Hill-Sachs Lesion & Bankart Lesion

Bankart Lesion

Definition

Types

Epidemiology of Glenoid Bone Loss

• Present in 40% of first dislocations, and 85% of recurrent dislocations
• Significant bone loss = >20–25% of glenoid width (~6–8 mm) — associated with higher recurrence rates after Bankart repair (recurrence rate jumps from 4% to 67%) — Miller's Review of Orthopaedics, 9th ed.
• Bone fragments in bony Bankart lesions undergo rapid absorption within 1 year of injury

Hill-Sachs Lesion

Definition

Incidence

• 40% of patients with recurrent subluxations (no frank dislocation)
• 90% of first-time dislocations
• Nearly 100% of recurrent dislocations

Engaging vs. Non-Engaging

• An engaging Hill-Sachs lesion is oriented such that, when the shoulder is placed in abduction + external rotation, the defect engages the anterior glenoid rim — causing the humeral head to slip off the glenoid → recurrent instability

On-Track vs. Off-Track Concept (Bipolar Bone Loss)

Glenoid Track = 0.84 × glenoid diameter Hill-Sachs Interval = distance from rotator cuff footprint to medial margin of the Hill-Sachs lesion

• On-track: Hill-Sachs interval ≤ glenoid track → low failure risk → arthroscopic Bankart repair alone is appropriate
• Off-track: Hill-Sachs interval > glenoid track → high recurrence risk → requires remplissage (filling in the Hill-Sachs defect) or Latarjet procedure (bone block to glenoid)

Reversed Lesions (Posterior Dislocation)

• Reverse Hill-Sachs lesion (also called McLaughlin lesion): impaction fracture on the anterior humeral head
• Reverse Bankart: fracture/labral tear at the posterior glenoid rim

MRI Appearance

Imaging Summary

Recurrence Risk After First Dislocation

Treatment Principles

• Arthroscopic Bankart repair (ABR): Standard for soft-tissue lesions with adequate bone stock (on-track)
• Remplissage: Arthroscopic procedure that fills the Hill-Sachs defect with posterior capsule/infraspinatus tendon — for off-track lesions
• Latarjet procedure: Coracoid transfer to the anterior glenoid — for >25% glenoid bone loss or off-track lesions
• Bipolar lesions: Prevalence rises from 33% (primary instability) to 62% (recurrent instability); postoperative recurrence is 29% when both lesions are present — Rockwood & Green's Fractures in Adults, 10th ed.

Physiotherapy for Hill-Sachs & Bankart Lesion (Anterior Shoulder Instability)

Conservative (Non-Surgical) Physiotherapy

Who qualifies for conservative management?

• Primary dislocation in patients under 14 years — physical therapy + rotator cuff/deltoid strengthening
• Low-demand patients over 30 years — physical therapy is treatment of choice
• Active patients aged 14–30 without a Bankart lesion on MRI arthrogram — trial of PT + strengthening
• Multidirectional instability (AMBRII) — rehabilitation is the first-line treatment, focusing on rotator cuff and deltoid strengthening before considering surgery — Rockwood & Green's Fractures in Adults, 10th ed.

Surgery is indicated for patients who have recurrence of instability after a trial of physical therapy.

Post-Reduction Protocol

"The most important post-reduction therapy is a rehabilitation program aimed at restoring the static and dynamic stabilizers of the GHJ." — Rosen's Emergency Medicine

Goals of Conservative Physiotherapy

• Posterior capsule stretching (if tight)
• Avoid excessive anterior capsule stretching

• Rotator cuff strengthening — subscapularis (primary dynamic anterior stabilizer), infraspinatus, teres minor, supraspinatus
• Deltoid strengthening — provides superior compressive force
• Periscapular muscle strengthening — trapezius, serratus anterior, rhomboids (for scapular control)

• Closed kinetic chain exercises (wall push-ups, quadruped rhythmic stabilization)
• Joint position sense retraining
• Perturbation training

Post-Operative Physiotherapy (After Bankart Repair or Latarjet)

Phase I — Weeks 0–4 (Protection Phase)

• Sling with abduction pillow
• Passive ROM (supine):
  • Forward flexion → goal 90°
  • External rotation → goal 25°
• Elbow and wrist active + passive ROM
• Modalities: ice, TENS, ultrasound for pain and edema control
• No active shoulder movement
• Scapular retraction exercises (pain-free)

Phase II — Weeks 4–8 (Active Assisted ROM Phase)

• Gradually wean from sling
• Transition passive ROM → active assisted ROM
  • Forward flexion → goal 120°
  • External rotation progressed carefully
• Begin submaximal isometric rotator cuff exercises
• Pendulum exercises
• Scapular stabilization exercises
• Closed kinetic chain exercises (wall slides)
• Hydrotherapy if available

Phase III — Weeks 8–14 (Active ROM / Early Strengthening Phase)

• Restore full ROM in flexion and external rotation
• Begin isotonic rotator cuff strengthening:
  • Internal rotation (subscapularis)
  • External rotation (infraspinatus, teres minor)
  • Abduction, scaption (supraspinatus)
• Periscapular strengthening (rows, lat pulldowns)
• Proprioceptive neuromuscular facilitation (PNF) patterns
• Progress to light resistance band exercises

Phase IV — Weeks 14–22 (Advanced Strengthening & Functional Phase)

• Progressive resistance training
• Plyometric shoulder exercises (light ball throws, rhythmic stabilization)
• Sport-specific drills
• Overhead activity progression (if applicable)
• Return-to-sport criteria:
  • Full pain-free ROM
  • Strength symmetry ≥90% compared to contralateral side
  • Negative apprehension/relocation test
  • Satisfactory neuromuscular control

Phase V — Weeks 22+ (Return to Sport)

• Full unrestricted activity typically at 5–6 months post Bankart repair
• Contact athletes may require up to 9–12 months
• Maintenance strengthening program ongoing

Key Muscles to Target

Special Considerations

Immobilization Position — A Note

• Traditional position: internal rotation sling
• Newer evidence: external rotation bracing showed initial promise in reducing redislocation by keeping subscapularis taut and reducing strain on anterior capsule — however, meta-analyses show no definitive difference between IR and ER immobilization — Miller's Review of Orthopaedics, 9th ed.