Bankart lesion: Difference between revisions

m (I added levels of evidence, I changed the level of evidence of reference nr. 13 from 2 to 2B)
(Moved section on Differential Diagnosis)
 
(20 intermediate revisions by 4 users not shown)
Line 1: Line 1:
<div class="noeditbox">Welcome to [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
<div class="editorbox"> '''Original Editor '''- [[User:Nikki Rommers|Nikki Rommers]]
'''Original Editors'''  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}  
</div>  
</div>  


== Definition/Description  ==
== Introduction ==
[[File:Shoulder dislocation, anteroposterior after reduction, with Bankart and Hill-Sachs lesions, with labels.jpeg|thumb|Bankart and Hill-Sachs lesions]]
Bankart lesions are injuries of the anteroinferior aspect of the [[Glenoid Labrum|glenoid labral]] complex and are often found in association with a [[Hill Sachs Lesion|Hill-Sachs lesion]]. This injury is a common complication of anterior [[Shoulder Dislocation|shoulder dislocation]] and/or repeated anterior [[Shoulder Subluxation|shoulder subluxation]]<nowiki/>s. The dislocation of the shoulder joint (anterior) can damage the connective tissue ring around the glenoid labrum. It can also bring damage to the connection between the labrum and capsule. Usually associated with poor construction of the medial glenohumeral ligament. This injury is common for athletes that practice volleyball, tennis, handball, people who do overhead activities.<ref>Radiopedia [https://radiopaedia.org/articles/bankart-lesion Bankart Lesions] Available:https://radiopaedia.org/articles/bankart-lesion (accessed 10.1.2023)</ref><ref>Widjaja A, Tran A, Bailey M, Proper S (2006). Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation. ANZ J Surg 76 (6): 436–8.</ref>
== Pathology ==
[[File:AC ligs.png|thumb|Glenoid Labrum (marked lig.)]]
Bankart lesions occur when the [[humerus]] is compressed against the labrum as happens anterior shoulder dislocations or subluxations.. There is detachment of the anteroinferior labrum from the underlying glenoid (possibly with extension further superiorly or posteriorly). Impaction fracture of the anteroinferior glenoid margin frequently occurs simultaneously


A Bankart lesion<ref>Widjaja A, Tran A, Bailey M, Proper S (2006). Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation. ANZ J Surg 76 (6): 436–8.</ref> is a lesion of the anterior part of the glenoid labrum of the shoulder. This injury is caused by repeated anterior shoulder subluxations. The dislocation of the shoulder joint (anterior) can damage the connective tissue ring around the glenoid labrum. It can also bring damage to the connection between the labrum and capsule. Usually it has to do with none or poorly construction of the medial glenohumeral ligament. This injury is common for athletes that practice volleyball, tennis, handball, people who do overhead activities,… <br><br>
Two types of Bankart lesions,  


== Clinically Relevant Anatomy  ==
# Soft Bankart lesion: labrum tears from the glenoid, and the injury involves only the soft tissue. Most common
 
# Bony Bankart lesion:  labrum tears and a part of the bony glenoid fractures or breaks off. May lead to notable bone loss in the glenoid, a cause chronic instability.<ref>Facty Health [https://facty.com/conditions/joint-pain/bankart-lesions-and-shoulder-instability/ Bankart Lesions and Shoulder Instability] Available:https://facty.com/conditions/joint-pain/bankart-lesions-and-shoulder-instability/ (accessed 10.1.2023)</ref>
The Bankart lesion is an injury of the glenohumeral joint. This is a ball-and-socket joint binds the scapular and the humerus. Parts of the joint are the labrum, a fibrocartilaginous structure around the glenoid, the capsule and ligaments and supporting muscle tendons.<ref name="p1"/><ref name="p3">D. Y. Wen, ‘Current concepts in the treatment of anterior shoulder dislocations’, American Journal of Emergency Medicine, Volume 17, Number 4, 1999, p 401-407 (Level of Evidence 2A)</ref><br>
In many cases of anterior dislocation patients have a Bankart lesion. A reverse Bankart lesion can occurs in case of a posterior dislocation.


== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==
 
[[File:Anterior-shoulder-dislocation-1.jpeg|thumb|Anterior-shoulder-dislocation]]
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. <ref name="p2">K. E. Wilk, L. C. Macrina, M. Reinold, ‘Non-operative Rehabilitation for traumatic and atraumatic glenohumeral instability’, North American Journal of Sports Fhysical Therapy, 2006, p 16-31 (Level of Evidence 1A)</ref>&nbsp;Glenohumeral dislocations are mainly caused by an abduction, extension and external rotation movement. <ref name="p1"/><ref name="p2"/><ref name="p3"/><br>
[[Anterior Shoulder Instability]] is the most common traumatic type of instability, representing approximately 95% of all shoulder instabilities. <ref name="p2">K. E. Wilk, L. C. Macrina, M. Reinold, ‘Non-operative Rehabilitation for traumatic and atraumatic glenohumeral instability’, North American Journal of Sports Fhysical Therapy, 2006, p 16-31 (Level of Evidence 1A)</ref>&nbsp;Traumatic shoulder dislocation commonly occur in in collision or contact sports. Abnormal translation of the humeral head during dislocation puts excessive loading on the labrum causing it to stretch along with the capsuloligamentous structures. This excessive stretch causes tearing or avulsion of the labrum with associated capsular injury.<ref name=":0">Tupe RN, Tiwari V. [https://www.ncbi.nlm.nih.gov/books/NBK587359/ Anteroinferior Glenoid Labrum Lesion] (Bankart Lesion). Available:https://www.ncbi.nlm.nih.gov/books/NBK587359/ (accessed 10.1.2023)</ref>
 
In many cases of anterior dislocation patients have a Bankart lesion. <br>
 
A reverse Bankart lesion can occurs in case of a posterior dislocation.<br><br>
 
== Characteristics/Clinical&nbsp;  ==
== Characteristics/Clinical&nbsp;  ==


We can distinguish to types of Bankart lesions: a soft tissue Bankart lesion and a bony Bankart lesion.<br>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.. <ref name="p1"/><ref name="p2"/>  
Bankart lesions usually report a primary or recurrent anterior shoulder dislocation. They present with generalised [[shoulder]] pain and the signs and symptoms of recurrent shoulder instability. Some patient present with catching, locking, or popping sensations in the shoulder.<ref name=":0" />


<br>A bony Bankart lesion shows besides the soft tissue damage also a fracture of the anteroinferior glenoid rim.&nbsp;<ref name="p1"/>
== Differential Diagnosis ==
A number of lesions are closely related have similar appearances, including:


<br>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.&nbsp;<ref name="p1"/>
* Anterior labroligamentous periosteal sleeve avulsion (ALPSA)
 
*[[Rotator Cuff Tears]]
<br>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.<br>
*[[SLAP Lesion]](Superior Labrum Anterior Posterior)
 
== Differential Diagnosis&nbsp;  ==
 
*&nbsp;ALPSA lesion (anterior labral periosteal sleeve avulsion) free and adherent
*Cuff frying
*[[Rotator Cuff Tears]]  
*[[SLAP Lesion]](Superior Labrum Anterior Posterior)  
*[[Impingement / Instability Differentiation|Impingement]]
*[[Impingement / Instability Differentiation|Impingement]]
 
* Perthes lesion
If you want to be sure about the diagnosis you will do a&nbsp;MRI.&nbsp;It is the most common imaging tool used to diagnose labral lesions.  
* Glenolabral articular disruption (GLAD)
 
* Humeral avulsion of the glenohumeral ligament (HAGL)
* Bony humeral avulsion of the glenohumeral ligament (BHAGL)<ref>Radiopedia Anterior glenolabral injuries https://radiopaedia.org/articles/anterior-glenolabral-injuries?lang=gb Available:https://radiopaedia.org/articles/anterior-glenolabral-injuries?lang=gb (accessed 10.1.2023)</ref>
== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


Many patients who sustain a shoulder dislocation will sustain a Bankart lesion. <ref name="p4">S. Waldt, A. Burkart, A. B. Imhoff, M. Bruegel, E. J. Rummeny, K. Woerler, ‘Anterior Shoulder Instability: Accuracy of MR Arthrography in the Classification of Anteroinferior Labroligamentous Injuries’, Radiology, Volume 237, Number 2, 2005, p 578-583 (Level of Evidence 2B)</ref>&nbsp;Although Bankart lesions often occur in patients with shoulder dislocation, they are hard to detect in physical examination.  
Many patients who sustain a shoulder dislocation will sustain a Bankart lesion. <ref name="p4">S. Waldt, A. Burkart, A. B. Imhoff, M. Bruegel, E. J. Rummeny, K. Woerler, ‘Anterior Shoulder Instability: Accuracy of MR Arthrography in the Classification of Anteroinferior Labroligamentous Injuries’, Radiology, Volume 237, Number 2, 2005, p 578-583 (Level of Evidence 2B)</ref> Although Bankart lesions often occur in patients with shoulder dislocation, they are hard to detect in physical examination.


