9/30 - Shoulder Instability Post-Op

Question 1

what is a bankart lesion

Answer 1

labral tear
- stretching anterior-inferior capsule & IGHL
- periosteal stripping of subscap from neck of glenoid fossa

Question 2

what is the gold standard for surgical intervention for anterior instability

Answer 2

bankart repair

Question 3

what happens anatomically during a bankart repai

Answer 3

reattachment of avulsed anterior capsule to glenoid rim

Question 4

what are indications for a bankart repair (3)

Answer 4

• symptomatic recurrent anterior shoulder dislocations
• failed conservative therapy
• unidirectional anterior instability

Question 5

what are contraindications for a bankart repair (3)

Answer 5

• voluntary instability w emotional/psycho problems (ie popping it out to show you)
• seizure disorder
• multidirectional instability

Question 6

why is multi-directional instability a contraindication to a bankart repair

Answer 6

only stabilizing anterior
- still other instability

Question 7

what ms are impacted by a bankart repair

Answer 7

subscap

Question 8

why is there a difference in immediate management after an open vs arthroscopic bankart repair

Answer 8

open - more collateral damage
- cutting thru more stuff
- creates bleeding environment
- inc potential for scar tissue but helps w healing
- can move sooner

arthroscopic - less collateral damage
- less bleeding&raquo_space; dec healing environment
- immobilized longer

Question 9

what is a difference in rehab motions after open vs arthroscopic bankart d/t involved structures

Answer 9

arthroscopic - subscap intact
- ER / IR @30° ABD

cut thru anterior capsule in both, want to avoid loading anterior capsule for both

Question 10

what is a good way to do scap retractions in phase 1 after arthroscopic bankart repair and why

Answer 10

plantar grade (or side lying)
- minimizes shoulder ext

Question 11

what are milestones to progress from phase 1 to phase 2 of rehab after an arthroscopic bankart repair (3)

Answer 11

1. appropriate healing
   - compliant w immobilization guidelines
2. staged ROM goals achieved
   - not exceeded
3. minimal to no pain w ROM (0-2/10)

Question 12

why is elevation in the scapular plane a good exercise in phase 2 of rehab after an arthroscopic bankart repair

Answer 12

minimal capsular tightness
subacromial clearance
optimal length-tension RC/scap

Question 13

what are the milestones to progress from phase 2 to phase 3 of rehab after an arthroscopic bankart repair (3)

Answer 13

full ROM without substitution
good dynamic scap control
strengthening w 0-2/10 pain

Question 14

what are 3 goals of phase 3 of rehab after an arthroscopic bankart repair

Answer 14

1. normal strength, endurance, NM control and power
2. gradual stress to anterior capsulolabral structures
3. gradual return to full ADLs, work duties, rec activities

Question 15

who is someone who would progress to phase 4 of rehab after an arthroscopic bankart repair

Answer 15

someone who needs to get back to sport or has an intense job
- not everyone needs to get to this phase

Question 16

what are milestones to return to full activity after an arthroscopic bankart repair (4)

Answer 16

MD clearance
no pain / full ROM
no sensation of instability
adequate RC/scap strength w/o pain

Question 17

what is a better way of asking/testing if someone has any remaining sensation of instability

Answer 17

NM control
- do they have proprio reposition sense

Question 18

when would you see a surgical intervention for a SLAP type 1

Answer 18

if some other RC involvement

Question 19

what are precautions for type 2 SLAP lesion repairs (4)

Answer 19

1. control forces 8 weeks
2. no overhead motions 4 weeks
   3. no isolated biceps 8wks
   4. no resisted biceps 12wks

Question 20

when you begin AROM of biceps after a type 2 SLAP lesion repair, what is an important consideration for how you do this

Answer 20

should be co-contraction w other ms
- dec load on biceps

shouldn’t be isolated biceps contraction/activity

Question 21

what is milestone criteria to reach the minimal protection phase of rehab after a type 2 SLAP lesion repair (4)

Answer 21

full and painless AROM
good stability
4/5 or greater strength
no pain/tenderness

Question 22

what are milestones to get to the advanced strengthening phase of rehab after a type 2 SLAP lesion repair (3)

Answer 22

full pain-free AROM
strength 75-80% of uninvolved
no pain / tenderness

Question 23

what are milestones to get to the return to activity phase of rehab after a type 2 SLAP lesion repair (3)

Answer 23

full functional ROM
satisfactory shoulder stability
no pain / tenderness

Question 24

why is a biceps tenodesis often done

Answer 24

if biceps were to be reattached to glenoid, might retear
- so reattach it lower

Question 25

why does a biceps tenodesis work

Answer 25

other ms can do what biceps do

Question 26

what is a good pt population for biceps tenodesis

Answer 26

lower level pts
- other ms are now going to be doing what the biceps does

Question 27

what is a takeaway if you know that the tendon/ms was repaired and restored to original place

Answer 27

more tenuous bc quality of tissue might not be great

Question 28

tenodesis vs tenotomy

Answer 28

tenodesis - need to wait for healing
- but good stability

tenotomy - not waiting for anything to heal
- just cut
- can get popeye’s sign as bicep’s tendon retracts

Question 29

why can’t you fix bone loss w a soft tissue procedure

Answer 29

bone loss will get worse over time
- see wasting away

Question 30

what ms are your biggest considerations post-op

Answer 30

biceps
subscap