Dr. David Lintner - Orthopedic Sports Medicine Surgeon

TRAUMATIC INSTABILITY

ACLR OR BANKART PROCEDURE

Melanie McNeal, PT, CSCS, CFT

DAVID LINTNER, MD

Patients who have suffered a traumatic subluxation and/or dislocation with residual pathologic shoulder laxity will undergo this type of procedure. There are several different surgical procedures that can be performed for this injury. During a Bankart or capsulolabral reconstruction, the capsule must be reattached in the correct anatomical location. It may also be necessary to perform a capsular repair to restore adequate tension to the inferior gleno-humeral ligament in order to obtain appropriate joint stability. The primary goal for the therapist following this surgery is to eventually restore adequate and sufficient ROM in order for the patient to perform all desired activities.

Several factors will govern the protocol following surgery to correct a torn/injured capsulolabral complex. First and foremost, the therapist must be aware of the extent of the injury and the exact procedure performed. It is not uncommon to perform a Bankart and capsular shift procedure concomitantly. Protection of the repair is of utmost importance during the rehab process. Stress to the anterior capsule should be avoided initially. ROM limitations must be observed. The second factor is how the procedure was performed - openly or arthroscopically. Loss of motion following ATS is very uncommon. Following open procedures, due to the increased fixation as well as increased pain, loss of motion is often a problem and the therapist should be more aggressive in attaining full ROM. The therapist should also be aware of the method of fixation used (e.g., suture anchors, sutures, bioabsorbable tacks, or staples). Each method obtains a different strength of fixation and rehab should progress with this knowledge in mind. Dr. Lintner uses suture anchors to fixate the capsule to the bone. The subscapularis muscle is also divided from the lateral tendon insertion for the repair to be made and then sutured back to the bone after the repair is complete. This must be taken into account following surgery by avoiding stress to the subscapularis muscle initially.

Fourthly, tissue status must be considered. This can be obtained from the surgical op-report. Rehab will alter based on whether the patient’s capsule is thick and healthy or thin and porous.

The therapist must also consider the demands for the patient’s desired activities as well as work demands. It is imperative that the patient has the strength and ROM necessary for those activities.

Suggestions during rehab:

1. The RC gets a better blood supply when the shoulder is slightly away from the body; therefore, advocate the use of a towel roll under the arm when in a resting position.

2. The RC muscles are very small; therefore, we use lower intensities to isolate each muscle without recruitment from surrounding larger muscles. Focus on hypertrophy initially by high volume (V= Reps X intensity/weight). Following the hypertrophy phase, strength is the focus with lower reps and higher intensities/weight.

OPEN AND ATS BANKART/ACLR REPAIR

PHASE ONE (Week 1-3)

In phase one, the general goals are to protect the surgical repair, initiate ROM to prevent adhesions and increase circulation, decrease pain and inflammation, and stress emphasis of HEP.

A sling will be worn for 4 to 6 weeks unless instructed otherwise by Dr. Lintner.

The sling is to be removed to perform following exercises 2-3X/Day.

ROM limitations:

Passive and active-assisted ROM ONLY:

OPEN REPAIR ATS REPAIR

Flexion/scaption 0-120° by wk 3 0-60° wk 2

0-90° wk 3

ER in scapular plane 0-30° by week 3 0-10° wk 2

0-20° wk 3

IR in scapular plane as tolerated 0-45° wk 2

0-60° wk 3

NO ACTIVE ER, ABDUCTION, OR EXTENSION

Active wrist and elbow full ROM

EXERCISES:

ROM: Pendulums

Rope and pulley – flexion, scaption

AA cane/wand into flexion, ER at 0° and 45°

Supine AA flexion

Seated or supine posterior cuff stretch into horiz adduction

Grade I-II g-h and scapular joint mobs and manual stretching

Strength: Hand gripping exercises - putty

Submax pain-free shoulder isometrics at 0° abduction

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE TWO (Week 3-6)

General goals in Phase Two are to gradually restore ROM, initiate active muscle contractions with a focus on regaining proper scapulo-humeral rhythm, begin to train joint proprioception, and continue with HEP.

