Instability Study has enrolled the largest cohort of patients undergoing shoulder stabilization to date [1]. At mid-term follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series [16]. Eighteen per cent of patients had signs of instability during the 8-year follow-up period after arthroscopic intra-articular Bankart repair using absorbable tacks [106].

Other Considerations: The natural history of first-time shoulder dislocations is bound up with arthropathy [22]. Detailed and specific information about prognosis is critical in the management of a first-time anterior shoulder dislocation [11].

Key Evidence

  • [L4] The MOON Shoulder Instability Study has enrolled the largest cohort of patients undergoing shoulder stabilization to date. (10.1177/0363546518755752)
  • [L5] Non-traumatic shoulder instability's aetiologies and clinical manifestations are multifactorial. (10.1177/17585732251320070)
  • [L5] Proper evaluation of bone loss best determines shoulder instability surgical indications and outcomes. (10.1016/j.arthro.2021.01.004)
  • [Commentary] With modern arthroscopic management, posterior shoulder instability represents a condition where reliable and lasting recovery may be achievable, supported by emerging data suggesting durable protection against recurrent instability and sustained athletic participation. (10.1016/j.arthro.2025.09.003)
  • [L5] The consensus statement aims to improve diagnosis and treatment of shoulder instability through universal agreement on outcome measurement tools and tailored treatment based on pathology, patient age, activity demands, and surgeon skills. (10.1016/j.arthro.2009.06.022)
  • [L5] Failure of primary shoulder stabilization procedures is often related to uncorrected anatomic pathology, and the instability severity index score permits precise identification of patients at risk. (10.1016/j.arthro.2010.11.057)
  • [L3] A thorough clinical exam is the most important factor when determining indication for shoulder instability surgery. (10.1016/j.xrrt.2026.100675)
  • [L5] Substantial variability was observed in the scoring of important elements in the radiological report for the evaluation of anterior shoulder instability, regardless of modality. (10.1016/j.jseint.2024.03.012)
  • [L1] Surgical treatment of primary, traumatic, anterior shoulder instability results in reduced rates of recurrence compared with nonsurgical treatment at 10-year follow-up. (10.1016/j.arthro.2006.11.026)
  • [L2] The FEDS classification, particularly the frequency and etiology of the patient's shoulder instability, may be helpful in identifying patients with a higher likelihood of undergoing surgical treatment. (10.1016/j.jse.2016.07.053)
  • [L2] Detailed and specific information about prognosis is critical in the management of a first-time anterior shoulder dislocation. (10.1016/j.jse.2010.10.037)
  • [L1] The current literature supports a variety of different imaging modalities that provide clinically acceptable accuracy in diagnosing and quantifying Hill-Sachs lesions, as well as determining whether they will cause persistent anterior shoulder instability. (10.1016/j.arthro.2020.08.005)
  • [L5] Shoulder laxity does not imply a pathologic process and must be differentiated from instability. (10.1177/03635465000280062501)
  • [L2] The FEDS classification, particularly the frequency and etiology of the patient's shoulder instability, may be helpful in identifying patients with a higher likelihood of undergoing surgical treatment. (10.1016/j.jse.2016.07.054)
  • [L4] The thresholds defined in this study can provide a guideline for interpreting patient outcomes following arthroscopic stabilization for posterior shoulder instability, allowing for earlier detection of recurrent posterior instability. (10.1016/j.jseint.2025.08.006)
  • [L3] At midterm follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series. (10.1016/j.arthro.2019.11.109)
  • [L2] RCTs reporting on shoulder instability surgery are well performed but poorly reported. (10.1177/1758573218754370)
  • [Commentary] Management of shoulder instability should be based on clinical indication, and surgical stabilization should not be done prophylactically in the hope of increasing the number of future games played or enhancing performance. (10.1016/j.arthro.2021.01.053)
  • [L4] These results emphasize the importance of performing long-term follow-up studies after surgical reconstruction for unidirectional, posttraumatic, anterior shoulder instability. (10.1177/03635465020300060401)
  • [L1] This study demonstrates a long-term benefit in overall shoulder stability and functional outcome in high-risk patients who have undergone ABR for first-time anterior dislocation. (10.2106/jbjs.19.00858)
  • [L3] At mid-term follow-up, patients with a history of anterior shoulder instability undergoing total shoulder arthroplasty can expect continued improvement in function compared with preoperative values. (10.1016/j.jse.2023.07.005)
  • [Abstract] The natural history of the first time shoulder dislocations is bound up with arthropathy. (10.1016/j.jse.2007.02.100)
