Management of In-Season Anterior Instability and Return-to-Play Outcomes


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Management of In-Season Anterior Instability and Return-to-Play Outcomes


Jonathan F. Dickens, MD and Maj. Michael A. Donohue, MD


Glenohumeral instability in young athletes is common and may lead to prolonged absence from sports participation.1 Anterior dislocation of the glenohumeral joint most commonly occurs with the arm in a forward flexed, abducted, and externally rotated position. The broad spectrum of anterior shoulder instability in athletes ranges from complete dislocation requiring reduction to microinstability in the overhead athlete, which may be clinically harder to diagnose but equally challenging to treat.2,3 Most commonly, athletes experience traumatic shoulder subluxation events without sustaining a complete dislocation of the joint.1,4 The amount of external rotation required to place the shoulder at maximal risk has been debated. Tanaka et al5 clinically evaluated the position of maximal anterior translation in sedated patients, and found that maximal anterior translation occurred with 90 degrees of abduction, but only 26 degrees of external rotation. Most likely, there is multifactorial variability in the exact position of risk for athletes.


A review of the National Collegiate Athletic Association (NCAA) Injury Surveillance System found that recorded events of shoulder instability occur at a rate of 0.12 per 1000 exposures.1 Men were more often injured compared to women. Additionally, shoulder instability events accounted for 25% of all shoulder injuries that occurred. The majority of events occurred in contact sports, namely football, hockey, and wrestling, and during contact with another player. Sustaining such an injury is not without concern for lost time from play. Almost half of the players lost more than 10 days of sports participation following a dislocation event.1


Orthopedic surgeons treating these patients can find themselves in a conundrum to recommend expeditious return to play of the athlete, especially when the athlete is in-season. The young, in-season, contact athlete represents the most at-risk and challenging patient population to treat shoulder instability because these patients have the highest performance demands on their shoulder are the most at-risk for instability. Immediate surgical intervention at the time of the in-season instability event precludes return to play in the same season. On the other hand, nonoperative management may allow the athlete to return to an acceptable level of performance and sport, between 5 days and 4 weeks following the injury, with an in-season recurrence rate between 37% and 73%.4,68 Interestingly, an anonymous survey of team physicians who manage high school, collegiate, and professional athletes found that only 7% of treating orthopedic surgeons would recommend immediate in-season surgical stabilization of the athlete with a first-time dislocation.9


The management of the in-season athlete with shoulder instability is complex, and determining the optimal management requires consideration of many variables including the position and sport played, timing of the injury during the season, current level of play, expected future level of play, future risk of recurrent instability, clinical laxity, findings, glenohumeral bone loss, and ligamentous injury. Additional variables such as the type of instability event (eg, subluxation or dislocation), length and position of immobilization, as well as the use of braces have been considered as additional variables that may influence the risk of recurrence for the in-season athlete. This chapter will review the management considerations and controversies surrounding in-season anterior shoulder instability relevant to the team physician and athlete.


ANATOMICAL CONSIDERATIONS FOR IN-SEASON RETURN TO PLAY


There is a spectrum of injuries associated with anterior instability, and correct identification of the pathoanatomy is critical to prevent recurrence, optimize outcomes, and guide treatment. The most commonly injured structure following a shoulder dislocation is the anterior labrum (ie, Bankart lesion).10 Before routine access to magnetic resonance imaging (MRI), Taylor and Arciero evaluated first-time dislocators with either surgery or nonoperative management.11 In the surgically treated cohort, they found at the time of surgery that 97% had a Bankart tear or separation of the capsuloligamentous tissue following a single first-time dislocation. As routine use of MRI preoperatively has become standard treatment, Owens and colleagues3 similarly found 97% of first-time traumatic anterior subluxators had a Bankart lesion on MRI.