<br>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.&nbsp;<ref name="p1">Magnetic Resonance Imaging in Orthopaedics and Sports Medicine, Volume II, David W. Stoller, 2007, p 1329-1338</ref>  
# [[X-Rays|X-rays]] are important to obtain to rule out associated fractures and frank bony defects such as bony Bankart, Hill-Sachs, glenoid fractures, coracoid fractures, and greater tuberosity fractures.
# [[MRI Scans|MR]]I with or without contrast is the gold standard investigation for soft tissue injuries such as glenoid labrum and capsuloligamentous injury. <ref name=":0" />


<br>According to some studies a Bankart lesion can be diagnosed if contrast medium is interposed between the glenoid and the detached labroligamentous complex.&nbsp;<ref name="p4"/>
== Outcome Measures  ==


<br>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.&nbsp;<ref name="p5">J. Beltran, Z. S. Rosenberg, V. P. Chandnani, F. Cuomo, S. Beltran, A. Rokito, ‘Glenohumeral Instability: Evaluation with MR Arthrography’, Scientific Exhibit, Volume 17, Number 3 (Level of Evidence 2C)</ref><br>A bony Bankart lesion can also be discovered by radiographs.<br><br>
# [[Oxford Shoulder Instability Score]]
# [[Hawkins / Kennedy Test|Hawkins’ Test]]
See also [[:Category:Shoulder - Outcome Measures]]


== Outcome Measures<br>  ==
== Treatment ==
[[File:Latarjet-Procedure, Bankart repair.jpeg|thumb|Larajet procedure: treatment Bankart lesion]]
The patient's expectations, age, and sporting involvement (contact vs. non-contact) are vital factors to assess when treating a Bankart injury. Young patients involved in contact sports (high demand), they will be considered for surgery. In Bankart repairs, the labral fragment is sutured back to the glenoid rim using suture anchors.


'''''WOSI: Western Ontario Shoulder Instability Index'''''<br>Western Ontario Shoulder Instability Index (WOSI), which is a subjective quality of life measurement tool specific to shoulder instability. Walch-Duplay score, which is the gold standard score used in Europe.<br>The WOSI consists of four subscales: physical symptoms and pain; sport, recreation, and work function; lifestyle and social functioning; and emotional well-being. Twenty-one items are scored using a visual analogue scale measuring 100 mm horizontally placed under each question. This questionnaire requires a minimum of explanations to the patient for the filling of scales. The best possible score indicating the highest possible shoulder-related quality of life is 0 and the worst possible score indicating the poorest quality of life is 2100. <ref name="p8"/><br><br>  
Candidates for nonoperative management are patients showing no signs of shoulder instability, preserved normal osseous restrain to instability, and not using shoulder use for sports.<ref name=":0" />  


'''''Walch Duplay'''''<br>The European Society of Shoulder and Elbow Surgery recommended using the Walch-Duplay score which was inspired by the Rowe rating scale and takes into account both subjective and objective data (stability, pain, sport level recovery, mobility) to assess clinical outcome. The Walch-Duplay score is the most currently used score in Europe for the assessment of the patient undergoing shoulder stabilization surgery. However, it is not a self-administrated questionnaire.<br>The Walch-Duplay score (0 to 100 points) and the WOSI (0 to 2100 points) were recorded at the last follow-up. The Walch-Duplay score is composed of four items: activity, stability, pain and mobility. According to the Walch-Duplay score, results were classified as excellent (91 and 100 points), good (76 and 90 points), fair (51–75 points) or poor (under 50).<br>The correlation between the Walch-Duplay score and the WOSI is strong. The better the Walch-Duplay score is, the lower the WOSI is.<ref name="p8">F. KHIAMI, ET AL. (February 2012), Anterior shoulder instability arthroscopic treatment outcomes measures: The WOSI correlates with the Walch-Duplay score, Revue de chirurgie Orthopédique et Traumatologique, volume 98, pages 48-53fckLRLevel of evidence: 4</ref><br>
== Physical Therapy Management    ==
[[File:Stiff Brace for after Shoulder Surgery.jpeg|thumb|Stiff brace post surgery]]
Examination See [[Shoulder Instability]]<br>Interventions include the arthroscopic Bankart repair, an open Bankart repair or conservative management.  


