The labrum is a rim of cartilage that surrounds the Glenoid or shoulder socket. A Bankart Lesion refers to a tear of the labrum and attached joint capsule along the lower front quadrant of the Glenoid. This usually occurs when someone dislocates or subluxates (partially dislocates) their shoulder. The labrum has a poor blood supply and joint fluid within the tear interferes with healing. Additionally, the labrum may slip off the face of the Glenoid and no longer contributes to shoulder stability. These factors make it unlikely that a Bankart tear heals. Patients in their teens and twenties have an 80 – 90% chance of repeat dislocations with nonoperative treatment following a Bankart tear. Studies have shown that repair of a Bankart lesion in young active patients after a first time dislocation has a better than 90% success rate. In my opinion, Bankart tears or Bankart lesions in this age group are best treated with arthroscopic labral repair known as a Bankart Reconstruction.
Normal Anterior Labrum as seen from back of a right shoulder, head is to the left and feet are to the right
Signs and Symptoms of a Bankart Tear/Bankart Lesion
Bankart tears usually cause pain in the front of the shoulder and may be associated with clicking or catching or sense of slipping of the shoulder. The onset of symptoms usually occurs after a traumatic event such as a shoulder dislocation. This often is a result of a fall on an outstretched arm in front of or to the side of the body. Examination of the shoulder reveals pain and clicking with compression and rotation of the shoulder and may reveal looseness or apprehension when the shoulder is tested for laxity.
Close up view of Bankart lesion as seen from back of shoulder (head to the right, feet to the left)
Diagnosis of Bankart Tear/Bankart Lesion
Although the signs and symptoms may lead to a probable diagnosis, there is not one single exam finding or group of symptoms that are specific for a Bankart tear. Many of these findings overlap with other shoulder problems. X-rays and an MRI combined with an arthrogram (injection of dye into the shoulder joint) are recommended to confirm the diagnosis and rule out other conditions.
MRI-Arthrogram of Bankart Lesion (black arrow). Labrum is dark triangular structure at edge of socket (white arrow shows normal labrum in back).
Treatment of Bankart Tears
In my opinion, most Bankart tears in young active patients following a dislocation should be treated operatively. This is because the labrum has a very low likelihood of healing and the redislocation rate is 80-90% without surgery in young patients. Surgical treatment has a 90-95% success rate. When an athlete dislocates their shoulder in season, having surgery or continuing to play is a difficult decision. Depending on the age and level of play, time in season, and player and family desires, it is possible to continue play and consider surgical repair at the end of a season. This may be done if there is adequate range of motion, strength, and stability. A shoulder brace or harness may be worn in some sports and positions. There is a risk of recurrent dislocation, which may cause further damage to the shoulder that can have lasting effects.
Dr. Khalfayan’s Tip: The decision to have surgery is a significant one for an athlete and is more difficult if it impacts play during a season. The athlete and family should understand that there is a chance of damaging the labrum more and also damaging the joint surface (articular) cartilage with repeat dislocations. This can lead to poor quality labral tissue for repair or arthritic changes of the shoulder. The risk varies widely and is very individual. I recommend that patients consult with an experienced sports medicine specialist.
Arthroscopic Bankart Reconstruction
Surgery for a Bankart lesion or tear consists of repair of the labrum to the glenoid (socket) in addition to tightening the joint capsule, which is usually stretched out. This is called a Bankart Reconstruction and my preference is to do this arthroscopically. Arthroscopy uses small incisions and allows the surgeon to view the shoulder joint on a TV monitor.
This is a very precise way to use small instruments to perform the surgery without a large incision and without cutting into the rotator cuff tendon called the Subscapularis. Subscapularis dysfunction can occur in as many as 23-70% of open Bankart Reconstructions resulting in weakness or atrophy of the shoulder. Arthroscopic surgery also has the advantage of less pain and easier rehabilitation than open surgery using large incisions.
Repair of the labrum involves creating bleeding of the bone on the edge of the socket where the labrum tore away and placing suture anchors in the bone to tie the labrum down to it. The surgery is done as an outpatient procedure allowing patients to go home the same day. Dr. Khalfayan performs this surgery at the Seattle Surgery Center.
Close-up of Bankart lesion in a left shoulder after it is prepared for repair
Repaired Bankart Lesion
Rehabilitation of Bankart Reconstruction
The rehabilitation following a Bankart Reconstruction usually takes 4-6 months depending on the sport or activity level. A shoulder immobilizer with a small pillow next to the side is used to protect the repair for the first six weeks.
Physical therapy is started 1 week after surgery and involves passive range of motion where the therapist moves the shoulder within a specified range. Active motion where the patient starts moving the shoulder without assistance begins at 6 weeks after surgery. There is a progression to more aggressive strengthening at three to four months after surgery and return to some sports at four to six months after surgery. Return to pitching typically takes ten to twelve months and swimming eight to ten months after surgery. It is important to recognize that return to sport is based on multiple factors including biologic healing, return of strength and endurance, subjective improvement, and a gradual/incremental return to sport specific activities. Therefore, return to sport timeframes may vary.
Dr. Khalfayan’s Tip: Sleeping is difficult after surgery. It’s helpful to sleep in a semi-reclining position propping yourself up on pillows behind your head, neck, and upper back or in a recliner until you are comfortable sleeping flat in bed.