Bankart Lesion – Causes, Symptoms, Diagnosis, Treatment

A Bankart lesion is an injury of the anterior (inferior) glenoid labrum of the shoulder due to anterior shoulder dislocation. It is characterized as a detachment of the anteroinferior capsulolabral glenoid complex, resulting in loss of labral height and elongation of the anterior band of the inferior glenohumeral ligament.[rx] This anatomical defect was described by Bankart as the “essential lesion,” responsible for the perpetuation of shoulder instability. When this happens, a pocket at the front of the glenoid forms that allow the humeral head to dislocate into it. It is an indication for surgery and often accompanied by a Hill-Sachs lesion, damage to the posterior humeral head.^[rx]

A Bankart lesion is the avulsion of the anteroinferior capsule and labrum from the glenoid rim and is usually associated with a traumatic anterior glenohumeral dislocation in a young population.^[rx,rx] A traumatic anterior glenohumeral dislocation may also be associated with an avulsion fracture of the anterior glenoid rim. This is known as a bony Bankart lesion and the amount of bone loss is an important factor in recurrent glenohumeral instability.^[rx–rx] The Bankart lesion is named after English orthopedic surgeon Arthur Sydney Blundell Bankart (1879–1951).^[rx] A bony Bankart is a Bankart lesion that includes a fracture of the anterior-inferior glenoid cavity of the scapula bone.^[rx]

Types of Bankart Lesion

Bankart lesion is often associated with the Hill-Sachs lesion due to their common mechanism of injury. Bankart Lesion may involve the labrum only (“soft Bankart“), or involve the glenoid bone itself (“bony Bankart”).

