CONSENSUS REHABILITATION GUIDELINES. Arthroscopic Anterior Stabilization with or without Bankart Repair GENERAL INFORMATION

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1 Revised July 2007 CONSENSUS REHABILITATION GUIDELINES Arthrscpic Anterir Stabilizatin with r withut Bankart Repair GENERAL INFORMATION Surgical Prcedure: Familiarity with the surgical prcedure and understanding its effect n rehabilitatin is vital. Arthrscpic Bankart repairs address shulder instability by repairing an unstable labrum back t the glenid thrugh the use f sutures 2,27,32 r suture anchrs 34,42. Early prcedures utilized staples t secure the labrum which resulted in high recurrence rates and pst perative cmplicatins. 21,30 Histrically many f the arthrscpic techniques did nt adequately address cncmitant capsular laxity leading t higher recurrence rates cmpared t the traditinal pen Bankart repairs. 6,9,10,20,24,29,36 Currently, arthrscpic plicatins f the capsule are perfrmed mre readily during arthrscpic Bankart repair t take up redundancy in the glenhumeral jint capsule. 1,4,8,15,16 The capsule can be flded nt itself and / r stabilized t the labrum. 12,15,38 The additin f capsular plicatin t the arthrscpic Bankart repair has resulted in a reductin in recurrence rates f arthrscpic shulder stabilizatin prcedures. 1,4,39 In many series, failure rates are nw similar t pen surgical prcedures. 7,17,19,22 Histrically patients recvering frm arthrscpic surgery have an easier time regaining P/AAROM than cmparable pen surgeries withut significant lng term ROM lss. 7,13 Surgical prcedures and indicatins are rapidly evlving. 4,14,23,25,37 Structures Which Require Prtectin During Rehabilitatin: Due t the arthrscpic nature f these surgeries, the rtatr cuff is nt significantly disturbed. Therefre AROM, dynamic stability activities, and strengthening des nt need t be delayed t prtect the rtatr cuff. Hwever, sutures, anchrs, capsule, ligaments, and labrum need significant prtectin frm undue stress fr a perid f time (usually at least 6 weeks) t facilitate apprpriate tissue healing. 26,33 Therefre clse cmmunicatin with the physician is vitally imprtant t discuss assciated lesins, tissue quality, fixatin methd and psitin. Based upn this infrmatin, ROM and strengthening activities will be slwly increased during the initial pst perative time perid t ensure adequate healing Critical Rehabilitatin Principles Histrically, 2 4 weeks f immbilizatin is cmmn after arthrscpic instability repair 11,17,43. Hwever, there is evidence that immediate staged ROM is safe and may prvide an earlier return t functinal activity and ROM althugh lng term results are nt significantly different 18. Therefre, we advcate 0 4 weeks f immbilizatin dependent n factrs such as the patient s specific injury / pathlgy, c mrbidities, amunt f natural laxity, past surgical histry, specific surgical technique (including type f fixatin and arm psitin at the time f capsular plicatin), and physician philsphy. Balancing the speed f P/AAROM gains is vitally imprtant t adequately prtect the surgical repair and t assure ROM is nt gained t quickly r t slwly. Gaining ROM t quickly (especially ER) is a mre cmmn prblem and may result in recurrent laxity, while gaining ROM t slwly may result in residual stiffness.

