Introduction
An efficiently functioning glenohumeral joint depends on the integrity and coordinated interaction of both static and dynamic components. The structures essential for maintaining normal shoulder function are particularly susceptible to injury and dislocation. Such dislocations frequently involve the glenoid labrum, bony rim, ligaments, capsule, and humeral head [1]. The incidence of anterior shoulder instability ranges from eight to 17 dislocations per 1,000 person-years. Anterior shoulder dislocation rates are notably high among young athletes, particularly in contact sports such as football and rugby [1–5]. Anterior shoulder instability has multiple causes; however, the capsulolabral complex and Bankart lesion are commonly observed in young patients. A Bankart lesion is characterized by an anterior and inferior detachment of the labrum from the glenoid, along with capsuloligamentous injury below the equator of the glenoid [6]. Arthroscopic techniques for anterior shoulder stabilization have advanced considerably over the past two decades [7]. The outcomes of arthroscopic Bankart repair (ABR) are comparable to those of open repair in terms of recurrence rates, range of motion (ROM), and complications [8–11]. Recent studies have indicated that athletes undergoing ABR exhibit a higher rate of return to sport (RTS) compared to those treated with other anterior shoulder stabilization methods [12]. However, the rate at which athletes experience RTS following ABR varies widely among individual studies [13].
Methods
The present study was a review based on a literature search; consequently, neither institutional review board approval nor informed consent was necessary.
The study involved a literature search of the Google Scholar and PubMed databases through February 18th, 2024. Keywords and terms like “arthroscopy Bankart repair” and “return to sports” were employed. The inclusion criteria specified that articles must be written in English and assess the relationship between ABR and RTS.
Results
The search yielded 11 relevant studies that satisfied the inclusion criteria (Table 1). These articles covered the timeframe from surgery to the resumption of athletic activities. Most studies suggest that athletes typically experience RTS approximately 6 months after surgery.
| No. | Study | Year | Sample (N) | Mean age (years) | Surgical technique | Return to sport |
|---|---|---|---|---|---|---|
| 1 | Hurley et al. [2] | 2021 | 156 | 28±8 | ABR | 12 weeks for contact in training, 6 months for full contact and competition |
| 2 | Harada et al. [6] | 2023 | 50 | 16.8±1.7 | ABR | 6.6±2.7 months (range, 3–18 months) for return to sport, 9.3±4.0 months (range, 6–24 months) for competitions, and 10.6±4.3 months (range, 8–24 months) for complete return |
| 3 | Porcellini et al. [15] | 2002 | 25 | 25.6 | ABR | 12 weeks for non-contact sports, 5 months for contact sports |
| 4 | Kelley et al. [32] | 2021 | 62 | 18± 7 | ABR | 6.5±0.7 months |
| 5 | Blonna et al. [33] | 2016 | 30 | >18 | ABR | 3–5 months for non-collision sports, 6 months for collision sports |
| 6 | Sedeek et al. [34] | 2008 | 37 | 26.3 | ABR | 3 months for non-contact sports, 4 months for contact sports |
| 7 | Ide et al. [40] | 2004 | 55 | 20 | ABR | 4 months for contact sports, 8.1 months for overhead sports, and 3.6 months for non-contact and non-overhead sports |
| 8 | Buckup et al. [41] | 2018 | 20 | 27.75 | ABR | 6 months for non-contact and non-overhead sports, 7 months for overhead and contact sports, and 10 months for competition |
| 9 | Gibson et al. [42] | 2016 | 34 | 23 | ABR | 11 weeks |
| 10 | Wilson et al. [43] | 2020 | 43 | 18.1±3.7 | Arthroscopic shoulder stabilization surgery | 6 months |
| 12 | Plath et al. [50] | 2015 | 66 | 29.3±10.4 | ABR | 3 months for specific training, 6 months for overhead and high-contact sports |
Discussion
A Bankart lesion is characterized by an anterior and inferior detachment of the labrum from the glenoid, accompanied by an injury to the capsuloligamentous structures below the equator of the glenoid (Fig. 1). This type of lesion commonly results from a traumatic anterior glenohumeral dislocation and is particularly prevalent among younger individuals [14]. Additionally, a traumatic anterior glenohumeral dislocation can lead to an avulsion fracture of the anterior glenoid rim, which is termed a bony Bankart lesion [15–17]. The extent of bone loss is a crucial determinant in the likelihood of recurrent glenohumeral instability following stabilization surgery [18].