Injury to the anterior labrum does not occur in isolation. The inferior glenohumeral ligament (IGHL) undergoes permanent deformation following a single dislocation that increases with repeat instability.12 Bigliani et al13 investigated the tensile strength of the IGHL in cadaveric specimens. Despite determining the ultimate tensile strength of the IGHL, a more important finding from this study was significant elongation of the ligament before ultimate failure or rupture. Additionally, in a follow-up study, Ticker and colleagues14 found that the tensile strength of the IGHL decreased in the more anterior-inferior portions of the ligament. If the athlete continues to experience repeat dislocation or even subluxation events following in-season return to play, the capsuloligamentous structures are at risk for increased deformation. This information should be considered when deciding on the optimal timing (in-season vs off-season) and method of surgical stabilization (arthroscopic vs open). It also highlights the important technical consideration of appropriate retensioning of the IGHL to restore shoulder stability.


A bony Bankart represents a fracture of the anterior glenoid rim and can occur acutely following injury. Multiple authors have investigated both first-time and recurrent instability for glenoid morphology and bone loss properties with very similar results. Milano et al15 found that 72% of patients had presence of a bone defect in the setting of anterior instability. Similarly, Sugaya and colleageus16 used 3-dimensional computed tomography (CT) reconstruction in 100 consecutive patients with recurrent anterior instability. Ninety percent (90%) demonstrated changes in the glenoid contour. Fifty percent (50%) had a bony Bankart lesion that was identified, and 40% had glenoid erosion. This demonstrates that in the setting of recurrent shoulder instability, risk of glenoid bone loss increases.


More recently, Dickens and colleagues17 analyzed a cohort of first-time shoulder dislocation events in athletes at a single institution who were followed for 4 years during the course of their collegiate career. After sustaining only a single event, 52% of the athletes demonstrated greater than 5% bone loss, and 17% of the athletes demonstrated greater than 13.5% bone loss.17 Thirteen and a half percent bone loss is significant and will be discussed later because it has been defined as a “subcritical” amount of glenoid bone loss that may predispose patients to poorer subjective outcomes following arthroscopic stabilization surgery.18 Contact athletes were more likely than noncontact athletes to sustain a primary dislocation with concomitant bone loss.


As surgeons consider athletes for return to play during the season of injury, they must evaluate for acute bony Bankart injuries and bone loss. With the exception of avulsion fragment, all acute bony Bankart fractures should exclude the athlete from return to play in season and we recommend early surgical fixation to prevent malunion. For those with early glenoid bone loss, the surgeon must consider the risk of continued glenoid erosion that occurs with recurrent instability during the season. Any amount of glenoid bone loss may place the athlete at risk for recurrent instability. Arciero et al19 performed cadaveric testing of combined lesions of the glenoid and humeral head. With as little as 2 mm of glenoid bone loss and the presence of a Hill-Sachs defect, there was an 18% to 43% decrease in load to translation. This decreased load to translation places the shoulder at risk for recurrent instability. Athletes with any measurable glenoid bone loss and a Hill-Sachs lesion should be considered for early surgical stabilization. Additionally, athletes with greater than 10% glenoid bone loss should be withheld from competition in favor of early surgical intervention given the risk recurrent instability.


Less commonly, other capsuloligamentous structures may be injured during anterior shoulder instability. A humeral avulsion of the glenohumeral ligament (HAGL) may occur from 1.5% to 9% of the time, although a recent study found a 25% occurrence in female athletes undergoing shoulder stabilization.2022 This may indicate that the true incidence is higher than often estimated and may be a missed lesion. Ticker et al14 reviewed the biomechanical properties of the IGHL and found that in a slow rate of strain, the IGHL more commonly failed at the humeral insertion, whereas the fibers of the IGHL were more resistant at the humeral insertion to fast rates of strain.14 In vivo, the HAGL is cited to occur either in a high-energy traumatic event or with repetitive microtrauma in the overhead athlete.23 With an HAGL lesion, there is a significant decrease in the load to translation of the glenohumeral joint.24 However, the athlete may not complain of frank instability as the primary symptom. Provencher and colleagues found that most patients’ primary complaint was related to pain rather than instability.25 In many cases the continued symptoms associated with HAGL lesions prevent return to sport in athletes; however, even when the athlete is asymptomatic we recommend early surgical intervention to facilitate surgical repair and mitigate the risk or recurrent instability.