• The soft tissue Bankart lesion – involves injury to the anterior or anteroinferior glenoid labrum, the fibrocartilagenous structure that surrounds and deepens the bony glenoid.
• An osseous or bony Bankart lesion – (a, b) is a fracture of the anterior-inferior glenoid cortical rim on which the labrum rests
• Like the Hill-Sachs lesion – a Bankart lesion may result in anterior shoulder joint instability and recurrent dislocations.
• Perthes lesion – Perthes lesion is a variant of Bankart lesion in where there is a tear of the glenoid labrum, with an intact scapular periosteum. There is only minimal displacement of the torn anterior labrum in this case, and hence the lesions are difficult to understand and diagnose on routine MRI or MRA. MRA with the arm in ABER stretches the anteroinferior joint capsule, IGHL, and helps in better delineation of the lesion.[rx,rx] It is important to detect this on MRA as it can be missed on arthroscopy because of the minimal displacement it occurs.
• Anterior labroligamentous periosteal sleeve avulsion (ALPSA) – ALPSA lesion was first defined by Neviaser et al.[rx] as avulsion and medial rolling of the inferior labor-ligamentous complex structure along the scapular neck. This is an important diagnosis to make as the lesion can be easily missed on arthroscopy.[rx] An ALPSA lesion, during an operative procedure, needs to be converted to a Bankart lesion (reapposition of the medially rolled labrum to the glenoid rim) followed by a Bankart repair. The procedure needs relatively more expertise and more operating time. Preoperative proper knowledge of the severity of the lesion is useful for the operating surgeon and their team.
• Glenolabral articular disruption (GLAD) – As described by Neviaser[rx] a GLAD lesion consists of a superficial anterior-inferior labral tear associated with an anterior-inferior articular cartilage injury. The use of intra-articular contrast in the MRA helps to visualize small tears at the level of the anterior-inferior glenoid rim. GLAD lesions are usually not a cause of instability unless associated with other labral pathologies. They can present with clicking during shoulder joint movement.
• Superior labral anterior-posterior (SLAP) type 5 lesion – The SLAP lesion, described by Snyder et al,[rx] is an injury involving the superior aspect of the glenoid labrum, which includes the biceps tendon anchor. SLAP tears were initially classified into four distinct but related types of lesions. Maffet et al.[16] added three more types. Currently, ten types or patterns are recognized.[rx,rx] A sagittal MRI or MRA can demonstrate the complete extent of the labral tear.
• Humeral avulsion of glenohumeral ligament (HAGL) lesion – HAGL lesions are much less common than Bankart lesions as a cause of anteroinferior instability.[rx] On MRA, or in the presence of joint effusion, the normal distended axillary pouch is a U-shaped structure, which changes into a J-shape as the anterior band of the inferior glenohumeral ligament (IGHL) droops inferiorly.
• Bony humeral avulsion of the glenohumeral ligaments (BHAGL) lesion – In the BHAGL lesion, there is a small avulsed osseous fragment attached to the torn end of the humeral attachment of the IGHL.[rx]
• Glenoid avulsion of the glenohumeral ligaments (GAGL) lesion – Glenoid avulsion of the glenohumeral ligaments (GAGL) implies an avulsion of the IGHL from the inferior pole of the glenoid, without an associated inferior labral disruption[rx].
• Inferior ALPSA or cul-de-sac lesion – In this case, there is the medial displacement of both the anterior-inferior labrum and the IGHL under the inferior neck of the glenoid. On coronal MRI images, there is the characteristic greater medial displacement of the capsule (and IGHL) relative to the anteroinferior labrum[rx].
• Hill-Sachs lesion – Hill-Sachs lesion consists of a bony injury to the posterosuperior humeral head as a result of inferior displacement. In Hill-Sachs and reverse Hill-Sachs lesions, preoperative determination of the extent of bone loss is surgically important as greater than 30% loss increases the chance of repeated dislocations and necessitates bone grafting.
• Findings in posterior instability – Less common than anteroinferior instability, posterior instability represents only instability cases.[rx] It can occur as a component of multidirectional instability (MDI) as well as after trauma. The prevalence of posterior labral tears in patients with posterior instability is less and more variable. Ligamentous abnormality involving the posterior band of the inferior glenohumeral ligament may be seen in isolation or in posterior or anteroinferior instability.[rx]
• Reverse Hill-Sachs lesion – This consists of an anteromedial superior humeral head impaction fracture that is often associated with a reverse Bankart lesion (posterior glenoid labrum disruption).
• Reverse HAGL lesion – In posterior instability there is sometimes complete avulsion of the posterior attachment of the shoulder capsule and the glenohumeral ligament from the posterior humeral neck[rx] .
• Posterior GLAD lesion (focal posterior cartilage deficiency) – This lesion has been described recently and can be associated with posterior instability.[rx–rx]
  Posterior glenoid rim deficiency – In recurrent posterior instability, two shapes of the posterior-inferior glenoid – the “lazy J” and the “delta” shapes – are reported to be more often found than in normal subjects.[rx]
• Bennett lesion – It is an extra-articular crescentic posterior ossification associated with posterior labral injury and capsular avulsion. It is best visualized on CT; it may be missed on arthroscopy as it is extra-articular.[rx,rx]
• Rotator cuff interval tear – RCI tears typically do not appear as complete disruption of the fibers of its components but as thinning irregularity, or focal discontinuity of the rotator interval capsule[rx].

Causes of Bankart Lesion

Bankart lesions are frequently the result of high-energy trauma and sports injuries (either acute injuries or overuse injuries from repetitive arm motions). Though anyone can sustain this injury, young people in their twenties are most susceptible.

Possible causes of shoulder dislocations and lesions:

