What year did he first start
coaching at Penn State?
1950
What was the number of victories
while on the sidelines of Penn
State?
62% of all Penn State Victories
• 513 victories (104 as an
assistant and 406 as a
coach)
• Total Wins for Penn
State is 827
Shoulder Capsular Anatomy
• 1. Superior Glenohumeral Ligament
• 2. Middle Glenohumeral Ligament
• 3. Anterior band of Inferior
Glenohumeral Ligament
• 4. Inferior Glenohumeral ligament
complex /
Axillary Pouch
• 5. Posterior band of inferior
glenohumeral
ligament
• 6 . Posterior capsule
• 7. Long head of Biceps tendon
• 8. Supraspinatus, Infraspinatus, Teres
minor
tendons
• 9. Subscapularis tendon
• 10. Glenoid
Bankart lesion
Bankart lesion
• The Bankart lesion is a
specific injury to a part of
the shoulder joint called
the labrum. The shoulder
joint is a ball and socket
joint, similar to the hip;
however, the socket of
the shoulder joint is
extremely shallow, and
thus inherently unstable.
Bankart lesion
• To compensate for the shallow
socket, the shoulder joint has
a cuff of cartilage called a
labrum that forms a cup for
the end of the arm bone
(humerus) to move within.
•
This cuff of cartilage makes
the shoulder joint much more
stable, yet allows for a very
wide range of movements (in
fact, the range of movements
your shoulder can make far
exceeds any other joint
Bankart lesion
• When the labrum of the
shoulder joint is torn, the
stability of the shoulder
joint is compromised.
• A specific type of labral
tear is called a Bankart
lesion.
• A Bankart lesion occurs
when an individual sustains
a shoulder dislocation.
Bankart lesion
•
As the shoulder pops out of joint, it
often tears the labrum, especially in
younger patients.
•
The tear is to part of the labrum
called the inferior glenohumeral
ligament. When the inferior
glenohumeral ligament is torn, this is
called a Bankart lesion.
Bankart lesion
• is an injury of the anterior (inferior) glenoid labrum due to
repeated (anterior) shoulder dislocation.
• When this happens, a pocket at the front of the glenoid
forms that allows the humeral head to dislocate into it.
• often accompanied by a Hill-Sachs lesion, damage to the
posterior humeral head.
• It is named after Arthur Sydney Blundell Bankart, an
English orthopaedic surgeon, who lived from 1879-1951.
Bony Bankart
• is a Bankart lesion that
includes a fracture in of
the anterior-inferior
glenoid cavity of the
scapula bone.
• Bankart lesion = avulsion of the anteroinferior
capsulolabrum.
• Bony Bankart = fracture of the anteroinferior
glenoid.
• Occurs in 97% of first time acute traumatic
dislocations in young patients. (Taylor DC, AJSM
1997;25:306).
Shoulder Dislocation
• Bankart lesion is a
common injury.
• Because the glenohumeral
ligament helps maintain
the shoulder in proper
position, a Bankart lesion
(a tear of the inferior
glenohumeral ligament),
will make the shoulder
prone to repeat dislocation.
chances of a repeat dislocation after a
Bankart injury?
• Depend on the age of the patient.
• Younger patients are most likely to sustain a Bankart injury if their
shoulder dislocates, and are therefore more likely to have a
repeat, or recurrent, dislocation.
• Statistically, the chances of redislocating the shoulder are greater
than 80% in patients younger than 30 years of age.
•
• Over 30 years old, the chance of a repeat dislocation drops
significantly.
Symptoms of a Bankart Lesion
•
•
•
•
•
a sense of instability
repeat dislocations
catching sensations
aching of the shoulder
Often patients will complain that they cannot
"trust" their shoulder, fearing it may
dislocate
Signs and Symptoms
• The most common symptom of a bankart tear is pain. Following a
shoulder dislocation, moderate to severe pain is felt, especially within
the first several days after injury.
