A Bankart Lesion is a class of Non- SLAP Lesion related Glenoid Labrum Tears where there is an Avulsion Fracture of theAnterior-Inferior Labroligamentous Complexfrom the Glenoid Caivty which causes the Anterinferior Glenoid Labrum and Anterior Inferior Glenohumeral Ligament to become detached (SOURCE-4). A Bankart Lesion is one of the most common complications of Anterior Glenohumeral Dislocations followed by Hill-Sachs Lesion s, Bony Bankart Lesions and other Labral tears, including Bankart variations described below (SOURCE-1+3+5+9):
Bony Bankart Lesion - detachment of the Anteroinferior Labrum due to an Avulsion Fracture of the Glenoid Rim
Reverse Bankart- posteroinferior Glenoid Labrum Tear , with an estimated prevalence of 2% is considered rare and often occurs concomitantly with additional posteroinferior cartilage damage
Anterior Labral Periosteal Sleeve Avulsion (ALPSA)- a Bankart lesion with avulsion of the Scapula Periosteum
Posterior Labrocapsular Periosteal Sleeve Avulsion (POLPSA)- a Reverse Bankart lesion with avulsion of the Scapula Periosteum
Bankart Lesions and their variations are most often the consequence of Anterior Glenohumeral Dislocation , particularly with The Shoulder Girdle in GH Joint - External Rotation and GH Joint - Abduction (SOURCE-6+9). During traumatic dislocation the excessive translation of the Head of Humerus surpasses the capacity of the Glenoid Labrum , bony Cavity and related capsuloligamentous structures, causing an Avulsion Fracture of the Labrum and related capsular injury (SOURCE-9). While the Glenoid typically takes an upright pear-shape, the loss of avulsed bone or presence of an associated compression defect leaves an almost upside-down pear-shape, a key sign of a Bony Bankart Lesion (SOURCE-6). This morphology may be indicative of a sequelae of Glenohumeral Instability -related pathology, even when following certain surgical repair techniques (SOURCE-6). Recurrent Dislocations account for a higher proportion of Bankart Lesions when compared to first-time dislocations (SOURCE-7). A compromised Glenoid Cavity bares less resistance to sheer forces which are then compensated for by the Bone - Ligament interface, predisposing injuries such as a Bankart Lesion (SOURCE-6).
Bankart lesions were the most common type of soft-tissue lesion associated with Glenohumeral Dislocation or Glenohumeral Instability (SOURCE-6+7). The traumatic onset in compromising overhead positions is most often associated with young males, in particular those involved in contact or overhead sports (SOURCE-6+7). Two such sports, Rugby and American Football, represent a significant proportion of Bony Bankart Lesions, although through diverging mechanisms (SOURCE-6):
Rugby - through a mechanism colloquially referred to as a “stiff-arm”, the arm is straightened posteriorly to push away an advancing potential tackler. The axial loading through the arm with ~70º GH Joint - Abduction and ~30º GH Joint - Extension may compromise the Anterior Glenoid Rim, leading to an intra-articular Fracture as opposed to soft-tissue injury
American Football - conversely these injuries are often the result of rotational stress, where a tackler produces an external obliquely-directed force to The Hand or arm which drives The Shoulder Girdle into excessive GH Joint - External Rotation . This rotational force Tears the Glenohumeral Capsular Ligaments from the Anterior Glenoid
Bankart Lesions are complex injuries that rarely occur in isolation. The following pathologies are commonly associated with them, often serving as predisposing factors or occurring concomitantly:
SLAP Lesion - when a Bankart Lesion extends superiorly to include the proximal Long Head of Biceps Tendon , it is considered aType-V SLAP Lesion(SORUCE-1)
Glenohumeral Instability - following a traumatic episode of Glenohumeral Dislocation , 97% of patients with anterior instability were found to have a Bankart Lesion (SOURCE-2). Recurrent instability or subsuquent Dislocation predisposes further injury (SOURCE-6)
Avulsion Fracture - the anterior edge of the Glenoid Cavity and Humeral Notch are highly associated with Bankart Lesions, occurring in 72% and 90% of lesions, respectively (SOURCE-3 (19+20))
Hill-Sachs Lesion - compression of the Posterosuperior Head of Humerus often occurs concomitantly with Bankart Lesions in response to trauma (SOURCE-9)
Rotator Cuff Tear - often occurs concomitantly with Bankart Lesions, associated with roughly 13% of anterior Glenohumeral Dislocations (SOURCE-9)
Osteoarthritis - is one of the more common complications following arthroscopic repair of a Bankart Lesion (SOURCE-13). Depending on which surgical procedure was utilised, conservative management may have even higher rates of Osteoarthritis (SOURCE-14). In either case, Osteoarthritis is a common complication of the unstable shoulder (SOURCE-14).