• Car accidents – A sudden blow to the shoulder can knock the ball from its socket, tearing the labrum.
• Sports collisions – Crashing into another person with speed and force — for example, during a football or hockey tackle  — can shove the shoulder out of alignment or drag the arm forward or backward, leading to dislocations.
• It Falls from sports – Falling and landing on one’s shoulder can lead to shoulder dislocations in athletes, especially in sports where falling with height or speed is common, like gymnastics, skating, rollerblading, or skiing. Sliding into bases during softball or baseball can also harm the shoulder.
• Falls not from sports – Falling off a ladder or tripping on a crack in the sidewalk can deliver enough force to dislocate the shoulder.
• Overuse injuries – In some athletes, overuse of the shoulder can lead to loose ligaments and instability. Swimmers, tennis players, volleyball players, baseball pitchers, gymnasts, and weight lifters are prone to this problem. In addition, non-athletes may develop instability from repeated overhead motions of the arm (for example, swinging a hammer).
• Loose ligaments  – Some people have a genetic predisposition to loose ligaments throughout the body (e.g., double-jointed individuals). They may find that their shoulders pop out of alignment easily. Treatment for these patients is often more complex.
• The acromioclavicular joint injury that also causes shoulder dislocation
• Bicipital tendonitis problem
• Clavicle fractures in acute or chronic injury
• Rotator cuff muscle injury may also cause a shoulder dislocation
• Shoulder subluxation also causes shoulder dislocation
• Swimmer’s shoulder joints injury most often causes shoulder dislocation
• Traumatic injury, unilateral or by lateral, bankart lesion in most commonly, surgical abnormal.
• Atraumatic injury, multidirectional movement injury, bilateral disorder,
• Proper or lake of rehabilitation timely also causes shoulder dislocation,
• Inferior capsular shift injury also causes shoulder dislocation
• Unilateral- or multi-directional instability injury
• Atraumatic injury cases are often multidirectional with the associated hyperlaxity problems.
• Traumatic injury in most cases is often unidirectional injury with an associated capsulolabral injury.
• Lake of presence or absence of accompanying soft-tissue hyperlaxity problem may also cause a shoulder dislocation
• In most cases of soft tissue hyperlaxity, including patulous capsular laxity injury,

Symptoms of Bankart Lesion

This type of labrum tear shares many symptoms with other shoulder injuries. A thorough doctor’s exam is necessary to properly diagnose symptoms.

Symptoms of a Bankart lesion can include

• Pain – When reaching overhead, at night, or with daily activities. Pain that does not improve with rest, change in activity, OTC medications, or ice, warrants consultation with your healthcare provider.
• Instability and weakness – The shoulder may feel ‘loose’. Patients may report apprehension about moving the shoulder into certain positions away from the body. Patients may also report recurrent instability, subluxation, or dislocation with low energy movements, like rolling over in bed or putting on a seat belt.
• Limited range of motion  
• Mechanical symptoms – Grinding, catching (not moving fluidly), locking in place, or popping can all be symptoms of torn tissue getting caught in the joint.
• A feeling of pain and tightness in the whole shoulder area causes pain for shoulder dislocation
• A feeling of tightness especially when you are throwing a ball overarm in cricket-playing, golf
• Decrease range of motion is lost in the following direction such as external rotation, abduction, internal rotation, forward flexion.
• Pain on the back and decrease the range of motion.
• Dull, aching pain with paresthesia, itching, numbness
• The referred pain and may felt in whole shoulder joints to the arms, forearms
• The sleep disturbance and the problem with deprivation
• Severe sharp pain and with rapid movement (eg. trying to catch mobile phone)
• The difficulty with activities of daily living such as dressing, driving, and personal care.
• Lack of movement in all directions of your hand
• Symptoms will worsen at night and morning stiffness may be felt.
• Muscle contraction of the coracohumeral ligament limits external rotation of the arm and forearms
• Muscle contracture and tendinopathy and capsulitis may be felt.
• Dull or deep-seated pain in the rotator cuff muscle and spread into the biceps muscles.

Helpful Clues for Common Diagnoses

• It May be either “cartilaginous” (labrum) or “bony” (glenoid fracture with labrum attached)
• Most common labral injury in 1st-time dislocators
• Labroligamentous structures are completely avulsed from glenoid with periosteal sleeve tear; ± fracture
• Acute cartilaginous: Discrete or fragmented tear across the labral base
• Chronic cartilaginous: “Fibrotic” medial mass
• Bony: Describe the size of fracture fragment (> 25% of the glenoid face will likely require open surgical procedure)
• It May be either “cartilaginous” (labrum) or “bony” (glenoid fracture with labrum attached
• Glenoid labrum articular disruption
• Labral tear and adjacent articular cartilage damage
• Assess for displaced articular cartilage fragment