<br>'''''The instability shoulder index score'''''<br>The Instability Shoulder Index Score (ISIS) was developed to predict the success of arthroscopic Bankart repair. Scores range from 0 to 10, with higher scores predicting a higher risk of recurrence after stabilization. The Instability Shoulder Index Score (ISIS) to predict the success of isolated arthroscopic Bankart repairs for recurrent anterior shoulder instability. <br>Patients who underwent more complex arthroscopic procedures such as Hill-Sachs remplissage or open Latarjet had higher preoperative ISIS outcomes<br>A 10-point score was created and applied retrospectively. A score above 6 was associated with a 70% risk of recurrence, and the authors proposed using supplemental surgical procedures (such as an open Latarjet) to address this high risk.<br>ISIS has been used in several clinical studies. The studies have shown that you can use the ISIS for investigate several pathologies. <br>In conclusion, our results show that ISIS measurements are highly reliable and support the clinical use of the ISIS<br>for traumatic anterior instability severity grading for surgeons wishing to do so. It also correlates with the number of prior dislocations but not with patients’ perceptions of instability as reported by quality-of-life questionnaires. In the 5 academic centers involved, a higher ISIS was predictive of patients undergoing more complex surgery (Hill- Sachs remplissage or open Latarjet.&nbsp;<ref name="p9">DOMINIQUE M. ET AL (December 27), Validation of the Instability Shoulder Index Score in a Multicenter Reliability Study in 114 Consecutive cases, Am J Sports Med 2013 41: 278fckLRLevel of evidence: 2B</ref>  
# Arthroscopic Bankart repair the muscle strength is regained faster, but the recurrence rates after open Bankart repair are significantly lower.<ref name="p8">F. KHIAMI, ET AL. (February 2012), Anterior shoulder instability arthroscopic treatment outcomes measures: The WOSI correlates with the Walch-Duplay score, Revue de chirurgie Orthopédique et Traumatologique, volume 98, pages 48-53fckLRLevel of evidence: 4</ref>
# Recurrence rate after operative Bankart treatment is significantly reduced compared to a non-operative treatment. <ref name="p6">NETTO ET AL ; Treatment of Bankart Lesions in Traumatic Anterior Instability of the Shoulder: A Randomized Controlled Trial Comparing Arthroscopy and Open Techniques; 2012fckLRLevel of evidence: 2</ref> After surgery there is of course rehabilitation needed which can be slightly comparable to the non-operative rehabilitation program.&nbsp;<ref name="p7">VOOS ET AL. Prospective Evaluation of Arthroscopic Bankart Repairs for Anterior Instability;. 2009 fckLRLevel of evidence: 4</ref>


'''''Hawkins’ Test'''''<br>Firstly, the examinator has to hold the arms in 90 degrees anteflexion. Then he has to a do passive endoration of the arm by use of his other arm. If the test is positive, it causes pain in the region of the deltoideus. During this manoeuvre the tuberculum majus drives under the coracoacromial ligament. This is the cause of the pain.<br>The test was positive for 31% of Bankart lesions.&nbsp;<ref name="p0">T. DUNCAN TENNENT,* FRCS(ORTH), WILLIAM R. BEACH, MD, AND JOHN F. MEYERS, MD, A Review of the Special Tests Associated with Shoulder Examination Part I: The Rotator Cuff Tests. Vol. 31, No. 1, 2003. pag 157-158.fckLRLevel of evidence: 3A</ref>  
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. <ref name="p2" /><ref name="p9">DOMINIQUE M. ET AL (December 27), Validation of the Instability Shoulder Index Score in a Multicenter Reliability Study in 114 Consecutive cases, Am J Sports Med 2013 41: 278fckLRLevel of evidence: 2B</ref>&nbsp;For the first six weeks after surgery, emphasis is placed on protected motion. For the second six weeks, emphasis is placed on strengthening exercises so that strong muscles will protect the shoulder as it returns to normal activities. Usually the rehabilitation program is divided in 4 phases. The programs for non-operative treatment and postoperative rehabilitation are very similar.


