MS exam 2: Shoulder instability; surgical interventions and rehab

Anterior instability Non-anatomic surgeries:-Putti-Platt/Magnuson-stack-Modified Bristow/Latarjet

-Putti: shorten/advances subscaplaris to decr ant dislocation-Bristow: transfer coracoid tip to anteroinferior glenoid neck

What are the Pros/cons of non-anatomic anterior instability procedures

Pros: prevents dislocaioncons: -does not restore normal motion-loss of ER-inability to return to throwing sports

Describe a Bankart lesion

-labral tear-stretching of anterior-inferior capsule and IGHL-poriosteal stripping of subscap from neck of glenoid fossa

Anatomic Anterior instability repair:-Bankart repair-indications?

Reattchment of avulsed anterior capsule to glenoid rim-Make vertical incision along ant axial fold-subscap tendon divided Indications: -symptomatic recurrent anterior shoulder dislocations -failed conservative therapy-only helpful for unidirectional anterior instability

Contraindicaitons for Bankart repair

-voluntary instability w/emotional/psychological problems -seizure disorder-multidirectional instability

What are the factors impacting rehab for Bankart repair?

-open procedure or arthroscopy-method of fixation (sutures or anchors)-concomitant procedures (capsular shift; thermal shrinkage)

What are the rehab precautions w/ an open Bankart repair?

-avoid early agressive motion and activities -avoid excessive ER and extension-Avoid resisted or foreceful IR-lengthy immobilizaiton

For an open Bankart Repair, how do you treat motion?

-immediate to tolerance -ER/IR in scapular plane (45 deg abd initially --> 90 wk 5)-Gradual incr in shoulder elevation wk 2: 0-100wk 4: 0-155wk 6: 1-180

How do you treat strength for an open Bankart repair?

-submax isometrics immediately (rhythmic initaiton and stab)-isotonics wk 3-plyometrics wk 10

When can you start functional activities w/an open Bankart repair?

-sport specific training at week 12-14-contact sports at 5 months-overhead sports after 6-7 months

What are the rehab precautions for arthroscopic Bankart repair?

-sling for 6 wks (out for ROM; sling continues for comfort >6 wks)-no overhead motion for 4 wks-sleep in immobilizer for 4 wks-no excessive ER or ext for 4 wks slower rehab than open

How do you treat motion for an arthroscopic Bankart repair?

-immediate in scapular plane-ER/IR at 30 deg ABD-Elevation to 90 for 3 wks (stress to inferior capsule; progress to 135 deg wk 6)-Full ROM by wk 12

Arthroscopic Bankart repair Phase 1 rehabilitation (0-6 wks)-goals?

-maximal protection-absolute immobilization (0-4 wks)-achieve staged ROM goals (AAROM; scap retraction)

What are the milestones to continue to Phase 2 (6-12 wks)?

-appropriate healing-staged ROM goals achieved -min to no pain w/ROM (0-2/10)

What are the interventions for Phase 2 rehab for arthroscopic Bankart repair?

-cross body stretching for IR-scapular stability-elevation in scapular plane (full can): minimal capsular tightness; subacromial clearance; optimal length-tension RC/scap

What are the milestones to reach phase 3 (12-24 wks)?

-full ROM w/o substitution -good dynamic scapular control-strengthening w/ 0-2/10 pain

What are the goals for Phase 3 rehab?

-normal strength, endurance and neuromuscular control and power-gradual stress to anterior capsulolabral structures-gradual return to full ADLs, work duties, recreational activities

What is the intervention for Phase 3 rehab (12-24 wks) for arthroscopic Bankart repair

-Progressive strength/endurance (high speed/multi-planar)-Neuromuscular control-Activity specific interventions (work, sport, hobbies)-core and scapular stability-plyometrics (overhead athletes)

What are the milestones to return to full activity after an arthroscopic Bankart repair?

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

T/F: conservative treatment of anterior instability has lower recurrence rates than surgical repairs

false: both surgical repairs have lower recurrence rates (both forms of Bankart repairs)

Which repair is better: open or arthroscopic Bankart repair?

-argued that open might be better for athletes, but overall conflicting evidence and not a significant dif in success rate

Anatomic Anterior instability repair: Capsular shift/capsular plication-What is it?-Indications?-pros/cons?

