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.     

Sports ability after Bankart procedure in professional athletes

Recurrent anterior shoulder instability and the restoration of sports ability after surgery are common problems, especially among professional athletes. The purpose of this study was to evaluate the rate, level and time of returning to sports activity after Bankart procedure in anterior shoulder instability in high level atheletes. From 1992–1994 61 patients suffering from recurrent anterior shoulder instability were operated on open Bankart procedure. 44 out of 61 were professional athletes. There were 7 handball, 7 basketball, 6 football, 2 waterpolo and 1 base-ball player and 4 wrestlers, 2 weightlifters, 2 boxers, 3 bicyclists, 2 motorists, 2 swimmers, 2 sailors, 2 kayakers and 2 skiers. The mean duration of instability was 19.1 months (3–72) before operation. 29 patients had posttraumatic recurrent anterior dislocation and 15 patients had posttraumatic anterior subluxations. The average number of redislocations was 4.4, ranging from 2 to 11. At the follow-up examination the patients were tested clinically for instability using the special score created by Walch and Duplay and the Constant functional score. We measured the strength of the rotator cuff by Kintrex isokinetic device from the 10th postoperative week. 35 out of 44 professional athletes could be fellowed-up. The average follow-up period was 14.2 months, from 6 to 31. 88% of the patients were able to return to sports participation, 66% on the previous levels and 22% on a lower level. 12% of the patients finished their professional sports career. The mean rehabilitation period was 5.8 months, the average period of full restoration of sports ability was 9.3 months. Similar results were documented with the Constant score and the Walch-Duplay test (88% excellent or good, 12% fair). The main reason for the inability to continue sports activity was some pain during extreme abduction and extrnal rotation of the arm and recurrent sensations of subluxation (3 cases). Based on the results of the follow-up examinations an early diagnosis is paramount followed by timely surgical intervention to restore anatomical integrity in proven cases of shoulder instability in professional athletes. The open Bankart procedure is preferred giving excellent functional results and providing good chances for the atheletes to return to their previous sports level.     

Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy

Twenty-five athletes (26 shoulders) who underwent an inferior capsular shift procedure for multidirectional glenohumeral instability based on isolated capsular and ligamentous redundancy were evaluated at a median of 54 months (range, 25 to 113) after the operation. Twenty-one athletes (84%) returned to their preinjury activity level at a median of 5 months after surgery. Of 21 athletes involved in sports using overhead motions, 16 (76%) returned to their previous sport after the operation, and 12 (57%) were still active in this sport at the preinjury level at follow-up. According to the Rowe score, 23 shoulders (88%) were excellent or good. The University of California at Los Angeles score for 24 shoulders (92%) was excellent or good. The operations on two shoulders (8%) failed. One patient had a spontaneous redislocation, and one had recurrent subluxations. Nine contralateral shoulders had a history of significant instability; four of these had undergone Bankart repair. We concluded that athletes who have multidirectional instability based on isolated capsular and ligamentous redundancy can be successfully treated by an inferior capsular shift preserving the subscapularis tendon insertion. We found a high rate of return to demanding upper extremity sports in our patients, range of motion was restored in the majority of shoulders, and the failure rate after a median of 54 months was acceptable.     

Arthroscopic laser-assisted capsular shift in the treatment of patients with multidirectional shoulder instability

BACKGROUND: In recent years, various investigators have begun using lasers in the treatment of shoulder instability. HYPOTHESIS: Arthroscopic laser-assisted capsular shift is an effective treatment for patients with multidirectional shoulder instability. STUDY DESIGN: Retrospective cohort study. METHODS: We retrospectively identified 28 patients (30 shoulders) with multidirectional shoulder instability who were unresponsive to nonoperative management and who had undergone the laser-assisted capsular shift procedure. Twenty-five patients (27 shoulders) with an average follow-up of 28 months were available for review. All patients underwent a physical examination and completed a general questionnaire; the University of California, Los Angeles, shoulder rating scale; the Western Ontario Shoulder Instability Index; and the Short-Form 36 quality of life index. RESULTS: In 22 shoulders, results of the procedure were considered a success because the patients had no recurrent symptoms and at latest follow-up had required no further operative intervention. In five shoulders, results were considered a failure because of recurrent pain or instability and the need for an open capsular shift procedure. With recurrent instability as a measure of failure, the overall success rate was 81.5%. CONCLUSIONS: Our results with laser-assisted capsular shift are comparable with the results of other open and arthroscopic techniques in relieving pain and returning athletes to their premorbid function.     

