Bankart Repair Rehabilitation Protocol

This protocol outlines a general rehabilitation program following a Bankart repair. It is a guideline and should be adjusted based on individual patient presentation, surgeon's preferences, specific surgical findings, and healing progress. Close communication with the surgeon is crucial throughout the rehabilitation process. This protocol assumes the patient has undergone an arthroscopic or open Bankart repair to address anterior shoulder instability resulting from detachment of the anterior inferior glenohumeral ligament (AIGHL) and labrum from the glenoid.

Pathophysiology

A Bankart lesion is a tear of the anteroinferior labrum of the glenoid. This often occurs due to anterior shoulder dislocation. The labrum provides stability to the glenohumeral joint, deepening the socket and resisting anterior translation of the humeral head. The AIGHL is crucial for resisting anterior translation, especially in abduction and external rotation. A Bankart repair aims to reattach the torn labrum and AIGHL to the glenoid rim, restoring stability to the shoulder joint and preventing recurrent dislocations.

Phase I: Protection (Weeks 0-4)

Goals: Protect the surgical repair, minimize pain and inflammation, initiate early range of motion (ROM) while respecting surgical constraints, and maintain muscle activation without stressing the repair.

• Immobilization: Sling worn at all times (except for showering and exercise) for 4 weeks. The type of sling (abduction pillow vs. standard sling) will be determined by the surgeon.
• Pain and Edema Management:
  • Cryotherapy: Apply ice packs for 15-20 minutes several times daily.
  • Elevation: Keep the arm elevated as much as possible.
  • Gentle hand, wrist, and elbow exercises to reduce swelling.
  • Pain medication as prescribed by the physician.
• Range of Motion (ROM):
  • Week 1-2: Pendulum exercises, passive forward flexion to 90 degrees, passive external rotation to 20-30 degrees (surgeon's preference), passive internal rotation as tolerated with arm at the side.
  • Week 3-4: Increase passive forward flexion to 120 degrees, passive external rotation to 30-45 degrees (surgeon's preference), continue passive internal rotation as tolerated.
  • Important: Avoid active elevation and external rotation during this phase. Follow the surgeon's specific ROM restrictions.
• Muscle Activation:
  • Scapular setting exercises (protraction, retraction, elevation, depression).
  • Isometric shoulder exercises (flexion, abduction, extension, internal rotation, external rotation) performed with arm in neutral and submaximal effort. Hold for 5 seconds, repeat 10 times.
  • Gripping exercises (using a soft ball or putty).
  • Biceps and triceps isometrics, low intensity.
• Precautions:
  • Avoid active shoulder movements outside of prescribed ROM.
  • Avoid lifting objects.
  • Avoid reaching behind the back.
  • Avoid activities that cause pain or clicking.

Phase II: Loading (Weeks 4-12)

Goals: Gradually restore full pain-free ROM, improve muscle strength and endurance, and normalize scapulothoracic rhythm.

• Sling Weaning: Discontinue sling use as tolerated, typically around week 4. Start with short periods out of the sling and gradually increase.
• Range of Motion (ROM):
  • Week 4-6: Progress to active-assisted ROM exercises for forward flexion, abduction, and external rotation. Start using a dowel or pulleys to assist with motion. Continue passive ROM exercises.
  • Week 6-8: Begin active ROM exercises. Emphasize full pain-free ROM in all planes.
  • Week 8-12: Continue active ROM exercises. Focus on achieving full and symmetrical ROM. Consider joint mobilization techniques if restrictions persist (performed by a qualified physical therapist).
• Strengthening:
  • Week 4-6: Begin with light resistance exercises using elastic bands (TheraBand) for internal rotation, external rotation, flexion, abduction, and extension. Focus on proper form and control.
  • Week 6-8: Progress resistance with elastic bands. Introduce light dumbbell exercises (1-2 lbs) for the same muscle groups. Focus on rotator cuff strengthening (internal rotation, external rotation, scaption).
  • Week 8-12: Continue progressive strengthening exercises. Gradually increase weight and resistance. Introduce exercises for scapular stabilizers (rows, shrugs, rhomboid squeezes). Consider proprioceptive exercises (e.g., using a wobble board).
• Scapular Stabilization: Continue scapular setting exercises. Add exercises to improve scapulothoracic rhythm, such as wall slides, push-ups against the wall, and rows.
• Cardiovascular Fitness: Begin low-impact aerobic exercises, such as walking or stationary cycling.
• Precautions:
  • Avoid activities that cause pain or apprehension.
  • Avoid lifting heavy objects.
  • Avoid sudden or forceful movements.
  • Progress exercises gradually and monitor for signs of overstressing the repair.

Phase III: Return to Function (Weeks 12+)

Goals: Restore full strength, power, and endurance; improve neuromuscular control and proprioception; and return to desired activities (sports, work, etc.).

• Strengthening: Continue progressive strengthening exercises, gradually increasing weight and resistance. Incorporate sport-specific or work-specific exercises.
• Neuromuscular Control and Proprioception:
  • Balance and stability exercises (e.g., single-leg stance, using a balance board).
  • Plyometric exercises (e.g., medicine ball throws, jump rope). Start with low-impact plyometrics and gradually progress to higher-impact activities.
  • Sport-specific or work-specific drills to improve coordination and agility.
• Endurance Training: Progressively increase the duration and intensity of exercises to improve muscular endurance.
• Return to Activity: Gradually return to desired activities. Start with modified activities and gradually increase the intensity and duration as tolerated. Emphasize proper technique and body mechanics.
• Maintenance Program: Continue a home exercise program to maintain strength, ROM, and proprioception.
• Precautions:
  • Avoid overtraining.
  • Monitor for signs of recurrence of instability.
  • Continue to use proper technique and body mechanics.
  • Gradual return to sport, work and other higher intensity activities to prevent re-injury.

Common Special Tests for Shoulder Instability

• Apprehension Test: Assesses anterior instability. The arm is abducted to 90 degrees and externally rotated. A positive test is indicated by apprehension or facial grimacing.
• Relocation Test: Performed following a positive apprehension test. A posterior force is applied to the anterior aspect of the humeral head. If the patient reports decreased apprehension or increased comfort, the test is considered positive.
• Anterior Load and Shift Test: Assesses anterior translation of the humeral head on the glenoid. The humeral head is "loaded" into the glenoid fossa, and then an anterior force is applied to the humeral head. The amount of translation is graded.
• Sulcus Sign: Assesses inferior instability. The examiner applies an inferior traction force to the humerus. A positive test is indicated by a visible sulcus (gap) between the acromion and the humeral head.
• Posterior Apprehension Test: Assesses posterior instability. The arm is flexed to 90 degrees and internally rotated. A posterior force is applied to the elbow. A positive test is indicated by apprehension or pain.

Disclaimer: This protocol is for informational purposes only and should not be considered medical advice. It is essential to consult with a qualified healthcare professional for personalized guidance and treatment.