Revising Bankart Protocols:Revising Bankart Protocols:Incorporating Evidence-Based Medicine and Incorporating Evidence-Based Medicine and

Current ConceptsCurrent Concepts

Brian Richardson, PT, MS, CSCSBrian Richardson, PT, MS, CSCSAndAnd

Jasper Richardson, MEd., MS-HCM, ATC, LAT, CSCS, NASM-PESJasper Richardson, MEd., MS-HCM, ATC, LAT, CSCS, NASM-PES

Focus Question:Focus Question:

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

Brief Review of Bankart Repair:Brief Review of Bankart Repair:- generally for recurrent shoulder dislocations- generally for recurrent shoulder dislocations- surgical intervention following “failed” surgical intervention following “failed” conservative treatmentconservative treatment- goal of re-attaching an unstable labrum and goal of re-attaching an unstable labrum and addressing concomitant capsular laxity to addressing concomitant capsular laxity to restore glenohumeral stabilityrestore glenohumeral stability

- location of repair (anterior vs posterior) - location of repair (anterior vs posterior) dependent on “direction” of instabilitydependent on “direction” of instability

• • Anterior (95%)Anterior (95%)

• • Posterior (5%)Posterior (5%)

Components used to Evaluate/Revise Components used to Evaluate/Revise Bankart Protocols:Bankart Protocols:

1.1.Published ResearchPublished Research (Evidence-Based Medicine)(Evidence-Based Medicine)

2.2.Current Concepts Current Concepts (what are other providers (what are other providers

doing?)doing?)

3.3.Physician InputPhysician Input

Anterior Bankart RepairAnterior Bankart Repair

Literature ReviewLiterature Review

• • Limited published Limited published literature regarding literature regarding rehabilitation guidelines rehabilitation guidelines following anterior Bankart following anterior Bankart repairs.repairs.

• • One Level 1 (EBM) study:One Level 1 (EBM) study:(included “detailed” overview of (included “detailed” overview of protocol)protocol)

• • Some additional studies Some additional studies (lower level of evidence) (lower level of evidence) noted results of protocols noted results of protocols without describing protocol without describing protocol details:details:(one study included in (one study included in comparison that comparison that included “good” protocol details)included “good” protocol details)

Review of Level 1 Study:Review of Level 1 Study:

- 62 patients divided into 2 groups:62 patients divided into 2 groups:

1.1. 3-weeks immobilized using abduction sling and “conventional” 3-weeks immobilized using abduction sling and “conventional” rehab protocolrehab protocol

2.2. Accelerated rehab program with ROM and strengthening Accelerated rehab program with ROM and strengthening immediately on same day as surgeryimmediately on same day as surgery

- All non-athletes with recurrent anterior shoulder dislocation and a All non-athletes with recurrent anterior shoulder dislocation and a Bankart lesionBankart lesion

- (2003)(2003)

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

Review of Level 1 Study:Review of Level 1 Study:

- Findings:Findings:

1.1. No difference in recurrence rate of dislocations between groupsNo difference in recurrence rate of dislocations between groups

2.2. Patients in accelerated group resumed functional ROM faster and Patients in accelerated group resumed functional ROM faster and returned to functional activities earlierreturned to functional activities earlier

3.3. Less pain reported in accelerated groupLess pain reported in accelerated group

4.4. Patients in accelerated group reported more satisfaction with outcomePatients in accelerated group reported more satisfaction with outcome

- Implications:Implications:

Support for inclusion of early motion in rehabilitationSupport for inclusion of early motion in rehabilitation

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

““Current Concepts”Current Concepts”

• ASSET – American Society of ASSET – American Society of Shoulder & Elbow TherapistsShoulder & Elbow Therapists

• ““Consensus Rehabilitation Consensus Rehabilitation Guidelines” Guidelines” – arthroscopic anterior – arthroscopic anterior stabilization with or without Bankart stabilization with or without Bankart

• Non-Bankart specificNon-Bankart specific

• Detailed, but generalDetailed, but general

• Obtained from organization’s website Obtained from organization’s website (www.asset-usa.org)(www.asset-usa.org)

““Current Concepts”Current Concepts”

• Protocol from Advanced Protocol from Advanced Continuing Education Continuing Education Institute (2004)Institute (2004)

• Protocol obtained from Protocol obtained from surgeon before coming to surgeon before coming to VanderbiltVanderbilt

• Compare to current Compare to current anterior Bankart protocolanterior Bankart protocol

ComparisonComparison• • A visual comparison was created to compare our A visual comparison was created to compare our

current protocol to the available literature and current protocol to the available literature and current concepts.current concepts.

