J Shoulder Elbow Surg (2018) 27, 1342–1347

www.elsevier.com/locate/ymse

Return to sport following arthroscopic Bankart

repair: a systematic review
Muzammil Memon, MDa, Jeffrey Kay, MDa, Edwin R. Cadet, MDb,
Shayan Shahsavar, BScc, Nicole Simunovic, MScd, Olufemi R. Ayeni, MD, PhD, FRCSCa,*

a
Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
b
Raleigh Orthopaedic Clinic, Raleigh, NC, USA
c
Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
d
Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada

Hypothesis and background: The purpose of this systematic review was to determine the return-to-
sport rate following arthroscopic Bankart repair, and it was hypothesized that patients would experience
a high rate of return to sport.
Methods: The MEDLINE, Embase, and PubMed databases were searched by 2 reviewers, and the titles,
abstracts, and full texts were screened independently. The inclusion criteria were English-language studies
investigating arthroscopic Bankart repair in patients of all ages participating in sports at all levels with
reported return-to-sport outcomes. A meta-analysis of proportions was used to combine the rate of return
to sport using a random-effects model.
Results: Overall, 34 studies met the inclusion criteria, with a mean follow-up time of 46 months (range,
3-138 months). The pooled rate of return to participation in any sport was 81% (95% confidence interval
[CI], 74%-87%). In addition, the pooled rate of return to the preinjury level was 66% (95% CI, 57%-
74%) (n = 1441). Moreover, the pooled rate of return to a competitive level of sport was 82% (95% CI,
79%-88%) (n = 273), while the pooled rate of return to the preinjury level of competitive sports was 88%
(95% CI, 66%-99%).
Conclusion: Arthroscopic Bankart repair yields a high rate of return to sport, in addition to significant
alleviation of pain and improved functional outcomes in the majority of patients. However, approximate-
ly one-third of athletes do not return to their preinjury level of sports.
Level of evidence: Level IV; Systematic Review
© 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Arthroscopy; Bankart; repair; return; sport; play

In 1923 Bankart described that anterior dislocations of the
humeral head can cause tears of the labrum, capsule, and peri-
osteum from the anterior glenoid rim, and this lesion was
thereafter described as the Bankart lesion.2 The rate of
*Reprint requests: Olufemi R. Ayeni, MD, MSc, FRCSC, McMaster
University Medical Centre, 1200 Main St W, 4E15, Hamilton, ON L8N 3Z5,
Canada.
E-mail address: ayenif@mcmaster.ca (O.R. Ayeni).
recurrent anteroinferior shoulder instability following trau-
matic dislocation is extremely high, particularly in younger
athletes,32 necessitating surgical stabilization to give ath-
letes the opportunity to return to sport at a competitive level.8
Surgical stabilization for Bankart lesions can be achieved both
arthroscopically and via open means, and it consists of fixing
the torn labrum onto the glenoid, anatomically correcting the
pathology.28

1058-2746/$ - see front matter © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
https://doi.org/10.1016/j.jse.2018.02.044
Return to sport: arthroscopic Bankart repair
The open Bankart repair was reported by Bankart2 in
1923, with numerous techniques and advancements in the
procedure developed since then. Although both arthro-
scopic Bankart repair and open Bankart repair are currently
considered gold standards for treatment,26 the open tech-
niques have been shown to restrict the motion of the shoulder
postoperatively, with particular emphasis on the decrease in
external rotation.5 In addition, motion loss has been a short-
coming of both arthroscopic and open procedures, although
it has been more frequently reported following open proce-
dures, likely as a result of the subscapularis takedown.20,27
These concerns, in addition to the more extensive soft-
tissue dissection and immediate postoperative pain following
the open technique, have encouraged continued advance-
ment of arthroscopic Bankart repair techniques. However,
studies have demonstrated that muscle strength is equiva-
lent after open and arthroscopic repairs at 12 months
postoperatively.15,37 While the recurrence rates for instabili-
ty are lower following open Bankart repair, arthroscopic
procedures have generally produced better functional results
over time in terms of range of motion, and as such, arthro-
scopic Bankart repair has become more frequently
performed.4,10,11,30 The rate at which athletes return to sport
following arthroscopic Bankart repair varies considerably
across individual studies, with reported rates ranging from
as low as 20% to a perfect return-to-sport rate of 100%.31
The purpose of this systematic review was to determine
the return-to-sport rate following arthroscopic Bankart repair.