  • [L4] The long-term data suggest that these benefits are durable, and the Latarjet procedure should be considered as a viable and reliable treatment option for anterior glenohumeral instability. (10.1016/j.jseint.2025.04.033)
  • [L4] There is substantial variability in outcome reporting for high-impact anterior shoulder instability literature with 28 different outcome tools used, making it difficult to compare outcomes between studies. (10.1016/j.arthro.2016.07.027)
  • [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)
  • [L5] The answer remains unclear but promising; long-term data will be crucial in the surgical evolution to solve the exceedingly difficult problem of shoulder instability. (10.1002/arj.70033)
  • [L4] The degree of arthropathy 33 to 35 years after the B-L repair seems to follow the natural history of shoulder dislocation with respect to arthropathic joint degeneration. (10.1016/j.jse.2014.09.021)
  • [L4] Shoulder arthroplasty in the setting of prior anterior instability results in improved subjective and functional outcome scores that are comparable to patients without a history of instability. (10.1016/j.jseint.2022.08.012)
  • [L5] The biomechanical shoulder model is consistent with clinical observations. (10.1016/j.jse.2016.05.031)
  • [L2] A clinical evaluation of altered shoulder kinematics is still complicated. (10.3390/ijerph17082974)
  • [L5] Updates on the thrower's shoulder, including anatomy, mechanics, pathomechanics, and treatment, are essential for clinicians and researchers treating or investigating the shoulder. (10.1016/j.arthro.2022.02.024)
  • [L4] Pain can serve as a clinical indicator of larger labral pathology in patients presenting with shoulder instability. (10.1177/17585732251316476)
  • [L5] This review provides an overview of anterior shoulder instability, discusses the implications of bone deficiency in recurrent instability, and reviews prevailing treatment options for diagnosis, quantification, and surgical management. (10.2106/jbjs.l.01377)
  • [L5] The findings of this study clearly indicated that shortening of the clavicle affects the kinematics in the shoulder girdle. (10.1177/0363546509355143)
  • [L5] Shoulder and spine surgeons should be wary and vigilant of accurately diagnosing the etiology of the presenting symptoms to ensure proper management and optimize prognosis. (10.1016/j.xrrt.2024.02.007)
  • [L5] The purpose of this article is to review the current literature concerning shoulder anatomy/pathology related to shoulder stability/instability to improve clinical diagnosis and surgical treatment of our patients. (10.1016/j.arthro.2011.05.017)
  • [L4] The PHAGL lesion is challenging to diagnose clinically and can be the cause of posterior instability or a component of the spectrum of shoulder instability. (10.1016/j.arthro.2007.02.006)
  • [L3] Minor shoulder instability is an intra-articular pathology presenting with extra-articular subacromial impingement symptoms. (10.1007/s00167-011-1552-7)
  • [L1] Shoulder instability cannot reliably be classified using the ICD-9 coding system. (10.1016/j.jse.2008.10.005)
  • [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)
  • [L4] To assess the effectiveness of an arthroscopic stabilization procedure for anterior shoulder instability using the Rowe score, a difference of at least 9.7 in the score is clinically relevant. (10.1016/j.jse.2017.10.032)
  • [L5] Advances in understanding shoulder biomechanics, pathophysiology, and diagnostic techniques, along with improvements in surgical methods like arthroscopy, are necessary for clinicians to properly prevent and treat common shoulder injuries in throwing athletes. (10.1177/03635465000280022301)
  • [L3] Despite anatomical similarities, different biomechanical properties between the hip and shoulder joints likely cause epidemiological differences between ONHH and ONFH. (10.1186/s12891-023-07022-4)
  • [L3] Furthermore, these findings suggest a plausible mechanical progression of kinematic and strength changes associated with the development of rotator cuff pathology. (10.1016/j.jse.2016.11.048)
  • [L5] Coracoid impingement is a rare finding, and identification and proper management of this condition can yield excellent pain relief and functional outcomes in the patient with ongoing anterior shoulder pain. (10.5435/00124635-201104000-00003)
  • [L5] Over the past several centuries, a number of procedures have been developed to address posterior shoulder instability, particularly as this pathology has become better understood. (10.1016/j.jses.2019.08.008)
  • [L5] Recurrent posterior instability of the shoulder is difficult to diagnose and technically challenging to treat, but improved understanding of anatomy, biomechanics, and advanced arthroscopic techniques have allowed for relatively reliable surgical results. (10.1177/0363546510384232)
  • [L5] The study demonstrates abnormal kinematics and path of glenohumeral motion throughout a rotational range of motion in the thrower's model compared with an intact shoulder. (10.1177/0363546506287740)
  • [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)
  • [L5] Tears of the subscapularis have greater biomechanical consequences than do tears of the infraspinatus. (10.1016/j.arthro.2009.09.007)