• Popping or feelings of instability are another common problem
associated with Bankart tears. Your shoulder labrum acts as a bumper
for the shoulder socket, helping to keep your humerus in place. If this
bumper is displaced, it allows your humerus to move too far forward and
down within the joint, causing feelings of instability.
• The torn portions of the labrum may also become caught within the
joint, causing popping or feelings of the shoulder locking up.
• Weakness of the muscles and loss of range of motion are also common
symptoms associated with bankart lesions.
Diagnosis of a Bankart Lesion
• Most young patients (under the age of 30) who sustain a
shoulder dislocation will sustain a Bankart lesion; therefore,
there is a high suspicion of this injury whenever a patient
dislocates their shoulder.
•
On examination, patients will often have a sense their
shoulder is about to dislocate if their arm is placed behind
their head.
Bankart Clinical Evaluation
•
Occurs following traumatic dislocation. May have clicking or popping with shoulder
motion.
•
Apprehension Test: examiner applies anteriorly directed force to the humeral head with
the shoulder in abduction and external rotation. Positive result is the patient felling that
the shoulder is going to dislocate.
•
Relocation Test: posteriorly directed force is applied to the humeral head with patient in
abduction and external rotation (Apprhension Test position). Positive result is relief of the
feeling of impending dislocation.
•
Load and shift:
•
Sulcus sign: distraction force is applied to the arm with the patient seated with are at the
side. The magnitude of displaced and any apprehension sensations are compared to the
contralateral limb. Any abnormalities indicated inferior instability.
•
Evaluate axillary nerve function
Rotatory Stress Test
• -was developed to
reliably test for
anterior instability of of
the shoulder;
• in most cases, the test
will identify a Bankart
Lesion, but on
occassion the test will
pick up a Hagl lesion
(avulsion of IGHL);
test begins on normal side;
- w/ the arm supported in the
surgeon's axilla, and one hand
translates the shoulder anteriorly;
- the shoulder is then abducted and
externally rotated;
- the shoulder is again translated
anteriorly;
- w/ a normal inferior glenohumeral
ligament, anterior translation should
decrease markedly;
Xray / Diagnositc Tests
•
A/P and Lateral view in the plane of the scapula, and axillary view. Generally normal.
•
West Point view: patient prone with arm in 90° abduction and neutral rotation. Xray beam is
directed 25° posterior to the horizontal plane and 25° medial to the vertical plane. Useful for
evaluating the anterior glenoid rim / bony bankart lesions.
•
Hill-Sachs lesion: impression fracture of the posterosuperior aspect of the humeral head,
produced by contact with the anteroinferior glenoid when dislocated. Hill-Sachs lesion is
demonstrated on plain AP radiograph in internal rotation.
•
CT scan is best to evaluate bony anatomy and should be considered for the recurrent dislocator
suspected of having a large Hill-Sachs or bony Bankart lesion.
•
MRI arthrogram (gadolinium): the anterior and posterior labrum are best seen on axial images
and appear as dark triangular structures. Bankart lesions appear as a loss of the normal triangular
shape or contrast material may extend between the labrum and glenoid( acute injuries.) Chronic
injuries may scar down to the glenoid and be difficult to see by MRI.
X-Rays
• X-rays are sometimes normal, but they may show an injury
to the bone called a Hill-Sachs lesion.
• This is a divot of bone that was injured when the shoulder
dislocation occurred. A MRI may also be obtained in patients
who are suspected of having a Bankart lesion.
• Bankart lesions do not always show up well on MRI scans.
• When a MRI is performed with an injection of contrast, a
Bankart lesion is much more likely to be seen.
Radiographs:
• - West Point Axillary
View: may identify
bony Bankhart;
•
- Stryker Notch
Classification / Treatment
•
•
Consider primaryAnterior instability repair for hightly athletic young (<25y/o) patients with MRI confirmed
Bankart lesions.