<br><br>  
# Phase 1, 1-6 weeks:  consists of sling immobilization with a limited active range of motion for 0 to 4 weeks, this allows 20<sup>o</sup> of abduction and 40<sup>o</sup> of internal rotation. <ref>S-H Kim, K-I Ha, M-W Jung, M-S Lim, Y-M Kim, J-H Park, ‘Accelerated Rehabilitation After Arthroscopic Bankart Repair for Selected Cases: A Prospective Randomized Clinical Study’, Arthroscopy, 2003, Volume 19, Number 7 (Level of Evidence 1B)</ref> This provides an earlier return to functional activity. <ref name="p2" /><ref name="p6" /><ref name="p8" /><ref name="p0">T. DUNCAN TENNENT,* FRCS(ORTH), WILLIAM R. BEACH, MD, AND JOHN F. MEYERS, MD, A Review of the Special Tests Associated with Shoulder Examination Part I: The Rotator Cuff Tests. Vol. 31, No. 1, 2003. pag 157-158.fckLRLevel of evidence: 3A</ref>&nbsp;Immobilization in external rotation reduces the risk of recurrent shoulder dislocations. <ref name="p7" /> 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 [[Closed Chain Exercise]]<nowiki/>s, such as pushing your underarm against a wall towards exorotation. <ref name="p9" /><ref name="p6" /><ref name="p2" /> The goals are to diminish pain and protect healing soft tissues.<ref name="p2" /><ref name="p0" />
# Phase 2, 6 to 12 weeks: progressive passive motion is important, together with active-assisted range of motion exercises. <ref name="p2" />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. <ref name="p0" /> 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.
# Phase 3, 12 weeks to 4 months: Strengthening exercises (see [[Anterior Shoulder Instability|anterior shoulder instability]])
# Phase 4, 4 to 6 months: Fully unrestrained activitiesfocused 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.<ref name=":0" /> <ref name="p6" /><ref name="p0" />
<br>There are 7 key factors that need to be considered in the rehabilitation of the unstable shoulder. These are:<br>• Onset of the pathology (traumatic, chronic)<br>• Degree of instability<br>• Frequency of dislocation<br>• Direction of instability (anterior, posterior, multidirectional)<br>• Concomitant pathologies<br>• End range neuromuscular control<br>• Premorbid activity level&nbsp;<ref name="p2" />