ROM Limitations/goal:

OPEN REPAIR ATS REPAIR

Flexion/elevation 140° by wk 4 0-140° wk 6

160° by wk 6

ER in scapular plane 0-75° by wk 6 30° by wk 6

IR in scapular plane Full ROM by wk 6 Full ROM wk 6

EXERCISES:

ROM: C contiinue with AAROM exercises from Phase One – pulley, cane/wand

Initiate towel IR stretch if needed

Posterior capsule stretch

G-H joint mobilizations emphasizing post and inf glides. Should be pain-free and in loose/open packed position.

Passive stretching should be performed following mobilizations.

Strength: UBE with no resistance

Scapular stabilizer strengthening – rows, shrugs, punches

IR/ER with theraband using towel roll between upper arm and thorax

Side-step holding t-band at neutral IR/ER for isometric resistance

DB therex – flexion, scaption, empty can, deceleration

Biceps, Triceps strengthening

Rhythmic stab progressing from supine to sidelying to partial sitting to standing as tolerated

Push-up progression (wall, table, counter, knees, regular) emphasize “plus” portion of push-up

Modalities: Heat prior to tx

Ice following tx and when needed

PHASE THREE (Week 6-12)

The goals in this phase are to restore full active ROM, progress strengthening and scapular stabilization exercises, and initiate more functional drills into rehab program.

ROM goals:

OPEN REPAIR ATS REPAIR

Flexion/elevation: Full ROM 8-10 weeks 0-160° by wk 8

Full ROM 10-12 wk

External rotation: Full ROM 8-10 weeks 0-75° by wk 8

Full ROM 10-12 wk

Internal rotation: Full ROM 8-10 weeks

EXERCISES:

ROM: Continue with previous exercises to gain full ROM

May need to add chicken wing stretch for ER

Mobilizations may be more aggressive if needed

Strength: Continue with previous T-band and C. column exercises,

increasing intensity, sets, reps as able

Continue with db therex increasing sets, reps, and intensity (up to 7 lbs)

PNF patterns with T-band and manual resistance

Initiate T-band ER at 90/90 position – slow and fast reps

Initiate prone db therex including scaption at 130° with thumb up, horiz abduction with thumb up, extension with palm down, ER

Week 8:

Initiate two-handed plyometrics including ball toss –chest pass, OH pass, diagonals

Week 10:

Biodex – isokinetics for IR/ER beginning in modified neutral position, progress to 90/90 position in scapular plane

Modalities: Ice as needed

PHASE FOUR (Week 12-24)

Goals include regaining full functional strength, implementing functional or sports specific training, and establishing a progressive gym program for continued strengthening and endurance training.

*Continue as needed with ROM exercises

*UBE high resistance, for endurance

* Progress to one-handed plyos including ball toss, ball on wall

*Eccentric RC strengthening using plyoball, deceleration tosses, T-band

*Large muscle exercises including shoulder press, lat pull-downs, bench press – do not allow elbow to extend past plane of thorax

*For high school athletes: at 12 weeks, passive ER should be 100-105°; allow the athlete to gain the rest on his own.

*For college/pro athletes: at 12 weeks, active ER should be 100-105° and passive ER should be 110-115° - allow the rest to come on its own

*Initiate interval throwing program at wk 16 – consult with physician first

*Initiate sports specific/functional training

*At week 12, do a biodex test at 180°/sec and 300°/sec. – goal is for strength to be at 80% of unaffected side

*Expected Biodex results: ER/IR ratio at 180°/sec: male–66; female- 71

Peak T/BW range for ER at 180°/sec: male11-15; female 8-12

Peak T/BW range for IR at 180°/sec: male 17-23; female 13-17

Home ׀ Dr. Lintner ׀ Staff ׀ Sports Injuries ׀ Surgery Information ׀ Rehabilitation Protocols ׀ Patient Education ׀ Links ׀ Contact Us