Rehabilitation Concepts of the Shoulder after Bankart - PowerPoint PPT Presentation

1 / 24
About This Presentation
Title:

Rehabilitation Concepts of the Shoulder after Bankart

Description:

Decreased size and amount of collagen fibers (decreased strength) ... Non-absorbable sutures. Boileau et al., JBJS Am 2006. Arthroscopic Procedure ... – PowerPoint PPT presentation

Number of Views:514
Avg rating:3.0/5.0
Slides: 25
Provided by: TAJ66
Category:

less

Transcript and Presenter's Notes

Title: Rehabilitation Concepts of the Shoulder after Bankart


1
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

2
  • Ultimately, success is a race between biologic
    healing and fixation failure
  • Snyder-Mackler Axe, 2005

3
Effects Of Disuse (inactivity or immobilization)
  • Decreased size and amount of collagen fibers
    (decreased strength)
  • Random orientation of fibers during remodeling

4
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
5
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

6
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

7
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

8
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

9
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

10
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

11
Conclusions
  • Accelerated rehabilitation that incorporates an
    early controlled motion is safe in selected
    patients after arthroscopic Bankart repair using
    suture anchors.

12
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

13
Anatomic Issues
Glenoid Labrum
Size Mis-match
Capsulolabral complex Rotator Cuff
Interval GH Ligaments
Dynamic Factors Rotator Cuff Scapular Mm.
14
Procedure-Modified Rehabilitation
  • Rehabilitation
  • Speed
  • Volume
  • Intensity
  • Depends on the surgery performed

15
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

16
Procedure ModifiedRehabilitation
  • Bankart Repair
  • Avoid High 5 position
  • Closed-Pack position
  • Avoid Low 5 position
  • Tension to Rotator Cuff Interval (SGHL, MGHL)

17
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

18
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
19
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

20
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
21
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
22
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

23
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

24
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
Write a Comment
User Comments (0)
About PowerShow.com