Secondarily, functional outcomes in these patients were ex-
amined, including stability, pain, function, and time to return
to sport.
Methods
This is a systematic review wherein the methodology was guided
by the PRISMA (Preferred Reporting Items for Systematic Reviews
and Meta-analyses) statement as well as a previous systematic review
by our group.7,23
Search strategy
The PubMed, Embase, and MEDLINE databases were searched on
July 15, 2017, for literature addressing return to sport following ar-
throscopic Bankart repair. “Bankart” and “arthroscopy” were the terms
used to search for all eligible studies to be included in this review
(Appendix Table S1).
Study screening
The titles, abstracts, and full texts were screened by 2 reviewers in-
dependently. The senior author (O.R.A.) resolved any disagreements
regarding study inclusion between reviewers when necessary. To
ensure inclusion of all eligible studies, the citation lists of the in-
cluded studies were screened to capture additional studies.
1343
Assessment of study eligibility
The study question and eligibility parameters were established a priori.
Therapeutic studies of all levels of evidence, English-language studies,
human studies, studies of living subjects, and studies reporting return
to sport and functional outcomes following arthroscopic primary and
revision Bankart repair for individuals with a confirmed Bankart lesion
were included. The exclusion criteria were nonhuman studies, ca-
daveric investigations, conference presentations, textbook chapters,
review papers, and technique guides.
Quality assessment
The Methodological Index for Non-Randomized Studies (MINORS)
tool was used in duplicate to evaluate the quality of the included
studies.29 Noncomparative studies may receive a score of up to 16,
while comparative studies may receive a score of up to 24. The senior
author (O.R.A.) resolved any disagreements regarding study quality
assessment between reviewers when necessary.
Assessment of agreement
The κ statistic was used during the title, abstract, and full-text screen-
ing to assess inter-reviewer agreement, while the intraclass correlation
coefficient (ICC) was used for the MINORS scores. Substantial agree-
ment corresponded to a κ or ICC value of 0.61 or greater; moderate
agreement, κ or ICC value of 0.21-0.60; and slight agreement, κ
or ICC value of 0.20 or less.19
Data abstraction and analysis
Data were abstracted in duplicate and recorded in a Microsoft Excel
spreadsheet (version 2007; Microsoft, Redmond, WA, USA). Data
regarding authors, year of publication, study design, level of
evidence,36 sample size, age, sex, follow-up, clinical and radio-
graphic findings, management, and outcomes were obtained. The
primary outcome was the rate at which patients returned to sport.
To determine the pooled rate of return to sport, a meta-analysis of
proportions was conducted. To establish the variance of the raw pro-
portions, a Freeman-Tukey transformation was applied.12 The
transformed proportions were then combined using the DerSimonian-
Laird random-effects model (to incorporate the anticipated
heterogeneity).9 The proportions were back-transformed using an
equation derived by Miller.22 The Cochran Q and I2 tests were used
to assess the heterogeneity. Values of I2 between 25% and 49% were
considered low statistical heterogeneity; values between 50% and
74%, moderate; and values greater than 75%, high.16
In instances in which data were not presented uniformly, a nar-
rative report was provided with descriptive statistics. Minitab statistical
software (version 17; Minitab, State College, PA, USA) was used
to calculate means, proportions, ranges, κ values, and ICC values.
Results
Search strategy
The search yielded 2657 total studies, of which 1062 were
eliminated because they were duplicate studies, producing 1595
1344
Figure 1 PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-analyses) flow diagram demonstrating system-
atic review of literature for return-to-sport outcomes after arthroscopic
Bankart repair.
studies screened at the title stage. A systematic screening strat-
egy yielded 34 included full-text articles (Fig. 1). There was
considerable agreement between reviewers during the title
(κ = 0.814; 95% confidence interval [CI], 0.801-0.827), ab-
stract (κ = 0.868; 95% CI, 0.819-0.917), and full-text (κ = 1.00)
screening stages.
Study characteristics
Overall, 1866 patients (1923 shoulders) underwent arthro-
scopic repair of a Bankart lesion. Patient characteristics
included a mean age of 26 years (range, 11-73 years), mean
follow-up period of 46 months (range, 3-138 months), and
a sex proportion of 72% male patients.
