Bankart lesion

Original Editor - Nikki Rommers

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Definition/Description

Bankart lesions are injuries of the anteroinferior aspect of the glenoid labral complex and are often found in association with a Hill-Sachs defect. 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 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.

Pathology

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.

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

Anterior Shoulder Instability is the most common traumatic type of instability, representing approximately 95% of all shoulder instabilities.  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.

Characteristics/Clinical 

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.

Differential Diagnosis 

• ALPSA lesion (anterior labral periosteal sleeve avulsion) free and adherent
• Cuff frying
• Rotator Cuff Tears
• SLAP Lesion(Superior Labrum Anterior Posterior)
• Impingement

If you want to be sure about the diagnosis you will do a MRI. It is the most common imaging tool used to diagnose labral lesions.

Diagnostic Procedures

Many patients who sustain a shoulder dislocation will sustain a Bankart lesion. 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.

Outcome Measures

1. WOSI: Western Ontario Shoulder Instability Index: a subjective quality of life measurement tool specific to shoulder instability. Walch-Duplay score, which is the gold standard score used in Europe.
   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.
2. The instability shoulder index score: 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.
   Patients who underwent more complex arthroscopic procedures such as Hill-Sachs remplissage or open Latarjet had higher preoperative ISIS outcomes
   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.
   ISIS has been used in several clinical studies. The studies have shown that you can use the ISIS for investigate several pathologies.
   In conclusion, our results show that ISIS measurements are highly reliable and support the clinical use of the ISIS
   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. 
3. Hawkins’ Test
4. See also Category:Shoulder - Outcome Measures

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 of the Shoulder and people with outlet impingement. For this test was reported: a sensibility of 88% and a specificity of 96%.

How do you do this test?
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.

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.
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

Treatment

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.

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. It is proven by several studies that recurrence rate after operative Bankart treatment is significantly reduced compared to a non-operative treatment. After surgery there is of course rehabilitation needed which can be slightly comparable to the non-operative rehabilitation program. 
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. (Level of evidence 2B)

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 

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.  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 Closed Chain Exercises, such as pushing your underarm against a wall towards exorotation. The goals are to diminish pain and protect healing soft tissues.(Level of )

In the second phase a progressive passive motion is important, together with active-assisted range of motion exercises. (Level of evidence 1A)(Level of evidence 2B) 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. (Level of evidence 3A) 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.