The humeral head is often injured as a contrecoup lesion (Hill-Sachs). This lesion is an impaction fracture of the posterosuperolateral portion of humeral head adjacent to the rotator cuff insertion. The Hill-Sachs lesion occurs anywhere from 7% to 93% of the time following instability events and approaches 100% in recurrent instability.11,2627 With continued instability, the bipolar lesions that occur at the glenoid and the humeral head can lead to continued bone loss on both sides and engagement of the Hill-Sachs lesion on the anterior glenoid as described by Burkhart and De Beer.28 A large Hill-Sachs lesion that engages may lead to failure of a Bankart repair procedure. This concept of the “engaging Hill-Sachs” lesions has now led to the concept of the glenoid track as described by Yamamoto et al29 in 2007. The glenoid track represents a comparison of the width of the Hill-Sachs lesion to 83% of the width of the glenoid minus the width of bones loss (Figure 5-1). If the Hill-Sachs lesion is wider than the glenoid track, this is considered an off-track lesion and predisposes the patient to failure of a soft-tissue–only repair of the Bankart lesion.29 In the setting of an off-track lesion, the athlete should be considered for surgical stabilization and not returned to play.



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Figure 5-1. The glenoid track. Glenoid width * 0.83—width of missing bone compared to the size of the Hill-Sachs lesion. The strip represents a theoretical overlay of the glenoid track over the Hill-Sachs lesion and demonstrates that the track is wider than the Hill-Sachs lesion, therefore portending a better outcome following a soft-tissue–only surgery to the glenoid.


ATHLETE CONSIDERATIONS FOR IN-SEASON RETURN TO PLAY


There are numerous individual and athletic participation variables that contribute to the decision making for in-season return to play, and each decision should be made using a shared decision-making model. At a minimum the following questions for the in-season athlete can help guide surgeons in their clinical decision making:



  1. What is the age of the patient? When did instability first occur? Is this a primary in-season event or recurrence? Younger patients have an increased risk of recurrent instability.30 Instability occurring early in the playing season may lead the surgeon to recommend early stabilization. By contrast, near the end of the season the athlete has a lower number of absolute exposures remaining and may wish to complete the season. Athletes with recurrent dislocation would be recommended for surgery.
  2. Does the athlete play a contact, collision, or overhead sport? Is the injury in the dominant arm of an overhead athlete? These athletes are higher risk for recurrent instability with nonoperative treatment.31,32 Up to 55% of overhead athletes may not be able to return to play at their previous level following surgical stabilization.33
  3. What was the position of the arm and was this a contact event? If a noncontact injury, the surgeon must elucidate the mechanism of injury. (For example, Owens et al4 described anterior subluxation in boxers missing a punch.)
  4. What is their level of play? Where in the season is the athlete and what is his or her expected level of contribution from a shared decision-making standpoint based on athlete, coach, trainer, and physician input?

A thorough understanding of the patient’s history is clearly multifactorial and takes into account more than just the clinical instability event. Although axillary neuropraxia or rotator cuff atony may initially occur following injury, continued weakness must cue the examiner to consider neurologic injury or rotator cuff injury.34,35 If there is evidence of a nerve injury or rotator cuff tear, the athlete cannot return to play.


In-season athletes require additional consideration of their history and indications for their potential to return to play meaningfully. Dickens et al6 demonstrated that many athletes will attempt to return to play in-season with varying degrees of success. Contact and collision athletes experience the highest risk for continued instability when they attempt to return to play in-season. Often, though, a starting athlete at higher levels of play may be considered essential, and the surgeon must have a complete understanding of the patient’s history as well as clinical exam findings and imaging to make a determination of return to play while protecting the player from additional injury to the shoulder that may lead to increased bone loss.



PHYSICAL EXAMINATION


A complete physical examination will serve to validate the surgeon’s diagnosis and allows him or her to identify any other associated conditions such as hyperlaxity or neurological concerns. If an athlete is being examined on the playing field and has a glenohumeral dislocation, the neurovascular status should be established both before and following reduction. In the training room the exam requires a systematic approach. We advocate the first step in examination is purely observational to determine the athlete’s range of motion in all planes and additionally to identify any scapular dyskinesis. All exams should begin by evaluating the uninjured shoulder first.