General Glenoid Labrum Tear signs include (SOURCE-9):
Catching, locking or popping sensations associated with shoulder movment
A history of Glenohumeral Dislocation or recurrent Glenohumeral Instability is particularly relevant to Bankar Lesions (SOURCE-9).
The following Shoulder - Special Tests may be used to evaluate for the presence of a Bony Bankart Lesion, with a high combined sensitivity and specificity (SOURCE-5+9):
Anterior Apprehension Test - evaluates a patients perceived stability. The “Bony” variation in 45º GH Joint - Abduction and 45º GH Joint - External Rotation has a sensitivity of 100% and specificity of 86% for bony lesions of the anterior Glenoid Rim
Load & Shift Test - reveals the extent of instability
The following imaging techniques may be relevant in the diagnosis of a Bankart Lesion. A posture of combined GH Joint - Abduction and GH Joint - External Rotation may increase imaging sensitivity through tension in the Inferior Glenohumeral Ligament (SOURCE-2+9):
Radiographs (X-Rays)- an integral step in initial work up to rule out associated Fractures including a Bony Bankart, Hill-Sachs Lesion or of the Glenoid Cavity, Coracoid Process of Scapula or Greater Tuberosity of Humerus (SOURCE-9). Some have reported X-Rays are more effective at establishing Bankart lesion severity than an arthroscopy (SOURCE-3). The following views may be relevant (SOURCE-9):
Anteroposterior (AP) View
Axillary View
Scapular-Y View
Acromial Outlet View
West Point Axillary View - used for Bony Bankart Lesions
Magnetic Resonance Imaging (MRI)- considered the gold standard imaging modaility for the evaluation of soft-tissues including Glenoid Labrum and Capsuloligamentous injury (SOURCE-9). Acute Bankart findings include hemorrhagic effusion and capsulolabral elevation from the anterior/ inferior Glenoid Rim (SOURCE-9).MR-arthrogramwhich utilises contrast dye may be more accurate for the detection of stable Labral lesions with a sensitivity of 91-98% and specificity of 82-93% (SOURCE-2+9)
Computed Tomography (CT Scan)- in particular 3D-CT is superior for the evaluation of Bone -loss, providing a clear image of the orientation of the Humeral defect or accurately quantifying disturbance of the Glenoid Rim following a Bony Bankart Lesion (SOURCE-11). This modality is therefore useful for preoperative planning (SOURCE-11).
The notable risk of re-injury is the primary reason Bankart Lesions are often handled through surgical intervention (SOURCE-9). Indications for conservative managment include little-to-no Bone -loss where the osseous restraints remain intact, no obvious Glenohumeral Instability and those with less physical demand (over 30 years of age, no sports participation) (SOURCE-9). Additionally, multidirectional or atraumatic instability, Collagen disorders such asEhlers-Danlosand post-traumatic arthritis associated with recurrent instability are considered relative contraindications to surgery (SOURCE-9). The goal of conservative management is to reduce Pain , improve Range of Motion and eventually return to a normal level of physical activity (SOURCE-8). If conservative management fails, surgical reattachment of the Glenoid Labrum may be required (SOURCE-8).
Stretching within the limits of Pain can be used to restore tissue length and improve overall joint mechanics that often develop in response to Pain and dysfunction. A specific stretching regimen should consider the extent of the Bankart lesion, presence of concomitant injury, patients circumstances (age, activity level, etc.) and the surgical procedure undertaken, if any. As a general trend, shoulder movement is restricted for about a month following surgery to provide adequate time for the implicated tissues to heal. While certain Range of Motion , such as GH Joint - Flexion may approach end-range by week 6, other ranges such as GH Joint - External Rotation should be restricted for up to 12 weeks following arthroscopic repair (SOURCE-12).
