Rehabilitation Concepts of the Shoulder after Bankart

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Rehabilitation Concepts of the Shoulder after
Bankart SLAP Repair

• Noel M. Goodstadt, MPT, OCS, CSCS
• Associate Director, Orthopedics
• Coordinator of Orthopedic Clinical Residency
• University of Delaware Physical Therapy
• Delaware, USA

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• Ultimately, success is a race between biologic
  healing and fixation failure
• Snyder-Mackler Axe, 2005

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Effects Of Disuse (inactivity or immobilization)

• Decreased size and amount of collagen fibers
  (decreased strength)
• Random orientation of fibers during remodeling

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Effects Of Activity

• Increased size and amount of collagen fibers
  (increased strength)
• Orientation of fibers along lines of tensile
  stress
• Application of Wolfs Law to soft tissue

Tendon, Longitudinal Cut
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What should the PT know about the surgery?

• Bankart Repair
• Open
• Type of subscapularis resection
• Size of the tear
• Ligaments involved
• Arthroscopic
• Size of the tear
• Ligaments involved

• SLAP Repair
• Arthroscopic
• LHB Tendon repair
• type II and type IV

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Bankart Repair Has arthroscopic repair caught
up with open repair?

• Mohtadi et al., Arthroscopy 2005
• Meta-Analysis
• Open repair has a more favorable outcome with
  respect to recurrence and return to activity
• Carreira et al., AJSM 2006
• Minimum 2 year follow-up
• Arthroscopic Repair
• Low recurrence rates (10)
• Suture anchors
• Non-absorbable sutures

• Boileau et al., JBJS Am 2006
• Arthroscopic Procedure
• Risk factors for recurrent instability
• Glenoid Bone Loss gt 25
• Hill Sachs Lesion
• lt 3 anchors sutures

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Accelerated Rehabilitation post Bankart Repair

• RCT of patients undergoing Bankart Repair
• 62 subjects in 2 groups
• Traditional Group
• Accelerated Group
• Concluded
• Accelerated rehabilitation that incorporates an
  early controlled motion is safe in selected
  patients after arthroscopic Bankart repair using
  suture anchors.
• Kim et al., Arthroscopy 2003

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Accelerated Rehabilitation post Bankart Repair

• RCT of patients
• Inclusion Criteria
• Traumatic unidirectional anterior instability
• Recurrent dislocations
• Not actively participating at the time in sports
• Affected shoulder had classic Bankart lesion with
  a healthy labrum
• Size of lesion was limited to 1cm above the
  midglenoid notch
• 62 patients included
• Power 23 subjects/group

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Conventional Rehab Group

• Immobilization for 3 weeks
• After 3 weeks, gentle pendulum exercises and
  AAROM for forward elevation
• 4 weeks
• IR PREs
• 6 weeks
• ER with a bar and ER strengthening were initiated
• 9 weeks
• More vigorous cuff strengthening exercise
• Including diagonals

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Accelerated Group

• Sling for sleep first 2 weeks
• Initiated gradual exercise from post-op day 1
• Forward elevation limited to 90 first 2 weeks
• 4 weeks
• Full ROM was allowed, except for extreme external
  ROM
• All strength and ROM exercises at subpainful
  conditions

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Conclusions

• Accelerated rehabilitation that incorporates an
  early controlled motion is safe in selected
  patients after arthroscopic Bankart repair using
  suture anchors.

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Surgical TechniqueType 2/4 SLAP Repair

• Biomechanical Analysis
• No significant difference between tissue tacks
  and sutures in regard tensile load at repair
  failure.
• DiRaimondo et al., AJSM 2004
• Created SLAP lesions increase ER ROM and GH
  translation
• Repair of SLAP lesions with 2 anchors restore ER
  and GH translation to levels of intact capsules
• Pannosian et al., J Shoulder Elbow Surg. 2005

• Surgical Technique Studies
• Outcomes
• 75 to 86 of excellent to good results, as well
  as return to previous sports activity
• Rhee et al, Arthroscopy 2005
• Samani et al. Arthroscopy 2001
• Kartus et al. Knee Surg Sports Trauma Arthrosc,
  2004

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Anatomic Issues
Glenoid Labrum
Size Mis-match
Capsulolabral complex Rotator Cuff
Interval GH Ligaments
Dynamic Factors Rotator Cuff Scapular Mm.
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Procedure-Modified Rehabilitation