== [[Image:Bankart.jpg|right|270x406px]]Examination  ==
When you have to examine a patient with an internal joint problem you can use a specific test: the internal rotation resistance strength test.
The IRRST is a valid stability test, which differentiates an intra-articular pathology from an impingement syndrome. A study was carried out on 110 patients; the patients were split in 2 groups: people with internal impingement and people with outlet impingement. For this test was reported: a sensibility of 88% and a specificity of 96%<ref>M.H. Moen, R.-J. de vos, E.R.A. van Arkel, A. Weir, J. Moussavi, T. Kraan, D.C. de Winter: De meest waardevolle klinische schoudertesten. Sport en geneeskunde. Oktober 2008, nummer 4. P6-10</ref>.
<br>How do you do this test<ref>Zaslav KR. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the schoulder. J. Shoulder Elbow Surg 2001 Jan-Feb;10(1):23-7.</ref>?<br>You have to stand behind the patient. His injured arm is in a position of 90° abduction and 80° of external rotation. (See picture). You have to ask the patient to resist maximally the first external rotation (A) and then the internal rotation (B). Here you are testing manually the isometric muscle for the external rotation and internal rotation. If the patient has a good strength in external rotation and a weakness while doing the internal rotation, than you can say that the IRRST is positive.
<br>A positive IRRST is based on the fact that at a fixed position of the arm, the medial rotators the caput humerus will do a translocation to the front against the frontal labrum. <br>A positive result is predictive for an internal impingement, that is frequently a Bankart lesion, and a negative test would suggest a classic outlet [[Impingement / Instability Differentiation|impingement]]<ref>K. Van Nugteren, D. Winkel, P. van der Tas. Van, Onderzoek en behandeling van de schouder: orthopedisch casuistiek. Maart 2007, hoofdstuk 4, p43-47. Level Vf</ref> <br><br>
== Medical Management <br>  ==
Arthroscopic repair with suture anchors is an effective surgical technique for the treatment of an isolated Bankart lesion. Open repair does not always show us a significantly improvement of functionality of the shoulder. <ref name="p4"/><ref name="p5"/><ref name="p6">NETTO ET AL ; Treatment of Bankart Lesions in Traumatic Anterior Instability of the Shoulder: A Randomized Controlled Trial Comparing Arthroscopy and Open Techniques; 2012fckLRLevel of evidence: 2</ref> Identification of risk factors for recurrence allows for appropriate patient counseling and consideration of open stabilization. Risk factors are having an age under age 25, ligamentous laxity, and with a large (&gt;250 mm³) Hill-Sachs lesion <ref name="p7">VOOS ET AL. Prospective Evaluation of Arthroscopic Bankart Repairs for Anterior Instability;. 2009 fckLRLevel of evidence: 4</ref>. After arthroscopic surgery there are still one third of the stabilized shoulders that experienced still at least one dislocation after 8 to 10 years after surgery. This dislocation has a negative effect on the functionality of the shoulder<ref name="p8"/>
Arthroscopic repair contains: A suture anchor is placed medially to the fracture on the glenoid neck, and its sutures are passed around the bony fragment through the soft tissue including the inferior glenohumeral ligament complex. The sutures of this anchor are loaded in a second anchor that is placed on the glenoid face. This creates a nontilting 2-point fixation that compresses the fragment into its bed. By use of the standard technique, additional suture anchors are used superiorly and inferiorly to the bony Bankart piece to repair the labrum and shift the joint capsule.&nbsp;<ref name="p9"/> This way of surgery successful restores the shoulder stability with a high patient satisfaction.<ref name="p0"/>
After a failed arthroscopic Bankart repair, open surgery shows us u positive outcome, including a low recurrence rate and reliable functional return. <ref name="p1"/> Unless after open surgery there is a loss of the external rotation component. <ref name="p2"/>
<br>For a nonoperative treatment, there is no significant difference between IAL (intra-articular, lidocaine) and IVAS (intravenous analgesia with or without sedation). However, compared to IVAS, IAL may be less expensive, shorter recovery time, and may be associated with fewer adverse effects. <ref name="p3"/><br><br>
== Physical Therapy Management <br>  ==
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.
<br>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.<ref name="p8"/> (Level of evidence 4) It is proven by several studies that recurrence rate after operative Bankart treatment is significantly reduced compared to a non-operative treatment. <ref name="p6"/>(Level of evidence 2B) After surgery there is of course rehabilitation needed which can be slightly comparable to the non-operative rehabilitation program.&nbsp;<ref name="p7"/>(Level of evidence 4)
<br>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.&nbsp;<ref name="p6"/>(Level of evidence 2B)
<br>''Rehabilitation''
<br>There are 7 key factors that need to be considered in the rehabilitation of the unstable shoulder. These are:<br>• Onset of the pathology (traumatic, chronic)<br>• Degree of instability<br>• Frequency of dislocation<br>• Direction of instability (anterior, posterior, multidirectional)<br>• Concomitant pathologies<br>• End range neuromuscular control<br>• Premorbid activity level&nbsp;<ref name="p2"/>(Level of evidence 1A)
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. <ref name="p2"/>(Level of evidence 1A)<ref name="p9"/>(Level of evidence 2B)&nbsp;Usually the rehabilitation program is divided in 3 phases. The programs for non-operative treatment and postoperative rehabilitation are very similar.
<br>The first phase of rehabilitation consists of sling immobilization with a limited active range of motion for 0 to 4 weeks, this allows 20<sup>o</sup> of abduction and 40<sup>o</sup> of internal rotation. <ref>S-H Kim, K-I Ha, M-W Jung, M-S Lim, Y-M Kim, J-H Park, ‘Accelerated Rehabilitation After Arthroscopic Bankart Repair for Selected Cases: A Prospective Randomized Clinical Study’, Arthroscopy, 2003, Volume 19, Number 7 (Level of Evidence 1B)</ref> (Level of evidence 1B) This provides an earlier return to functional activity. <ref name="p2"/>(Level of evidence 1A)<ref name="p6"/>(Level of evidence 2B)<ref name="p8"/>(Level of evidence 4)<ref name="p0"/>(Level of evidence 3A)&nbsp;Immobilization in external rotation reduces the risk of recurrent shoulder dislocations. <ref name="p7"/> (Level of evidence 4) 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. <ref name="p9"/>(Level of evidence 2B)<ref name="p6"/>(Level of evidence 2B)<ref name="p2"/> (Level of evidence 1A)The goals are to diminish pain and protect healing soft tissues.<ref name="p2"/>(Level of evidence 1A)<ref name="p0"/>(Level of evidence 3A)
<br>In the second phase a progressive passive motion is important, together with active-assisted range of motion exercises. <ref name="p2"/>(Level of evidence 1A)<ref name="p6"/>(Level of evidence 2B)&nbsp;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. <ref name="p0"/>(Level of evidence 3A)&nbsp;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.<br>
<br>
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. <ref name="p6"/>(Level of evidence 2B)<ref name="p0"/>(Level of evidence 3A)<br><br>
== Key Research  ==
add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>
== Resources <br>  ==
add appropriate resources here <br>
== Clinical Bottom Line  ==
add text here <br>
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
<rss>Feed goes here!!</rss>
</div>
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />&nbsp;  
<references />&nbsp;  


[[Category:Vrije_Universiteit_Brussel_Project|Template:VUB]] [[Category:Sports_Injuries]]
[[Category:Vrije Universiteit Brussel Project]]
[[Category:Sports_Injuries]]
[[Category:Sports Medicine]]

Latest revision as of 10:23, 10 January 2023

Original Editor - Nikki Rommers

Top Contributors - Nikki Rommers, Estelle Hovaere, Lucinda hampton, Kim Jackson, Chrysolite Jyothi Kommu, Julie Schuermans, Admin, WikiSysop, 127.0.0.1, Elodie Baele, Naomi O'Reilly, Fasuba Ayobami, Birgit Schauvliege and Wanda van Niekerk

Introduction[edit | edit source]

Bankart and Hill-Sachs lesions

Bankart lesions are injuries of the anteroinferior aspect of the glenoid labral complex and are often found in association with a Hill-Sachs lesion. This injury is a common complication of anterior shoulder dislocation and/or repeated anterior shoulder subluxations. The dislocation of the shoulder joint (anterior) can damage the connective tissue ring around the glenoid labrum. It can also bring damage to the connection between the labrum and capsule. Usually associated with poor construction of the medial glenohumeral ligament. This injury is common for athletes that practice volleyball, tennis, handball, people who do overhead activities.[1][2]

Pathology[edit | edit source]

Glenoid Labrum (marked lig.)