Initial Phase - for the first ~6 weeks following arthroscopic repair, shoulder motion is restricted to protect the tissue healing process. From ~7-10 days following repair Range of Motion may be cautiously commenced as tolerated by the patient, progressing from passive movements to active-assisted movements by the end of this phase (SOURCE-12):
Passive Range of Motion
GH Joint - Flexion - limited to 130º in first 4 weeks, 130-180º at week 6
Forward Elevation Stretch - rudimentary passive stretch with moderate GH Joint - Flexion range
GH Joint - External Rotation - limited to 30º in first 4 weeks, 30-60º at week 6
Water Therapy for Range of Motion - may be undertaken from weeks 2-4 if wounds are healed
Active Assisted Range of Motion
Seated Thoracic Rotation with Breathing - large lateral flexion and rotation range coupled with breathing
Mid-Phase - from roughly the 6 to 12 weeks following arthroscopic repair Range of Motion is continued to progress with the aims of achieving full, Pain -free active shoulder range by the end of this phase (SOURCE-12):
Active Range of Motion
GH Joint - Flexion - full 180º of forward arm elevation may be possible by as early as week 6
Dowel External Rotation Stretch - self-guided GH Joint - External Rotation stretch with overpressure
Genie Stretch - rudimentary horizontal adduction stretch
Split Stance Biceps Stretch - self-guided anterior shoulder stretch with large GH Joint - Extension range
Late Phase - with resistance training often commenced by week 8-12, more advanced stretching techniques may be undertaken in the late phase (beyond week 12) (SOURCE-12). As tolerated by the patient, this may include compound stretches performed with the intention of increasing Range of Motion and introducing forms of resistance to translate newly found Flexibility into functional Mobility . A return to sport should be anticipated between ~5-9 months (SOURCE-5+8+12):
Door Frame Shoulder Stretch - self-guided anterior shoulder stretch with large Horizontal GH Joint - Abduction range
Sleeper Stretch - greater emphasis on GH Joint - Internal Rotation
Bent Over Lat Stretch - accessible active stretch with large GH Joint - Flexion or Horizontal GH Joint - Adduction range
Shoulder Dislocates - mobility exercise that emphasises the greatest circumduction range possible
Dead Hangs - whole body traction for Pull and Push muscles with large overhead range
Bretzel 1.0 - whole body technical stretch that incorporates anterior shoulder
Bretzel 2.0 - variation with greater hip extension range
While specific time frames may be contingent on the type of Bankart, presence of concomitant injury and chosen conservative/ surgical approach, the general sentiment of Strength training is similar. For example, following Bony Bankart arthroscopic repair it is suggested the shoulder is immobilised for 4 weeks, while following the Latajet Procedure immobilisation is recommended for up to 6 weeks (SOURCE-5+8+12).Initial Phase - precaution around the extent of shoulder rotation is the chief concern in the initial phase following multiple procedures. Following the Latarjet Procedure, passive GH Joint - External Rotation is only permitted to neutral for the first 6 weeks (SOURCE-8). Similarly, following an open Bankart repair, External Rotation is limited to 30º for the same 6 weeks to protect the Subscapularis Tendon (SOURCE-5). Precaution should be given to both External Rotation strengthening and and GH Joint - Internal Rotation range following Remplissage (SOURCE-10):
Rotator Cuff Pendulums - oscillatory motion that afford a distracting glide to the Humeral Head
Shoulder Sling - passive shoulder movement produced by asymptomatic side
Active-Assisted GH Joint - Flexion with arm in Elbow - Supination - assistance afforded by asymptomatic hand or practitioner
Isometric Rotator Cuff Exercises - when tolerated:
Rotator Cuff Banded Rotations (isometric only)
GH Joint - External Rotation (isometric only)
GH Joint - Internal Rotation (isometric only)