Stability testing often cannot be performed in the acute period following injury. Once the athlete has regained pain-free motion of the injured shoulder, this can be employed. Multiple special tests for evaluation of shoulder instability have been established—all with varying degrees of sensitivity and specificity.36 Individually, each test may be patient dependent such as a large football lineman compared to a thin runner. Therefore, using a constellation of systematic tests will confirm the suspected diagnosis. The authors routinely use the apprehension test35 with Jobe’s relocation37 and surprise test. In the setting of all 3 exam findings being positive, the positive predictive value for anterior instability is 93.6%.38 Additionally, we also advocate the use of the load shift test,39 with grading of the degree of translation as described by Hawkins et al.40 This test should be performed both during evaluation in the clinic setting, but also before surgery when the patient is under anesthetic sedation. Other tests used include the Gagey test41 to examine the IGHLs, the sulcus sign to examine to examine for capsular laxity, and Beighton scoring for general hyperlaxity.42 Testing of rotator cuff strength, superior labrum/biceps, neurologic status, and impingement should also be performed.


IMAGING


Following reduction, a complete radiographic evaluation is obtained. For the team physician, we recommend plain-film imaging either the day of injury after glenohumeral reduction, or the following days as part of an expedited workup, especially if the athlete may wish to return to play without surgery. We routinely use an instability series of plain film x-ray imaging that includes anteroposterior (AP), Grashey, Axillary Y, and West Point views. The plain-film imaging allows for evaluation of glenohumeral location, to rule out fracture, as an initial evaluation for glenoid bone loss or fracture, and to determine presence of a Hill-Sachs lesion.


The study of choice for soft-tissue evaluation is MRI with or without intra-articular contrast. In general, the authors recommend early advanced axial imaging of the athlete with a first-time or recurrent in-season subluxation or dislocation event to assess for concomitant pathology and underappreciated bone loss, which more common in contact and collision athletes. We will use a standard MRI if an athlete is within approximately 10 days from a dislocation event. An MR arthrogram with intra-articular contrast is otherwise used for evaluation. MRI allows for visualization of soft-tissue status for the labrum as well as for associated injuries, including rotator cuff tears and HAGL. Although not routinely used for evaluation of bone loss, the MRI can provide a gross status of glenoid and humeral head bone loss, which may lead the surgeon to obtain a CT scan.


For the in-season athlete who will attempt same-season return to play criteria without surgical intervention, we do not routinely obtain a CT scan. CT is usually reserved for the athlete with bone loss and surgical intervention is planned.


TREATMENT


The most common question for any athlete, trainer, and coach following a shoulder instability event in-season is what is the timeline for return to play? This can be a dilemma for all parties involved in the athlete’s care. The goal of treatment is safe return to play. Following the spectrum of treatment options that may best address the instability, whether operative or nonoperative, and appropriate rehabilitation, there is no set time criteria for return to play. Instead, rehabilitation and return to play can be multifactorial. Decision making is critical for the surgeon in guiding the patient through treatment options. By the conclusion of either treatment option, the athlete should have a pain-free shoulder with symmetric strength and no symptoms of recurrent instability during sport-specific activity. Our recommended algorithm is shown in Figure 5-2. Our recommended key criteria for return to play are noted in Table 5-1.



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Figure 5-2. Decision-making algorithm. The flowchart demonstrates our recommended decision-making algorithm for an in-season athlete who sustains an instability event. (Abbreviations: CT, computed tomography; HAGL, humeral avulsion of the glenohumeral ligament; MRI, magnetic resonance imaging.)


Nonsurgical Management of the In-Season Athlete


For the in-season athlete, nonoperative treatment represents the only potential for return to play in the same season. Many athletes therefore prefer nonoperative treatment to allow for in-season return to play; however, only suitable candidates for nonoperative treatment should be considered for in-season return to play. Nonoperative rehabilitation is a focus elsewhere in this textbook but includes a short period of immobilization for soft-tissue rest, followed by rehabilitation to regain full symmetric motion and strength of the shoulder, and finally sport-specific protocols.


