The shoulder is a complex joint formed by the socket-shaped glenoid fossa and the spherical head of humerus. Surrounding the glenoid fossa is the labrum, a type of fibrocartilage that supports joint stability and maintains the positioning of the humeral head within the glenoid fossa ¹. A Bankart injury occurs when the anterior labrum is torn, typically due to shoulder dislocations, and is often associated with sports-related injuries. A Bankart lesion generally involves the anterior region of the glenoid labrum and is often caused by recurrent anterior shoulder dislocations. Damage to the connective tissue ring of the glenoid labrum can result from these dislocations, leading to gleno-humeral ligament injuries due to repeated dislocations or inadequate reconstruction ².

Research indicates that individuals over 50 are more prone to developing bony Bankart lesions, whereas the median age for patients with primary ³. Low-energy falls are frequently the primary cause of these injuries. The aim of this research protocol is to develop an evidence-based physiotherapy method tailored for the post-operative management of Bankart lesions, focusing on improving patient outcomes and promoting successful rehabilitation techniques ^4.

The patient, a 21-year-old male, had a history of anterior right shoulder dislocations caused by falling on an outstretched arm. Initially, he avoided visiting the hospital and managed the injury by resting, which temporarily relieved the pain. After three years of unbearable pain, he consulted a doctor, who referred him to an orthopaedic specialist. Imaging and tests diagnosed right shoulder Bankart lesion, and surgery was scheduled two months later.

On examination the patient’s right glenohumeral joint range of motion was restricted for all the movements namely: Flexion, extension, abduction, adduction, internal rotation and external rotation ranging from 10 degree to 20 degree which is about 10% of the total range of motion as shown in the Table 2. Manual muscle testing (MMT) and Hand-held muscle dynamometer was used to check the muscle power of shoulder joint. The MMT showed muscle power ranging from 2+ to 3 out of 5 over all the muscle group namely flexors, extensor, abductors, adductors and rotators as shown in the Table 3. The hand-held dynamometer showed muscle power of 25 newtons to 65 newtons for all the muscle group of shoulder joint as shown in the Table 4. Following physical examination, a treatment program was immediately initiated as follows ^{5, 6, 7, 8, 9, 10, 11}:

Cryotherapy - To alleviate pain in the shoulder, cover the affected area with a towel and apply an ice pack while reclining in a comfortable position. Repeat this process three times a day for a week, with each application lasting 15 minutes.

Pendulum Exercise - Stand with one hand resting on a chair. Swing the opposite arm in a slow circular motion, forwards and backwards, while allowing it to hang freely. Repeat this exercise five times, two or three times daily.

Wand Exercise - Lie down on a firm bed and hold a piece of PVC piping around your waist with both hands. Maintain a straight elbow position as you move the piping from side to side and up and down. Perform 30 sets of this exercise three times a day.

Following this four-week rehabilitation program, the patient was permitted to gradually return to pre-dislocation training. At this time, he had regained full range of motion and strength compared to the unaffected limb.

The patient underwent four weeks of Physiotherapy management, where the changes of the Pain, Range of motion, Manual Muscle testing and Muscle strength were tabulated in the Table 1, Table 2, Table 3, Table 4. The Percentage of improvement in the Outcome values were graphically represented in the histogram as Figure 8, Figure 9, Figure 10, Figure 11.

When deciding on the best management approach for Bankart Lesion – traumatic anterior shoulder dislocations, surgeon chooses between operative and nonoperative treatments. The patient’s age at the initial dislocation plays a crucial role, as younger age is associated with a higher recurrence rate. Consequently, the literature suggests that a primary surgical approach might be advisable for younger individuals experiencing their first traumatic anterior dislocation ^{12, 13}. Hence, the Patient in my case underwent corrective surgery followed by physiotherapy management.

The primary goal of rehabilitation is to restore the patient to a pain-free state with high functionality as quickly and safely as possible. Rehabilitation of the shoulder following dislocation mainly focuses on improving the dynamic muscular restraints for shoulder stability. However, the evidence supporting rehabilitative exercises for managing anterior shoulder dislocations is limited ⁵. A recent Cochrane review found no randomized controlled trials (RCTs) addressing any aspects of conservative management, including rehabilitation, for anterior shoulder dislocations. Most literature on rehabilitation protocols is based on expert opinion, highlighting a significant lack of robust evidence for drawing definitive conclusions.

Following the available protocol for treating a Bankart lesion based on the evidence available includes, four weeks of cryotherapy, an exercise regimen, and strengthening exercises, the patient’s range of motion improved to 90%, and pain was reduced to zero on a 10-point visual analogue scale (see Table 1, Table 2). Additionally, the patient regained approximately 95% of muscle strength according to manual muscle testing and 86% in the hold test using a handheld dynamometer (see Table 3 and Figure 10). These results align with previous studies that demonstrated significant improvements in muscle power.

Functional activities such as household chores, lifting, and overhead tasks were initially unmanageable due to pain and limited range of motion. The patient first underwent pain management, followed by mobilization, strengthening, and finally plyometric exercises. This progression allowed the patient to successfully perform activities like throwing, overhead lifting, weight lifting, and sleeping on the operated shoulder. Swanik et al. (2002) demonstrated significant improvements in proprioception in subjects trained with plyometric exercises ^8. Similarly, Naughton et al. (2004) improved proprioception in fifteen subjects with previous anterior dislocations using an upper-body wobble board training regimen, where subjects stabilized themselves with shoulder movements while balancing on a wobble board with a Swiss ball under their pelvis ⁹. The current case study aligns with previous research regarding functional activity training as above.

Overall, this case study indicates a correlation between physiotherapy training and anterior shoulder instability. Anterior dislocations likely cause mechanical laxity, which alters motor control of the dynamic stabilizers and predisposes individuals to further shoulder injuries. Post-operative physiotherapy training can improve shoulder function and activity of daily life in bankart lesion.

The case study on evidence-based postoperative physiotherapy management for Bankart lesions demonstrated substantial improvements in shoulder range of motion, muscle strength, and functional activity.