Mid-Phase - while this phase remains poorly defined, weeks ~7-12 generally represent the cautious and progressive introduction of rotational and overhead movement and rudimentary resistance exercises such as those using a resistance band (SOURCE-8+10). One possible benchmark for those that underwent the Latarjet Procedure is 50% GH Joint - External Rotation of the asymptomatic side at week 8 (SOURCE-8). Once tolerated, basic strengthening exercises may be introduced (SOURCE-8):
Band Pull-Apart - basic isotonic exercise for Scapular Retractors
Prone Horizontal Abduction - rudimentary Scapulothoracic Joint - Retraction exercise
Banded Unilateral Lat Activations - activate lat, posteroinferior drawer on Humerus
Face Pulls - bilateral isonotic horizontal pull exercise that emphasises GH Joint - External Rotation
Side-Lying Shoulder External Rotations - maximises effect of gravity against External Rotation with upper arm fixed against torso
Standing Shoulder External Rotations - incorporates upright torso posture
Circumduction Row - isotonic exercise with variable load used to emphasise mid-to-lower Trapezius
Inverted Rows - rudimentary isotonic horizontal pull exercise that utilises bodyweight
One Arm Row - unilateral DB version of Seated Row
Lat Pulldown - rudimentary weighted isotonic vertical pull movement with a high range of motion
Bird-Dog Row - One Arm Row variation that emphasises Posterior Sling
Pallof Press - low load horizontal push exercise that emphasises anti-rotation of Core
Bottoms-Up Kettlebell Walk - typically isometric exercise for entire arm musculature with perturbation from walking
Prone Lat Pulldown - Lat Pulldown variation that emphasises Thoracic - Extension
Farmers Carry - upperbody/ Core isometric exercise with perturbation of walking
Suitcase Carry - unilateral farmers carry which emphasises crossbody functional patterns
Late Phase - weight/ gym related exercise may be commenced as late as 4-6 months depending on the procedure/ extent of injury (SOURCE-8). Exercise progression is continued with the aims of a full recovery (including return to sport) within 6 months following Latarjet or 5-9 months following a Bony Bankart (SOURCE-5+8). Exercise selection should consider increasing loads, range of motion and incorporating functional patterns, in particularly those that closely reflect the patients demands:
Front Raises - isotonic GH Joint - Flexion exercise with many variations
Side Raises - isotonic GH Joint - Abduction exercise with many variations
Lu Raises - large GH Joint - Abduction range with no Humerus rotation to promote Scapulothoracic Joint - Upward Rotation
Push Press - explosive overhead movement with large range that incorporates entire body
Pull-Up - bodyweight or greater load through large overhead motion
Kneeling Landmine Press - explosive Vertical Push exercise with a large overhead range
Split Stance Landmine Press - explosive unilateral, whole-body Vertical Push exercise
DB Hang Clean - unilateral clean progression, often performed explosively
DB Snatch - unilateral isotonic, explosive shoulder exercise with large overhead range
DB Snatch to Step-Up - wholebody DB Snatch variation that emphasises diagonal functional patterns
Rope Climb - pull-up variation with entire load bestowed on alternating arm
Medball Pullover Throw - plyometric Pullover variation
Without significant associated Bone -loss, an arthroscopic Bankart repair may adequately reattach compromised soft-tissue, irrespective of the lesions size (SOURCE-5). Bony Bankart Lesions that disturb less than 5% of the Glenoid Rim may be managed conservatively, while in those less than 20% arthroscopic repair may suffice (SOURCE-5). In these instances, arthroscopic and open Bankart repairs are comparable (SOURCE-6). Where there is significant Bone compromise (>25%) in Hill-Sachs Lesion or Large Bony Bankart Lesions arthroscopic repair alone may lead to recurrent Glenohumeral Instability and open surgery with a Latajet Procedure (coracoid transfer) or a Bone graft (Iliac Crest of Distal Tibia ) are required (SOURCE-5+8). The Latarjet Procedure may also be indicated to better address the associated complications with an inverse pear-shape morphology (SOURCE-6). The return to overhead activities and contact sports should be expected within 5-9 months (SOURCE-5).
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