-corrects anteroinferior GH jt instability; labrum is intact-indication: atraumatic instability-Pro: addresses lax structures w/o compromising ROM-con: posterior translation

T/F: Arthroscopic capsular plication is the most common procedure for anterior-inferior instability. Capsule is shifted superiorly and capsule repaired to intact labrum


Rehab for Arthroscopic capsular plication:-ABD sling for ___ wks-PROM in ____ immediately-____ once sling D/C-______ after 3 wks as tolerated -full ROM by ___ wks -Progressive ___ and ____ activities -Throwing full speed at _____

2 wks"safe zone"isometricsIsotonics12 wksstrength and sport/work 1 yr

What is thermal shrinkage for anterior instability?

-rarely done anymore-probe used to heat capsule and ligaments to tighten them-unidirectional only-poor long term outcome due to failure

What are the surgical interventions for a type I SLAP lesion?

-arthroscopic debridement to labrum-remember: biceps is intact here, so often won't have surgery

Type 1 Slap lesion surgical rehab:-immediate _____-full _____, begin ___ and ____ at week 2-_______ stabilization-progress ____ at weeks 4-6-return to _____ at week 7+

-P/AAROM-PROM, AROM, isotonics-dynamic-strengthening-activity

What is the surgical intervention for Type II SLAP lesion

-arthroscopic debridement and re-attachment of labrum to glenoid

Precautions for type II SLAP lesion repair:-control forces ____ wks-no ___ motions for 4 wks-no isolated ____ for 8 wks-no resisted ____ for 12 wks

8 wksoverheadbicepsbiceps

Type II SLAP lesion rehab 0-4 wks:-sling for ___ wksImmediate "controlled motion":-Weeks 1-2:---elevation: ___---ER @ ____---IR:____-Weeks 3-4---Elevation: __---ER @___---IR: ___-____ strength-_____ stabilization wk 3

4 wks75ER @ 30:15 IR 4590ER @30:30IR 60isometricrhythmic

Type II SLAP lesion surgical rehab wks 5-6:Progress mobility:-elevation to ___-ER @-IR @_____ scaptionProne ___ and _______ manual resistanceIR/ER tubing at ___ deg ABD_____ biceps strengthening

14545 abd: 50 deg45 abd: 60 degFull canrow, H-abdPNF0 degNO biceps strengthening

Type II SLAP lesion surgical rehab wks 7-9:Progress mobility to-elevation: __-ER: ___-IR: ___Progress ___Continue ____initiate ___ programBegin AROM of _____

180@90 abd: 90@75 abd 90 isotonicsPNFThrower's ten programBiceps

Type II SLAP lesion surgical repair rehab wks 10-12:-work on thrower's motion: ER____-continue ___ and ___-Progress ___

ER@90 abd to 115-120strengthening and stretching-isotonics

Type II SLAP lesion surgical repair rehab wks 12-20:Milestone criteria:-full/painless ___-Good ___-____ strength -no ____Light ____ wks 12-16Interval sport program initated wks _____

AROMStability4/5 or greaterpain/tendernessplyometrics16-20

Type II SLAP lesion surgical repair Advanced strengthening phaske wks 20-26Milestones:-____ AROM-strength ____% of uninvolved-no ______


Type II SLAP lesion surgical repair return to activity phase months 6-9:Milestones:-Full ____ ROM-Satisfactory shoulder ___-no _____

Functionalstability pain/tenderness

What is the surgery for SLAP lesion type III

excision of bucket handle tear of labrum

Type III SLAP lesion surgical rehab:-immediate ______-full ____, begin ___ and ___ at wk 2-________ stabilizaiton-progress _____ at wk 4-6-return t0 ___ wk 7+very similar protocol to type ___ SLAP lesion

PROM/AAROMPROM, AROM, isotonicsDynamic Strengthening activity Type 1 bc biceps intact

What is the surgical intervention for type IV SLAP lesion

-excision of bucket handle tear of labrum -possible biceps tenodesis

Type IV SLAP lesion surgical rehab:-sleep in immobilizer for __ wks-elevation to ___ only for 4 wks-Full ____ by 10 wks-No isolated ____ for 4 months-Progressive ___ at wks 10-12-light _____ wks 12-16-interval throwing wks ____-full activity in ______

4 wks90 degROMbicepsstrengthening plyometrics 16-206-9 months

What is biceps tenodesis?

-removal of long head of biceps from glenoid -reattachment tp proximal humerus -"keyhole" technique uses pre-drilled hole in humerus, insert knotted end of tendon-screw fixation most common

When is a bicpes tenodesis indecated?

-anticipated irreversible changes to biceps tendon- over 25% tearing or atrophy-any luxation of tendon from bicipital groove-biceps pathology in context of SLAP lesion

What are rehab considerations for biceps tenodesis?

-no biceps loading for 6 wks -additional precautions in context of surgical procedures performed