Shoulder instability: return to play

Shoulder instability in the competitive athlete is a relatively common problem. The etiology of glenohumeral instability that can affect the athlete runs a wide spectrum, from an isolated traumatic dislocation to repeated microtrauma or congenital laxity. Although many athletes are able to adapt to a mild laxity that might only occasionally affect them, it can be much more difficult to adapt or return to play after a dislocation or repeated subluxation episodes. This article focuses on the return to play for competitive individuals after a glenohumeral dislocation or reconstructive surgery for shoulder instability.     

Nonoperative management for in-season athletes with anterior shoulder instability

BACKGROUND: Acute or recurrent anterior shoulder instability is a frequent injury for in-season athletes. Treatment options for this injury include shoulder immobilization, rehabilitation, and shoulder stabilization surgery. PURPOSE: To determine if in-season athletes can be returned to their sports quickly and effectively after nonoperative treatment for an anterior instability episode. METHODS: Over a 2-year period, 30 athletes matched the inclusion criteria for this study. Nineteen athletes had experienced anterior dislocations, and 11 had experienced subluxations. All were treated with physical therapy and fitted, if appropriate, with a brace. These athletes were followed for the number of recurrent instability episodes, additional injuries, subjective ability to compete, and ability to complete their season or seasons of choice. RESULTS: Twenty-six of 30 athletes were able to return to their sports for the complete season at an average time missed of 10.2 days (range, 0-30 years). Ten athletes suffered sport-related recurrent instability episodes (range, 0-8 years). An average of 1.4 recurrent instability episodes per season per athlete occurred. There were no further injuries attributable to the shoulder instability. Sixteen athletes underwent surgical stabilization for their shoulders during the subsequent off-season. CONCLUSIONS: Most of the athletes were able to return to their sport and complete their seasons after an episode of anterior shoulder instability, although 37% experienced at least 1 additional episode of instability during the season.     

Treatment of multidirectionalshoulder instability in the athlete

Multidirectional instability in the athlete refers to symptomatic laxity of the shoulder in more than one direction.This is in contrast to unidirectional instability, which involves subluxation or dislocation in only one direction. The diagnosis and treatment of this disorder can be challenging owing to the unusual demands athletes place on their shoulders to be effective in their sport. The laxity required for overhand throwing, gymnastics, swimming, volleyball and tennis — while increased compared with that required for activities of daily living or with that of the opposite shoulder — must be symptomatic to be pathologic. Formerly, it was thought that generalized ligamentous laxity was a requirement for multidirectional instability, but now it is realized many athletes have multidirectional instability in the setting of otherwise normal ligamentous laxity. Nonoperative treatment is frequently successful in these athletes. When conservative management is unsuccessful, the capsular shift procedure has demonstrated good results in allowing these athletes to return to their sport. Arthroscopic and thermal capsulorrhaphy also offer other options for surgical treatment of this problem and will be briefly discussed.     

Treatment of glenohumeral instabilityin the pediatric athlete

Shoulder instability in the skeletally immature athlete is an uncommon but challenging clinical problem. Theclassification of shoulder instability in the pediatric athlete is similar to that in the adult athlete, but may also include the voluntary and habitual dislocator. The natural history of such instability depends on the classification of instability type. Traumatic anterior dislocation has an exceedingly high recurrence, and posterior dislocation is less well known. A natural history of voluntary instability is also uncertain. As in the adult athlete, clinical evaluation is made by history and physical exam. An understanding of the bony development of the glenohumeral joint is crucial in interpreting radiographs of the skeletally immature athlete with glenohumeral instability. The treatment of glenohumeral instability will depend on the classification of the instability type. Surgical treatment, when indicated, should emphasize an anatomic approach aimed at correcting the underlying glenohumeral pathology. This article is intended to provide an overview of the approach to diagnosis and treatment of glenohumeral instability in the pediatric athlete.     

