Shoulders

Bankart Lesions- A type of Shoulder Labral Tear

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Published on Tuesday, 01 September 2009 05:00

Written by Vic Goradia, M.D.

When the labrum tears away from the glenoid, patients experience pain, catching, clicking and/or locking. The tear has different names depending on which part of the labrum tears.

Tears on the top part are known as Superior Labral Anterior Posterior (SLAP) lesions. Since this is a mouthful it is much easier to refer to them simply as SLAP lesions. Tears in the front part of the labrum that extend to the bottom are known as Bankart Lesions.

Bankart Lesions are Another Type of Labral Tear

Bankart lesions occur as a result of a shoulder dislocation or multiple dislocations. When the ball (humeral head) dislocates out of the socket (glenoid), the ligaments that normally hold these two structures together will either stretch or tear.

When they tear it is called a Bankart Lesion. In this case the inferior (i.e. lower) glenohumeral ligament pulls the inferior labrum away from the glenoid. Less commonly the ligament will pull the labrum with a piece of bone—this is known as a bony Bankart lesion.

The Dislocated Shoulder

Most shoulder dislocations have to be forcefully relocated (i.e., put back in place) by a doctor, sometimes with sedation. Next, the patient is placed in a sling for immobilization that allows some scarring and healing of the damaged ligament, labrum and /or bone. In many cases, however, these structures do not heal correctly.

Many published studies have noted re-dislocation rates of 75-90% in patients under the age of 25 with a first time dislocation. This risk is greatest for dominant arms of active individuals.

You need an immobilizer sling for a dislocated shoulder. Studies have shown variable results with non-surgical treatment.

Surgical Treatment of SLAP and Bankart Lesions

Fortunately, if surgery is required it can be performed completely arthroscopically through small skin punctures with use of a fiber optic camera. When arthroscopic surgical techniques were first developed in the 1980’s and 1990’s, the outcomes were less favorable than traditional open surgical procedures.

However as our understanding of the anatomy and available instruments have improved, arthroscopic techniques have become the standard for most experienced shoulder surgeons. Currently, surgeons have numerous different types of instruments, sutures and anchors available to them for use in repair of labral tears.

The basic technique for labral repair requires the surgeon to appropriately mobilize the labrum. This means they have to free it from the surrounding scar tissue. Next the glenoid bone has to be prepared so it bleeds and allows the labrum to re-attach to it. Most surgeons use dissolvable anchors. These are placed into the glenoid bone. The sutures from these anchors are passed through the torn labrum. At that point the surgeon can tie a knot or use a knotless technique for final repair.

Bankart Lesion Recommendations According to Patient Age

• Under age 25: If a patient has a first-time dislocation and is under the age of 25 years, I will discuss options of immediate surgery vs. trying a period of immobilization. The latest research shows that immobilization in external rotation (with the arm rotated out) is best if non-surgical treatment is
  attempted. I carefully counsel the patient about the 75-90% risk of recurrent dislocations.
  
• Over age 40: For individuals over 40 years of age that have a first-time dislocation, I base my recommendations on the patients’ activity level and work requirements. Many patients can be treated without surgery unless they have strenuous hobbies or work.
• 25-40 years old: The middle group of patients, from 25-40 years of age, fall in a gray area. Again, it is important to note their activity level, how loose their shoulder feels when I examine it and how large the tear appears on the MRA.

Regardless of age, if patients have recurrent dislocations or are apprehensive about participating in activities because of their shoulder, I will recommend and discuss surgery.

My Surgical Technique for Bankart Lesions

I currently use an all-arthroscopic technique with knotless, dissolvable anchors. The key to the procedure is placing the anchors in the right place and appropriately mobilizing the labrum as I noted above.

After Surgery

• After arthroscopic repair of a Bankart tear, patients are generally given a sling or immobilizer.
• Approximately one week after surgery, I send patients to physical therapy for protected range of motion exercises.
• As the tear begins to heal over a period of 6-8 weeks, the therapist begins a strengthening program.
• At 12 weeks most patients can begin heavier strengthening and light sports specific
training.
• Most patients resume non-contact sports by 4-6 months and contact sports by 6-9
months.

Baseball pitchers and other similar overhead athletes require a slightly modified rehabilitation program that focuses strongly on throwing mechanics after the initial healing period. As with all surgeries, your surgeon should work closely with the physical therapist to develop a specific rehabilitation program for every patient. For athletes you should include the athletic trainer(s) and coaches in a “team” approach to treatment.