1. Revising Bankart Protocols: Incorporating Evidence-Based Medicine and Current Concepts Brian Richardson, PT, MS, CSCS And Jasper Richardson, MEd., MS-HCM, ATC, LAT, CSCS, NASM-PES

2. Focus Question: Do our present guidelines for anterior and posterior Bankart repairs reflect the most current literature? Do our present guidelines for anterior and posterior Bankart repairs reflect the most current literature?

3. Brief Review of Bankart Repair: - generally for recurrent shoulder dislocations - surgical intervention following “ failed ” conservative treatment - goal of re-attaching an unstable labrum and addressing concomitant capsular laxity to restore glenohumeral stability - location of repair (anterior vs posterior) dependent on “ direction ” of instability Anterior (95%) Anterior (95%) Posterior (5%) Posterior (5%)

4. Components used to Evaluate/Revise Bankart Protocols: 1.Published Research (Evidence-Based Medicine) 2.Current Concepts (what are other providers doing?) 3.Physician Input

5. Anterior Bankart Repair

6. Literature Review Limited published literature regarding rehabilitation guidelines following anterior Bankart repairs. Limited published literature regarding rehabilitation guidelines following anterior Bankart repairs. One Level 1 (EBM) study: One Level 1 (EBM) study: (included “ detailed ” overview of protocol) Some additional studies (lower level of evidence) noted results of protocols without describing protocol details: Some additional studies (lower level of evidence) noted results of protocols without describing protocol details: (one study included in comparison that included “ good ” protocol details)

7. Review of Level 1 Study: -62 patients divided into 2 groups: 1.3-weeks immobilized using abduction sling and “conventional” rehab protocol 2.Accelerated rehab program with ROM and strengthening immediately on same day as surgery -All non-athletes with recurrent anterior shoulder dislocation and a Bankart lesion -(2003) Accelerated Rehabilitation After Arthroscopic Bankart Repair for Selected Cases: A Prospective Randomized Clinical Study Seung-Ho Kim, Kwon-Ick Ha, et al. Arthroscopy. Vol.19,No.7, 722-731.

8. Review of Level 1 Study: -Findings: 1.No difference in recurrence rate of dislocations between groups 2.Patients in accelerated group resumed functional ROM faster and returned to functional activities earlier 3.Less pain reported in accelerated group 4.Patients in accelerated group reported more satisfaction with outcome -Implications: Support for inclusion of early motion in rehabilitation Accelerated Rehabilitation After Arthroscopic Bankart Repair for Selected Cases: A Prospective Randomized Clinical Study Seung-Ho Kim, Kwon-Ick Ha, et al. Arthroscopy. Vol.19,No.7, 722-731.

9. “Current Concepts” ASSET – American Society of Shoulder & Elbow TherapistsASSET – American Society of Shoulder & Elbow Therapists “Consensus Rehabilitation Guidelines” – arthroscopic anterior stabilization with or without Bankart“Consensus Rehabilitation Guidelines” – arthroscopic anterior stabilization with or without Bankart Non-Bankart specificNon-Bankart specific Detailed, but generalDetailed, but general Obtained from organization’s website (www.asset-usa.org)Obtained from organization’s website (www.asset-usa.org)

10. “Current Concepts” Protocol from Advanced Continuing Education Institute (2004)Protocol from Advanced Continuing Education Institute (2004) Protocol obtained from surgeon before coming to VanderbiltProtocol obtained from surgeon before coming to Vanderbilt Compare to current anterior Bankart protocolCompare to current anterior Bankart protocol

11. Comparison A visual comparison was created to compare our current protocol to the available literature and current concepts. A visual comparison was created to compare our current protocol to the available literature and current concepts. The comparison was then presented to our shoulder surgeons for review and comment. The comparison was then presented to our shoulder surgeons for review and comment.