In one of the earliest evaluations of the natural history of shoulder instability, Wheeler et al30 prospectively tracked West Point cadets for a minimum of 14 months following traumatic anterior shoulder dislocation events. The West Point cadet population was optimal to track because not only is the population young and active, they are required to participate in contact and collision type activities and sports in preparation for entering the military. In these young athletes, shoulder instability treated nonoperatively recurred in 92%. These patients not only experienced recurrent subluxation events, but 82% sustained recurrent dislocations.30 These high rates of recurrent instability treated nonoperatively served to bolster the findings of 2 previous studies of the natural history of shoulder instability that found rates of recurrent instability of 94% in patients younger than 20 years.43,44


One of the primary indications for nonoperative management and attempted return to play is the first time dislocator with no bone loss and imaging consistent with a Bankart lesion. Additionally, athletes who do not participate in contact sports or overhead sports likely have a better chance to return to play in the same season.4,6,30,31 The young athlete who participates in contact sports must be counseled regarding the high risk of recurrent instability with nonoperative management.


Several studies have evaluated time lost from sport. The first prospective, multicenter study to assess same-season return to play in collegiate level athletes sustaining an instability event found that 73% of athletes who attempted same-season return to sport were able to return to competition at a median of 5 days.6 Less encouraging though was that just more than one-quarter (27%) of those athletes who attempted same-season return to play were not able to rehabilitate successfully and did not return to play.6 Buss and colleagues8 were the first to report return-to-play outcomes for in-season athletes treated with an accelerated rehabilitation program. In their retrospective review, athletes were able to return to play at a mean of 10 days.8 Previous to this, several return-to-play studies that examined nonoperative treatment employed cumbersome periods of immobilization and rehabilitation lasting from 1 to 3 months.30,45


Pain associated with an instability event, especially complete dislocation of the glenohumeral joint, can be improved with a short course of immobilization. No consensus for use of immobilization or the position of immobilization exists. Buss et al8 as mentioned earlier returned athletes to play at a mean of 10 days and used no immobilization in their rehabilitation protocol. Henry and Genung were among the earliest to examine use of immobilization in shoulder instability rehabilitation.46 They followed 121 patients who were immobilized for approximately 3 weeks and 59 patients who were not immobilized following injury. The rates of recurrent dislocation were similar—90% and 85%, respectively. Paterson et al47 conducted a meta-analysis of 5 level-1 studies and 1 level-2 study to determine efficacy of immobilization. They found no benefit in sling immobilization greater than 1 week, and no effect on rates of recurrence whether or not a sling was used.47 Based on these studies, we recommend a short course of immobilization as needed for pain but no longer than 3 to 5 days to facilitate early supervised motion.


A significant controversy related to immobilization is the position of the arm while immobilized. Itoi and colleagues48,49 published first in a cadaveric specimen followed by an in vivo MRI study that immobilization of the arm in a position of external rotation better reduces the anterior labrum to glenoid following shoulder dislocation and reduces rates of recurrent instability. However, several studies from other institutions attempted to reproduce these results with varying results. Additionally, concern has been raised regarding patient discomfort while immobilized in an externally rotated position. Paterson et al47 did not find a significant difference in recurrence rates based on position of immobilization in their meta-analysis, though. We do not advocate immobilization in the externally rotated position. Rather, patients should be placed into a position of comfort before beginning shoulder motion. The ultimate decision depends on surgeon preference.


Outcomes following nonoperative management have historically relied on early studies that demonstrated extraordinarily high rates of recurrence in young athletes.30,45 Those studies, however, did not evaluate same-season return to play and ability to successfully complete the season without recurrence. Dickens et al6 prospectively observed same-season return to play in collegiate athletes treated nonoperatively. Forty-five athletes with a mean age of 20 years were included. All participated in contact sports except 2 who played baseball. Three-quarters (73%) were able to return to play at a median of 5 days. Only 12 of 45 (27%) though remained completely asymptomatic through the rest of the season. Despite the high rate of recurrent instability symptoms, 67% of those with recurrent instability were able to complete the remainder of their season. Athletes who experience dislocation as their primary instability event were at higher risk for repeat symptomatic instability.6


