Instability

The Injury

The shoulder joint is a ball and socket joint that connects the bone of the upper arm (humerus) with the shoulder blade (scapula). The shallow socket in the scapula is the glenoid cavity. The capsule is a broad ligament that surrounds and stabilizes the joint. The glenoid labrum is a rim of cartilage attached to the glenoid rim. If the arm is pulled out of its socket, the capsule and labrum tear, usually from the rim of the glenoid cavity. A dislocation occurs when the humerus comes completely out of the socket and stays out. A subluxation occurs when the humerus comes partly out of the socket and then slips back in. When the capsule tears from the glenoid rim, the shoulder can become unstable and dislocate or sublux repeatedly. The most common direction for the humeral head to dislocate is toward the front of the body (anteriorly).  This typically occurs if the arm goes too far behind the body when the arm is away from the body. The humeral head can also dislocate toward the back of the body (posteriorly) when force is directed toward the back of the shoulder.  This can occur when falling forward on an outstretched arm or blocking with the arm straight ahead in football.

Treatment of Shoulder Instability

Some patients who dislocate their shoulder do well after the injury and do not have recurrent instability. They tend to be older in age and not active in sports. Young people, especially athletes, are prone to have recurrent dislocations and subluxations and usually need surgery to correct the shoulder problem. The unstable shoulder joint can be repaired arthroscopically.  In some instances, an open procedure is performed in which the muscles are separated to expose the shoulder capsule but this is rarely required. If the capsule is found to have torn away from the bone, holes are made in the glenoid rim. Stitches are passed through each hole and through the capsule and tied, securing the capsule to the glenoid rim. The capsule heals back to the bony rim and prevents the shoulder from re-dislocating. It takes several months for the capsule to heal back to the bone.

Results and Risks of Surgery

The success rate of the open Bankart repair is approximately 97%. The success rate of arthroscopic Bankart repair is similar. If there is a fracture of the glenoid rim (Bankart lesion) and a compression fracture of the humeral head (Hill-Sachs lesion), there is an increased risk of recurrent instability following repair.  Procedures aimed at treating these lesions help prevent further instability.

Two nerves are at risk during surgery since they are near the operative field, but they are rarely injured. As with any surgical procedure, there are potential risks. The incidence of infection is less than 0.5%. The shoulder can lose some motion after surgery, especially if the shoulder has to be significantly tightened because of excess laxity.

Rehab after Bankart Shoulder Repair and Anterior Stabilization

Phase 0: 0 to 2 weeks after surgery

POSTOPERATIVE INSTRUCTIONS

You will wake up in the operating room. A sling and an ice pack will be in place. You will go to the recovery room and generally will be discharged after 1-2 hours. You can get out of bed when you wish. Apply ice to the shoulder to reduce pain and swelling. You may remove the sling whenever you wish and gently move the elbow, wrist and fingers. Follow the doctor’s instructions regarding moving your shoulder after surgery.

Goals:

1. Control pain and swelling
2. Protect the repair
3. Begin early shoulder motion

Activities:

1. Apply ice to the shoulder as tolerated to reduce pain and swelling. You can change the dressing to a smaller one to allow the cold therapy to reach the shoulder.
2. Remove the sling on the first day after surgery only to move your elbow, fingers and hand several times a day.  Otherwise, stay in the sling.
3. Begin the pendulum exercise several times a day.  These are performed by bending over at the waist and letting the arm hang down. Using your body to initiate movement, swing the arm gently forward and backward and in a circular motion not to exceed 18 inch circles. Repeat for 2 to 3 minutes at a time.
4. Remove the outer dressing on the second day after surgery and shower with incision covered until post op day #3 (POD #3). Leave the little pieces of tape (steri-strips) in place. You can get the wound wet in the shower after POD #3, but do not soak in a tub until 4 wks post op. To wash under the operated arm, bend over at the waist and let the arm passively swing away from the body. It is safe to wash under the arm in this position.
5. Keep your elbow slightly in front of your body; do not reach behind your body. When putting on clothing, lean forward and pull the shirt up and over the operated arm first. Then put the other arm into the opposite sleeve. To remove the shirt, take the unoperated arm out of the sleeve first, and then slip the shirt off of the operated arm.
6. Call the doctor’s office for any concerns, including, but not limited to, severe pain, fevers, chills or redness.

Office Visit: Please arrange to see the doctor in the office 10-14 days after surgery for examination and further instructions.

Phase One: 2 to 5 weeks after surgery

Goals:

1. Protect the repair
2. Ensure wound healing
3. Prevent shoulder stiffness

Activities:

1. Sling Use – your sling as instructed by your doctor. You may remove it whenever you wish if you are careful and keep the shoulder safe. Put the sling on when you are outside or in a crowd. Keep the sling on when sleeping at night for the first three or four weeks 6 wks.
2. Use of the operated arm – You may use your hand on the operated arm as long as you do not rotate the arm externally or away from your body. You should bend your arm at the elbow and use your fingers and hand, such as to reach up and touch your face. Keep your elbow in front of you.
3. Bathing and showering – You may shower or bath (bath at 4 wks) and wash the incision area. To wash under the operated arm, bend over at the waist and let the arm passively swing away from the body. It is safe to wash under the arm in this position. This is the same position as the pendulum exercise. Do not submerge the incisions under water until 4 wks post op.