Bankart lesions occur when the humerus is compressed against the labrum as happens anterior shoulder dislocations or subluxations.. There is detachment of the anteroinferior labrum from the underlying glenoid (possibly with extension further superiorly or posteriorly). Impaction fracture of the anteroinferior glenoid margin frequently occurs simultaneously

Two types of Bankart lesions,

  1. Soft Bankart lesion: labrum tears from the glenoid, and the injury involves only the soft tissue. Most common
  2. Bony Bankart lesion: labrum tears and a part of the bony glenoid fractures or breaks off. May lead to notable bone loss in the glenoid, a cause chronic instability.[3]

In many cases of anterior dislocation patients have a Bankart lesion. A reverse Bankart lesion can occurs in case of a posterior dislocation.

Epidemiology /Etiology[edit | edit source]

Anterior-shoulder-dislocation

Anterior Shoulder Instability is the most common traumatic type of instability, representing approximately 95% of all shoulder instabilities. [4] Traumatic shoulder dislocation commonly occur in in collision or contact sports. Abnormal translation of the humeral head during dislocation puts excessive loading on the labrum causing it to stretch along with the capsuloligamentous structures. This excessive stretch causes tearing or avulsion of the labrum with associated capsular injury.[5]

Characteristics/Clinical [edit | edit source]

Bankart lesions usually report a primary or recurrent anterior shoulder dislocation. They present with generalised shoulder pain and the signs and symptoms of recurrent shoulder instability. Some patient present with catching, locking, or popping sensations in the shoulder.[5]

Differential Diagnosis[edit | edit source]

A number of lesions are closely related have similar appearances, including:

  • Anterior labroligamentous periosteal sleeve avulsion (ALPSA)
  • Rotator Cuff Tears
  • SLAP Lesion(Superior Labrum Anterior Posterior)
  • Impingement
  • Perthes lesion
  • Glenolabral articular disruption (GLAD)
  • Humeral avulsion of the glenohumeral ligament (HAGL)
  • Bony humeral avulsion of the glenohumeral ligament (BHAGL)[6]

Diagnostic Procedures[edit | edit source]

Many patients who sustain a shoulder dislocation will sustain a Bankart lesion. [7] Although Bankart lesions often occur in patients with shoulder dislocation, they are hard to detect in physical examination.

  1. X-rays are important to obtain to rule out associated fractures and frank bony defects such as bony Bankart, Hill-Sachs, glenoid fractures, coracoid fractures, and greater tuberosity fractures.
  2. MRI with or without contrast is the gold standard investigation for soft tissue injuries such as glenoid labrum and capsuloligamentous injury. [5]

Outcome Measures[edit | edit source]

  1. Oxford Shoulder Instability Score
  2. Hawkins’ Test

See also Category:Shoulder - Outcome Measures

Treatment[edit | edit source]

Larajet procedure: treatment Bankart lesion

The patient's expectations, age, and sporting involvement (contact vs. non-contact) are vital factors to assess when treating a Bankart injury. Young patients involved in contact sports (high demand), they will be considered for surgery. In Bankart repairs, the labral fragment is sutured back to the glenoid rim using suture anchors.

Candidates for nonoperative management are patients showing no signs of shoulder instability, preserved normal osseous restrain to instability, and not using shoulder use for sports.[5]

Physical Therapy Management[edit | edit source]

Stiff brace post surgery

Examination See Shoulder Instability
Interventions include the arthroscopic Bankart repair, an open Bankart repair or conservative management.

  1. Arthroscopic Bankart repair the muscle strength is regained faster, but the recurrence rates after open Bankart repair are significantly lower.[8]
  2. Recurrence rate after operative Bankart treatment is significantly reduced compared to a non-operative treatment. [9] After surgery there is of course rehabilitation needed which can be slightly comparable to the non-operative rehabilitation program. [10]

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. [4][11] For the first six weeks after surgery, emphasis is placed on protected motion. For the second six weeks, emphasis is placed on strengthening exercises so that strong muscles will protect the shoulder as it returns to normal activities. Usually the rehabilitation program is divided in 4 phases. The programs for non-operative treatment and postoperative rehabilitation are very similar.

