Post-Surgical Shoulder Stiffness After Arthroscopic Bankart Repair: A Rehabilitation Case Study

Post-operative shoulder stiffness after Bankart repair can limit gym training, overhead activities, and confidence in movement even when daily work is unaffected. This case study explains a structured rehabilitation approach used to improve shoulder rotation, stability, strength, and functional performance after one year of persistent restriction.

Background

A patient presented with right shoulder stiffness one year after undergoing arthroscopic Bankart repair for shoulder instability associated with a mild Hill-Sachs lesion. The surgery had been performed by an orthopaedic surgeon, followed by physiotherapy starting one month post-operatively for approximately three months.

Although the patient had returned to an active lifestyle and was not significantly limited in professional activities, several functional and gym-based movements remained restricted. He was unable to perform push-ups, chest press, hanging, lat pull-downs, and comfortable overhead movements. He also reported a sense that the shoulder “would come off” when moving into higher ranges, creating fear and avoidance of those positions.

Clinical Presentation

On observation, the patient had good posture and maintained an active lifestyle. There was no resting pain, but pain and stiffness appeared beyond the available range of shoulder motion. A key movement compensation was noted during side elevation: instead of abducting the arm in the frontal plane, he moved the arm forward into the scapular plane to raise it higher.

Initial Active Range of Motion

• Shoulder flexion: 140 degrees
• Shoulder abduction: 90 degrees
• Internal rotation: 30 degrees
• External rotation: 10–15 degrees

Initial Muscle Strength Findings

• Anterior deltoid: Grade 4 up to 90 degrees
• Middle deltoid: Grade 3+ up to 50 degrees
• Middle trapezius: Grade 2+
• Lower trapezius: Grade 2
• Latissimus dorsi: Grade 3

Shoulder rotation strength was not tested initially because of pain and stiffness. The main clinical concerns were restricted external rotation, poor overhead control, reduced scapular strength, insufficient shoulder stability, and fear of end-range movement.

Rehabilitation Priorities

The rehabilitation plan was divided into progressive 10-day blocks. The focus was not only to increase range of motion, but also to improve the patient’s trust in the shoulder through strengthening, stability training, and controlled exposure to previously avoided positions.

In post-Bankart repair cases, regaining external rotation must be approached carefully and progressively. The goal is to restore functional mobility without aggressively stressing the anterior capsule or creating a sense of instability. For this patient, the program emphasized controlled loading, scapular activation, rotator cuff strengthening, and graded closed-chain work.

Phase 1: Days 1–10

Goals

• Decrease pain at end range
• Improve shoulder rotation range
• Begin shoulder stability training
• Reduce fear during controlled movement

Rehabilitation Exercises

The initial phase focused on low-load activation and mobility. Rotator cuff isometrics were used to activate the stabilizing muscles of the shoulder without provoking symptoms. External rotation was introduced in controlled positions to begin improving the most restricted movement.

• Rotator cuff isometrics
• Side-lying external rotation with 0.5 kg
• Standing external rotation with light resistance
• Shoulder protraction in lying with 1 kg
• Prone active external rotation
• Prone shoulder adduction with elbow bent for middle trapezius activation
• Quadruped shoulder protraction and push-up plus position
• Quadruped knee lift for early closed-chain stability

Mobility Work

• External rotation with a stick in lying, arm by side
• External rotation with a stick in standing, arm by side
• External rotation in lying with the arm at 50–60 degrees of abduction
• Anterior shoulder and arm stretch by holding a bar behind the body and gently turning away

During this phase, the intention was to expose the shoulder to rotation without forcing the range. The patient was encouraged to move slowly, stay within tolerable discomfort, and avoid compensatory trunk or scapular movement.

Phase 2: Days 10–20

Goals

• Improve strength in the rotator cuff and scapular muscles
• Continue gaining shoulder rotation range
• Progress shoulder stability exercises
• Introduce functional pressing patterns gradually

Once the patient tolerated basic activation and mobility work, strengthening was progressed with mild resistance and more functional positions. Exercises were selected to improve both dynamic stability and confidence during loaded shoulder movements.