• • The comparison was then presented to our shoulder The comparison was then presented to our shoulder surgeons for review and comment.surgeons for review and comment.

ComparisonComparisonAn example of level of variation observed… An example of level of variation observed…

Current ProtocolCurrent 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

Immobilization / Immobilization / SlingSling

(Level 1)

(ASSET)

Comparison Continued…Comparison Continued…An example of exercise progression… 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

Anterior Bankart Protocol RevisionsAnterior Bankart Protocol Revisions

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

Revised Anterior Bankart ProtocolRevised Anterior Bankart Protocol

• Open vs. Arthroscopic:Open vs. Arthroscopic:- Old protocol based on open procedure (“the subscapularis is Old protocol based on open procedure (“the subscapularis is

detached”)detached”)- Revised protocol based on arthroscopic procedureRevised protocol based on arthroscopic procedure

• Timetable for full recovery:Timetable for full recovery:- Old protocol: 9-12 months- Old protocol: 9-12 months- Revised protocol: 3-6 months- Revised protocol: 3-6 months

• Sling Guidelines: Sling Guidelines: (revised protocol)(revised protocol)

- Worn in “uncontrolled” environments for 6 weeksWorn in “uncontrolled” environments for 6 weeks- Worn during sleeping for 6 weeksWorn during sleeping for 6 weeks- Discontinue completely at 6 weeksDiscontinue completely at 6 weeks

Highlights / Key PointsHighlights / Key Points

Revised Anterior Bankart ProtocolRevised Anterior Bankart Protocol

• Active movement allowed earlier in protocol:Active movement allowed earlier in protocol:- Old protocol: no active Internal Rotation for 6 weeksOld protocol: no active Internal Rotation for 6 weeks

- Revised protocol: no active Internal Rotation for 2 weeksRevised protocol: no active Internal Rotation for 2 weeks

• Earlier initiation of isometric strengthening:Earlier initiation of isometric strengthening:- flexion/extension, abduction, external rotation, flexion/extension, abduction, external rotation, no internal rotationno internal rotation

- Submaximal Submaximal

- Old protocol: begin 1 week POST-OPOld protocol: begin 1 week POST-OP

- Revised protocol: begin Day 3 POST-OPRevised protocol: begin Day 3 POST-OP

Highlights / Key PointsHighlights / Key Points

Revised Anterior Bankart ProtocolRevised Anterior Bankart Protocol

• Earlier initiation of scapula/rotator cuff related exercises:Earlier initiation of scapula/rotator cuff related exercises:- Old protocol: begin supine serratus press at 4 weeks- Old protocol: begin supine serratus press at 4 weeks- Revised protocol: begin supine serratus press at 2 weeks- Revised protocol: begin supine serratus press at 2 weeks

- Old protocol: begin shoulder IR/ER (theraband) at 6 weeks- Old protocol: begin shoulder IR/ER (theraband) at 6 weeks- Revised protocol: begin shoulder IR (theraband) at 2 weeks - Revised protocol: begin shoulder IR (theraband) at 2 weeks - Revised protocol: begin shoulder ER (theraband) at 4 weeks - Revised protocol: begin shoulder ER (theraband) at 4 weeks

• Earlier initiation of Sport Specific Activities:Earlier initiation of Sport Specific Activities:• - Old protocol: 16 weeks- Old protocol: 16 weeks• - Revised protocol: 12 weeks - Revised protocol: 12 weeks (if full motion, normal strength, and no (if full motion, normal strength, and no

dyskinesis)dyskinesis)

Highlights / Key PointsHighlights / Key Points

Posterior Bankart RepairPosterior Bankart Repair

Literature ReviewLiterature Review

EBM Search = EBM Search = (fill in name here)(fill in name here)

General Literature Search = General Literature Search = (fill in name here)(fill in name here)

Note: Insert sound of crickets for discussion of literature regarding rehabilitation for Note: Insert sound of crickets for discussion of literature regarding rehabilitation for posterior Bankart repairs.posterior Bankart repairs.

