Open Bankart Repair Physiotherapy Protocol
A Bankart repair is carried out for patients with traumatic anterior recurrent
dislocation of the shoulder. Almost invariably the patient will have undergone
an investigation such as an MRI arthrogram or rarely, a diagnostic
arthroscopy prior to their Bankart repair to accurately define the cause of their
instability and to allow the details of the operation to be planned. All patients
will have detachment of the anterior glenoid labrum (a Bankart lesion) and all
of them will have a dent on the back of the humeral head (the Hill Sachs
lesion) caused by the posterior aspect of the humeral head striking the front of
the glenoid at the moment of dislocation. Many patients will have dislocated
so many times that they will have stretched the anterior and the inferior parts
of the shoulder capsule creating additional laxity.
The primary aim of surgery is to secure the glenoid labrum back in to place
and restore normal tension back to the capsule and the ligament. In patients
with a large Hill Sachs lesion it may be necessary to deliberately restrict the
range of external rotation to prevent the defect in the posterior humeral head
from reaching the front of the glenoid when dislocation can still occur even in
the presence of an intact labrum.
The goals of post operative rehabilitation are to restore shoulder movement
and to restore the balancing and controlling functions of the muscles around
the scapula and the glenohumeral joint. In the later stages of rehabilitation
strength and stability during the functional activities that the patient requires
become important and this stage of the programme needs to be individualised
for the patients particular working and sporting demands.
Restrictions are placed on the range of movement during the first four weeks
for two reasons. The labral repair is held together by a very small number of
stitches and healing of the labrum to the glenoid needs to occur before undue
stresses are placed on it. Secondly the subscapularis muscle is detached to
gain access to the shoulder and has to be allowed to heal back in to place
before it can be stretched. This means restrictions are placed on the range of
external rotation for the first four weeks and the patient is advised to use their
sling when they are not carrying out their exercises and in bed at night.
Authors Mr S J Gregg-Smith and Mr G Jennings Consultant Orthopaedic
and Trauma Surgeons. Produced Feb 2010
Post-Op Physiotherapy for Open Bankart Repairs
Phase 1 (Immediately Post-Op to 2 weeks)
The shoulder is rested in a sling for approximately for 4 weeks
following surgery to allow the labrum and ligaments to heal and to
protect the repair of the subscapularis muscle.
Exercises:
1. Postural advice especially sleeping position
2. Active assisted shoulder flexion no more than 90º
3. Passive external rotation to neutral
4. Postural correction out of the sling
5. Shoulder girdle range of movement and setting exercises
6. Neck, hand and elbow exercises to maintain range of movement
Aims at 2 weeks:
Active assisted shoulder flexion to 90º
Passive shoulder external rotation to neutral
Decrease pain and swelling with use of painkillers/anti-inflammatories
NB: Avoid combined abduction and external rotation for six weeks
Phase 2 (weeks 3-4)
Exercises:
1. Isometric flexion, abduction, external and internal rotation, as
pain allows.
2. Active-assisted shoulder flexion as far as pain allows.
3. Active-assisted external rotation to neutral.
7. Shoulder girdle range of movement and setting exercises
4. Serratus anterior isometric
5. Scar massage when stitches removed
Aims at 4 weeks:
Wean off sling during day
Active-assisted shoulder external rotation to neutral
Active-assisted shoulder flexion more than 130º
NB: Avoid combined abduction and external rotation for six weeks
Authors Mr S J Gregg-Smith and Mr G Jennings Consultant Orthopaedic
and Trauma Surgeons. Produced Feb 2010
Phase 3 (weeks 5-12)
Exercises:
1. Active shoulder flexion
2. Active shoulder external rotation 20º then full range from week 7.
3. Hydrotherapy if patient not progressing
4. Hand behind back exercises
5. Theraband exercises
6. Proprioceptive exercises
7. Core stability exercises e.g. superman
8. Dynamic trunk stability
Aims:
Full range of movement
Good scapulothoracic control
Authors Mr S J Gregg-Smith and Mr G Jennings Consultant Orthopaedic
and Trauma Surgeons. Produced Feb 2010