Upper extremity injuries in the paediatric athlete

Injuries to the upper extremity in paediatric and adolescent athletes are increasingly being seen with expanded participation and higher competitive levels of youth sports. Injury patterns are unique to the growing musculoskeletal system and specific to the demands of the involved sport. Shoulder injuries include sternoclavicular joint injury, clavicle fracture, acromioclavicular joint injury, osteolysis of the distal clavicle, little league shoulder, proximal humerus fracture, glenohumeral instability and rotator cuff injury. Elbow injuries include supracondylar fracture, lateral condyle fracture, radial head/neck fracture, medial epicondyle avulsion, elbow dislocation and little league elbow. Wrist and hand injuries include distal radius fracture, distal radial physeal injury, triangular fibrocartilage tear, scaphoid fracture, wrist ligamentous injury thumb metacarpalphalangeal ulnar collateral ligament injury, proximal and distal interphalangeal joint injuries and finger fractures. Recognition of injury patterns with early activity modification and the initiation of efficacious treatment can prevent deformity/disability and return the youth athlete to sport.     

Return to australian rules football after acute elbow dislocation: A report of three cases and review of the literature

Acute elbow dislocation is an uncommon problem encountered in contact sports such as Australian Rules Football [ARF]. Previously there have been few guidelines presented as to when the athlete can safely return to sport following such an injury. During the 1998 playing season the author as medical officer of a professional ARF team encountered three athletes who had an elbow dislocation. All resulted from a fall on an outstretched hand during competition. The athletes returned to football at 13 days, 21 days and 7 days respectively. All subsequently completed the football season without re-injury and at post-season clinical review and one year subsequent to this no athlete described residual symptoms nor was there any loss of range of motion of the elbow joint. Clinical recommendations that allow for athletes to make a safe and early return to contact sport following an episode of acute elbow dislocation include; 1) commencing active mobilization as soon as possible after injury, 2) using passive mobilization to attain full extension as soon as possible, 3) allowing the athlete to return to training before full extension is achieved and 4) allowing the athlete to return to contact sport as soon as full extension is achieved with assistance of elbow stability taping.     

Recurrent shoulder instability among athletes: changes in quality of life,sports activity,and muscle function following open repair

Background: Recurrent anterior shoulder instability is a disabling condition in young athletes with possibly underestimated impact on quality of life and sports activity. Commonly used clinical scoring systems do not reflect the impairment of quality of life and sports activity. It was our aim to assess the return to preinjury levels of quality of life and sports activity as well as the changes in muscle function among competitive and recreational athletes. Hypothesis: Patients suffering from post-traumatic recurrent shoulder instability have to adopt their participation in sports and therefore discover a reduction in quality of life. Open stabilization procedures are able to improve shoulder function and to reduce recurrence rates. However, return to preinjury shoulder function is not guaranteed. Study design: Retrospective longitudinal cohort study on 19 consecutive athletes with recurrent, post-traumatic shoulder instability. All patients were treated with an open, capsulo-labral repair. The minimum follow-up was 24 months. Methods: Life quality (SF12) and sports activity data (Athletic Shoulder Outcome Scoring System) were retrospectively collected for the time before injury (time 1) and for the time with recurrent instability (time 2). Two years after surgical stabilization (time 3), we followed our patients with different clinical outcome scores, rotator surface EMG measurement, isokinetic muscle strength testing, and a radiological evaluation. This design of a three-step follow-up allowed for calculating the impact on quality of life and sports activity following the injury. Results: Two years after surgery, the clinical scoring systems revealed good-to-excellent results in all patients. Quality of life physical component summary remained diminished by 9.2% despite the surgical procedure and was therefore significantly lower as compared to preinjury levels (p < 0.05). Sports activity was also significantly lower at the time of follow-up (p < 0.05). In this specific procedure, external rotation was not impaired postoperatively. EMG testing showed an overall reduction of muscle activity, however not significant. Isokinetic muscle strength was significantly diminished for external rotation and shoulder abduction. Conclusions: Open reconstruction procedures for recurrent shoulder instability can restore shoulder function and stability to near-normal values. Despite good-to-excellent clinical results, there is a significant impairment of quality of life and sports activity 2 years after surgery. Muscle activity and muscle strength are diminished. Recurrent shoulder instability remains a disabling condition to the young athlete. Future strategies have to emphasize restoration of quality of life, sports activity, and muscle function.     

