Arthroscopic or Open Bankart Procedure, Latarjet Procedure
REPAIR OF ANTERIOR INSTABILITY
ARTHROSCOPIC OR OPEN BANKART PROCEDURE, LATARJET PROCEDURE
Melanie McNeal, PT, CSCS, CFT
for patients of 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). 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. For open repairs or Latarjet procedures a portion of 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 vary 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:
- 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.
- 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.
- We now use closed chain rotator cuff exercises using the DS2 Platform to facilitate cuff strength and shoulder proprioception. Like closed chain exercises for the knee, these can be safely initiated early in the post op course.
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
0-60° wk 2;
0-80° wk 3;
0-100° by wk 3
ER in scapular plane
0-10° wk 2
0-40° by week 3
IR in scapular plane
0-60° wk 3
FOR OPOEN SURGERY<: NO ACTIVE IR, NO PASSIVE EXTENSION
Active wrist and elbow full ROM
EXERCISES
ROM:
- Pendulums
- Rope and pulley – flexion, scaption
- Table Slides
- 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:
Flexion/elevation
140° by wk 4
160° by wk 6
ER in scapular plane
0-75° by wk 6
IR in scapular plane
Full ROM by wk 6
EXERCISES
ROM:
- Continue with AAROM exercises from Phase One – pulley, cane/wand
- Add closed chain active-assist flexion with DS2 Platform
- 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.
- Initiate unweighted prone db therex including scaption at 130° with thumb up, horiz abduction with thumb up, extension with palm down, ER.
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
- Closed chain cuff contractions/strengthening DS2 Platform Shoulder Rehab, Phase 1using DS2 Platform
- 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. Not yet: 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:
Flexion/elevation: Full ROM 8-10 weeks
External Rotaion: Full ROM 8-10 weeks
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
- Progress to DS2 Platform Shoulder Rehab, Phase 2 closed chain exercises with DS2 Platform
- Initiate T-band ER at 90/90 position – slow and fast reps
- Emphasize prone db therex including scaption at 130° with thumb up, horiz abduction with thumb up, extension with palm down, ER. Add resistance, maintain proper form
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
- Progress to DS2 Platform Shoulder Rehab, Phase 3, includes overhead exercises closed chain exercises with DS2 Platform
- 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