2 Balancing the speed f P/AAROM gains can be accmplished thrugh the use f staged ROM gals. 18,43 The ptimal speed f P/AAROM gains is different fr each patient and based n factrs such as their specific injury / pathlgy, c mrbidities, amunt f natural laxity, past surgical histry, specific surgical technique (including type f fixatin and arm psitin at the time f capsular plicatin), and physician philsphy. Staged ROM gals can be determined at least tw ways: 1. Physician preference based n the factrs abve. 2. If guidance is nt given by the physician, then the fllwing table can be used as a general guideline: * Passive Frward Elevatin in the scapular plane & Passive External Rtatin # Active Frward Elevatin in the scapular plane abd Abductin PFE * PER & at 20 abd PER at 90 abd AFE # POW cntraindicated NA POW POW POW 12 WNL WNL WNL WNL PROM greater than the mtins listed abve shuld be avided. Interventins shuld nt be frceful r painful. Precautins/Cntraindicatins: Adequate prtectin f the surgical repair fr at least the first six weeks is vital. During this early time perid ROM / stretching int end range psitins, especially end range ER by the side and end range ER in abductin shuld NOT be perfrmed as these mtins place tensin n the anterinferir shulder capsule. Because f the minimally invasive nature f these prcedures, the pain that sme patients experience is minimal allwing fr greater use f their arm than is advisable. Therefre, extensive patient educatin is vital t cnvey the imprtance f prtecting the surgical repair. Heavy lifting and use f the arm in psitins requiring end range ROM are nt allwed in the early pstperative perid (<POW 6). SPECIFIC REHABILITATION GUIDELINES Phase 1 (POW 1 t ~ POW 6) GOALS: Maximally prtect the surgical repair (capsule, ligaments, labrum, sutures) Achieve staged ROM gals. DO NOT exceed them. Patient educatin in pst perative restrictins Minimize shulder pain and inflammatry respnse Ensure adequate scapular functin INTERVENTIONS TO AVOID D nt allw r perfrm ROM / stretching beynd staged ROM gals, especially ER by the side and end range ER in abductin. D nt allw the patient t use their arm fr heavy lifting r any use f the arm which requires ROM greater than the staged ROM gals. SPECIFIC INTERVENTIONS Activities f Primary Imprtance: 1) Patient educatin regarding limited use f the arm despite lack f pain r ther symptms 2) Prtectin f repair 3) Achieve staged ROM gals thrugh gentle ROM activities 4) Minimize inflammatin

3 Activities f Secndary Imprtance: 1) Nrmalize scapular psitin, mbility, and dynamic stability 2) ROM f uninvlved jints 3) Begin restratin f shulder strength Immbilizatin Strict sling immbilizatin f glenhumeral jint 0 4 weeks, fllwed by sling use when in the cmmunity r when the patient is up fr lng perids f time fr the remainder f phase 1. Mst cmmnly a standard sling (glenhumeral jint in IR and adductin) is used thrugh a range f 2 4 weeks. Patient Educatin Explain nature f the surgery Discuss precautins specific t the nature f the surgical repair (abductin/ ER stress the anterir inferir capsule) Imprtance f meeting staged ROM gals (especially nt gaining ROM t fast) Imprtance f tissue healing Prper sling use (assure sling prvides upward supprt t the glenhumeral jint). Limiting use f arm fr ADL s ROM Fllwing the strict immbilizatin perid begin: Pendulums (unweighted) Passive/ active assisted frward elevatin in plane f scapula (PFE) t achieve staged ROM gals (ex: self assistexercise wand/ ppsite hand, family r therapist assist, rpe and verhead pulley, table slides with invlved arm n a twel n a table r cuntertp with assistance prvided by the uninvlved arm). ROM shuld nt be frceful Passive / active assisted external rtatin (PER) with the arm supprted and shulder in slight abductin t achieve staged ROM gals (ex: family r therapist assist, self assist with l bar). ROM shuld nt be frceful Scapular clck exercises r alternately elevatin, depressin, prtractin, retractin; prgress t scapular strengthening as patient tlerates (Smith et al 2006). Submaximal rtatr cuff ismetrics as tlerated AROM f uninvlved jints Pstural awareness/educatin Pain Management Activity restrictin Prper fitting f sling t supprt arm Scar management. Mdalities PRN MD prescribed r OTC medicatins MILESTONES TO PROGRESS TO PHASE II 1) Apprpriate healing f the surgical repair by adhering t the precautins and immbilizatin guidelines. 2) Staged ROM gals met but nt significantly exceeded. 3) Inflammatin cntrlled (painfree within the allwed ROM).

