Laterjet and bankart 

Sling

• 4 weeks in the “gunslinger position” and only removed for axillary hygiene and to perform exercises.
• It must be worn for bed.

Things that can be done from day 1

• Active assisted supported movements within the safe zone*
• Hand, wrist, cervical spine, thoracic spine and elbow ranges of movement
• Pain relief as prescribed
• Regular application of ice packs can also be an effective source of pain relief. Once block has worn off

* Safe zone is generally elevation in the scapular plane 120 degrees, ER to 0 degrees unless stated as otherwise by the surgeon in the operation notes (dependent on pain and end feel). The safe zone should not compromise the surgical repair.

What are the Restrictions?

• Avoid combined abduction and external rotation until 8 weeks
• Do not force stretch at end of ranges particular external rotation

When can strengthening commence?

• Dependent on dynamic control and range of movement and pain level- usually 8 weeks

NOTE: Following a stabilisation procedure be mindful that bone/tissue repair will not reach its maximum healing at approximately 8 weeks post repair and that the integrity of the repair relies essentially on the fixation constraints both of bone and soft tissue.

However all these timeframes are guidelines not specifics and should be considered on an individual patient basis.

Patient Education and Advice

Patients should be able to return to driving within 6 weeks but this is dependent on their regained range of movement and control. Patients should be given guidance by their consultant and should also seek advice from the DVLA.

Patients should be allowed to return to swimming at 4 months starting with gentle breaststroke.

Patients employed in manual jobs should avoid heavy lifting for 6 months.

Patient should be able to return to sporting activity at 6-9 months dependent on type of sport and level of contact.

Early Phase 0-4 weeks

Goals of Rehabilitation

• Protect the bone/ soft tissue repair and optimise tissue healing
• Reduce pain and swelling which may be a cause of muscle inhibition
• Gain and maintain the safe zone of range of movement (ROM)
• Prevent compensatory movement’s e.g. shoulder hitching which may compromise recovery
• Promote proprioception
• Optimal recruitment of the dynamic stabilisers

Exercises

• Maintain hand ,wrist , cervical spine, thoracic spine and elbow ranges of movement
• Reinforce posture correction and good movement patterns
• Active assisted/supported flexion, abduction and external rotation mobilisation within the safe zone e.g. table slides, ball rolls stick exercises
• Rotator cuff facilitation exercises within the safe zone
• Scapula mobilisation exercises e.g.shoulder shrugs, scapula retractions and protractions
• Closed kinetic chain exercises can be incorporated minimal weight bearing below 90 e.g. Prayer position
• Encourage use of the hand whilst in the sling for light activities such as writing, feeding

NOTE: Research demonstrates that patients who engage their hand on the side of the operated shoulder during the immobilisation phase of rehabilitation generally have better outcomes in relation to pain and function.

Guidance for exercise progression

• Good pain control
• Progressing range of movement
• Absence of compensatory movements such as hitching
• Exercise compliance

Middle Stage 4- 8 weeks

Goals of Rehabilitation

• Protect the bone/ soft tissue repair
• Gain and maintain the functional range of movement (ROM)
• Prevent compensatory movements
• Enhance proprioception
• Optimise recruitment of the dynamic stabilisers (ensure optimal subscapularis function)

Exercises

Mostly closed chain/arm supported exercises. Active range can progress range naturally at 6 weeks.

•  Progress active assisted/active supported range of movement aiming for full range by 6 weeks respecting pain
• Progress to active movements from 6 weeksrespecting pain
• Proprioception exercises e.g. weight-bearing activities: if stable can use this to help with scapula exercises. E.g. Table lean, wall lean +/- marching, can build to 4 point kneel.
• Progress cuff initiation and recruitment through range e.g. wall slides , lateral wall slides
• Specific subscapularis re-education and activation if indicated
• Strengthening of the rotator cuff, biceps ,triceps and deltoid but display caution with strengthening into external rotation due to repair
• Build global fitness as appropriate: core stability, fast walk to slow jog as able, static bike.

Guidance for exercise progression

• Pain free functional range of movement
• Good rotator cuff activation and control through functional range
• No muscle patterning under load

At 8 weeks the bone /soft tissue repair should be stable and patients should have been to
clinic and had an x-ray to check for healing at approximately 6 weeks post-surgery. However patients need to be assessed individually regarding the appropriateness of starting to specifically strengthen dependent upon operative findings, tissue quality, patients age and whether the it was a primary or revision surgical procedure