Shoulder instability manifests through the disruption of the dynamic and static stabilizing elements of the glenohumeral joint, which can result in dislocation, subluxation, or a sensation of apprehension accompanied by pain. The stability of the shoulder is maintained by the glenoid labrum, the glenohumeral ligament complex, negative intra-articular pressure, and articular conformity. Furthermore, the rotator cuff and scapular stabilizers represent key dynamic contributors to shoulder restraint [1].
Anterior dislocation is the most common type of shoulder dislocation, accounting for approximately 97% of these injuries [19]. Anterior dislocation typically occurs when an individual falls with the arm abducted and externally rotated, causing the posterosuperior aspect of the humeral head to impact the anteroinferior aspect of the glenoid rim. This can result in damage to the humeral head, the glenoid labrum, or both (Fig. 2). Additionally, an indentation may develop on the humeral head due to a compression fracture, occurring when the humeral head is forced against the anterior glenoid rim during dislocation [20]. Rotator cuff injuries can arise in more than 50% of elderly patients [21].
Patients with a history of shoulder dislocation face an increased risk of recurrent dislocation. This often occurs due to inadequate tissue healing, laxity, and high levels of activity. Moreover, patients who have sustained rotator cuff tears or glenoid fractures are at a heightened risk of recurrent dislocation [19]. Another critical factor is glenoid bone loss exceeding 20%, which significantly contributes to recurrent anterior shoulder instability [22].
Regarding the recurrence rate of instability after ABR, research indicates a higher occurrence among younger patients [7]. In one study, patients aged 22 years or younger experienced a recurrence rate after ABR of 13.3%, whereas older patients exhibited a rate of 6.3% [23]. Similarly, another study reported a recurrence rate of 51% among contact athletes aged 18 years or younger, compared to a 12% recurrence rate in a group of 25-year-old athletes [24]. Moreover, their findings indicated that the risk of recurrence among adolescent athletes was 2.2 times greater in athletes younger than 16 years old compared to those older than 16 years. However, the recurrence rate varies based on the type of sport, with contact and collision sports—such as rugby and American football—displaying exceptionally high recurrence rates [6]. In soccer, one study reported that goalkeepers have a recurrence rate more than eight times higher than field position players and experience worse functional outcomes. Goalkeepers often stop high-velocity shots with their hands, dive with outstretched arms, and forcefully throw balls, all actions that increase their risk of shoulder injury [25].
In a retrospective study of 271 patients who underwent primary ABR for anterior shoulder instability, researchers found that off-track Hill-Sachs lesions (HSL)—those that extend medially beyond the glenoid track—were associated with a higher risk of anterior engagement and instability compared to on-track HSL. The rate of surgical revision for patients with off-track HSL was 48% at an average follow-up of 53.5 months, while the rate for those with on-track HSL was 13% at an average follow-up of 42.3 months [22]. Another study, which included 100 recreational athletes who received ABR and were followed for an average of 12.7±2.1 years, revealed a 19% rate of subjective apprehension and a 19% rate of redislocation. Additionally, gradual declines were noted in clinical outcomes and sports activity levels over time. Surgeons are advised to carefully select candidates for ABR by considering risk factors such as the presence of off-track lesions, age under 20 years, and participation in contact sports [26].
The findings regarding follow-up procedures after primary anterior shoulder dislocation consistently support the use of ABR. Relative to ABR, a significantly higher recurrence rate of instability was observed after conservative treatment. Consequently, it is logical to anticipate the need for additional future procedures in patients initially treated conservatively. A key consideration is that instability frequently results in symptoms that can disrupt patients’ engagement in sports activities [27].