Rehabilitation Exercises

• Standing wall push-off with elbows bent
• Shoulder flexion with a mild theraband around the wrists
• W and Y exercises with 0.5 kg
• Rotator cuff strengthening with mild resistance band, arm by side
• Rotator cuff strengthening with the arm at 50–60 degrees abduction
• Bilateral shoulder flexion with a 3 kg weighted bar
• Push-up plus in plank position with 5-second holds, 10 repetitions
• Push-ups on an elevated surface

This phase helped transition the patient from isolated strengthening to more integrated shoulder control. The serratus anterior, middle trapezius, lower trapezius, and rotator cuff were trained together to improve scapulohumeral rhythm and reduce compensatory movement patterns.

Phase 3: Days 20–30

Goals

• Enhance rotator cuff strength
• Improve shoulder stability under body weight
• Develop proprioception and confidence
• Return to gym-based pushing and pulling movements

The final phase emphasized higher-level stability and proprioceptive training. Closed-chain exercises were advanced because they encourage co-contraction around the shoulder and help the patient tolerate load through the arm.

Rehabilitation Exercises

• Push-up plus with downward dog progression
• Bear walk
• Shoulder taps
• Plank hold
• Plank with leg lift
• Plank with arm reach
• Side plank with knees bent
• Plank with hands on a BOSU ball
• Push-ups on the ground

These exercises challenged the shoulder in multiple directions while maintaining control. The use of planks, shoulder taps, and BOSU-based positions improved proprioception and helped address the patient’s fear that the shoulder might become unstable in overhead or loaded positions.

Outcome After 30 Days

At the end of the rehabilitation period, the patient demonstrated meaningful improvements in shoulder range of motion and functional ability. Most importantly, he returned to previously restricted gym exercises without pain or stiffness.

Final Range of Motion

• Shoulder flexion: 160 degrees
• Shoulder abduction: 160 degrees, with improved movement in the frontal plane
• External rotation with arm by side: 40 degrees
• External rotation in abducted position: 25 degrees

Functional Gains

• Push-ups performed without pain or stiffness
• Pull-ups resumed
• Lat pull-downs performed comfortably
• Chest press resumed without shoulder symptoms
• Improved confidence in overhead and loaded shoulder positions

Clinical Discussion

This case highlights that post-surgical stiffness after Bankart repair may persist even after standard rehabilitation, especially when external rotation, scapular control, and confidence in movement are not fully restored. A patient may appear functional in daily life but still struggle with higher-demand activities such as gym training, hanging, pressing, and overhead work.

The rehabilitation strategy worked because it addressed multiple contributing factors: limited joint range, rotator cuff weakness, scapular muscle inhibition, reduced closed-chain stability, and fear of movement. Instead of focusing only on stretching, the plan combined mobility with progressive strengthening and proprioceptive loading.

Another important feature was graded exposure. The patient feared that the shoulder would “come off” in certain ranges. By gradually introducing controlled external rotation, plank variations, push-up progressions, and overhead patterns, the patient learned to trust the shoulder again while building the muscular support required for stability.

Key Takeaways

• Post-operative shoulder stiffness can affect sports and gym activities even when daily work is normal.
• External rotation limitation is common after Bankart repair and should be restored progressively.
• Scapular strengthening is essential for improving overhead movement and reducing compensation.
• Closed-chain exercises such as push-up plus, planks, and shoulder taps are valuable for shoulder stability.
• Fear of movement should be addressed through controlled, graded exposure rather than avoidance.
• Return to gym exercises should be based on pain-free control, range, and stability, not time alone.

Conclusion

In this case, a structured 30-day rehabilitation program helped improve shoulder mobility, strength, stability, and confidence one year after arthroscopic Bankart repair. The patient regained the ability to perform push-ups, pull-ups, chest press, and lat pull-downs without pain or stiffness.

For patients with post-surgical shoulder stiffness, successful rehabilitation requires more than passive stretching. A progressive plan combining rotator cuff strengthening, scapular control, mobility work, proprioceptive training, and functional loading can restore both movement and confidence in the shoulder.