4 Phase 2 (~POW 6 ~ POW 12) GOALS Achieve staged ROM gals t nrmalize PROM and AROM. DO NOT exceed them. Minimize shulder pain Begin t increase strength and endurance Increase functinal activities INTERVENTIONS TO AVOID D nt perfrm ROM / stretching beynd staged ROM gals. D nt perfrm any stretch t gain end range external rtatin r external rtatin w/ 90º f abductin unless significant tightness is present. D nt allw the patient t use their arm fr heavy lifting r any activities which require ROM beynd the staged ROM gals D nt perfrm any strengthening exercises that place a large lad n the shulder in the psitin f hrizntal abductin r the cmbined psitin f abductin with external rtatin (ex: NO push ups, pec flys). This places excessive lad n anterir capsular structures during this timeframe. D nt perfrm scaptin with internal rtatin (empty can) at any stage f rehabilitatin due t pssibility f impingement. SPECIFIC INTERVENTIONS Activities f Primary Imprtance: 1) Cntinued Patient Educatin 2) P/AAROM as needed t achieve staged ROM gals. DO NOT significantly exceed them. 3) Establish basic rtatr cuff and scapular neurmuscular cntrl within the allwed ROM Activities f Secndary Imprtance: 1) Intrductin f functinal patterns f mvement 2) Prgressive endurance exercises. Patient Educatin Cunsel abut using the upper extremity fr apprpriate ADL s in the painfree ROM (starting with waist level activities and prgressing t shulder level and finally t verhead activities ver time). Cntinue educatin regarding avidance f heavy lifting r quick sudden mtins. Educatin t avid psitins f instability during ADL s such as end range external rtatin, and cmbined abductin / external rtatin. ROM P/AAROM as needed t achieve staged ROM gals in all planes. Many times nly light stretching r n stretching is needed. If ROM is significantly less than staged ROM gals, gentle jint mbilizatins may be perfrmed. Hwever they shuld be dne nly int the limited directins and nly until staged ROM gals are achieved. Address scapulthracic and trunk mbility limitatins. Ensure nrmal cervical spine ROM and thracic spine extensin t facilitate full upper extremity ROM. Neurmuscular Re educatin Address abnrmal scapular alignment and mbility PRN Strengthen scapular retractrs and upward rtatrs (PRE s r manually resisted exercises) Increase pectralis minr flexibility if limited (manual stretching, twel mbilizatins) Bifeedback by auditry, visual, r tactile cues Clsed chain exercises may be helpful (quadruped psitin while wrking t maintain prper psitin f the scapula, quadruped w/ scapula prtractin, prgressing frm quadruped t tripd psitin, NO PUSH UPS)

5 Address cre stability deficits PRN Activities t imprve neurmuscular cntrl f the rtatr cuff and shulder girdle such as use f unstable surfaces, bdy blade, manual exercises (PNF). Strength / Endurance Scapula and cre strengthening (PRE s, manually resisted exercises, cre stabilizatin exercises) Balanced rtatr cuff strengthening t maintain the humeral head centered within the glenid fssa during prgressively mre challenging activities. Shuld be initially perfrmed in a psitin f cmfrt with lw stress t the glenhumeral jint such as < 45 elevatin in the plane f the scapula (ex: elastic band r dumbbell external rtatin, internal rtatin, frward flexin, shulder extensin nt past the plane f the bdy). Exercises shuld be prgressive in terms f muscle demand / intensity. It is suggested t use activities that have dcumented EMG activity (Specific Guidelines References). Resisted activities shuld prgress frm assistive exercises (ex. rpe/ verhead pulley and/ r finger ladder) t active exercises and finally the additin f external resistance (ex. elastic bands r 1 2 lbs. weight). Exercises shuld als be prgressive in terms f shulder elevatin (ex: start w/ exercises perfrmed at waist level prgressing t shulder level and finally verhead activities). Nearly full elevatin in plane f the scapula shuld be achieved befre prgressing t elevatin in ther planes. Exercises shuld be prgressive in terms f adding incremental stress t the anterir capsule, gradually wrking twards a psitin f elevated external rtatin in the crnal plane the psitin. Rehabilitatin activities shuld be pain free and perfrmed withut substitutins r altered mvement patterns. Rehabilitatin shuld include bth clsed (ex: quadruped t tripd) and pen chain activities. Rehabilitatin shuld als include bth islated and cmplex mvement patterns. Depending upn the gals f the exercise (cntrl vs. strengthening), rehabilitatin activities can als be prgressive in terms f speed nce the athlete demnstrates prficiency at slwer speeds. The rtatr cuff and scapula stabilizer strengthening prgram shuld emphasize high repetitins (abut reps) and relatively lw resistance (abut 1 3 lbs). N heavy lifting r plymetrics shuld be perfrmed during this stage. Elbw flexin/ extensin strengthening with arm at side (shulder 0º elevatin) can begin in this phase and prgress as apprpriate. Pain Management Mdalities PRN Ensure apprpriate use f arm during ADL s Ensure apprpriate level f therapeutic interventins Weaning frm use f medicatins MILESTONES TO PROGRESS TO PHASE III 1) Staged AROM gals met withut pain r substitutin patterns. 2) Apprpriate scapular psture at rest and dynamic scapular cntrl during ROM and strengthening exercises 3) Cmpletin f current strengthening activities withut pain r difficulty