Study quality
Among the 34 studies included in our analyses, there were
25 retrospective case series (level IV evidence), 3 prospective
M. Memon et al.
case series (level IV evidence), 4 retrospective comparative
studies (level III evidence), 1 prospective comparative study
(level II evidence), and 1 randomized clinical trial (level I ev-
idence). The area of best performance based on the MINORS
checklist was the use of endpoints appropriate to the studies’
aims, which was found in 28 of the 34 studies (82%). The
area of worst performance was prospective calculation of study
size, which was found in 3 of the 34 included studies (9%).
All 34 studies included a clearly stated aim, and 27 studies
(79%) reported the inclusion of consecutive patients. The
median MINORS score for the noncomparative studies was
9 (range, 7-12), and the median score for comparative studies
was 15 (range, 14-16) (Table S2). The overall inter-rater agree-
ment for the MINORS score was high, with an ICC of 0.890
(95% CI, 0.874-0.906).
Patient preoperative characteristics and
arthroscopic procedure
Among the 1866 included patients, the preoperative level of
sports participation was reported for 1020 patients. Of these
1020 patients, 560 were involved in recreational sports, 415
were competitive athletes, and 45 were professional athletes.
Furthermore, of the 415 competitive athletes, 3 participated
at the local level, 18 participated at the regional level, and 3
participated at the national level (Table S3). In addition, among
the 1866 included patients, the preoperative type of sport in-
volvement was reported for 925 patients: noncontact sports
(26%, 240 of 925), contact sports (42%, 393 of 925), sports
involving overhead movements (29%, 270 of 925), or high-
impact sports (2%, 22 of 925). While there is no single definition
of “contact” sports, this study used the commonly cited clas-
sification of the American Academy of Pediatrics Committee
on Sports Medicine, which categorizes contact sports to include
boxing, field hockey, football, ice hockey, lacrosse, martial
arts, rodeo, soccer, and wrestling.1 The specific sports played
are listed in Table S3. In addition, of the 34 included studies,
29 reported that the Bankart lesion was of traumatic origin;
the remaining 5 studies did not report whether the Bankart
lesion was of traumatic or atraumatic origin. Finally, the mean
time from injury to arthroscopic management was 14 months
(range, 0.25-288 months). The details of the arthroscopic pro-
cedure, including patient positioning and arthroscopic portals
used, as well as concomitant procedures performed, are de-
scribed in Table S4.
Rehabilitation protocol and criteria for return to
sporting activities
Overall, 22 of the 34 included studies reported the rehabil-
itation protocol that was used postoperatively. Of these 22
studies, 16 reported that patients initially used a sling for 3-4
weeks postoperatively, after which they began pendulum ex-
ercises, advancing to forward flexion and abduction motions,
and eventually progressed to full range of motion by 3 months
Return to sport: arthroscopic Bankart repair
and full return to play by 6 months. There were 2 studies that
reported mobilization of the shoulder on the first postoper-
ative day, followed by gradual exercises, which allowed for
return to full play at 6 months. Furthermore, 2 studies re-
ported that patients maintained sling immobilization for a
period of 6 weeks, prior to beginning progressive resistance
exercises. Finally, 2 studies reported an initial 3-week period
of shoulder immobilization, followed by full range of motion
permitted at 6 weeks and return to full activity at 3 months
after surgery. The criteria for returning to sporting activities
were reported by 22 of the 34 included studies and entailed
successful completion of the rehabilitation protocol. In ad-
dition, 26 of the 34 included studies reported on the
postoperative period until patients were allowed to return to
sport, which demonstrated that patients were allowed to return
to sport after a mean duration of 5.7 months (range, 1.9-32
months) postoperatively (Table S4). There was inconsistent
reporting of brace use postoperatively, with only 7 of the 32
included studies having reported its use.