  • [L5] The success of treating anterior glenohumeral instability relies on multiple factors, including glenoid bone loss. (10.1016/j.arthro.2021.09.002)
  • [L5] Simulated anterosuperior rotator cuff tears involving the superior half of the subscapularis significantly alter shoulder biomechanics and lead to increased anterosuperior and superior glenohumeral translation under higher loads. (10.1016/j.arthro.2008.10.005)
  • [L1] The Latarjet is a safe and effective procedure for patients with shoulder instability. (10.1177/1758573220945318)
  • [L5] Although each technique was able to restore different elements of the joint kinematics, none of the strategies completely restored the shoulder girdle to its preinjured state. (10.1177/03635465221095231)
  • [L4] Clavicle shortening of >10% greatly affects scapular kinematics in vivo. (10.1016/j.jse.2017.03.013)
  • [Case_report] Integrating DDR into the clinical workflow allows dynamic noninvasive examination of shoulder kinematics and provides an inexpensive method to objectively quantify disease severity with low radiation dosage. (10.1016/j.jseint.2023.02.015)
  • [L5] In the setting of shoulder instability without evidence of a labral tear, the capsulolabral advancement technique may be considered biomechanically superior. (10.1016/j.arthro.2012.04.140)
  • [L1] Arthroscopic stabilization for recurrent anterior shoulder instability can be performed safely; the clinical outcomes are comparable to those after traditional open stabilization. (10.1177/0363546506288239)
  • [L3] Glenohumeral decentering is significantly associated with diminished shoulder function and active range of motion in all planes. (10.1016/j.jse.2025.03.038)
  • [L5] Successful treatment of anterior instability of the shoulder requires a balance between restoring joint stability and minimizing loss of glenohumeral motion. (10.1177/03635465030310011001)
  • [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)
  • [L4] Arthroscopic treatment of posterior shoulder instability is an effective means to improve symptoms associated with recurrent posterior subluxation of the shoulder. (10.1177/0363546505278301)
  • [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)
  • [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)
  • [L3] Nonoperative treatment of shoulder instability has substantial societal costs. (10.1177/1758573218773543)
  • [L4] The proposed classification system is a helpful guide to the degree of glenoid bone loss when embarking on revision shoulder arthroplasty. (10.1302/0301-620x.98b3.36664)
  • [L3] For experienced shoulder surgeons, the Snyder classification is a reliable system for identifying SLAP lesions. (10.1177/0363546510392332)
  • [L2] The FEDS system has content validity and is highly reliable for classifying glenohumeral instability. (10.1016/j.jse.2010.10.027)
  • [L3] Objective and subjective scoring systems correlate significantly with the clinical condition of patients with recurrent shoulder instability and associated bony defects. (10.1177/0363546515626541)
  • [L3] Female patients undergoing the Latarjet procedure for recurrent shoulder instability showed similar 90-day complication and 2-year secondary surgery rates to a matched cohort of male patients. (10.1016/j.arthro.2024.02.043)
  • [L4] The formation of clusters based on glenoid morphology indicates that patterns exist in the types of glenoid defects, highlighting a need to further investigate a three-dimensional classification system and potentially new standardized revision implant component designs. (10.1016/j.jse.2026.04.002)
  • [L5] Arthroscopic repair for posterior shoulder instability yields favorable mid-term outcomes, with significant improvements in functional scores and a low recurrence rate at a mean follow-up of 10.6 years. (10.1016/j.arthro.2025.07.040)
  • [L4] This combination has long-term outcomes in terms of the recurrence rate and does not significantly influence the range of motion of the shoulder. (10.1007/s00167-018-5261-3)
  • [Commentary] One- to 2-year follow-up after instability surgery may be similar, but longer follow-up will almost certainly show diminished patient-reported outcomes as recurrence rates increase. (10.1016/j.arthro.2024.11.073)
  • [L1] Despite the wide array of available PROMs for assessing shoulder instability surgery outcomes, the availability of clinically significant outcome thresholds such as MCID and PASS remains relatively limited. (10.1016/j.arthro.2024.07.039)
  • [L1] This study supports the need for standardized outcome reporting after arthroscopic anterior shoulder instability surgery in adolescents. (10.1016/j.arthro.2017.10.041)
  • [L4] Shoulder arthroplasty may improve functional outcomes for patients experiencing instability arthropathy with a history of stabilization surgery. (10.1016/j.xrrt.2023.01.003)
  • [L1] Capsular injury is commonly seen in magnetic resonance imaging of patients with anterior shoulder instability. (10.1016/j.xrrt.2024.08.004)
  • [L4] By contrast, the presence of a posterior glenoid fracture (bony Bankart lesion) did not represent a contraindication to arthroscopic shoulder stabilization. (10.1177/03635465251403499)