6 Phase 3 (~POW 12 ~POW 24) GOALS Nrmalize strength, endurance, neurmuscular cntrl, and pwer Gradual and planned build up f stress t anterir capsule and labral tissues Gradual return t full ADL s, wrk, and recreatinal activities INTERVENTIONS TO AVOID D nt increase stress t the shulder in a shrt perid f time r in an uncntrlled manner. D nt perfrm advanced rehabilitatin exercises (such as plymetrics r exercises at end range abductin/ ER) if the patient des nt perfrm these activities during ADL s, wrk, r recreatin. D nt prgress int activity specific training until patient has nearly full ROM and strength. D nt perfrm weightlifting activities which place excessive stress n the anterir capsule. Fr instance, lat. pull dwns and military press perfrmed with the hands behind the head stress the anterir capsule with n additinal benefit in terms f muscle activity. Similarly activities which encurage shulder hyperextensin such as dips shuld als be avided. SPECIFIC INTERVENTIONS Activities f Primary Imprtance: 1) Prgressive strengthening and endurance exercises 2) Prgressive neurmuscular cntrl exercises 3) Activity specific prgressin sprt, wrk, hbbies Activities f Secndary Imprtance: 1) Finalizatin f ROM 2) Finalizatin f specific deficits fr cre and scapular stability Patient Educatin Cunsel in imprtance f gradually increasing stress t the shulder while returning t nrmal ADL s, wrk and recreatinal activities including heavy lifting, repetitive activities, and verhead sprts. ROM PROM / Stretching/Jint Mbilizatins as needed t address any remaining deficits. Neurmuscular Re educatin Address any remaining deficits at the rtatr cuff, scapular, r trunk. Strength / Endurance / Pwer Cntinue shulder strengthening prgram as initiated in Phase 2 with increasing emphasis n high speed, multi planar activities which incrprate the entire kinetic chain. Gradually prgress rehabilitatin activities t replicate demanding ADL / wrk activities Prgressive return t weight lifting prgram emphasizing the larger, primary mver UE muscles (deltid, latissimus drsi, pectralis majr) Start with relatively light weight and high repetitins (sets f repetitins) and gradually decrease repetitins and increase weight ver a several mnth perid. Suggested upper extremity exercises fr early Phase 3 Biceps curls shulder adducted (added in Phase 2) Triceps press dwns r kick backs shulder adducted (added in Phase 2) Shulder shrugs Rws(scapular retractin) shulder adducted Lat bar pull dwns w/ hands in frnt f the head Dumbbell verhead shulder press dne with hands starting in frnt f the shulders (nt in the abducted / externally rtated psitin Push ups as lng as the elbws d nt flex past 90º

7 Suggested upper extremity exercises t be added in intermediate Phase 3 Istnic pressing activities (ex. chest/ incline presses, dumbbell/ barbell bench) Dumbbell shulder raises t 90º Rws (scapular retractin) shulders elevated Machine / barbell shulder presses which d nt require end range abductin / external rtatin Prne rtatr cuff/ scapular strengthening (prne hrizntal abductin, Scapular MMT psitins, Hughstn exercises ) Suggested upper extremity exercises t be added in late Phase 3 Any verhead press with shulders in abducted/ ER psitin (military press) Pectralis majr flys Dead lift Pwer cleans Upper extremity exercises that are nt advisable fr this patient ppulatin Dips Lat Pull Dwns r military press with the bar behind head Plymetric prgram (as necessary) Criteria t initiate plymetric prgram Gals f returning t verhead athletics r ther wrk r recreatinal activities requiring large amunts f upper extremity pwer Adequate strength f entire shulder girdle musculature Pain free w/ basic ADL s and current strengthening prgram At least 3 weeks f tlerance t high speed multi planar activities which prgressively mimic functinal demands. Parameters Due t the explsive nature f this type f exercise, emphasis f plymetrics exercises shuld be n quality nt quantity. Perfrm a few times a week and utilize mderate repetitins ( apprximately 3 5 sets f reps) Begin with beach ball / tennis ball with prgressin t lightly weighted balls (plyballs) Sample activities: 2 handed tsses waist level verhead diagnal 1 handed tsses (begin with arm at side and gradually increase the amunt f shulder abductin/ ER and gradually decrease UE supprt). Interval Sprt Prgrams such as thrwing prgrams, swimming, glf nce apprved by physician (usually POW 16 r lnger). MILESTONES TO RETURN TO SPORT, WORK, HOBBIES: Clearance frm physician N cmplaints f pain nr instability Restratin f sufficient ROM fr task cmpletin Full strength (5/5) f rtatr cuff and scapular musculature Adequate shulder girdle endurance fr desired activity Regular cmpletin f an independent strengthening/ neurmuscular cntrl prgram If the patient struggles with cnfidence r shulder stability, a stabilizing brace may be cnsidered fr return t activity, but is mst cmmnly used nly fr cllisin sprts.

