Revising Bankart Protocols:

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Revising Bankart Protocols Incorporating
Evidence-Based Medicine and Current Concepts
Brian Richardson, PT, MS, CSCS And Jasper
Richardson, MEd., MS-HCM, ATC, LAT, CSCS, NASM-PES
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Focus Question

• Do our present guidelines for anterior and
  posterior Bankart repairs reflect the most
  current literature?

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Brief Review of Bankart Repair

• - generally for recurrent shoulder dislocations
• surgical intervention following failed
  conservative treatment
• goal of re-attaching an unstable labrum and
  addressing concomitant capsular laxity to restore
  glenohumeral stability
• - location of repair (anterior vs posterior)
  dependent on direction of instability
• Anterior (95)
• Posterior (5)

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Components used to Evaluate/Revise Bankart
Protocols

• Published Research
• (Evidence-Based Medicine)
• Current Concepts
• (what are other providers doing?)
• Physician Input

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Anterior Bankart Repair
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Literature Review
Limited published literature regarding
rehabilitation guidelines following anterior
Bankart repairs. One Level 1 (EBM)
study (included detailed overview of
protocol) Some additional studies (lower level
of evidence) noted results of protocols without
describing protocol details (one study included
in comparison that included good protocol
details)
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Review of Level 1 Study
Accelerated Rehabilitation After Arthroscopic
Bankart Repair for Selected Cases A Prospective
Randomized Clinical Study Seung-Ho Kim, Kwon-Ick
Ha, et al. Arthroscopy. Vol.19,No.7, 722-731.

• 62 patients divided into 2 groups
• 3-weeks immobilized using abduction sling and
  conventional rehab protocol
• Accelerated rehab program with ROM and
  strengthening immediately on same day as surgery
• All non-athletes with recurrent anterior shoulder
  dislocation and a Bankart lesion
• (2003)

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Review of Level 1 Study
Accelerated Rehabilitation After Arthroscopic
Bankart Repair for Selected Cases A Prospective
Randomized Clinical Study Seung-Ho Kim, Kwon-Ick
Ha, et al. Arthroscopy. Vol.19,No.7, 722-731.

• Findings
• No difference in recurrence rate of dislocations
  between groups
• Patients in accelerated group resumed functional
  ROM faster and returned to functional activities
  earlier
• Less pain reported in accelerated group
• Patients in accelerated group reported more
  satisfaction with outcome
• Implications
• Support for inclusion of early motion in
  rehabilitation

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Current Concepts

• ASSET American Society of Shoulder Elbow
  Therapists
• Consensus Rehabilitation Guidelines
  arthroscopic anterior stabilization with or
  without Bankart
• Non-Bankart specific
• Detailed, but general
• Obtained from organizations website
  (www.asset-usa.org)

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Current Concepts

• Protocol from Advanced Continuing Education
  Institute (2004)
• Protocol obtained from surgeon before coming to
  Vanderbilt
• Compare to current anterior Bankart protocol

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Comparison

• A visual comparison was created to compare our
  current protocol to the available literature and
  current concepts.

The comparison was then presented to our
shoulder surgeons for review and comment.
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Comparison
An example of level of variation observed
Immobilization / Sling
(ASSET)
(Level 1)
Current Protocol sling 48-72 hours, can be
removed after 3 days for light activity (as
needed during day), wear at night for 6 weeks,
discontinue sling completely at 6 weeks
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Comparison Continued
An example of exercise progression
(Level 1)
Current Protocol do not begin IR/ER with low
resistance Theraband until 6 WEEKS POST-OP
Note Level 1 begin isotonic strengthening
for ER at side at week 4
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Anterior Bankart Protocol Revisions

• Based on the feedback provided from the shoulder
  surgeons the protocol was revised.
• Based heavily on Level 1 study results
• Additional specific requests from physicians

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Revised Anterior Bankart Protocol
Highlights / Key Points

• Open vs. Arthroscopic
• Old protocol based on open procedure (the
  subscapularis is detached)
• Revised protocol based on arthroscopic procedure
• Timetable for full recovery
• - Old protocol 9-12 months
• - Revised protocol 3-6 months
• Sling Guidelines (revised protocol)
• Worn in uncontrolled environments for 6 weeks
• Worn during sleeping for 6 weeks
• Discontinue completely at 6 weeks

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Revised Anterior Bankart Protocol
Highlights / Key Points