•
Bony Bankart Lesion:
-If >25% of the glenoid is involved in a bony-Bankart lesion (anterior rim fracture) the joint will be
unstable without ORIF of the bony lesion, or bone grafting the defect. (Bigliani LU, AJSM 1998;26:41)
•
-Glenoid bone loss (inverted pear glenoid) can be assessed arthroscopically. A 25% reduction in the length from
the anterior glenoid to the bare spot in the center of the glenoid compared to the distance from the
posterior rim to the bare spot indicates glenoid deficiency and the need for ORIF of the bony lesion, or
bone grafting the defect. (Burkhart SS, Arthroscopy 2002;18:488)
•
-Arthroscopic repair techniques: (Sugaya H, JBJS 2006;88Am:159), (Millett PJ, Arthroscopy 2008),
•
-Chronic Anterior Instability with Glenoid deficiency: Glenoid deficiency greater than 25% generally requires
treatment (bone grafting vs coracoid transfer). Treatment options = Latarjet procedure (Allain J, JBJS
1998;80:841), (Burkart S, AJSM), Tricortical iliac crest great (Warner JJ, AJSM 2006:34:205), Open
anterior soft tissue stabilization [large defects loose @7ºER] (Pagnani M, JBJS 2008;36A:1805).
•
Engaging Hill-Sachs lesions: consider grafting defect arthrscopically using synthetic bone plugs (Smith&
Nephew), or Arthroscopic Hill-Sachs remplissage with arthroscopic posterior capsulodesis and
infraspinatus tenodesis. (AAOSNow June2007).
Associated Injuries / Differential
Diagnosis
•
Hill-Sachs lesion: impression fracture ot the humeral articular surface caused by translation of the
humeral head over the glenoid rim. Found in @85% of anterior dislocations. If >25% of the
articular surface is involved allograft or autograft bone graft to repair the defect is indicated
•
SLAP
•
RTC Tear
•
Shoulder Instability
•
HAGL lesion
•
ALPSA: anterior labroligamentous periosteal sleeve avulsion; medialized Bankart with medial
displacement of the torn anterior labrum.
•
Perthes lesion: nondisplaced labral tear
•
GLAD lesion: glenolabral articular disruption: nondisplaced anterior labral tear associated with
articular cartilage injury.
Treatment
• There are two general options for the treatment of a
Bankart lesion.
• One option is to allow the arm to rest, and the
inflammation to subside with the use of a sling.
• This is usually followed by physical therapy to regain
motion of the extremity.
• The potential downside of this option is that people who
dislocate a shoulder once are much more likely to
dislocate the shoulder again.
Initial Treatment
•
for a shoulder dislocation is centered around the R.I.C.E. principles, as well as immobilization of
the shoulder to allow the tissues to heal. Labral tears are considered a secondary problem with
shoulder dislocations.
•
If you have a dislocation, you will most likely have to have the shoulder reduced or put back into
place by a physician. You will be given a sling to wear, and may be referred for an MRI.
•
MRI of the shoulder will often show damage to the joint capsule, but it may not pick up on a
labral tear. That is why many surgeons order an MRI Arthrogram.
•
This procedure involves injection of a dye into the shoulder joint and then an MRI to see if any of
the dye escapes from the shoulder capsule.
•
If you have a labral tear, the area that is torn will allow the dye to move out of the shoulder joint.
Although MRI Arthrograms are much better to find labral tears than a regularr MRI, there is still a
good chance that you may have a negative MRI but still have a tear.
Is surgery after an initial dislocation
recommended?
•
Some orthopedic surgeons recommend surgery to repair a Bankart lesion after a
shoulder dislocation in young athletes.
•
The usual treatment is a period of rest, followed by aggressive physical therapy.
•
Then a gradual return to activities. If the shoulder dislocates again, surgery is
usually considered.
•
However, some orthopedic surgeons will repair a Bankart lesion after one
dislocation in young athletes.
•
Because the chance of repeat dislocation is so high, especially in athletes who
participate in contact sports, this type of immediate Bankart repair can be
justified.
Surgery or no Surgery
• there is no reason why surgery cannot be delayed, and physical
therapy can be attempted.
• It is important to remember that a Bankart repair is a significant
surgery, and recovery is not easy. Physical therapy can be
attempted, but the patient must understand that a repeat
dislocation is possible.