8 DISCLAIMER These general rehabilitatin guidelines were created by the membership f the American Sciety f Shulder and Elbw Therapists fr the rehabilitatin f varius shulder and elbw pathlgies. These dcuments are simply t be used as guidelines. This infrmatin is prvided fr infrmatinal and educatinal purpses nly. The specific treatment f a patient shuld be based n individual needs and the medical care deemed necessary by the treating physician and rehabilitatin prfessinal. ASSET takes n respnsibility r assumes n liability fr imprper use f these guidelines. We recmmend yu cnsult with yur treating physician r rehabilitatin prfessinal fr specific curses f treatment.

9 REFERENCES GENERAL INFORMATION 1. Armstrng, A.; Byer, D.; Ditsis, K.; and Yamaguchi, K.: Arthrscpic versus pen treatment f anterir shulder instability. Instr Curse Lect, 53: , Benedett, K. P., and Gltzer, W.: Arthrscpic Bankart prcedure by suture technique: indicatins, technique, and results. Arthrscpy, 8(1): 111 5, Cle, B. J.; L'Insalata, J.; Irrgang, J.; and Warner, J. J.: Cmparisn f arthrscpic and pen anterir shulder stabilizatin. A tw t six year fllw up study. J Bne Jint Surg Am, 82 A(8): , Cle, B. J.; Millett, P. J.; Rme, A. A.; Burkhart, S. S.; Andrews, J. R.; Dugas, J. R.; and Warner, J. J.: Arthrscpic treatment f anterir glenhumeral instability: indicatins and techniques. Instr Curse Lect, 53: , Cle, B. J., and Warner, J. J.: Arthrscpic versus pen Bankart repair fr traumatic anterir shulder instability. Clin Sprts Med, 19(1): 19 48, Dra, C., and Gerber, C.: Shulder functin after arthrscpic anterir stabilizatin f the glenhumeral jint using an absrbable tac. J Shulder Elbw Surg, 9(4): 294 8, Fabbriciani, C.; Milan, G.; Demntis, A.; Fadda, S.; Ziranu, F.; and Mulas, P. D.: Arthrscpic versus pen treatment f Bankart lesin f the shulder: a prspective randmized study. Arthrscpy, 20(5): , Fleega, B. A.: Arthrscpic reinfrced capsular shift f anterir shulder instability. Arthrscpy, 20(5): 543 6, Freedman, K. B.; Smith, A. P.; Rme, A. A.; Cle, B. J.; and Bach, B. R., Jr.: Open Bankart repair versus arthrscpic repair with transglenid sutures r biabsrbable tacks fr Recurrent Anterir instability f the shulder: a meta analysis. Am J Sprts Med, 32(6): , Geiger, D. F.; Hurley, J. A.; Tvey, J. A.; and Ra, J. P.: Results f arthrscpic versus pen Bankart suture repair. Clin Orthp Relat Res, (337): 111 7, Grana, W. A.; Buckley, P. D.; and Yates, C. K.: Arthrscpic Bankart suture repair. Am J Sprts Med, 21(3): , Hewitt, M.; Getelman, M. H.; and Snyder, S. J.: Arthrscpic management f multidirectinal instability: pancapsular