  1. Phase 1, 1-6 weeks: consists of sling immobilization with a limited active range of motion for 0 to 4 weeks, this allows 20o of abduction and 40o of internal rotation. [12] This provides an earlier return to functional activity. [4][9][8][13] Immobilization in external rotation reduces the risk of recurrent shoulder dislocations. [10] 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 Closed Chain Exercises, such as pushing your underarm against a wall towards exorotation. [11][9][4] The goals are to diminish pain and protect healing soft tissues.[4][13]
  2. Phase 2, 6 to 12 weeks: progressive passive motion is important, together with active-assisted range of motion exercises. [4]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. [13] 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.
  3. Phase 3, 12 weeks to 4 months: Strengthening exercises (see anterior shoulder instability)
  4. Phase 4, 4 to 6 months: Fully unrestrained activitiesfocused 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.[5] [9][13]


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 [4]

References[edit | edit source]

  1. ↑ Radiopedia Bankart Lesions Available:https://radiopaedia.org/articles/bankart-lesion (accessed 10.1.2023)
  2. ↑ Widjaja A, Tran A, Bailey M, Proper S (2006). Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation. ANZ J Surg 76 (6): 436–8.
  3. ↑ Facty Health Bankart Lesions and Shoulder Instability Available:https://facty.com/conditions/joint-pain/bankart-lesions-and-shoulder-instability/ (accessed 10.1.2023)
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 K. E. Wilk, L. C. Macrina, M. Reinold, ‘Non-operative Rehabilitation for traumatic and atraumatic glenohumeral instability’, North American Journal of Sports Fhysical Therapy, 2006, p 16-31 (Level of Evidence 1A)
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Tupe RN, Tiwari V. Anteroinferior Glenoid Labrum Lesion (Bankart Lesion). Available:https://www.ncbi.nlm.nih.gov/books/NBK587359/ (accessed 10.1.2023)
  6. ↑ Radiopedia Anterior glenolabral injuries https://radiopaedia.org/articles/anterior-glenolabral-injuries?lang=gb Available:https://radiopaedia.org/articles/anterior-glenolabral-injuries?lang=gb (accessed 10.1.2023)
  7. ↑ S. Waldt, A. Burkart, A. B. Imhoff, M. Bruegel, E. J. Rummeny, K. Woerler, ‘Anterior Shoulder Instability: Accuracy of MR Arthrography in the Classification of Anteroinferior Labroligamentous Injuries’, Radiology, Volume 237, Number 2, 2005, p 578-583 (Level of Evidence 2B)
  8. ↑ 8.0 8.1 F. KHIAMI, ET AL. (February 2012), Anterior shoulder instability arthroscopic treatment outcomes measures: The WOSI correlates with the Walch-Duplay score, Revue de chirurgie Orthopédique et Traumatologique, volume 98, pages 48-53fckLRLevel of evidence: 4
  9. ↑ 9.0 9.1 9.2 9.3 NETTO ET AL ; Treatment of Bankart Lesions in Traumatic Anterior Instability of the Shoulder: A Randomized Controlled Trial Comparing Arthroscopy and Open Techniques; 2012fckLRLevel of evidence: 2
  10. ↑ 10.0 10.1 VOOS ET AL. Prospective Evaluation of Arthroscopic Bankart Repairs for Anterior Instability;. 2009 fckLRLevel of evidence: 4
  11. ↑ 11.0 11.1 DOMINIQUE M. ET AL (December 27), Validation of the Instability Shoulder Index Score in a Multicenter Reliability Study in 114 Consecutive cases, Am J Sports Med 2013 41: 278fckLRLevel of evidence: 2B
  12. ↑ S-H Kim, K-I Ha, M-W Jung, M-S Lim, Y-M Kim, J-H Park, ‘Accelerated Rehabilitation After Arthroscopic Bankart Repair for Selected Cases: A Prospective Randomized Clinical Study’, Arthroscopy, 2003, Volume 19, Number 7 (Level of Evidence 1B)
  13. ↑ 13.0 13.1 13.2 13.3 T. DUNCAN TENNENT,* FRCS(ORTH), WILLIAM R. BEACH, MD, AND JOHN F. MEYERS, MD, A Review of the Special Tests Associated with Shoulder Examination Part I: The Rotator Cuff Tests. Vol. 31, No. 1, 2003. pag 157-158.fckLRLevel of evidence: 3A

 

Retrieved from "https://www.physio-pedia.com/index.php?title=Bankart_lesion&oldid=324920"