Buss and colleagues8 retrospectively reviewed same-season return to play in 30 athletes. Their time to return to play as previously mentioned was a mean of 10 days. In this group, almost all were young (mean age, 16 years) contact athletes with the exception of 2—a skier and a gymnast. Seventy percent of the athletes returned to play with the use of a brace. Their return-to-play criteria though were considered successful if the athlete returned to all or part of the same season. Reassuringly, 90% were able to return. The athletes experienced an average of 1.4 recurrent instability episodes following return to play. The majority experienced no recurrence, but some athletes experienced as many as 8 more events.8


Based on the earlier described evidence, most studies suggest there is a high risk for recurrent dislocation or instability event in the young collision or contact athlete. However, the most recent publication following return to play in young athletes may show successful return to play for high school–level athletes in season. Shanley et al50 prospectively tracked high school athletes in a single geographic region during a 4-year period. Athletes were included only if they sustained an anterior instability event in season while playing on a school-sanctioned sports team and underwent medical treatment. Two key findings from this study address nonoperative return to play through the following season, and brace wear. Ninety-seven scholastic athletes with continued sports eligibility were treated nonoperatively. Of these, 82 (85%) were able to undergo successful rehabilitation and return to sport without an instability event for at least one season. Six of the 97 (6.2%) athletes sustained a recurrent instability event during the follow-up period. The 15 athletes who failed nonoperative treatment either through failure to return to sport or recurrent instability were all contact athletes, and the majority (60%) were male football players.50 Players sustaining subluxation events were 3 times more likely to return to play than those with dislocations. The overall rate of return to play in season and with successful following-season participation is almost double that of Dickens et al,6 but similarly mirrors improved success for those with only subluxation events. Caution should be taken in applying the results of high school athletes to collegiate or higher-level athletes, for whom the level of competition and risk associated with play varies.


In professional football players, return to play at the elite level can have significant effects on player longevity and team performance. Okoroha and colleagues51 hypothesized that these athletes could return to play at higher rates regardless of treatment type. They found that 92% of players treated nonoperatively were able to return to play. Players who sustained a subluxation event in season returned to play in less than 1 week, whereas those who sustained a dislocation returned to play at a mean of 3 weeks. When the authors specifically examined time of season during which the instability occurred, late-season athletes were more likely to be returned more quickly (0.5 weeks vs 3.1 weeks) than those early in the season. For those players who returned to play, recurrence occurred in 55% and at a mean of 2.5 weeks.51 This recurrence rate is similar to that published for a single National Football League team by LeClere et al52—42%. An important consideration from this study must be the level of play of the athlete. Elite contact or collision athletes may have greater medical and athletic training resources available to expedite their return to play, but continue to have high rates of recurrence despite this.


Overall, if an athlete meets appropriate criteria, he or she should be considered for same-season return to play. Many caveats exist, and the athlete must be counseled regarding the risks of return to play. Not only is recurrent instability a high risk, but the consequences of the continued instability’s impact on glenoid and humeral head bone loss must be factored into decision making.


ATHLETE PERFORMANCE


Once players meet return to play criteria, their level of performance may not be the same as before injury or they may complain of poorer subjective outcome scores. No studies have specifically tracked subjective outcomes scores in athletes following their return to play.53 Buss et al8 and Shanley and colleagues50 did not report subjective outcomes scores in their analyses of in-season return to play in athletes. However, data from Dickens et al,6 Sachs and colleagues,54 and Shaha et al18 can be extrapolated into expectations. Dickens et al6 performed logistic regression modeling on time and likelihood to return to play using Western Ontario Shoulder Instability Index (WOSI), American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores. For every point higher scored on the WOSI and SST at the time of injury, athletes were 5% and 3% more likely to return to play in season. In determining time to return to play, for every 10-point improvement in the WOSI, SST, and ASES score, athletes were able to return to play 1.3 days, 1.2 days, and 1.3 days sooner respectively than those scoring more poorly.