Diagnosis of Bankart Lesion

• Labral height – This parameter was assessed in two moments: prior to the Bankart lesion and after the knotting. A depth digital caliper (0–150 mm/6″; resolution 0.01 mm/0.005″; Digimess) was used for measurement. The measurement was performed three times, and the arithmetic mean of the measurements was used.
• Biomechanical traction test – For biomechanical evaluation, the specimens were submitted to the traction test using the universal Emic DL500-MF test machine with a 500 N load cell. The scapula was attached to the lower surface with the aid of a pressure clamp, and the capsule was attached to the upper clamp with an Ethibond No. 5.0 suture. The test was performed by applying traction to the capsule perpendicularly to the articular surface. Initially, traction of 55 N was applied for two minutes to calibrate the system; subsequently, the capsular thickness was measured with an external micrometer with SPC output (Mitutoyo, graduation 0.001 ± 0.002 mm) at three equidistant points.
• Biomechanical traction test – The tests were interrupted after glenoid anchor avulsion occurred in 30% of the cases; in another 30%, after a tear at the knot-capsule interface, and in the remaining 40%, after an intrasubstance capsular tear. The required strength at the end of the test was greater in the shoulders with simple sutures than in those with Mason-Allen sutures. However, there was no statistically significant difference between the groups with simple sutures and Mason-Allen sutures.
• Western Ontario Shoulder Instability Index – Western Ontario Shoulder Instability Index (WSI), which is a subjective quality of life measurement tool specific to shoulder instability. Walch-Duplay score, which is the gold standard score used in Europe.
  The WOSI consists of four subscales: physical symptoms and pain; sport, recreation, and work function; lifestyle and social functioning; and emotional well-being. Twenty-one items are scored using a Visual Analogue Scale measuring 100 mm horizontally placed under each question. This questionnaire requires a minimum of explanations to the patient for the filling of scales. The best possible score indicating the highest possible shoulder-related quality of life is 0 and the worst possible score indicating the poorest quality of life is 2100. ^[rx]
• Walch Duplay – The European Society of Shoulder and Elbow Surgery recommended using the Walch-Duplay score which was inspired by the Rowe rating scale and takes into account both subjective and objective data (stability, pain, sport level recovery, mobility) to assess clinical outcome. The Walch-Duplay Score is the most currently used score in Europe for the assessment of the patient undergoing shoulder stabilization surgery. However, it is not a self-administrated questionnaire.
  The Walch-Duplay score (0 to 100 points) and the WOSI (0 to 2100 points) were recorded at the last follow-up. The Walch-Duplay score is composed of four items: activity, stability, pain, and mobility. According to the Walch-Duplay score, results were classified as excellent (91 and 100 points), good (76 and 90 points), fair (51–75 points) or poor (under 50).
  The correlation between the Walch-Duplay score and the WOSI is strong. The better the Walch-Duplay score is, the lower the WOSI is.^[rx]
• The instability shoulder index score – The Instability Shoulder Index Score (ISIS) was developed to predict the success of arthroscopic Bankart repair. Scores range from 0 to 10, with higher scores predicting a higher risk of recurrence after stabilization. The Instability Shoulder Index Score (ISIS) to predict the success of isolated arthroscopic Bankart repairs for recurrent anterior shoulder instability.
  Patients who underwent more complex arthroscopic procedures such as Hill-Sachs remplissage or open Latarjet had higher preoperative ISIS outcomes. A 10-point score was created and applied retrospectively. A score above 6 was associated with a 70% risk of recurrence, and the authors proposed using supplemental surgical procedures (such as an open Latarjet) to address this high risk. ISIS has been used in several clinical studies. The studies have shown that you can use ISIS to investigating several pathologies.
  It also correlates with the number of prior dislocations but not with patients’ perceptions of instability as reported by quality-of-life questionnaires. In the 5 academic centers involved, a higher ISIS was predictive of patients undergoing more complex surgery (Hill- Sachs remplissage or open Latarjet. ^[rx]
• Hawkins’ Test – Firstly, the examinator has to hold the arms in 90 degrees anteflexion. Then he has to do passive information of the arm by use of his other arm. If the test is positive, it causes pain in the region of the deltoideus. During this maneuver, the tuberculum majus drives under the coracoacromial ligament. This is the cause of the pain. The test was positive for 31% of Bankart lesions. ^[rx]

