A Bankart lesion is the most common type of shoulder dislocation where the humeral head moves anteriorly and inferiorly with applied force. This can cause the glenoid labrum to be disrupted, which will likely require surgical repair using the Bankart Procedure. This injury is common in athletes that participate in overhead sports but may also occur as the result of a fall, motor vehicle accident, or other stress to the shoulder.
There are two types of Bankart lesions. A soft tissue Bankart describes an injury where the anteroinferior labrum is torn from the glenoid rim. In a bony Bankart, an avulsion fracture of the glenoid rim occurs along with the labral tear.
Anatomy of the glenohumeral joint
The shoulder joint is made up of the humerus, scapula and clavicle. The glenohumeral joint is formed by the head of the humerus and the glenoid fossa of the scapula. This joint is supported primarily by the glenohumeral ligaments (superior, middle, and inferior) and the muscles of the rotator cuff.
The inferior glenohumeral ligament is most often injured during a shoulder dislocation, resulting in a Bankart lesion. The axillary nerve encircles the surgical neck of the humerus and may also be injured during shoulder dislocation or reduction. Axillary nerve injury will affect the deltoid muscle group and sensation to the proximal third of the upper arm.
Bankart lesion causes
Shoulder instability is often broken down into “born loose” or “torn loose.” Those who are born loose often have generalized ligamentous laxity. These people are commonly referred to as “double-jointed” because of their excessive range of motion. Those who injure their shoulder during a traumatic shoulder dislocation are torn loose.
Dislocation of the shoulder is a very common injury due to the lack of bony stability afforded by the joint. Shoulder dislocation is common in contact and collision sports because of the falls that may result from the interaction of opposing players. Sports that involve falls, such as skiing or gymnastics, also have high rates of shoulder dislocations. Bankart lesions may also occur during motor vehicle accidents or non-sports-related falls.
Those who participate in high-risk sports or have a history of recurrent dislocation or subluxation are more likely to suffer from a labral injury. Because many men in their teens and twenties participate in contact or collision sports, this group tends to see higher rates of Bankart lesion.
Dislocated shoulders should only be reduced by trained professionals. Every effort should be made after a dislocation to avoid causing a Hill-Sachs lesion, or posterior impaction fracture of the humeral head. Hill-Sachs lesions change the shape of the bone, which can create a situation where dislocation occurs more frequently and with ease.
Bankart lesion symptoms
The symptom presentation associated with a Bankart lesion is fairly consistent among patients. They tend to report a traumatic shoulder dislocation followed by feelings of instability. If the injury is not immediately surgically repaired, they generally have recurrent dislocations of increasing frequency and with less trauma at each subsequent episode. In fact, recurrence rates in patients with first-time dislocations that are managed conservatively have been reported as high as 100%.
Clinically, these patients tend to have generalized shoulder pain that worsens with moving their arm into a typical throwing position (abduction with external rotation) or behind their back (extension and internal rotation) as if to reach a back pocket. These patients may be unwilling to move into certain ranges of motion because of fear that their shoulder will dislocate again.
Completing a course of care that applies the neuromatix theory of pain allows the patient to create a healthy neurosignature that addresses information from previous experiences, values, emotions, and other factors. Failure to address these components of injury can lead to chronic pain.
Diagnosis of Bankart lesion.
The gold standard for diagnosing a Bankart lesion is magnetic resonance arthrogram but this does not mean the diagnosis can not be made in the clinic. Loh and colleagues evaluated more than a decade of patient records to determine a cluster of tests that is clinically useful for diagnosing Bankart lesions.
They found that a detailed patient history along with positive findings on the anterior apprehension and load and shift tests can diagnose anterior shoulder instability as consistently as imaging. Anterior instability does not always mean a Bankart lesion is present but a history of repeated dislocations along with instability should make the clinician suspicious of a labral tear.
Patients who have non-traumatic Bankart lesions, or tears associated with a dislocation that is spontaneously reduced, may not get to a clear cut diagnosis quickly. General shoulder pain when raising the arm is a common symptom among several conditions that should not be taken for granted.
Shoulder impingement and bursitis can be ruled out with resistive testing where the finding is strong and pain free. Special tests for impingement may also be employed to test the integrity of the structures in the subacromial space. Without a reported dislocation, clinical correlation with the patient’s subjective report is critical.