plicatin. Orthp Clin Nrth Am, 34(4): , Hubbell, J. D.; Ahmad, S.; Bezenff, L. S.; Fnd, J.; and Pettrne, F. A.: Cmparisn f shulder stabilizatin using arthrscpic transglenid sutures versus pen capsullabral repairs: a 5 year minimum fllw up. Am J Sprts Med, 32(3): 650 4, Ide, J.; Maeda, S.; and Takagi, K.: Arthrscpic Bankart repair using suture anchrs in athletes: patient selectin and pstperative sprts activity. Am J Sprts Med, 32(8): , Karas, S. G.; Creightn, R. A.; and DeMrat, G. J.: Glenhumeral vlume reductin in arthrscpic shulder recnstructin: a cadaveric analysis f suture plicatin and thermal capsulrrhaphy. Arthrscpy, 20(2): , Kelly, B. T.; Turner, A. S.; Bansal, M.; Terry, M.; Wlf, B. R.; Warren, R. F.; Altchek, D. W.; and Allen, A. A.: In viv healing after capsular plicatin in an vine shulder mdel. Iwa Orthp J, 25: , Kim, S. H.; Ha, K. I.; Ch, Y. B.; Ryu, B. D.; and Oh, I.: Arthrscpic anterir stabilizatin f the shulder: tw t six year fllw up. J Bne Jint Surg Am, 85 A(8): , Kim, S. H.; Ha, K. I.; Jung, M. W.; Lim, M. S.; Kim, Y. M.; and Park, J. H.: Accelerated rehabilitatin after arthrscpic Bankart repair fr selected cases: a prspective randmized clinical study. Arthrscpy, 19(7): , Kim, S. H.; Ha, K. I.; and Kim, S. H.: Bankart repair in traumatic anterir shulder instability: pen versus arthrscpic technique. Arthrscpy, 18(7): , Kss, S.; Richmnd, J. C.; and Wdward, J. S., Jr.: Tw t five year fllwup f arthrscpic Bankart recnstructin using a suture anchr technique. Am J Sprts Med, 25(6): , Lane, J. G.; Sachs, R. A.; and Riehl, B.: Arthrscpic staple capsulrrhaphy: a lng term fllw up. Arthrscpy, 9(2): 190 4, Laurencin, C. T.; Stephens, S.; Warren, R. F.; and Altchek, D. W.: Arthrscpic Bankart repair using a degradable tack. A fllwup study using ptimized indicatins. Clin Orthp Relat Res, (332): 132 7, Lee, M. P.: Open perative treatment fr anterir shulder instability: when and why? J Hand Ther, 18(3): 384 5, Manta, J. P.; Organ, S.; Nirschl, R. P.; and Pettrne, F. A.: Arthrscpic transglenid suture capsullabral repair. Five year fllwup. Am J Sprts Med, 25(5): 614 8, Mazzcca, A. D.; Brwn, F. M., Jr.; Carreira, D. S.; Hayden, J.; and Rme, A. A.: Arthrscpic anterir shulder stabilizatin f cllisin and cntact athletes. Am J Sprts Med, 33(1): 52 60, McEleney, E. T.; Dnvan, M. J.; Shea, K. P.; and Nwak, M. D.: Initial failure strength f pen and arthrscpic Bankart repairs. Arthrscpy, 11(4): , McIntyre, L. F., and Caspari, R. B.: The ratinale and technique fr arthrscpic recnstructin f anterir shulder instability using multiple sutures. Orthp Clin Nrth Am, 24(1): 55 8, 1993.