Outcomes
Return-to-sport outcomes
Return-to-sport outcomes were reported for all 1866 in-
cluded patients who underwent arthroscopic repair of a Bankart
lesion. Overall, patients returned to any level of sport after
a mean duration of 7.9 months (range, 1.9-32 months), with
a pooled rate of return to sport of 81% (95% CI, 74%-87%;
I2 = 90.64%). In addition, the preinjury level of sport was re-
ported in 1441 patients, with a pooled rate of return to the
preinjury level of 66% (95% CI, 57%-74%; I2 = 90.89%) at
a mean duration of 9.1 months (range, 1.9-32 months). Finally,
among the 273 patients who participated in competitive sports
preoperatively, the pooled rate of return to their competitive
level of sport was 82% (95% CI, 79%-88%; I2 = 82.08%) after
a mean duration of 5.6 months (range, 1.9-15.6 months), and
the pooled rate of return to the preinjury level was 88% (95%
CI, 66%-99%, I2 = 81.20%) (Table S5).
Subgroup analysis of patients returning to sports
Eight studies including 182 patients reported return-to-
sport outcomes for overhead throwing athletes. The pooled
rate of return to any sporting activities in these athletes was
78% (95% CI, 69%-86%; I2 = 45.64%). Return-to-sport rates
were specified for non-overhead athletes in 5 studies, with
a pooled rate of return to sport of 85% (95% CI, 64%-98%;
I2 = 81.50%). Four studies reported the rate at which pa-
tients returned to sports with accelerated rehabilitation, with
a pooled rate of 91% (95% CI, 69%-100%; I2 = 85.74%). Last,
4 studies reported the rate of return to sport with acute or
primary Bankart repair, with a pooled rate of 96% (95% CI,
90%-100%; I2 = 33.28%).
Pain and functional outcomes
Overall, there were 7 studies, including 407 patients, that
assessed pain outcomes with the use of outcome
1345
scores,3,14,17,21,24,31,34 including a visual analog scale in 3
studies,14,21,31 a pain score from 0 to 1 in 1 study,17 the indi-
vidual pain constituents of the Rowe score in 2 studies,3,24
and the Walch-Duplay score in 1 study.34 All pain scores dem-
onstrated significant improvement from the preoperative to
postoperative period (Table S6). In addition, there were 26
studies that assessed functional outcomes with the use of
outcome scores, including the Rowe score in 16 studies; Uni-
versity of California, Los Angeles shoulder score in 4 studies;
Western Ontario Shoulder Instability index in 4 studies; Tegner
activity scale in 1 study; Constant-Murley Shoulder Outcome
Score in 2 studies; Oxford Shoulder Score in 2 studies; Walch-
Duplay score in 1 study; and American Shoulder and Elbow
Surgeons shoulder score in 1 study. All functional outcome
scores demonstrated significant improvement from the pre-
operative to postoperative period (Table S6).
Discussion
The major finding of this systematic review was that there
is a relatively high rate of return to sport after arthroscopic
Bankart repair. A meta-analysis of proportions identified a
pooled rate of return to any level of sport of 81%, while 66%
of the included patients returned to their preinjury level of
sport. In addition, 82% of competitive athletes returned to their
competitive level of sport, with 88% of those competitive ath-
letes returning to their preinjury level of sport. As such,
approximately one-third of athletes did not return to their
preinjury level of sports. Subgroup analyses revealed the
highest rates of return to sport were noted in patients under-
going accelerated rehabilitation programs, patients undergoing
primary Bankart repair, and patients participating in non-
overhead sporting activities.
The findings in this study are significant, as there appears
to be a relatively high rate of return to sport in addition to
excellent pain and functional outcomes following arthro-
scopic Bankart repair. This is particularly important for athletes
because it has been reported that their primary expectation
following arthroscopic shoulder surgery is continued partic-
ipation in sports.35 However, return-to-sport rates appear to
be multifactorial, and psychological and social factors influ-
encing decisions to return to sport are often overlooked. On
the basis of a 2014 study by Tjong et al,33 involving a qual-
itative analysis of patients undergoing arthroscopic Bankart
repair, patients identified that factors influencing their deci-
sion to not return to sport included fear of reinjury and sporting
incompetence; shifts in priority, including greater career
demands; decreased confidence; and increasing age. Such find-
ings may explain why the return-to-sport rate was the highest
in the cohort of competitive athletes, who presumably have
higher motivation to return to sporting activities. These find-
ings highlight the need to address other factors in addition
to functional outcomes in athletes undergoing arthroscopic
Bankart repair.