Open repairs for the treatment of anterior shoulder instability

Successful treatment of anterior instability of the shoulder requires a balance between restoring joint stability and minimizing loss of glenohumeral motion. The choice of treatment should be individualized on the basis of the patient's occupation and level of participation in sports, as well as on the degree of instability of the shoulder. Despite discussions to the contrary, there is no single "essential lesion," as proposed by Bankart, that is responsible for recurrent anterior shoulder instability, although the Bankart lesion is by far the most important. The choice of operative treatment must be tailored to correct the abnormality that is identified at the time of surgery. A variety of promising arthroscopic techniques have been developed for the treatment of anterior shoulder instability; however, open stabilization remains the standard, especially for severe instabilities, revision procedures, and for athletes who participate in contact sports. This article will review the open surgical techniques used for treatment of anterior instability of the shoulder. Both current and historical operations will be discussed. Regardless of which procedure is chosen by a surgeon, the treatment should follow the guidelines taught by Rowe: anatomic dissection at the time of surgery, identification and repair of the lesions responsible for the instability, returning tissues to their anatomic locations, and early postoperative range of motion. By following these guidelines, the results of treatment of anterior instability of the shoulder can be optimized.     

Return to sport after a Bankart operation of the shoulder using the Mitek® anchor system

Sixteen athletes suffering anteior instability of the shoulder after primary or recurrent traumatic anterior dislocation were followed for a mean of 23.9 months after an open Bankart operation using Mitek® anchors. Nine patients resumed sports an average of 4.4 months postoperatively, while the remaining seven patients did not return to sports at all. By comparing the group of athletes who had resumed sports and the group who had not, we found in the former group a lower mean age, a higher number of athletes who had inflicted their first anterior dislocation during sports and a larger number of people injured on the dominant arm. However, none of the above-mentioned differences were statistically significant, and there were no differences in range of motion, degree of disability or stability of the operated shoulders in the two groups: returned vs. not-returned to sports. All the athletes performing sports at elite-level returned to sports, whereas all the recreational athletes did not. Among the reasons for not resuming sport, 71% gave sociopsychological reasons such as anxiety or lack of time. Two athletes (12.5%) had suffered redislocations after 12 and 19 months, respectively. No complications or other problems related to the use of Mitek anchors were observed.     

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.     

Comparison of shoulder stabilization using arthroscopic transglenoid sutures versus open capsulolabral repairs: a 5-year minimum follow-up

BACKGROUND: Few long-term studies have compared the efficacy of shoulder stabilization using arthroscopic or open procedures. PURPOSE: To directly compare the outcomes of shoulder stabilization using arthroscopic transglenoid sutures versus open capsulolabral repairs. STUDY DESIGN: Uncontrolled retrospective review. METHODS: Fifty patients (30 arthroscopic and 20 open) were followed for a minimum of 5 years (mean, 68 months). Pain, motion, strength, function, stability, patient satisfaction, radiographs, and ability to return to preinjury activity levels were evaluated. RESULTS: The arthroscopic group had a 17% (5 of 30) dislocation rate and a 60% (18 of 30) rate of instability. Sixty-seven percent (6 of 9) of patients participating in collision sports had repeat instability. Eight of 18 patients with instability required open repair for persistent symptoms. There were no limitations of motion following arthroscopic stabilization. The open group had no episodes of dislocations or instability. Forty-five percent (9 of 20) had some loss of external rotation (range, 10 degrees -40 degrees ) with a mean loss of 18. The one failure in this group had a 40 degrees loss of external rotation and difficulty with recreational activity. No patients participating in collision sports had repeat instability. CONCLUSION: We recommend open stabilization for patients participating in collision sports (for example, football, wrestling) or activities where better stability is required. For those participating in sports where performance may be compromised by loss of external rotation (such as swimming), newer arthroscopic techniques are recommended.     