Sachs and colleagues54 prospectively tracked patients treated at a single facility within a single, closed insurance payer system. This study included shoulder instability both of athletes and nonathletes from a full spectrum of ages (12-82 years). Important in this study are their outcomes scores at time of final follow-up, which were stratified into 3 patient groups—(1) patients who had a single dislocation and did not dislocate again, (2) patients who had recurrence with nonoperative management, and (3) patients who underwent successful Bankart repair. Those who sustained only a single dislocation event with no recurrence after return to their normal activity had similar Constant, ASES, and WOSI scores as those who underwent successful Bankart repair. However, those who experienced continued instability events following their primary dislocation had significantly worse scores on all 3 tests greater than the defined minimally clinically important difference for each test.54 The implications from these 2 studies suggest that improved scores on subjective testing at the time of injury and during the return-to-play period may demonstrate a player who is less likely to have recurrence with continued participation in season while deferring surgery to the off season.


Shaha et al18 defined “subcritical” bone loss in an attempt to determine whether outcomes following shoulder stabilization are worse for patients who had glenoid bone loss but less than 20% glenoid bone loss and thus did not undergo a bone augmenting procedure. In patients who had greater than 13.5% glenoid bone loss, there was not a statistically significant increase in recurrence; however, following stabilization, patients with subcritical bone loss had significantly worse WOSI scores that exceeded the minimally clinically important difference for WOSI scores. Based on these findings, patients can be counseled at the time of injury that if their WOSI, SST, and ASES scores are greater, they are more likely to return to play sooner; however, if imaging demonstrates glenoid bone loss greater than 13.5% and they attempt same-season return to play, their WOSI scores may be decreased. The WOSI score is important because its 21 questions specifically target disability related to use of the shoulder.55


Based on the earlier-mentioned findings, the optimal patient for in-season return to play is one who has greater subjective scoring on the WOSI test and less than 13.5% bone loss on MRI or CT imaging. The implication is 2-fold–earlier successful return to play in season, and decreased likelihood of disability or recurrence following return to play.


BRACING OPTIONS AND CONSIDERATIONS


A scarcity of literature exists regarding use of a sports brace either prophylactically in the contact athlete or following an instability event to provide protection from anterior shoulder instability.5659 Additionally, many of the data have focused on use in football players. A variety of braces exist and have the primary goal of preventing the player from placing the shoulder in a vulnerable position.


The Sully brace (Figure 5-3) is a neoprene elastic brace with elastic straps that wraps the torso, affected shoulder, and affected upper arm. Using hookable elastic, the brace is designed to provide a restriction both to abduction as well as external rotation. Based on its neoprene design, it can be less restrictive than a nonelastic material to be worn by an athlete. The elasticity afforded may be better suited for an athlete who requires more overhead motion or the ability to stretch slightly beyond the limits of strap setting. With less restriction of motion, a neoprene brace or taping may provide a proprioceptive sense of stability to the athlete.59,60 These types of interventions may theoretically provide external passive positioning sense to the shoulder while causing less discomfort with wear. Additionally, there is less restriction of motion for the athlete, which may facilitate increased compliance or interest in wear.


The SAWA brace (Figure 5-4) conversely is a nylon brace that is also worn across the torso, injured shoulder, and upper arm, but does not have the same elastic properties as a Sully brace. Nylon straps are used to limit abduction and external rotation. The advantage of this brace design is that it is should provide a hard stop to shoulder motion. The limitations of motion can be beneficial or detrimental depending on the sport and position played by the athlete. An analysis of the effectiveness of preset brace motion limiting abduction to 45 degrees was found to insufficiently limit collegiate football players both during active and passive testing.58 However, the brace did prevent complete abduction to 90 degrees. For a nonoverhead or nondominant-arm athlete, this can keep the shoulder from a position of maximum vulnerability. In a throwing athlete or positional player, the limitation of the dominant arm may decrease functional use of the arm and prevent full participation.



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Figure 5-3. Sully brace. This brace is a neoprene elastic brace, which may provide better comfort than a more rigid nylon brace, but may not limit shoulder motion.

Jul 27, 2021 | Posted by in ORTHOPEDIC | Comments Off on Management of In-Season Anterior Instability and Return-to-Play Outcomes
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