Traumatic anterior shoulder instability in the athlete

Anterior glenohumeral dislocation is common among athletes and may progress to recurrent instability. The pathoanatomy of instability and specific needs of each individual should be considered to prevent unnecessary absence from sport. Traditionally, primary dislocations have been managed with immobilization followed by rehabilitation exercises and a return to sporting activity. However, arthroscopic stabilization and external rotation bracing are increasingly used to prevent recurrent instability. In addition to the typical capsulolabral disruptions seen following a primary dislocation, patients with recurrent instability often have coexistent osseous injury to the humeral head and glenoid. In patients without significant bone loss, open soft‐tissue stabilizations have long been considered the ‘gold standard treatment’ for recurrent instability, but with advances in technology, arthroscopic procedures have gained popularity. However, enthusiasm for arthroscopic repair has not been supported with evidence, and there is currently no consensus for treatment. In patients with greater bone loss, soft‐tissue stabilization alone is insufficient to treat recurrent instability and open repair or bone augmentation should be considered. We explore the recent advances in epidemiology, classification, pathoanatomy and clinical assessment of young athletes with anterior shoulder instability, and compare the relative merits and outcomes of the different forms of treatment.     

Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports

From April 1, 1985, through June 30, 1987, 25 skilled athletes with shoulder pain secondary to anterior glenohumeral instability that had failed to improve with conservative therapy had an anterior capsulolabral reconstruction. All but one athlete completed a formal rehabilitation program with an average followup of 39 months. The results at followup were rated excellent in 68%, good in 24%, fair in 4%, and poor in 4%. Seventeen patients returned to their prior competitive level for at least 1 year. This operation and rehabilitation program may allow many athletes who participate in overhand activities or throwing sports to return to their prior level of competition.     

Screening the athlete's shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology

Chronic shoulder pain and dysfunction are common complaints among overhead athletes seeking care from physical medicine and rehabilitation. Impingement is a frequently described pathological condition in the overhead athlete. Impingement symptoms may be the result of rotator cuff pathology, shoulder instability, scapular dyskinesis or muscle dysfunction, biceps pathology, SLAP lesions and chronic stiffness of the posterior capsule. At present, numerous different shoulder tests have been described in literature and discussed with respect to their individual diagnostic accuracy. However, in view of the number of shoulder tests, it is often a challenge for the clinician to select the appropriate tests for diagnosing the underlying pathology. The purpose of this paper is to present and discuss a clinical algorithm which may be used in the early detection of the underlying causes of impingement symptoms. In this algorithm, a specific chronology and selection of diagnostic tests may offer the clinician a guideline in his physical examination of the athlete with shoulder pain.     

Special shoulder problems in the throwing athlete: pathology, diagnosis, and nonoperative management

Shoulder problems in the overhead and throwing athlete can result in rotator cuff tendinitis. Biomechanically, there is a delicate balance between mobility and stability of the shoulder complex. Repetitive overhead stressful motion can lead to overuse tendinitis, subtle instability, labral changes, and eventual fiber failure of the rotator cuff. Secondary impingement symptoms are commonly present. An accurate diagnosis along with an early and aggressive rehabilitation program is essential in the treatment of these athletes.     

Impingement of the rotator cuff in athletes caused by instability of the shoulder joint

An impingement of the rotator cuff can be caused by chronic anterior instability of the shoulder joint. This particular disease is often found in athletes engaged in overhead motion in abduction/external rotation of the arm, such as in ball sports like volleyball or European handball, racket sports like tennis or badminton, or swimming. For those patients that cannot be cured by conservative treatment such as muscular stabilization, surgical treatment is indicated: anterior reconstruction of the capsule and/or the glenoid labrum, and in addition — if necessary — subacromial decompression and revision of the rotator cuff. Between October 1988 and April 1992, we operated on 66 shoulders in 64 top athletes suffering from chronic anterior or multidirectional instability of the shoulder joint that had caused an impingement syndrome of the rotator cuff. In all cases, the athlete was unaware of the instability. Conservative treatment had been unsuccessful. Surgical treatment was successful in close to 90% of the athletes.     