““Current Concepts”Current Concepts”• Protocol from Advanced Protocol from Advanced

Continuing Education Continuing Education Institute (2004)Institute (2004)

• Protocol obtained from Protocol obtained from surgeon before coming to surgeon before coming to VanderbiltVanderbilt

• Compare to current Compare to current posterior Bankart protocolposterior Bankart protocol

Posterior Bankart Protocol RevisionsPosterior Bankart Protocol Revisions

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

Revised Posterior Bankart ProtocolRevised Posterior Bankart Protocol

• Timetable for full recovery:Timetable for full recovery:- Old protocol: 9-12 monthsOld protocol: 9-12 months- Revised protocol: 4-6 monthsRevised protocol: 4-6 months

• Immobilization / Sling Instructions:Immobilization / Sling Instructions:

- Revised protocol includes: “change external rotation brace to regular - Revised protocol includes: “change external rotation brace to regular sling” at 4 weekssling” at 4 weeks

• ROM Goals Included:ROM Goals Included:

- 4 weeks: forward elevation / flexion to 120º- 4 weeks: forward elevation / flexion to 120º- 6 weeks: forward elevation / flexion to 160º- 6 weeks: forward elevation / flexion to 160º- 8 weeks: full ROM with all movements- 8 weeks: full ROM with all movements

Highlights / Key Points / ClarificationsHighlights / Key Points / Clarifications

Revised Posterior Bankart ProtocolRevised Posterior Bankart Protocol

• Initiation of internal activities:Initiation of internal activities:- Old protocol:12 weeks POST-OP (“Can start internal rotation”)- Old protocol:12 weeks POST-OP (“Can start internal rotation”)

- Revised protocol: 6 weeks POST-OP (Begin internal rotation - Revised protocol: 6 weeks POST-OP (Begin internal rotation stretches – towel stretch, sleeper stretch)stretches – towel stretch, sleeper stretch)

• Glenohumeral joint mobilization Glenohumeral joint mobilization (revised protocol)(revised protocol)- - No posterior glides until 8 weeks post-opNo posterior glides until 8 weeks post-op

• Begin Sport Specific Activities once full motion, normal Begin Sport Specific Activities once full motion, normal strength, and no dyskinesis strength, and no dyskinesis (16 weeks POST-OP)(16 weeks POST-OP)

• Return to Sport Criteria:Return to Sport Criteria:1) ROM WNL 2) Normal Strength 3) Satisfactory clinical exam1) ROM WNL 2) Normal Strength 3) Satisfactory clinical exam

Highlights / Key Points / ClarificationsHighlights / Key Points / Clarifications

Summary of Outcomes/ResultsSummary of Outcomes/ResultsThere are very few articles outlining There are very few articles outlining

rehabilitation guidelines following anterior rehabilitation guidelines following anterior and posterior Bankart surgical repairs. and posterior Bankart surgical repairs.

The ones that were located were mostly Level The ones that were located were mostly Level 4 and 5 studies; one Level 1 article regarding 4 and 5 studies; one Level 1 article regarding anterior repairs was reviewed. anterior repairs was reviewed.

Based on the available protocols and in Based on the available protocols and in collaboration with our shoulder surgeons, the collaboration with our shoulder surgeons, the current anterior and posterior Bankart repair current anterior and posterior Bankart repair guidelines were revised and will be guidelines were revised and will be implemented in the clinic.implemented in the clinic.

Where do we go from here…Where do we go from here…

• • Continue to monitor published Continue to monitor published research & update protocol as research & update protocol as dictateddictated

• “• “Blank Slate” for research…Blank Slate” for research…- opportunity for “MOON” type research- opportunity for “MOON” type research

References: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 organization’s 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

QuestionsQuestions

??

Thank YouThank You““The Richardsons”The Richardsons”

(no relation)