Friday, December 2, 2011

Shoulder: Bankart surgery rehabilitation




Bankart surgery:
Bankart lesion is an injury of the anterior (inferior) glenoid labrum due to repeated (anterior) shoulder dislocation. Repeated dislocation forms a pocket at the front of the glenoid that allows the humeral head to dislocate into it. It is often accompanied by a Hill-Sachs lesion (damage to the posterior humeral head seen as a depression on X-ray). A bony bankart is a Bankart lesion that includes a fracture in of the anterior-inferior glenoid cavity.
Bankart lesion warrants surgery. In Bankart surgery the anterior (inferior) glenoid labrum is reattached to the glenoid. Generally there is a anterior approach to this shoulder operation. Rehabilitation is the key to successful reinstitution of functional activities. As it is a very common injury in sports like javelin throwing return to sports is heavily dependant on post operation physiotherapy. The following is an sample schema of physiotherapy & rehabilitation approach to the Bankart surgery.    

Don’ts:

Restrictions up to 4 weeks: (To protect the reattached anterior capsule & labrum)
  
1. Shoulder extension (backwards) past the plane of the body
2. Shoulder external rotation (arm rotation outwards) greater than 0° (straight in front); extensive repairs may require more restrictions

For posterior repairs (To protect the reattached posterior capsule & labrum)

1. Avoid any shoulder internal rotation (turning in) past the body i.e. hand behind back.

Restrictions up to 3 months:
No passive forceful stretching into external rotation/extension following an anterior repair and into internal rotation for a posterior repair.

Dos:

- Good posture is critical throughout the rehabilitation process to improve healing and decrease the risk of developing poor mechanics

- Aerobic conditioning throughout the rehabilitation process

- MD follow-ups Day 1, Day 8 - 10, 1 month, 4 months, 6 months and 1 year post-op

- All active exercises should be carefully monitored to minimize substitution or compensation

1 - 5 Days Post-op

1. Use of arm sling
2. Ice pack for first 3 - 5 days. (Apply over the dressing but should not sip into the dressing)
3. Postural education & sleeping posture advice (semi-reclined is most comfortable) 
4. Other general exercises: Stationary bike, stair machine etc
5. Codmann’s Pendulum exercise to reduce muscular spasms, Scapulothoracic stabilizer training, elbow flexion/extension, wrist and forearm strengthening, gentle passive/active assistive exercises of the arm in flexion (front) keeping below the level of the shoulder & finally cervical muscle stretching.

* Surgeon’s check up to change dressing etc.

5 - 14 Days Post-op

1. To reduce pain: IFT or TENS/ massage / contrast heat etc
2. Russian current for strengthening
3. Increase PROM and active assistive (AAROM) exercises as tolerated (from flexion out into the scapular plane) up to 90° unless otherwise indicated
4. Soft tissue therapy to developing scar as appropriate.
5. Scapulothoracic mobilization
6. General conditioning as tolerated (include trunk flexion & extension exercises)

2 - 4 Weeks Post-op

1. Now at this stage passive and active assisted flexion out to scaption (plane of the scapula) as tolerated.
 2. Sub-maximal isometrics (as dictated by pain) & Isotonic wrist, forearm.
 3. Resisted exercises using theraband are started from this phase onwards.
a.    Theraband resisted pull-downs from the front and the scapular plane
b.    Theraband resisted elbow flexion (high reps and low resistance)
4. Active scapular elevation, depression, and retraction exercises
5. Light weight bearing exercises

4 - 6 Weeks Post-op

1. By 4-6 weeks resting pain is substantially less.
2. Continue with passive and AAROM exercises (cane exercises, wall walking, table slide) from flexion & scaption out to abduction as tolerated
3.  Maximal isometrics
4. Active exercises from flexion into the scapular plane against gravity as tolerated
5. No resistance until able to perform 30 reps at limb weight with perfect mechanics
6. Rested internal rotation 0° to the body. (Only light resistance)
7. Add proprioceptive training exercises. (Alphabet writing, fine motor skills, work/sport specific exercises)

6 - 8 Weeks Post-op

1. Increase AROM exercises as tolerated (serratus anterior, upper, and lower trapezius).
2. Eccentrics exercises are added into protected ranges 
3. From this phase onwards begin LIGHT stretching into external rotation
4. GHJ joints play + mobilizations as tolerated
5. Increase proprioceptive training (prone on elbows, quadruped position ("on all four's") for rhythmic stabilization
6. Okay to begin jogging, road cycling, and standing arm resistance exercises in the pool

8 - 12 Weeks Post-op

Emphasis on regaining strength and endurance

1. PNF patterns (proprioceptive neuromuscular facilitation) can be started safely
2. AROM exercises: internal rotation and external rotation as motion allows
3. AROM exercises: lateral raises and supraspinatus isolation
4. Rower with a high seat, decline bench press, military press in front of body
5. Running, road or mountain biking, no activities with forceful, ballistic arm movement


3 - 6 Months Post-op

1. Aggressive stretching.
2. Start strenuous resistive exercises
3. Add light throwing exercises with attention to proper mechanics

6 Months Post-op

1.  Increase throwing program with focus on return-to-throwing sports as mechanics
2.  Sports conditioning with all of the normal shoulder movements


NB: Progression is based on individual patient presentation, which is assessed throughout the treatment process. People well versed with soft tissue & fascial tissue manipulations can appropriately employ them from 2nd week onwards.




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