Advances in the understanding of anterior instability of the shoulder

Anterior instability involves a spectrum of disease ranging from the obvious acute first-time dislocation to the athlete presenting with shoulder pain and no history suggestive of instability. It is important to recognize the pathophysiology and how it relates to this spectrum of disease. The arthroscope has helped to identify the underlying pathology in both acute and chronic situations. Diagnostically, a history of a painful shoulder, especially in the athlete, should suggest anterior instability. Tests of translation, apprehension, and the use of local anesthetic can be useful. Arthroscopy is used in situations in which the diagnosis is unclear. The management of anterior instability should emphasize strengthening of the rotator cuff and scapular stabilizers. Surgical repair requires correction of the underlying pathology with minimization of damage to other structures. Arthroscopic management of anterior instability includes repair, debridement of intra-articular lesions, and the possibility of acute correction of the pathoanatomic lesions.     

Sports-related injuries of the shoulder: instability

With current technology a properly conceived imaging strategy can demonstrate instability lesions in the athlete. Plain radiographs can diagnose acute dislocations and assess successful reductions. In addition, plain radiographs can demonstrate Hill-Sachs and, more importantly for instability, osseous Bankart lesions. In the acute setting, conventional MRI nicely demonstrates labral Bankart, ligamentous. and tendonous injuries that result from dislocations and can lead to instability. In the setting of chronic instability, MR arthrography best evaluates these lesions. In the postoperative shoulder, muitislice CT arthrography may be the modality of choice, but further investigation is needed. If large series validate multislice CT arthrography for the evaluation of postoperative instability lesions, this technique may become widely used in athletes and in other populations where recurrent instability is a problem. Other imaging strategies may also find an increasing central role in evaluating shoulder instability lesions. Indirect MR arthrography, for example, may have a role in assessing these lesions in athletes . Another intriguing technology for this application is the development of high field (0.5 Tesla or greater) open magnets. In such a setting, physiological relationships in the shoulder with motion and stress may be evaluated. Such imaging may farther illuminate our understanding of the stable and unstable shoulder. Unfortunately, with all imaging modalities, whether widely used or experimental, outcomes data is Lacking. How do the various imaging modalities and strategies affect patient outcome? The answer is unknown and needs to be answered before a definitive patient work-up for shoulder instability can be established.     

Advances in the management of traumatic anterior and atraumatic multidirectional shoulder instability

Dislocation of the shoulder is a common and often disabling injury to an athlete. Most shoulder dislocations are traumatic in origin, occur in the anterior direction and result in stretching and detachment of the anterior capsule and labrum. The most frequent adverse sequel of shoulder dislocation is recurrence--an event that occurs most commonly in active individuals and less frequently with age. In the past, many operative procedures failed to address the anatomical disruptions of shoulder instability. Recently, an enhanced understanding of shoulder instability pathoanatomy and significant technological advances have resulted in surgical procedures for shoulder instability that are less interventional and have focused on restoring disrupted static constraints.     

Secondary impingement in the shoulder. An improved terminology in impingement

Non-traumatic shoulder pain in the overhead athlete is a diagnostic challenge. In the last decade shoulder arthroscopy and magnetic resonance imaging (MRI) techniques have extended our knowledge. Previously unknown pathologic changes in the glenohumeral joint have been demonstrated and it is recognized that impingement symptoms and instability are often related. Shoulder dysfunction in overhead athletes may be caused by shoulder instability. However, a possible instability in the shoulder is often "silent" and difficult to demonstrate by ordinary tests and has therefore by some been termed "functional instability". It is now thought that functional instability in the shoulder may lead to a vicious cycle involving microtraumata and attenuation of the capsular complex, and may eventually lead to shoulder pain. Changes in shoulder proprioception, measured by testing kinaesthetic sense and position sense, can be related to different pathologic changes in the shoulder, and sensory motor control may be an important factor for functional stability in the shoulder. MRI and arthroscopical findings in athletes with shoulder pain are changes in the glenoid labrum, the humeral head, the rotator cuff, biceps tendon and the capsular complex. However, these findings often present other clinical entities than impingement and are not always associated with instability. Clinically, there are tests that can objectively distinguish some of the pathological findings. However, we need more exact methods to further improve our clinical diagnoses of the painful shoulder. One of the keys could be an extended knowledge about the pathophysiology behind functional instability. This review focuses on an improved terminology in impingement based on the current knowledge of impingement and instability in the shoulder.     