• Active movement allowed earlier in protocol
• Old protocol no active Internal Rotation for 6
  weeks
• Revised protocol no active Internal Rotation for
  2 weeks
• Earlier initiation of isometric strengthening
• flexion/extension, abduction, external rotation,
  no internal rotation
• Submaximal
• Old protocol begin 1 week POST-OP
• Revised protocol begin Day 3 POST-OP

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Revised Anterior Bankart Protocol
Highlights / Key Points

• Earlier initiation of scapula/rotator cuff
  related exercises
• - Old protocol begin supine serratus press at 4
  weeks
• - Revised protocol begin supine serratus press
  at 2 weeks
• - Old protocol begin shoulder IR/ER (theraband)
  at 6 weeks
• - Revised protocol begin shoulder IR
  (theraband) at 2 weeks
• - Revised protocol begin shoulder ER
  (theraband) at 4 weeks
• Earlier initiation of Sport Specific Activities
• - Old protocol 16 weeks
• - Revised protocol 12 weeks (if full motion,
  normal strength, and no
• dyskinesis)

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Posterior Bankart Repair
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Literature Review
EBM Search (fill in name here) General
Literature Search (fill in name here)
Note Insert sound of crickets for discussion of
literature regarding rehabilitation for posterior
Bankart repairs.
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Current Concepts

• Protocol from Advanced Continuing Education
  Institute (2004)
• Protocol obtained from surgeon before coming to
  Vanderbilt
• Compare to current posterior Bankart protocol

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Posterior Bankart Protocol Revisions

• Based on the feedback provided from the shoulder
  surgeons the protocol was revised.
• Specific requests/suggestions from physicians
• Corrected/clarified discrepancies

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Revised Posterior Bankart Protocol
Highlights / Key Points / Clarifications

• Timetable for full recovery
• Old protocol 9-12 months
• Revised protocol 4-6 months
• Immobilization / Sling Instructions
• - Revised protocol includes change
  external rotation brace to regular
• sling at 4 weeks
• ROM Goals Included
• - 4 weeks forward elevation / flexion to
  120º
• - 6 weeks forward elevation / flexion to
  160º
• - 8 weeks full ROM with all movements

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Revised Posterior Bankart Protocol
Highlights / Key Points / Clarifications

• Initiation of internal activities
• - Old protocol12 weeks POST-OP (Can start
  internal rotation)
• - Revised protocol 6 weeks POST-OP (Begin
  internal rotation stretches towel stretch,
  sleeper stretch)
• Glenohumeral joint mobilization (revised
  protocol)
• - No posterior glides until 8 weeks post-op
• Begin Sport Specific Activities once full motion,
  normal strength, and no dyskinesis (16 weeks
  POST-OP)
• Return to Sport Criteria
• 1) ROM WNL 2) Normal Strength 3) Satisfactory
  clinical exam

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Summary of Outcomes/Results

• There are very few articles outlining
  rehabilitation guidelines following anterior and
  posterior Bankart surgical repairs.
• The ones that were located were mostly Level 4
  and 5 studies one Level 1 article regarding
  anterior repairs was reviewed.
• Based on the available protocols and in
  collaboration with our shoulder surgeons, the
  current anterior and posterior Bankart repair
  guidelines were revised and will be implemented
  in the clinic.

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Where do we go from here

• Continue to monitor published research update
  protocol as dictated
• Blank Slate for research
• - opportunity for MOON type research

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References

• ACEi (Advanced Continuing Education Institute)
• Arthroscopic Anterior Bankart Repair (2004)
• Arthroscopic Posterior Bankart Repair (2004)
• ASSET (American Society of Shoulder Elbow
  Therapists) Arthroscopic Anterior Stabilization
  with or without Bankart Repair.
• A consensus rehabilitation guideline obtained
  from organizations website (www.asset-usa.org)
• Junji Ide, Satoshi Marda, and Katsumasa Takagi.
  Arthroscopic Bankart Repair Using Suture Anchors
  in Athletes. American Journal of Sports Medicine,
  Vol.32,No.8, 1899-1905.
• Seung-Ho Kim, Kwon-Ick Ha, et al. Accelerated
  Rehabilitation After Arthroscopic Bankart Repair
  for Selected Cases A Prospective Randomized
  Clinical Study. Arthroscopy. Vol.19,No.7, 722-731

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Questions?
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Thank You

• The Richardsons
• (no relation)