Recurrent shoulder instability after open reconstruction in athletes involved in collision and contact sports

The purpose of this study was to evaluate the incidence of recurrent instability in a group of young athletes who underwent open shoulder stabilization with a modified Bankart repair and anterior capsulorrhaphy. Recurrent dislocation was defined as an instability episode resulting in complete dislocation requiring manual reduction. Recurrent subluxation was defined as the subjective history of the shoulder "slipping or popping out" or pain and apprehension that caused cessation of athletics for at least 1 day. Sixty-six patients (64 men and 2 women) were included in the study. A collision sport precipitated instability in 53 patients and a contact sport in 13. The average follow-up was 47 months (range, 24 to 72). The average American Shoulder and Elbow Surgeons score was 95 points (range, 71 to 100). The average Rowe score was 80 points (range, 40 to 100). Two patients had experienced recurrent dislocation after surgery (3%). Eight patients (12%) had rare (fewer than three) episodes of postsurgical subluxation. Five patients (8%) had multiple recurrent subluxations after surgery. Postsurgical recurrent instability was significantly associated with preoperative episodes of subluxation. However, all patients with rare subluxation had an excellent functional result.     

Prevalence of knee instability in relation to sports activity

The objective was to estimate the prevalence of knee instability among active athletes and to investigate potential associations to type, amount and duration of sports participation. Based on a questionnaire, 339 athletes provided information about different features of occupation, sports activity and knee instability. The 12-month period prevalence of knee instability and constant or recurrent knee instability, and absence from sport and absence from work due to knee instability, was 22%, 14%, 5% and 1%, respectively. Knee instability as such, and constant or recurrent knee instability were found to be positively associated with female gender and different features of occupational work. In conclusion, knee instability is a commonly reported phenomenon among active athletes. It was found to be independent of the type and the amount of sports activity but highly dependent on female gender, type and amount of occupational work.     

Joint position awareness and sports activity after capsulolabral reconstruction in the overhead athlete

A total of 24 overhead athletes with posttraumatic, chronic anterior shoulder instability underwent surgery. Twenty-two patients were examined after an average follow-up of 2.8 +/- 0.7 years. On average, a Constant-Score and Constant-Murley-Score of 93.7 +/- 5.3 points and an ASES-Score of 95.0 +/- 5.1 points were achieved. The redislocation rate was 9 %. The study demonstrated, that despite the good clinical results, only 12 out of 22 (55 %) of patients were able to return to their previous sports activity level. This relevant problem is in agreement with other similar studies [ ], so it was further addressed by determination of joint position awareness (JPA) and electromyographic muscle activity. Postoperatively, a persisting deficit of JPA, as well as an altered EMG pattern, was found with a significant reduction in activity of the deltoideus muscle on the operated side. The analysis of the data of each patient showed that there was a significant relation between the restitution of JPA and ability to return to the previous sports activity level. In contrast, the relation between EMG pattern and full recovery to completely unrestricted shoulder function was not significant. The anterior capsulolabral reconstruction enables a reliable restoration of shoulder stability and a low rate of complications. The problem that a relatively high percentage of overhead athletes can not return to their previous performance level is based on an impaired joint position awareness.     