10 28. Mlgne, T. S.; Lapint, J. M.; Mrin, W. D.; Zilberfarb, J.; and O'Brien, T. J.: Arthrscpic anterir labral recnstructin using a transglenid suture technique. Results in active duty military patients. Am J Sprts Med, 24(3): , Mlgne, T. S.; McBride, M. T.; and Lapint, J. M.: Assessment f failed arthrscpic anterir labral repairs. Findings at pen surgery. Am J Sprts Med, 25(6): 813 7, O'Driscll, S. W., and Evans, D. C.: Lng term results f staple capsulrrhaphy fr anterir instability f the shulder. J Bne Jint Surg Am, 75(2): , Pagnani, M. J.; Warren, R. F.; Altchek, D. W.; Wickiewicz, T. L.; and Andersn, A. F.: Arthrscpic shulder stabilizatin using transglenid sutures. A fur year minimum fllwup. Am J Sprts Med, 24(4): , Rhee, K. J.; Ahn, S. R.; and Lee, J. K.: Arthrscpic capsular suture fr anterir instability f the shulder. Orthpedics, 15(2): , Rth, C. A.; Bartlzzi, A. R.; Cicctti, M. G.; Wetzler, M. J.; Gillespie, M. J.; Snyder Mackler, L.; and Santare, M. H.: Failure prperties f suture anchrs in the glenid and the effects f crtical thickness. Arthrscpy, 14(2): , Snyder, S. J., and Straffrd, B. B.: Arthrscpic management f instability f the shulder. Orthpedics, 16(9): , Speer, K. P.; Warren, R. F.; Pagnani, M.; and Warner, J. J.: An arthrscpic technique fr anterir stabilizatin f the shulder with a biabsrbable tack. J Bne Jint Surg Am, 78(12): , Steinbeck, J., and Jersch, J.: Arthrscpic transglenid stabilizatin versus pen anchr suturing in traumatic anterir instability f the shulder. Am J Sprts Med, 26(3): 373 8, Tauber, M.; Resch, H.; Frstner, R.; Raffl, M.; and Schauer, J.: Reasns fr failure after surgical repair f anterir shulder instability. J Shulder Elbw Surg, 13(3): , Taur, J. C., and Carter, F. M., 2nd: Arthrscpic capsular advancement fr anterir and anterir inferir shulder instability: a preliminary reprt. Arthrscpy, 10(5): 513 7, Treacy, S. H.; Savie, F. H., 3rd; and Field, L. D.: Arthrscpic treatment f multidirectinal instability. J Shulder Elbw Surg, 8(4): , Warner, J. J.; Miller, M. D.; and Marks, P.: Arthrscpic Bankart repair with the Suretac device. Part II: Experimental bservatins. Arthrscpy, 11(1): 14 20, Warner, J. J.; Miller, M. D.; Marks, P.; and Fu, F. H.: Arthrscpic Bankart repair with the Suretac device. Part I: Clinical bservatins. Arthrscpy, 11(1): 2 13, Wlf, E. M.: Arthrscpic capsullabral repair using suture anchrs. Orthp Clin Nrth Am, 24(1): 59 69, Levine, W.N.; Rieger, K.; McCluskey, G. M. III: Arthrscpic Treatment f Anterir Shulder Instability. Instr Cshurse Lect, 54: 87 96, 2005.

11 SPECIFIC GUIDELINES Decker MJ, Tkish JM, Ellis HB, Trry MR, Hawkins RJ. Subscapularis muscle activity during selected rehabilitatin exercises. Am J Sprts Med; 31(1): , 2003 Ekstrm RA, Dnatelli RA, Sderberg G. Surface electrmygraphic analysis f exercises fr the trapezius and serratus anterir muscles. J Orthp Sprts Phys Ther 2003; 33(5): Hintermeister RA, Lange GW, Schultheis JM, Bey MJ, Hawkins RJ: Electrmygraphic activity and applied lad during shulder rehabilitatin exercises using elastic resistance. Am J Sprts Med 26(2): , Hughes CJ, Hurd K, Jnes A, Springle S: Resistance prperties f Thera band tubing during shulder abductin exercise. J Orthp Sprts Phys Ther 29(7): , Krnberg M, Nemeth G, Brstrm L. Muscle activity and crdinatin in the nrmal shulder. Clin Orthp Rel Res;257:76 85, Reinld MM, Wilk KE, Fleisig GS, et al: Electrmygraphic analysis f the rtatr cuff and deltid musculature during cmmn shulder external rtatin exercises. J Orthp Sprts Phys Ther; 34(7): , Smith J, Dietrich CT, Ktajarvi BR, Kaufman KR. The effect f scapular prtractin n ismetric shulder rtatin strength in nrmal subjects. J Shulder Elbw Surg. 15(3): , Twnsend H, Jbe FW, Pink M, Perry J: Electrmygraphic analysis f the glenhumeral muscles during a baseball rehabilitatin prgram. Am J Sprts Med; 19(3): , Uhl TL, Carver TJ, Mattacla CG, Mair SD, Nitz AJ: Shulder musculature activatin during upper extremity weight bearing exercise. J Orthp Sprts Phys Ther; 33(3): Wise MB, Uhl TL, Mattacla CG, Nitz AJ, Kibler WB: The effect f limb supprt n muscle activatin during shulder exercises. J Shulder Elbw Surg; 13(6): , 2004.