12. Comparison An example of level of variation observed… Current Protocol Current 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 / Sling (Level 1) (ASSET)

13. Comparison Continued… 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

14. Anterior Bankart Protocol Revisions Based on the feedback provided from the shoulder surgeons the protocol was revised.Based on the feedback provided from the shoulder surgeons the protocol was revised. –Based heavily on Level 1 study results –Additional specific requests from physicians

15. Revised Anterior Bankart Protocol Open vs. Arthroscopic:Open vs. Arthroscopic: -Old protocol based on open procedure (“the subscapularis is detached”) -Revised protocol based on arthroscopic procedure Timetable for full recovery:Timetable for full recovery: - Old protocol: 9-12 months - Revised protocol: 3-6 months Sling Guidelines: (revised protocol)Sling Guidelines: (revised protocol) -Worn in “uncontrolled” environments for 6 weeks -Worn during sleeping for 6 weeks -Discontinue completely at 6 weeks Highlights / Key Points

16. Revised Anterior Bankart Protocol Active movement allowed earlier in protocol:Active movement allowed earlier in protocol: -Old protocol: no active Internal Rotation for 6 weeks -Revised protocol: no active Internal Rotation for 2 weeks Earlier initiation of isometric strengthening:Earlier initiation of isometric strengthening: -flexion/extension, abduction, external rotation, no internal rotation -Submaximal -Old protocol: begin 1 week POST-OP -Revised protocol: begin Day 3 POST-OP Highlights / Key Points

17. Revised 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 - Revised protocol: begin supine serratus press at 2 weeks - Old protocol: begin shoulder IR/ER (theraband) at 6 weeks - Revised protocol: begin shoulder IR (theraband) at 2 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 (if full motion, normal strength, and no- Revised protocol: 12 weeks (if full motion, normal strength, and no dyskinesis) dyskinesis) Highlights / Key Points

18. Posterior Bankart Repair

19. Literature Review EBM Search = (fill in name here) General Literature Search = (fill in name here) Note: Insert sound of crickets for discussion of literature regarding rehabilitation for posterior Bankart repairs.

20. “Current Concepts” Protocol from Advanced Continuing Education Institute (2004)Protocol from Advanced Continuing Education Institute (2004) Protocol obtained from surgeon before coming to VanderbiltProtocol obtained from surgeon before coming to Vanderbilt Compare to current posterior Bankart protocolCompare to current posterior Bankart protocol

21. Posterior Bankart Protocol Revisions Based on the feedback provided from the shoulder surgeons the protocol was revised.Based on the feedback provided from the shoulder surgeons the protocol was revised. –Specific requests/suggestions from physicians –Corrected/clarified discrepancies

22. Revised Posterior Bankart Protocol Timetable for full recovery:Timetable for full recovery: -Old protocol: 9-12 months -Revised protocol: 4-6 months Immobilization / Sling Instructions:Immobilization / Sling Instructions: - Revised protocol includes: “change external rotation brace to regular sling” at 4 weeks sling” at 4 weeks ROM Goals Included:ROM Goals Included: - 4 weeks: forward elevation / flexion to 120º - 6 weeks: forward elevation / flexion to 160º - 8 weeks: full ROM with all movements Highlights / Key Points / Clarifications

23. Revised Posterior Bankart Protocol Initiation of internal activities:Initiation of internal activities: - Old protocol:12 weeks POST-OP (“Can start internal rotation”) - Revised protocol: 6 weeks POST-OP (Begin internal rotation stretches – towel stretch, sleeper stretch) Glenohumeral joint mobilization (revised protocol)Glenohumeral joint mobilization (revised protocol) - No posterior glides until 8 weeks post-op Begin Sport Specific Activities once full motion, normal strength, and no dyskinesis (16 weeks POST-OP)Begin Sport Specific Activities once full motion, normal strength, and no dyskinesis (16 weeks POST-OP) Return to Sport Criteria:Return to Sport Criteria: 1) ROM WNL 2) Normal Strength 3) Satisfactory clinical exam Highlights / Key Points / Clarifications

24. Summary of Outcomes/Results There are very few articles outlining rehabilitation guidelines following anterior and posterior Bankart surgical repairs. The ones that were located were mostly Level 4 and 5 studies; one Level 1 article regarding anterior repairs was reviewed. Based on the available protocols and in collaboration with our shoulder surgeons, the current anterior and posterior Bankart repair guidelines were revised and will be implemented in the clinic.

25. Where do we go from here… Continue to monitor published research & update protocol as dictated Continue to monitor published research & update protocol as dictated “ Blank Slate ” for research … “ Blank Slate ” for research … - opportunity for “ MOON ” type research

26. 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

27. Questions ?

28. Thank You “The Richardsons” (no relation)