  • [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)
  • [L3] Magnetic resonance arthrography was an accurate method to assess accompanying lesions in first-time and recurrent anterior dislocation of the shoulder. (10.1177/0363546510371607)
  • [L3] This useful MRI measurement may help identify patients at risk for primary or recurrent anterior glenohumeral instability events and may therefore help with guiding treatment and prevention. (10.1177/2325967120986139)
  • [L3] In a US epidemiologic population of patients <40 years old, the rate of recurrent anterior shoulder instability was roughly one-third after initial physician consultation. (10.1177/0363546519886861)
  • [L1] Arthroscopic lavage reduced the recurrence rate and produced a better functional outcome at 1-year follow-up than non-operative treatment in young individuals with traumatic primary anterior shoulder dislocation. (10.1007/s001670050146)
  • [L1] Surgical treatments are more effective than conservative options in preventing recurrent instability in adolescents and young adults under 40 years of age with first-time anterior shoulder dislocation. (10.1016/j.arthro.2025.07.044)
  • [L4] Arthroscopic shoulder stabilization is now the treatment of choice, with increased use of MRI and bioabsorbable anchors, though consensus remains lacking on nonoperative treatments and rehabilitation. (10.1016/j.jse.2011.01.006)
  • [L3] In clinical settings where the likelihood of recurrent instability is low after nonoperative care or when an informed patient has an aversion to surgery, nonoperative treatment may be the preferred treatment strategy. (10.1016/j.jse.2011.01.031)
  • [L5] Surgical stabilization results in resolution of primary minor shoulder instability and secondary impingement. (10.1016/j.arthro.2006.11.025)
  • [L5] The author recommends that readers be highly cautious and take a closer look at whether the current study changes their mind about the effectiveness of nonoperative treatment of posterior shoulder instability, citing methodological limitations and lack of clinical data. (10.1016/j.arthro.2019.04.015)
  • [L3] Whereas nonoperative treatment is associated with faster return to play, operative management is associated with fewer recurrent instability events, greater time between recurrent instability events, and greater career longevity. (10.1016/j.arthro.2020.12.225)
  • [L5] Even without posterior instability complaints or findings, in patients with posterior shoulder pain during daily activities or sports, posterior labral tears should be considered even when MRI or MRA findings are ambiguous. (10.1016/j.arthro.2023.07.004)
  • [L4] Radiography can be used for screening patients for significant glenoid bone loss. (10.1186/s12891-015-0607-1)
  • [L3] ZTE MRI demonstrated high reproducibility for the evaluation of glenoid bone defect in shoulders with anterior instability. (10.1016/j.jseint.2024.03.003)
  • [L4] While variability in the management of first-time shoulder dislocations persists, emerging trends towards consensus on critical factors for consideration exist; however, a substantial proportion of respondents, particularly those over 55 years old, continue to base practices on personal experience rather than standardized protocols. (10.1002/ksa.70297)
  • [L4] Patients with multidirectional instability demonstrated quantifiable dynamic instability on cine MRI with significantly greater humeral head deviation and faster deviation velocity than healthy controls. (10.1016/j.jseint.2025.101419)
  • [L4] Posterior HAGL lesions identified on radiographic imaging are not clinically significant unless the patient has symptoms and a history specific for posterior instability. (10.1016/j.arthro.2007.03.020)
  • [L3] Bone defects seen in preoperative plain radiographs are less important and more accurate imaging is needed to reveal their true role for recurrence of instability. (10.1007/s00167-010-1105-5)
  • [L4] Simultaneous bilateral posterior shoulder dislocation is a rare entity that requires careful clinical and radiological evaluation, often necessitating CT scans for diagnosis. (10.1007/s00167-006-0066-1)
  • [L3] Radiographs seem inferior to CT scans for assessing osseous lesions especially at the glenoid rim. (10.1016/j.jse.2013.04.020)
  • [L4] In our series 9 shoulders (45%) remained completely stable at 3.8 years. (10.1016/j.arthro.2011.07.002)
  • [L2] Three-dimensional MRI (FRACTURE) is equivalent to 3D CT in quantifying bone loss in patients with shoulder dislocation and measuring shoulder morphologic parameters. (10.1016/j.arthro.2023.12.016)
  • [L5] Glenoid bone loss is a significant factor in recurrent anterior shoulder instability, present in up to 90% of cases, and requires careful diagnosis and quantification to guide treatment selection ranging from soft-tissue repair to bony reconstitution. (10.5435/00124635-200908000-00002)
  • [L4] This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. (10.1016/j.jseint.2023.08.005)
  • [L4] Eighteen per cent of the patients had signs of instability during the 8-year follow-up period. (10.1007/s00167-008-0534-x)