Shoulder instability in thefemale athlete

Glenohumeral instability is relatively commonly observed in the female athlete. Studies have shown an increased incidence of both asymptomatic and pathological laxity among women. Female athletes participating in sports involving repetitive use of the upper extremity may be at particular risk for developing symptoms. Shoulder instability is classified according to etiology, onset, degree, and direction. Accurate diagnosis is important to determine proper management. Female athletes presenting with symptoms of shoulder instability should be initially treated with a comprehensive rehabilitation program emphasizing strengthening of the rotator cuff and dynamic scapular stabilizing muscles. After failure of nonoperative management, satisfactory results can be obtained using either open or arthroscopic surgical techniques.     

Anterior shoulder dislocations in sports

Anterior shoulder dislocations, primary and recurrent, are among the most disabling injuries to the shoulder that can plague the athlete. The diagnosis is easily made by the following: the physical appearance of the shoulder; loss of capability by the athlete to internally and externally rotate the shoulder with the elbow at his side; by evaluating the mechanism of injury; and x-rays. Anterior shoulder dislocations should be reduced as soon as possible after diagnosis, to minimise the stretching effect on the neurovascular structures while the humeral head is dislocated. The reduction is not done to allow the athlete to return immediately to sport. Use of a simple traction method in the first 10 to 15 minutes following the injury will result in a successful reduction in the vast majority of dislocations. Reduction of the humeral head can be confirmed by the athlete regaining the capability to internally and externally rotate his shoulder with his elbow at his side. Following reduction, the athlete should begin a treatment regimen which includes a restrengthening programme emphasising the muscles of internal rotation and adduction plus rigid restrictions of activities until the goals of the rehabilitation programme are satisfied. The author's experience with this treatment regimen with athletes at the United States Naval Academy, has shown a decrease of the recurrence rate of primary anterior shoulder dislocations to 25% versus the 80% recurrence rate we have become familiar with from studies done which did not stress specific rehabilitation programmes. The athlete should also be instructed in a self-performed traction method for reduction should a redislocation occur, to minimise the stretching effect on the neurovascular structures and allow relief from discomfort. Surgery for primary and recurrent anterior dislocations should only be considered when the athlete fails to achieve the desired goals after participating in a specific, progressive, adequate rehabilitation programme.     

A prospective,randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute,traumatic, first-time shoulder dislocations

BACKGROUND: Nonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations. HYPOTHESIS: Early arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment. STUDY DESIGN: Prospective, randomized clinical trial. METHODS: Two groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months. RESULTS: Three patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability. CONCLUSIONS: Arthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.     

Treatment of glenohumeral instability in rugby players

Rugby is a high-impact collision sport, with impact forces. Shoulder injuries are common and result in the longest time off sport for any joint injury in rugby. The most common injuries are to the glenohumeral joint with varying degrees of instability. The degree of instability can guide management. The three main types of instability presentations are: (1) frank dislocation, (2) subluxations and (3) subclinical instability with pain and clicking. Understanding the exact mechanism of injury can guide diagnosis with classical patterns of structural injuries. The standard clinical examination in a large, muscular athlete may be normal, so specific tests and techniques are needed to unearth signs of pathology. Taking these factors into consideration, along with the imaging, allows a treatment strategy. However, patient and sport factors need to be also considered, particularly the time of the season and stage of sporting career. Surgery to repair the structural damage should include all lesions found. In chronic, recurrent dislocations with major structural lesions, reconstruction procedures such as the Latarjet procedure yields better outcomes. Rehabilitation should be safe, goal-driven and athlete-specific. Return to sport is dependent on a number of factors, driven by the healing process, sport requirements and extrinsic pressures. Level of evidence V.