Activity level and subjective knee function 15 years after anterior cruciate ligament injury: a prospective, longitudinal study of nonreconstructed patients

BACKGROUND: The activity level and subjective knee function after an anterior cruciate ligament (ACL) injury treated without reconstruction have not been well elucidated. HYPOTHESIS: Patients with ACL injury can achieve good knee function and satisfactory long-term activity level when treated by early activity modification combined with rehabilitation. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. Materials and METHODS: One hundred patients with an acute total ACL injury were observed for 15 years. All patients initially underwent arthroscopic surgery and a rehabilitation program. They were advised to modify their activity level, especially by avoiding contact sports. Patients with recurrent giving-way episodes and/or secondary meniscal injuries that required fixation (n = 6) were subsequently excluded and underwent reconstruction (n = 22). Sixty-seven patients with unilateral nonreconstructed ACL injury remained at the 15-year follow-up. The Lysholm knee score, Tegner activity level, and a visual analog score for global knee function were recorded at regular intervals. At the final follow-up, patients were further evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective knee evaluation form. RESULTS: Forty patients resumed their preinjury activity level or higher within 3 years. The median activity level 15 years after injury had decreased from 7 to 4 according to Tegner activity scale (P < .001). The mean Lysholm knee score was 96 and 95, 1 and 3 years after injury, respectively, but declined to 86 after 15 years (P < .001). Forty-nine patients had good/excellent results, and 14 had fair (n = 6) or poor function (n = 8) at 15 years. Patients injured in contact sports scored lower in the quality of life sub-scale of KOOS than those injured in noncontact sports (P < .05). Thirteen of the 67 patients (19%) were reoperated with an arthroscopic procedure because of knee symptoms. CONCLUSION: Early activity modification and neuromuscular rehabilitation resulted in a good knee function and an acceptable activity level in the majority of the nonreconstructed patients. The decline in activity level of patients engaged in contact sports at the time of injury affected their subjective quality of life more than patients involved in noncontact sports.     

Long-term results of arthroscopic Bankart repair with a bioabsorbable tack

BACKGROUND: Short-term to midterm data are available on arthroscopic shoulder stabilization using bioabsorbable tacks or suture anchors. It remains unknown whether these techniques can equal the success of open Bankart repair in the long term. PURPOSE: To assess the long-term outcome of arthroscopic Bankart repair using bioabsorbable tacks in patients with traumatic anterior shoulder instability with a minimum follow-up of 7 years. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Treatment outcomes were determined prospectively according to the Rowe score and retrospectively according to the Constant and American Shoulder and Elbow Surgeons scores. Included in this study were 18 consecutive patients with a mean age of 26.8 years (range, 16-62 years) who underwent arthroscopic Bankart repair using bioabsorbable tacks for traumatic anterior shoulder instability. The study group consisted of 14 male and 4 female patients. The mean follow-up was 8.7 years (range, 7.0-9.8 years). RESULTS: One patient had recurrent dislocations requiring further surgery, for an overall failure rate of 5.6%. An additional patient had 1 traumatic subluxation episode within the first postoperative year that did not recur. According to the Rowe score, which increased to 90.3 (17.8) from 32.8 (8.3) points preoperatively, 15 patients (83.3%) achieved a good or excellent result. The mean Constant score was 91.3 (SD, 6.9) points, and the mean American Shoulder and Elbow Surgeons score was 92.1 (SD, 6.9) points postoperatively. A return to the preinjury level of sports competition was reported by 64% of patients. No signs of synovitis occurred in any patient postoperatively. CONCLUSION: Arthroscopic Bankart repair for the treatment of recurrent traumatic anterior shoulder instability repair using bioabsorbable tacks offers reliable results with respect to failure rate, range of motion, and shoulder function during a minimum follow-up of 7.0 years. In contrast to previous reports on arthroscopic Bankart repair, results did not deteriorate during follow-up.     

Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair

BACKGROUND: Collision athletes are reported to be at high risk for redislocation after anterior stabilization of shoulder instability. Some authors have suggested that arthroscopic stabilization produces results similar to those of open stabilization. PURPOSE: To evaluate the results of anterior shoulder stabilization in collision athletes and to compare the clinical results between the arthroscopic and open methods. HYPOTHESIS: Open stabilization might produce better results than does arthroscopic stabilization in collision athletes. STUDY DESIGN: Cohort study; Level of evidence, 4. METHODS: Forty-eight shoulders of 46 collision athletes were enrolled for this study. The mean age of the patients at the time of surgery was 20 years, and the mean follow-up period was 72 months (range, 30-136 months). Sixteen shoulders underwent arthroscopic stabilization; 32 shoulders had open repairs. RESULTS: Visual analog scale, Rowe, and Constant scores improved after surgery, but no statistically significant difference was found between the arthroscopic and open repair groups. Thirty-seven athletes (83%) returned to near-preinjury sports activity levels (>/= 90% recovery) after operation. Two patients (4%) had subluxation and 6 (12.5%) had redislocation after surgery. The number of shoulders with postoperative subluxation or dislocation was 4 (25%) in the arthroscopic group and 4 (12.5%) in the open group (P = .041). Revision surgery was performed on 5 shoulders (10.4%). CONCLUSIONS: There were 8 (16.5%) instances of postoperative instability among the collision athletes studied. The arthroscopic group yielded a higher failure rate than did the open group. The authors believe open stabilization to be a more reliable method for anterior shoulder instability in collision athletes.     

Patient understanding,expectations, outcomes,and satisfaction regarding surgical management of shoulder instability

Shoulder instability is a common condition encountered by sports medicine and shoulder surgeons. Management can be challenging, both with regards to the underlying pathology and the high expectations associated with the very active patient population that this condition typically affects. High-performance athletes who are used to performing at activity levels which typically challenge the normal physiologic limits of the glenohumeral joint may be particularly difficult to treat. As physicians increasingly evaluate patient reported outcomes (PROs), a growing body of literature has emerged related to patient expectations for a variety of orthopaedic conditions, including shoulder instability. Physicians may face difficulty when using the literature to counsel patients due to the difference between a successful PRO and true patient satisfaction. Having a better understanding of patient expectations may improve preoperative evaluation, patient counseling, postoperative PROs, and patient satisfaction with shoulder instability surgery. The purpose of this paper was to review the literature regarding patient understanding of shoulder instability injuries, expectations following surgical repair of shoulder instability pathology, and satisfaction with operative intervention. Additionally, we sought to determine the effect of patient expectations on outcomes.     

Assessment of quadriceps/hamstring strength, knee ligament stability, functional and sports activity levels five years after anterior cruciate ligament reconstruction

The purpose of this study was to examine individuals 5 years after ACL reconstruction and analyze changes involving strength, stability, function, and sports activities. Nineteen males and six females, mean age = 31.4 +/- 7.31 years, participated in this study. Fifteen subjects had received extraarticular and ten subjects had received intraarticular ACL reconstructions. Subjects completed a 100 point subjective functional activity questionnaire and a sports participation survey. Knee ligament stability was assessed during an objective knee examination. Isokinetic quadriceps and hamstring muscle strength were tested at 240 and 120 deg/sec using the Cybex II dynamometer. Anterolateral rotatory instability and positive Lachman were elicited on the operated leg for 80% of the subjects. No significant relationship was found between objective instability and the functional activity score. For the intraarticular group, a significant correlation (P less than 0.05) was found between increased quadriceps and hamstring strength on the operated leg and return to functional activities. Subjects' functional activity score was positively correlated (P less than 0.001) with their ability to participate in sports. Subjects participating in sports involving cutting and twisting motions were less successful in returning to their preinjury participation levels and reported more subjective complaints of pain, swelling, and/or instability. These results indicate that long-term progressive rehabilitation emphasizing increased quadriceps and hamstring strength to approximate the nonoperated leg may enhance successful return to functional and sports activities after ACL reconstruction.     

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.     

Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft

BACKGROUND: Anterior shoulder instability associated with severe glenoid bone loss is rare, and little has been reported on this problem. Recent biomechanical and anatomical studies have suggested guidelines for bony reconstruction of the glenoid. HYPOTHESIS: Anatomical glenoid reconstruction will restore stability in shoulders with recurrent anterior instability owing to glenoid bone loss. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eleven cases of traumatic recurrent anterior instability that required bony reconstruction for severe anterior glenoid bone loss were reviewed. In all cases, the length of the anterior glenoid defect exceeded the maximum anteroposterior radius of the glenoid based on preoperative assessment by 3-dimensional CT scan. Surgical reconstruction was performed using an intra-articular tricortical iliac crest bone graft contoured to reestablish the concavity and width of the glenoid. The graft was fixed with cannulated screws in combination with an anterior-inferior capsular repair. RESULTS: At mean follow-up of 33 months, the mean American Shoulder and Elbow Surgeons score was 94, compared with a preoperative score of 65. The University of California, Los Angeles score improved to 33 from 18. The Rowe score improved to 94 from a preoperative score of 28. The mean motion loss compared with the contralateral, normal shoulder was 7 degrees of flexion, 14 degrees of external rotation in abduction, and one spinous process level for internal rotation. All patients returned to preinjury levels of sport, and only 2 complained of mild pain with overhead sports activities. No patients reported any recurrent instability (dislocation or subluxation). The CT scans with 3-dimensional reconstructions obtained 4 to 6 months postoperatively demonstrated union of the bone graft with incorporation along the anterior glenoid rim and preservation of joint space. CONCLUSION: Anatomical reconstruction of the glenoid with autogenous iliac crest bone graft for recurrent glenohumeral instability in the setting of bone deficiency is an effective form of treatment for this problem.     

Management of shoulder instability in in-season athletes

Although shoulder instability is common in young athletes, there are limited prospective data to guide treatment for competitive athletes who sustain a dislocation mid-season. The management of athletes during their competitive season requires an understanding of the natural history of shoulder instability, the specific needs of the injured athlete (eg, specific sport, player position), and the duration of treatment. Rehabilitation can enable an athlete with a shoulder dislocation to return to play within 3 weeks of injury. Bracing is an option, but it can result in restricted glenohumeral motion and thereby possibly affect performance. Surgical stabilization should be considered for the athlete with recurrent instability or inability to perform; however, this frequently results in the termination of the player's season. In this article, we review the available literature to help guide physicians treating athletes with shoulder instability.     

Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: a prospective study of 100 shoulders

BACKGROUND: There are few reports in the literature detailing arthroscopic treatment of unidirectional posterior shoulder instability. HYPOTHESIS: Arthroscopic capsulolabral reconstruction is effective in restoring stability and function and alleviating pain in athletes with symptomatic unidirectional posterior instability. This population has significant differences in glenoid and chondrolabral versions when compared with controls. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Ninety-one athletes (100 shoulders) with unidirectional recurrent posterior shoulder instability were treated with an arthroscopic posterior capsulolabral reconstruction and evaluated at a mean of 27 months postoperatively. A subset of 51 shoulders in contact athletes were compared with the entire group of 100 shoulders. Patients were evaluated prospectively with the American Shoulder and Elbow Surgeons scoring system. Stability, strength, and range of motion were evaluated preoperatively and postoperatively with standardized subjective scales. Forty-eight shoulders had magnetic resonance arthrograms performed and were available for review. The posterior inferior chondrolabral and bony glenoid versions were measured and compared with controls. RESULTS: At a mean of 27 months postoperatively, the mean American Shoulder and Elbow Surgeons score improved from 50.36 to 85.66 (P < .001). There were significant improvements in stability, pain, and function based on standardized subjective scales (P < .001). The contact athletes did not demonstrate any significant differences when compared with the entire cohort for any outcome measure. The results in the 71 shoulders followed for at least 2 years were similar to the overall group. On magnetic resonance arthrography, the shoulders with posterior instability were found to have significantly greater chondrolabral and osseous retroversion in comparison with controls (P < .001 and P = .008, respectively). CONCLUSION: Arthroscopic capsulolabral reconstruction is an effective, reliable treatment for symptomatic unidirectional recurrent posterior glenohumeral instability in an athletic population. Overall, 89% of patients were able to return to sport, with 67% of patients able to return to the same level postoperatively.