Postoperative rehabilitation therapy is essential for promoting the recovery of shoulder motion and strength, enabling patients to resume functional activities sooner and ultimately resulting in greater patient satisfaction [27–31]. The postoperative rehabilitation guidelines reported in the literature vary considerably, and broadly accepted guidelines for rehabilitation following ABR for anterior shoulder instability do not yet exist [31]. Kelley et al. presented a postoperative rehabilitation protocol for patients who have undergone ABR, including 2 years of follow-up. The specifics of this rehabilitation protocol are detailed in Tables 2, 3 [32].
ABR was identified as having the highest rate of RTS across all age groups, surpassing other stabilization procedures such as open Bankart repair, open Latarjet, and arthroscopic Latarjet procedures [6,33]. A cohort study by Blonna et al. compared 30 participants undergoing ABR with 30 participants undergoing the open Bristow-Latarjet procedure, resulting in a higher Subjective Patient Outcome for Return to Sports score in the ARB group [33]. A systematic review of 16 articles evaluated the RTS rate after various surgical anterior shoulder stabilization techniques, revealing the highest RTS rate among athletes who underwent ABR (97.5%). Other procedures examined included open Bankart repair (86.1%), open Latarjet procedure (83.6%), minimally invasive Latarjet procedure (94.0%), and ABR with remplissage (95.5%) [12].
Goals for ABR in young athletes include restoring shoulder function and enabling RTS at pre-injury levels [6]. Shoulder stabilization for Bankart lesions can be achieved through two methods: arthroscopic surgery or open surgery. Both treatments involve reattaching the torn labrum to the glenoid [34]. A review focusing on the RTS in teenagers following surgical stabilization reported an overall return rate of 95%, with 77% of patients reaching pre-injury levels of performance [6]. Various criteria were used to assess the athletes’ readiness to RTS, such as time elapsed since surgery, type of sport, strength, ROM, pain, and proprioception [35–37]. The type of sport played was linked to outcomes such as RTS failure or complete RTS.
The most common criterion for return to play (RTP) was the time elapsed since surgery, indicating a minimum duration between the surgical procedure and the athlete’s capability to RTP [36]. A retrospective study of 50 teenage athletes who underwent ABR revealed that the average time for RTS was 6.6±2.7 months, with a range of 3 to 18 months. The time to return to competitive play averaged 9.3±4.0 months (range, 6 to 24 months), while achieving a complete return to pre-injury levels took 10.6±4.3 months (range, 8 to 24 months) [6]. A systematic review encompassing 58 studies reported that the timeframe for RTS post-surgery varied from 1.5 to 12 months, with a return after 6 months being the most cited duration [37]. Another systematic review, which included 34 studies, found that patients were typically allowed to RTS after a mean of 5.7 months (range, 1.9 to 32 months) following surgery [13]. More recently, a survey study involving 317 surgeons from the United States and Europe indicated that the most frequently recommended time for athletes to resume sports was 4 months after surgery. However, most of these surgeons advised waiting an additional period, most often 2 months, before granting athletes clearance to RTS [38].
The type of shoulder sport played can influence the likelihood of RTS. Allain et al. categorized sports that place strain on the shoulder into four distinct groups, as shown in Table 4 [39].
| Group | Shoulder sport |
|---|---|
| G1 | Non-collision/non-overhead |
| G2 | High-impact/collision |
| G3 | Overhead |
| G4 | Martial arts |
A study by Ide et al. reported that overhead athletes exhibited the lowest rate of complete RTS at 68%, compared to contact athletes and non-contact/non-overhead athletes, who had respective return rates of 86% and 100% [40]. Another study suggested that athletes should only return to overhead sports after 7 months post-surgery, and they should wait until 10 months after surgery before returning to competitive sports. Additionally, it is expected that athletes who participate in overhead sports will fully recover their external rotation capacity following ABR. Failure to achieve this recovery could negatively affect sports-related outcomes [41]. Gibson et al. found that ABR, combined with an accelerated rehabilitation program, allows professional football players to RTP relatively quickly, with an average time of 11 weeks [42].