Return-to-sport rates in patients undergoing open Bankart
repair have ranged from 56% to 77% in the current
1346
literature, which are similar to albeit lower than the rates in
the present review. In addition, Klouche et al18 performed a
systematic review and meta-analysis of 25 studies evaluat-
ing the rate at which patients returned to sports following
rotator cuff repair. The study identified an overall rate of return
to sport of 85%, with 66% returning to their previous level
of play. However, fewer than 50% of competitive athletes re-
turned to the equivalent level of sport, whereas our study
demonstrated that 82% of competitive athletes returned to com-
petitive sports, with 88% of those athletes returning at the
preinjury level. These findings indicate a similar rate of return
to sport for athletes undergoing rotator cuff repair to that in
our study following arthroscopic Bankart repair; however, the
present study also identified a higher rate of return to sport
in competitive athletes. Of note, approximately one-third of
athletes were unable to return to their preinjury level of sport
in the current study. Given that only 11 of the 18 studies in-
volving competitive athletes reported the return-to-sport rate
at the preinjury level, this low rate of return to the preinjury
level may be influenced by a small sample size and missing
data. While our review suggests that a significant number of
competitive athletes were unable to return to their preinjury
sport, future studies should consistently report the return–
to–preinjury sport rate for competitive athletes to establish
a more accurate estimate.
As the focus on return to sport has increased within the
orthopedic literature, studies have examined factors that may
be associated with improved or worsened outcomes. Specif-
ically, it has been reported that postoperative sporting
proficiency is negatively correlated with preoperative risk level,
performance level, and Tegner activity scale, whereas age and
male sex have been demonstrated to be correlated with im-
proved return-to-sport outcomes.13,25 Furthermore, the type of
sport appears to influence return-to-sport outcomes, wherein
overhead athletes and martial artists experience a delayed return
to sport at an inferior level compared with noncollision or
non-overhead athletes and high-impact or collision athletes.31
The present study found that overhead athletes return to sport
at similar levels to the general athletic population, which may
be explained by a small sample size resulting from poor re-
porting of return to sport by sport type, leading to the
possibility that the athletes who participated in overhead sports
were higher-level athletes and were more motivated to return
to sport. As such, surgeons may consider the type of sport
played when discussing the recovery patients may expect fol-
lowing surgery. In addition, patients who have recurrent
dislocations before surgery experience a longer rehabilita-
tion process compared with those undergoing primary Bankart
repair,13,31 which is hypothesized to be due to poorer capsu-
lar quality and/or proprioception deficiencies in a shoulder
that has experienced multiple dislocations. Given these dif-
ferences in outcomes, Gerometta et al13 recommended that
surgery may be warranted in patients who have experienced
their first traumatic shoulder dislocation. To further support
this recommendation, a study by Crall et al6 demonstrated that
primary arthroscopic stabilization was more cost-effective than
M. Memon et al.
initial observation for the majority of patients experiencing
first-time anterior shoulder dislocations. This is supported by
the trend in the current review that patients undergoing primary
Bankart repair may achieve higher return-to-sport rates.
Limitations
The primary limitations of this review include the lack of high-
quality studies investigating return-to-sport outcomes following
arthroscopic Bankart repair. The included studies were mostly
case series, with retrospective collection of data. Further-
more, the included nonrandomized and noncomparative studies
may be prone to selection bias in the patients who are re-
cruited to be study participants. Moreover, the reporting of
certain data within the studies was not always consistent, in-
cluding information regarding preoperative type of sport,
preoperative sport level, rehabilitation protocol, definition of
return to sport, and pain and functional outcomes. There was
also significant heterogeneity in the return-to-sport rates across
the included studies. The rates of return to sport, however,
were combined using a random-effects model in a meta-
analysis of proportions to account for this heterogeneity. Last,
other potential sources of bias include reporting bias, inclu-
sion of only English-language studies, and incomplete retrieval
of studies; however, an extensive search of 3 databases was
used to mitigate the chances of such bias.
Conclusion
Arthroscopic Bankart repair yields a high rate of return
to sport, in addition to significant improvement in pain and
functional outcomes in the majority of patients. However,
approximately one-third of athletes do not return to their
preinjury level of sports.
Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not re-
ceived any financial payments or other benefits from any
commercial entity related to the subject of this article.
Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jse.2018.02.044.
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