See Also

References

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[75] Long‐term outcome of arthroscopic remplissage in addition to the classic Bankart repair for the management of recurrent anterior shoulder instability with engaging Hill–Sachs lesions. Knee Surgery, Sports Traumatology, Arthroscopy. 2018. DOI: 10.1007/s00167-018-5261-3

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[83] Prevalence Comparison of Accompanying Lesions between Primary and Recurrent Anterior Dislocation in the Shoulder. The American Journal of Sports Medicine. 2010. DOI: 10.1177/0363546510371607

[84] Increased Glenoid Index as a Risk Factor for Pediatric and Adolescent Anterior Glenohumeral Dislocation: An MRI-Based, Case-Control Study. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967120986139

[85] An Age-Based Approach to Anterior Shoulder Instability in Patients Under 40 Years Old: Analysis of a US Population. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519886861

[86] Arthroscopic lavage reduced the recurrence rate following primary anterior shoulder dislocation. Knee Surgery, Sports Traumatology, Arthroscopy. 1999. DOI: 10.1007/s001670050146

[87] Surgical Treatment Is Superior to Conservative Options in Preventing Recurrence of First-Time Anterior Shoulder Dislocation in Adolescents and Adults Under 40 Years of Age: A Systematic Review and Network Meta-analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2025. DOI: 10.1016/j.arthro.2025.07.044

[88] Management of traumatic anterior shoulder dislocation in the 17- to 25-year age group: a dramatic evolution of practice. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.01.006

[89] Operative versus nonoperative treatment after primary traumatic anterior glenohumeral dislocation: expected-value decision analysis. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.01.031

[90] Minor Shoulder Instability. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2006.11.025

[91] Editorial Commentary: Nonoperative Treatments Seem Unreliable in Posterior Shoulder Instability, But Let's Take a Closer Look. Arthroscopy. 2019. DOI: 10.1016/j.arthro.2019.04.015

[92] Career Longevity and Performance After Shoulder Instability in National Football League Athletes. Arthroscopy. 2021. DOI: 10.1016/j.arthro.2020.12.225

[93] Editorial Commentary: Patients May Have Posterior Glenoid Labral Tears in the Absence of Instability or Magnetic Resonance Imaging Findings. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.07.004

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[95] Evaluation of glenoid morphology and bony Bankart lesion in shoulders with traumatic anterior instability using zero echo time magnetic resonance imaging. JSES International. 2024. DOI: 10.1016/j.jseint.2024.03.003

[96] Management of first‐time shoulder dislocations: A survey of sport medicine physician perceptions. Knee Surgery, Sports Traumatology, Arthroscopy. 2026. DOI: 10.1002/ksa.70297

[97] Humeral head deviation and velocity in multidirectional instability of the glenohumeral joint: a cine magnetic resonance imaging study. JSES International. 2026. DOI: 10.1016/j.jseint.2025.101419

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[100] Simultaneous bilateral posterior dislocation of the shoulder: diagnostic problems and management. Knee Surgery, Sports Traumatology, Arthroscopy. 2006. DOI: 10.1007/s00167-006-0066-1

[101] The interobserver reliability in diagnosing osseous lesions after first-time anterior shoulder dislocation comparing plain radiographs with computed tomography scans. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.04.020

[102] Two‐Year Outcomes of Open Shoulder Anterior Capsular Reconstruction for Instability From Severe Capsular Deficiency. Arthroscopy. 2011. DOI: 10.1016/j.arthro.2011.07.002

[103] Three‐Dimensional Magnetic Resonance Imaging Fast Field Echo Resembling a Computed Tomography Using Restricted Echo‐Spacing Sequence Is Equivalent to 3‐Dimensional Computed Tomography in Quantifying Bone Loss and Measuring Shoulder Morphology in Patients With Shoulder Dislocation. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2023.12.016

[104] Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200908000-00002

[105] Preoperative planning with three-dimensional CT vs. three-dimensional magnetic resonance imaging does not change surgical management for shoulder instability. JSES International. 2024. DOI: 10.1016/j.jseint.2023.08.005

[106] A long‐term clinical follow‐up study after arthroscopic intra‐articular Bankart repair using absorbable tacks. Knee Surgery, Sports Traumatology, Arthroscopy. 2008. DOI: 10.1007/s00167-008-0534-x

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By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

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.