Lab Tests

• Laboratory tests – Leukocytosis is one of the most important tests for shoulder dislocation that supports the possibility of infection and bone-related disease.
• Serological test – Blood cultures, urine examination, stool examination, or other possible primary symptoms of shoulder dislocation, a bone infection that obligatory when a septic infectious shoulder dislocation is being considered for examination. The and elevated inflammatory condition markers like ESR or CRP include suggesting an infectious or inflammatory disease condition of the shoulder dislocation
• A serum uric acid level – It is often considered by clinicians and doctors when got shoulder dislocation, tendonitis is suspected, but it is not a reliable and dangerous condition as it may be spuriously elevated or high in acute inflammatory conditions or acutely during a or not.
• Random blood glucose –  The reference values for a normal random glucose test in an average adult are 80–140mg/dl (4.4–7.8 mmol/l), between 140-200mg/dl (7.8–11.1 mmol/l) is considered pre-diabetes, and ≥ 200 mg/dl is considered diabetes according to ADA guidelines you should visit your doctor or a clinic for additional tests to over sure.
• Ultrasound – It is basically done to investigate the thickness of the fascia, ligament injury with a shoulder dislocation are likely to have a thickened tendon with the associated fluid collection and that thickness values >4.0 mm that are the diagnostic of in shoulder dislocation [rx]
• Musculoskeletal ultrasound – It can further visualize the tendon and bony attachment of the thigh sites, muscles, ligaments, and nerves. Ultrasound can also be used to identify the area and extent, nature of the injury shoulder dislocation and used to evaluate periodically during the recovery phase. The most common findings on ultrasound are focal, fluid, tenosynovitis changes in the common flexor tendon position, how much thickening of the tendon sheath, partial or full-thickness tears, and tear of the tendon.[rx][rx] Ultrasound did for dynamic imaging studies, which can provide the additional benefit in regards to evaluation for shoulder dislocation
• Muscle Biopsy – Muscle biopsy is basically done to investigate abnormal congenital problems such as dutchmen muscular dystrophy, myasthenia graves, hemophilia, etc. A small part of the cell or tissue is collected from the thigh and send to investigate other abnormalities in shoulder dislocation.

Imaging

• X-Ray – Conventional x-ray and radiography is the most widely used imaging modality and allows for the detection of bone fractures, osteoporosis, and abnormal pathologies condition like fracture, osteoporosis, erosions, osteonecrosis, osteoarthritis, or a juxta-articular bone tumor, neoplasm, and shoulder dislocation. Characteristic features of shoulder dislocation include marginal osteophytes formation in shoulder joint space gradually narrowing, subchondral sclerosis formation in the shoulder dislocation.
• CT Scan – High contrast CT scan is more effective to diagnose procedures to investigate the shoulder dislocation. Abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc.
• MRI – It is called magnetic radical imaging is also helpful to find the bone conditions, abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, shoulder dislocation. It is the final stage test to confirm that all shoulder dislocation or any other abnormality suspected others condition forearms pain, such as shoulder pigmentation, soft tissue injury and bone tumors, osteonecrosis, osteomyelitis, arthritis, and stress fracture.[rx,rx]
• Bone scintigraphy – It is the most important test to diagnose bone cancer, neoplasm, fractures, necrosis of bone, and joints. It also helps to identify the tendon, sprained ligament, cartilage, muscle spasm, sprain, and strain with a shoulder dislocation. In where the latter may be projectional radiography (in cases of bony Bankart) and/or MRI of the shoulder. The presence of intra-articular contrast allows for better evaluation of the glenoid labrum.^[rx] Type V SLAP tears extend into the Bankart defect.^[rx]
• Nerve Conduction velocity test – It a special test for leg pain or thigh pain. It is the procedure where test the sensation of the peripheral nerve stimuli to send the central nervous system means brain. It helps to identify the sensory and motor nervous system problem from the central to the peripheral cell.[rx][rx]