ICE

Physical Therapy Protocol

Stretching/Passive Motion

Phase Two: 5 to 8 weeks after surgery

Goals:

1. Protect the shoulder and avoid overstressing the repair
2. Improve range of motion of the shoulder
3. Begin strengthening exercises

Activities:

1. Sling The sling is no longer necessary.
2. You may now use your arm. Avoid having the arm forcefully pulled behind you. Continue to avoid heavy weight lifting or manual labor. Follow any further instructions given to you by your doctor.

3. Precautions – Do not lift objects overhead with the weight of the object going behind the head. In other words, keep objects in front of you where you can see them.

4. Use ice or cold as necessary 15-20 minutes.

Phase Three: 8 to 12 weeks after surgery

Goals:

1. Protect the shoulder repair
2. Regain full range of motion
3. Continue gentle strengthening

Activities:

1. You may now use your arm in a more normal fashion. You may move the arm into all positions including external rotation and behind the back if it is comfortable. Avoid having the arm forcefully pulled behind you. Continue to avoid heavy weight lifting or manual labor. Follow any further instructions given to you by your doctor.
2. Precautions – Do not lift heavy weights overhead with the weight going behind the head. In other words, keep the weights in front of you where you can see them.

Phase Four: 12 to 24 weeks after surgery

Goals:

1. Protect the ligament repair
2. Regain full range of motion
3. Continue strengthening
4. Gradual return to full activity

Activities: Use the arm for normal daily activities. There is no restriction on your range of motion unless exceptions are outlined in your discussions with your doctor. Weight training can gradually resume with caution being paid to exercises such as bench press, incline press, dips, pull-downs behind the neck or other exercises where the hands are repeatedly placed behind you. In other words, perform exercises that allow you to see your elbow at all times.  If you are returning to contact sports, you should wait until six months after surgery.

Phase Five: 24 weeks after surgery onward

Goals:

1. Enhance muscular strength, power and endurance
2. Progress functional activities
3. Maintain shoulder mobility

Guidelines for Returning to Weight Training After Arthroscopic Labrum Repair

You should not return to training using heavy weights or on weight machines until your doctor determines that it is safe. In general, it is usually safe to return to heavier weight training at three months following labrum repair.

Before embarking on a weight-training program, you should have full range of shoulder motion and normal strength in the rotator cuff and scapular muscles. The doctor or a physical therapist will test your motion and strength before you start weight training.

When starting your weight-training program, you can start with 3 sets of 15-20 repetitions. Training with high repetition sets ensures that the weights that you are using are not too heavy. NEVER perform any weight training exercise to the point of muscle failure. “Muscle failure” occurs when, in performing a weight training exercise, the muscle is no longer able to provide the energy necessary to contract and move the joint(s) involved in the particular exercise. Joint, muscle and tendon injuries are more likely to occur when muscle failure occurs.

The following weight training exercises should be avoided after Bankart repair for shoulder instability:

1. Pull downs behind-the-neck (wide-grip)
2. Behind-the-neck shoulder press
3. Wide-grip bench press
4. Standing lateral deltoid raises
5. Triceps press overhead

The following exercises require special cautions:

1. Pull downs should only be done in front of the head, to the chest, with a medium (not wide) grip.
2. Shoulder press overhead should be done carefully, avoiding heavy weights. If doing shoulder presses, always start with the hand in front of the shoulder and end overhead where you can still see your hand. For persons using barbells, this is the “military press”.
3. If bench pressing, your grip should be no wider than the wider than the width of your shoulders. Avoid any exercises using grips wider or narrower than shoulder width.
4. Lateral deltoid raises should be avoided because of the impinging and wearing effect on the rotator cuff. Forward raises in the “thumb-up” position are usually safer and can be done with reasonable weights. Lateral raises from the prone or bent over position can be done as a substitute for standing lateral deltoid raises.
5. When doing incline bench press with barbells, there is a danger of shoulder dislocation if the lifter loses control of the bar when returning the barbell to the rack of the incline bench. Always have a spotter for removing and replacing the barbell in this exercise.
6. If you are doing any type of “chest-fly”, keep in mind the following precuations. Do not do any chest-fly exercise with straight elbows. Always allow the elbows to bend and never lower your hands (holding dumbbells) below the level of your chest.
7. If you are using a “Pec-Deck” machine, never let the weight stretch the arms so that your elbows pass behind your chin. You can set the arms on this machine a few clicks forward to adjust the maximum motion allowed.
8. If you a performing “dips” using a set of parallel bars, never lower yourself below the point where the elbows reach a 90-degree angle.
9. For triceps exercises, triceps pushdowns on a pulley system are safe as well as bentover triceps extensions.
10. When doing the upright-rowing exercise, keep your grip at least 12 inches apart. When pulling the bar upward toward the chin, do not raise the bar higher than the point at which the elbow reaches shoulder level.

Exercises Usually Problem-Free

1. Biceps Curls
2. Cable and bent-over rowing
3. Shoulder shrugs

If your goal is returning to high-level weight training or weight lifting, it will take 3 to 6 months of cautious, gradual progression to return to top form. In general, avoid increasing the amount of weight lifted by more than 10-15% (at a time) of your present working weight every 10-14 days.

Remember: Weight training is beneficial to improve muscular strength and protect the joints from injury. If done improperly by using too much weight and/or improper technique, weight training can cause serious injury.