• Rehabilitation
• Speed
• Volume
• Intensity

• Depends on the surgery performed

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Principles of Rehabilitation

• Minimize effects of immobilization
• Never overstress healing tissue
• Progress only when criteria fulfilled
• Base protocol on current research
• Adapt rehab program to patient

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Procedure ModifiedRehabilitation

• Bankart Repair
• Avoid High 5 position
• Closed-Pack position
• Avoid Low 5 position
• Tension to Rotator Cuff Interval (SGHL, MGHL)

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Procedure ModifiedRehabilitation

• SLAP Type 2/4 Repair
• Precautions
• Biceps
• No passive extension or horizontal abduction for
  2-4 weeks
• Caution with forceful supination with elbow
  flexed for 4-6 weeks
• No resisted shoulder flexion/horizontal adduction
  for 4-8 weeks
• No resisted elbow flexion for 8-12 weeks
• Rotator Cuff Interval (SHGL/MGHL)
• Caution of ER _at_ 0

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Procedure ModifiedRehabilitation

• Bankart Repair
• Early Phase (2-4 weeks)
• Immobilization weaned
• Treatment
• Joint mobs, scar mobs
• Scapulohumeral rhythm
• A/PROM
• Shoulder isometrics

• SLAP Repair Type 2/4
• Early Phase (2-4 weeks)
• Immobilization weaned
• Treatment
• Joint mobs, scar mobs
• Scapulohumeral rhythm
• A/PROM
• Abd/flex - gravity minimized

Milestones 90 for elevation 120 for
elevation 45 ER Extension to plane of the
body Full ROM posterior shoulder
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Procedure ModifiedRehabilitation

• Bankart Repair
• Early Mid Phase (5-6 weeks)
• Treatment
• A/PROM
• Isotonic Strengthening

• SLAP Type 2/4 Repair
• Early Mid Phase (5-6 weeks)
• Treatment
• A/PROM
• Isotonic Strengthening
• Start gravity minimized abd/flex

• Milestones
• 135 for elevation
• 60 ER
• Extension 20 beyond the plane of the body

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Procedure ModifiedRehabilitation

• Bankart Repair
• Late Mid Phase (7-8 weeks)
• Treatment
• PREs
• Dynamic Stabilization
• Bilateral Plyometrics
• Isokinetics

• SLAP Type 2/4 Repair
• Late Mid Phase (7-8 weeks)
• Treatment
• Isotonics

Milestones Full ROM Full ROM elevation
ER-70 (90 overhead athlete) ER -
60 Extension to 20 beyond the
plane of the body
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Procedure ModifiedRehabilitation

• SLAP Type 2/4 Repair
• Late Phase (9-12 weeks)
• Treatment
• Same as Bankart Repair
• Starting plyometrics bilateral to unilateral

• Bankart Repair
• Late Phase (9-16 weeks)
• Treatment
• PREs above shoulder height
• Progress strengthening to HEP
• Initiate Unilateral Plyometrics

Milestones Full AROM/PROM (SLAP) Strength 5/5
all motions
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When were in trouble

• Patients who have lt 25o ER or lt 45o Abd at 2
  weeks need to speed-up...
• Patients with lt 60o ER or lt 150o FE at 3 months
  post-op may require surgical intervention
• Patients who meet their milestones ahead of
  schedule?
• Hurry up and wait

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Procedure ModifiedRehabilitation

• Begin interval throwing program
• Bankart Repair
• Functional Phase (16-26 weeks)
• SLAP Type 2/4 Repair
• Functional Phase (12-16 weeks)
• Indication
• Negative Apprehension Test
• Negative OBriens Test
• Negative Belly Press Test
• After warm-up self OBrien Test
• If positive do not throw
• If negative proceed
• Progress sport/work specific rehabilitation

• Milestones
• Return to Sport/Work

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Soreness Rules

• Action
• 2 days off, drop down 1 step
• Stay at step that led to soreness
• 2 days off, drop down 1 step
• 1 day off, do not advance program to the next
  step
• Advance 1 step per week or as instructed by
  healthcare professional

• Criterion
• Soreness during warm-up that continues
• Soreness during warm-up that goes away
• Soreness during warm-up that goes away but
  redevelops during session
• Soreness the day after lifting (Not muscle
  soreness)
• No soreness