• The only concern is that a Bankart repair takes AT LEAST six
months to heal, and many patients want to return to activity as
soon as possible, without worrying about a repeat dislocation.
• Patients over 30 generally do not need surgery unless repeat
dislocations become a problem.
Surgery
• When surgery is performed, the torn labrum of the Bankart
lesion is reattached to the socket of the shoulder.
• The results of surgery are usually very good, with over 90%
of patients returning to their activities without any further
dislocations.
• More and more commonly this surgery is being performed
arthroscopically; however, there are indications in some
patients who should have a Bankart repair performed
through a standard incision.
Anatomy
•
Labral functions: origin of many capsuloligamentous structures, increases the depth of the
glenoid socket, facilitates the cavity-compression mechanism.
•
Blood supply: the labrum receives its blood supply from the suprascapular artery, circumflex
scapular branch of the subscapular artery, and the posterior circumflex humeral artery.
•
Anterior band of the IGHL is the primary restraint to anterior translation at 90° abduction.
•
Buford complex is a normal labral variation.
•
Perthes lesion = nondisplaced tear of the anteroinferior labrum held in position by an intact
medial scapular periosteum.
•
APLSA lesion = anterior labroligamentous periosteal sleeve avulsion, similar to Perthes lesion
except labrum is displaced. (Neviaser TJ, Arthroscopy 1993;9:17).
•
HAGL lesion = humeral avulsion of the glenohumeral ligaments.
Bankart Complications
•
Recurrent instability, Hardware failure, Anchor pull-out, Infection, Stiffness, CRPS, Nerve or vascular injury, Chondrolysis,
Hematoma, Chondral Injury, inability to return to sport, incomplete relief of pain, and Arthritis
•
Recurrent instability / failure
•
Hardware failure / Anchor pull-out
•
Infection
•
Stiffness
•
CRPS
•
Nerve injury: Axillary nerve, Brachial plexus
•
Fluid Extravasation:
•
Chondrolysis: though to be related to heat from electo cautery or radiofrequency probes used during capsular release or capsular
shrinkage.
•
Hematoma
•
Chondral Injury / arthritis
Follow-up Care
•
Post-Op:Shoulder immobilizer. Begin pendelum ROM, elbow/wrist/hand exercises immediately.
•
7-10 Days: continue shoulder immobilizer for 4-6weeks. Start Physical therapy, active assist and
active ROM; No external rotation past 40 degrees for 6 weeks.
•
6 Weeks: discontinue shoulder immobilizer. Progress with strengthening exercises.
•
3 Months: Progess with ROM and strengthening, start sport specific training.
•
6 Months: Return to sport if patient has full ROM, near full strength and no apprehension.
•
Anterior Instability Rehab Protocol.
•
Shoulder Outcome measures
•
Outcomes: 90% excellent or good results, 10% recurrent instability . Average ASES score = 92 of
100 points. Patient satisfaction = 8.9 on a 10-point visual analog scale. (Carreira DS, AJSM
2006;34:771). 11% recurrence for collision/contact athletes (Mazzoca AD, AJSM 2005;33:52).
Rehabilitation
•
After a shoulder dislocation, conservative shoulder rehabilitation that focuses on
restoring your range of motion, strength, and shoulder function is a good idea.
The goal is to try to avoid surgery if possible.
•
Depending on the severity of your injury, you may be able to avoid surgery with
proper rest and rehab. However, if you have a Bankart lesion or other labral tear,
you may have instability and require labral repair surgery.
•
Make sure that you follow your physicians instructions after your injury and go
through rehabilitation to restore your shoulder back to normal.
Summary
•
•
A Bankart lesion is a type of labral tear that occurs in the inferior and anterior
portion of the glenoid labrum. It is very common with shoulder dislocations. An
MRI Arthrogram is the best way to determine if you have a bankart tear. Rest and
rehabilitation are the keys to recovery, however many times this injury requires
surgical intervention to return your shoulder to normal.
Hagl Lesion:
• avulsion of inferior
ligament from the
humerus;