Treatment for Bankart lesion
Bankart lesions typically occur following a first-time traumatic dislocation. Most of the time, the preferred treatment is surgical repair in an effort to decrease the risk of repeated dislocations. Recurrent dislocations can lead to complications including Hill-Sachs lesions and axillary nerve traction injuries.
Patients who opt for the conservative route can experience success without a Bankart repair if they complete a comprehensive course of physical therapy that focuses on restoring dynamic stability.
Surgical repair of Bankart lesions can be performed using an open or arthroscopic approach. The open approach has the best outcomes but it is quite invasive and thus, rarely performed. The less invasive arthroscopic option allows the patient to build strength and return to their prior level of activity more quickly.
Arthroscopic repair of anterior labral tears involves placing suture anchors along the length of the tear to secure the tissue. The number of anchors is dependent on the size of the tear. Unlike SLAP tears where surgical repair of the labrum may or may not be warranted. Immediate surgical repair is the treatment of choice for Bankart tears.
The failure and revision rates are significantly reduced when compared to conservative management of this injury. Arthroscopic repair is associated with an increased likelihood of a return to sports. Rehabilitation following surgery generally lasts six months or more depending on the sport or activity the patient is returning to.
Conservative management of Bankart lesions generally begins with a period of immobilization followed by interventions to restore range of motion, improve strength, and enhance proprioception. Dislocating the shoulder is a traumatic experience that can create kinesiophobia or the fear of pain or movement.
To process pain and injury appropriately, patients who have a history of instability or are chronic dislocators should complete a course of rehabilitation that emphasizes restoring full range of motion, dynamic stability, and co-contraction of the muscles that support the glenohumeral joint. Failure to start a series range of motion exercises in the appropriate time frame could lead to an even more painful condition, frozen shoulder.
A 2017 study published in the Journal of Exercise Rehabilitation suggests that a robust rehabilitation program can restore strength in the injured arm to near that of the uninvolved side in as few as six weeks. In their study, 12 first-time dislocators began the program two weeks after the injury. The program consisted of dozens of exercises, performed five times per week, using elastic bands and weights.
Although it is well-known that surgery is preferable, this program may be a great option for bridging the gap between injury and a competitive sports season when there is not enough time to complete surgical intervention and rehabilitation.
As with any injury or illness, readers should consult with a physician or qualified medical professional to determine the best personal course of treatment.
History of Bankart lesion
Dr. Arthur Bankart, first described the lesion in the British Medical Journal in 1923. Although glenohumeral joint instability was well recognized at the time, he did not think the surgical techniques being used were effective at restoring shoulder stability but rather overtightened the joint capsule thereby limiting abduction.
Bankart showed his contemporaries that the shoulder capsule is not a naturally tense structure and that stability was lost from the detachment of the labrum from the glenoid rim rather than a capacious capsule. His repair was the first introduction to the use of sutures to repair the capsulolabral tissue.
Bankart lesion and massage therapy
Massage therapists working with patients who have Bankart lesions should be certain to obtain a detailed history. If the dislocation is recent, it is important that patient positioning respects the vulnerable positions of the joint to minimize the risk of another dislocation. These patients should not be placed in abduction with external rotation or extension with internal rotation due to the laxity in the anteroinferior capsule. They will be more comfortable if their affected arm is supported by towels and pillows when supine so that the humerus does not drop below the midline of their body.
Those who have had a recent dislocation or who have chronic instability will have associated tightness in the muscles that support the shoulder. They may feel pain or tension in their upper trapezius and lateral cervical paraspinal muscles on the involved side from hiking their shoulder to raise their arm in an effort to avoid pain with elevation.
The posterior muscles of the shoulder have also undergone trauma during dislocation and may be stiff and tender following injury. Positioning the patient in a prone position with their arm supported on the table may be the easiest approach to target the posterior musculature. If this position is not well-tolerated, the patient may need to lie with their arm over the side of the table supported by an armrest.
If you or someone you know has a Bankart lesion, using the biopsychosocial model of pain control is likely the most comprehensive approach to treatment. Where the traditional medical model may not be able to explain why two patients with the same injury can have very different experiences in terms of pain and disability, the biopsychosocial model accounts for the biological, psychological, and sociological influences that shape the individual pain experience.
The goal of the biopsychosocial approach is multifaceted. Pain relief, improved motion, decreased functional limitations, and addressing potential barriers to success are all factored into the model which allows for treatment plans that are unique to an individual’s needs.