Bankart lesion

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Bankart lesion, rehabilitation, operative repair, shoulder dislocation.

Definition/Description

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Clinically Relevant Anatomy

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Epidemiology /Etiology

The shoulder is designed for its mobility, with stability being sacrificed to achieve this mobility. Due to poor osseous congruency and capsular laxity, the glenohumeral joint is very unstable, which makes it the most frequently dislocated joint in the human body. It relies on dynamic stabilizers and the neuromuscular system for its stability. Anterior instability is the most common traumatic type of instability, representing approximately 95% of all shoulder instabilities. 2 Glenohumeral dislocations are mainly caused by an abduction, extension and external rotation movement. 1,2,3

In many cases of anterior dislocation patients have a Bankart lesion.

A reverse Bankart lesion can occurs in case of a posterior dislocation.

Characteristics/Clinical 

We can distinguish to types of Bankart lesions: a soft tissue Bankart lesion and a bony Bankart lesion.
A soft tissue Bankart lesion is an anteroinferior labrum avulsion damage of the glenoid rim. The posterior capsule may be stretched and the inferior glenuhumeral ligament is torn.. 1,2

A bony Bankart lesion shows besides the soft tissue damage also a fracture of the anteroinferior glenoid rim. 1

Patients with a Bankart lesion are recognized by shoulder pain which is not localized in a specific point and the pain gets worse when the arm is held behind the back. They also feel weakness and instability of the shoulder. 11

The image below shows a spin echo MR arthrographic image. It shows contrast medium interposition between the glenoid rim and the capsulolabral complex, which means that there is a Bankart lesion.

Differential Diagnosis

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Diagnostic Procedures

Many patients who sustain a shoulder dislocation will sustain a Bankart lesion. 4 Although Bankart lesions often occur in patients with shoulder dislocation, they are hard to detect in physical examination.

For the identification of a Bankart lesion you can use Magnetic Resonance Imaging (MRI). It can be used to quantify the associated medial displacements of the inferior glenohumeral ligament underneath the glenoid. 1

According to some studies a Bankart lesion can be diagnosed if contrast medium is interposed between the glenoid and the detached labroligamentous complex. 4

The soft tissue Bankart lesion can be seen at arthroscopy and MR arthrography as a fragment of labrum attached to the anterior band of the inferior glenuhumeral ligament and to a rupture in the periosteum of the scapula. 5
A bony Bankart lesion can also be discovered by radiographs.

Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

There are several options for interventions to the Bankart lesion. First of all we can make the difference between the operative and non-operative interventions.

Possible operative interventions include the arthroscopic Bankart repair and an open Bankart repair. In arthroscopic Bankart repair the muscle strength is regained faster, but the recurrence rates after open Bankart repair are significantly lower.8 It is proven by several studies that recurrence rate after operative Bankart treatment is significantly reduced compared to a non-operative treatment. 6 After surgery there is of course rehabilitation needed which can be slightly comparable to the non-operative rehabilitation program. 7

The conservative non-operative Bankart treatment had a significantly worse result with recurrent instability rates ranging from 17% to 96% in patients under age of 30 years. 6

Rehabilitation

There are 7 key factors that need to be considered in the rehabilitation of the unstable shoulder. These are:
• Onset of the pathology (traumatic, chronic)
• Degree of instability
• Frequency of dislocation
• Direction of instability (anterior, posterior, multidirectional)
• Concomitant pathologies
• End range neuromuscular control
• Premorbid activity level 2

Besides these key factors physiotherapist should also keep in mind that every patient is different and that we should never forget to personalize a rehabilitation program.

Focus of the rehabilitation program is on maximizing dynamic stability, scapula positioning, proprioception and improving neuromuscular control, as there are no specific exercises to improve the labrum quality. 2,9 Usually the rehabilitation program is divided in 3 phases. The programs for non-operative treatment and postoperative rehabilitation are very similar.

The first phase of rehabilitation consists of sling immobilization with a limited active range of motion for 0 to 4 weeks, this allows 20^o of abduction and 40^o of internal rotation. This provides an earlier return to functional activity.  Immobilization in external rotation reduces the risk of recurrent shoulder dislocations. After the 14 days passive movement is initiated in a pain free zone. Strengthening exercises are started as isometric contractions to initiate muscle recruitment of the rotator cuff muscles, mostly exercises in a closed kinetic chain, such as pushing your underarm against a wall towards exorotation. The goals are to diminish pain and protect healing soft tissues.

In the second phase a progressive passive motion is important, together with active-assisted range of motion exercises. 2,6 Strengthening of rotator cuff muscles is initiated in balanced exercises. Examples of exercises are movements of the shoulder executed with elastic bands or dumbbells as dynamic open chain strengthening exercises. 10 Rehabilitation should include both closed and open chain exercises. An example of a closed kinetic chain exercise is quadruped position with scapula protraction, progressing to tripod position. A patient can continue to phase three when a normal passive range of motion is achieved.

The third phase focuses on restoration of a full active range of motion. In this phase a progressively increasing resistance in dynamic exercises is stressed to regain full strength for ADL activities. Most imported in this phase is the return to full active activity of normal life. 6,10

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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