Strength is a challenging parameter to measure objectively due to the influence of various factors. A total of 25 studies have incorporated muscle strength within RTS criteria, including achievement of complete strength restoration, pre-injury strength levels, at least 80% of the strength of the contralateral side, strength comparable to the contralateral side, symmetric strength in abduction and external rotation as determined by manual testing, grade 5 strength in all intrinsic and extrinsic shoulder muscles, and strength that equal to or exceeding baseline values [36]. A retrospective study assessed strength recovery post-surgery using isokinetic and isometric devices to provide an objective evaluation. However, the findings in the literature are inconsistent, and functional goals were more frequently achieved than strength criteria [43]. A systematic review investigated the strength criteria for RTS. However, the results were inconsistent, and the studies did not uniformly assess strength with the same type of device [37].
The assessment of shoulder ROM involves evaluating both active and passive movements to ensure that the athlete demonstrates symmetrical, full, and sport-specific ROM without experiencing pain or apprehension [36,44].
Another important factor for RTS is the assessment of pain following ABR. Pain is considered a criterion for RTS, but it always appears in conjunction with other criteria. In this context, pain has been defined as the presence of “non-painful ROM” and being “pain-free” during physical examination or participation in sports. Here, key distinctions must be made. For the general population, a complete absence of pain is not a prerequisite. However, for athletes who aim to return to their sports activities and achieve pre-injury performance levels, being pain-free is essential [37,45].
To date, few studies have included shoulder proprioception as a criterion for RTP. Tambe et al. noted an improvement in shoulder proprioception as an RTP criterion, yet the study did not detail the specific assessment modality employed [46].
The rate of RTS at pre-injury levels varies widely according to the studies available, with figures ranging from 31% to 100% [13,37,47]. Memon et al. assessed the RTS in 1,866 patients following ABR. Their study found that 82% of competitive athletes accomplished RTS, and 88% of those returned to their pre-injury levels [13]. Abdul et al. examined RTS rates after shoulder stabilization surgery and reported a 97.5% RTS rate, with an average time of 5.9 months post-ABR [12]. Harada et al. observed high RTS rates in a cohort of 50 young athletes, with nearly all participants resuming sports; 96% returned to competitive play, and 76% fully regained their pre-injury performance levels without any complaints [6]. A systematic review that included 11 studies with 392 adolescent athletes who underwent ABR revealed a 79.8% return rate to sports at pre-injury levels [48]. In the sport of soccer, the RTS rate at the same level was significantly lower for goalkeepers compared to field players [25].
Athletes who experience injuries often face negative psychological responses, including depression, anxiety, irritability, and a lack of confidence. These psychological reactions can affect a patient’s decision to RTS, even after ABR [49]. A retrospective study evaluated patients who underwent ABR and did not RTS over a 24-month follow-up period. The study reported that 51.9% of patients harbored a persistent fear of re-injury, 25.0% believed their injury signified the natural conclusion of their athletic career, 15.4% felt that their lifestyle had changed, 11.5% experienced persistent pain, and 7.7% were unable to RTS due to other injuries [2]. In research by Tjong et al. involving 25 patients, several reasons were identified for not returning to sport after ABR, including fear of re-injury, a shift in priorities, mood disturbances, social support, and a lack of motivation [49]. Plath et al. reported that among athletes who did not RTS after ABR, the primary reasons were non–shoulder-related factors, followed by concerns about potential re-injury [50]. A recent study underscored kinesiophobia—fear of movement—as a prevalent factor affecting patients’ psychological readiness to RTS. Psychological interventions, such as cognitive-behavioral therapy and mindfulness, have been proposed to potentially improve RTS rates in these patients [51].
ABR results in a high percentage of athletes returning to athletic activities, leading to the development of various criteria to support the RTP. Most surgeons advise athletes to wait 6 months after surgery before resuming sports, to regain at least 80% of the strength in the contralateral limb or a level of strength comparable to that prior to the injury, to achieve a full or symmetrical ROM without pain, and to demonstrate improved shoulder proprioception. However, the type of sport also influences the rate of RTS, with overhead sports displaying the lowest return rates. While many athletes successfully return to their previous level of competition, some may experience adverse psychological responses during the process.
