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Return-to-Play Evaluation in the Postoperative Athlete for Anterior Shoulder Instability

Brian Busconi, MD; Jonathon A. Hinz, DO; Benjamin J. Brill, DO; and Vickie Dills, PT, DPT, OCS, ITPT, CSAC

Shoulder instability in the competitive athlete, because of a multitude of factors, can be challenging to treat. In 2018, the MOON Shoulder Instability Cohort confirmed previously associated risk factors of shoulder instability, which include male sex, contact sports, age younger than 30 years, and anterior instability.¹ The study further noted a significant risk for recurrence in the younger than 25-year-old age group. In a 25-year follow-up study, Hovelius found that the recurrence rate of shoulder instability was approximately 50% in 12- to 25-year-old study participants.² A number of additional studies have corroborated this number, with some studies finding the number to be substantially higher.³ Data gathered from these studies provide improved ability to predict recurrence rates of shoulder instability, thus improving management in the athletic population. Management of athletes presenting with shoulder instability can consist of nonoperative treatment or surgical intervention, including arthroscopic and open stabilization procedures. In this chapter we will be focusing on the return to play evaluation in the postoperative athlete.

BODY

Anatomy

Anatomic consideration for shoulder instability includes both active stabilizers and passive restraints (Table 15-1).⁴ Turkel et al in 1981 first described stabilization of the anterior shoulder at 0, 45, and 90 degrees of abduction.⁵ In this study, the investigators described the role of the subscapularis at 0 degrees, the middle glenohumeral ligament and subscapularis at 45 degrees, and the importance of the inferior glenohumeral ligament at 90 degrees of abduction (Figure 15-1). Another passive restraint addressed during shoulder instability surgery is the glenoid labrum. Biomechanically the glenoid labrum, when disrupted, can cause reduction in stability of 10% to 15%.³³ This information has provided the basis of continued study of capsular and labral importance in shoulder instability and has been instrumental in guiding decisions in regards to surgical procedures for shoulder instability.

Dynamic stability through the rotator cuff (RTC) was studied by Lee and colleagues, who introduced the dynamic stability index. The dynamic stability index takes into account compression as well as shear forces on the shoulder.⁶ Lee’s study concluded that the anterior (subscapularis) and posterior RTC (infraspinatus and teres minor) produce a significant amount of glenohumeral stability at the end range of motion (ROM), which is the position of instability.

Bigliani et al reports that congruency of the articular surfaces through midrange motion along with the dynamic stabilization of the RTC are the primary mode of stabilization.⁷ When there is a rotational force added, which creates increased translation, such as in the position of anterior dislocation, there is a significant relevance of the glenohumeral ligaments, particularly the inferior glenohumeral ligament.⁷

The complexity of structures and function in the shoulder complex demonstrates the significance of the intricate balance between the active stabilizers and passive restraints throughout shoulder ROM. The reestablishment of anterior instability of the glenohumeral joint through a surgical approach will restore static restraints of shoulder instability. However, recognizing the importance of dynamic stabilization supports the critical need for proper rehabilitation postoperatively.

The decision-making process for an athlete with shoulder instability is multifactorial. The patient can be preseason, in-season, or postseason. They can be a first-time dislocator or plagued with chronic instability. The pathology of the instability itself can be soft-tissue or bone related. This multifactorial picture can complicate the treatment process. In 2012 Owens and colleagues created a treatment algorithm for in-season instability. The pathway begins with imaging, both plain-film and magnetic resonance imaging. Next, the primary pathology is determined, bone or soft tissue. If the pathology is primarily bony (bone defect > 25%) surgery is indicated. If the pathology is primarily soft tissue, the next decision is made based on history and physical exam. If recurrent instability is the primary problem, surgery is discussed as the primary option; if it is an initial instability event, a course of rehabilitation including sport-specific training is discussed. In this scenario if the patient is able to return to sport, further decisions can be made after the season. With any type of recurrent instability surgery is proposed8 (Figure 15-2).

Nonoperative

Current nonoperative treatment consists of a period of immobilization followed by physical therapy and ultimately, return to play. The goals of nonoperative treatment are very similar to that of surgical management: the restoration of ROM, strength, and stability of the shoulder. In the current literature return to play following nonoperative treatment has mixed results. Recently, Shanley et al published results in the high school athletic population that 85% of patients with nonoperatively treated episodes of anterior shoulder instability were able to return for their subsequent season and a 6.2% recurrence rate.⁹ This is in stark contrast to 2 previously published studies that showed 80% recurrence of instability and 60% recurrence of instability.^3,10

The wide disparity in results can be from a multitude of factors and should not dismiss nonoperative treatment. First, when looking at the return-to-sport literature, desired outcomes of the study need to be evaluated. Some studies may have an end point of return to play, whereas another may have an end point of recurrence of stability. Using this published data in conjunction with the desires of the patient, the patient, physician, and therapy staff work together to accomplish the patient’s goals.

Operative

Traditionally data regarding recurrence rates for instability after arthroscopic repair have been approximately 10% to 12%,^3,11 and open repair procedures typically produce a recurrence rate of approximately 3% to 5%.^12–14 Petrera and colleagues published a meta-analysis that looked at arthroscopic procedures using only suture anchors vs the traditional open Bankart procedure and found no statistical difference in recurrences between the 2 procedures (6% vs 6.7%).¹⁵ They discussed that previous arthroscopic data used a mix of prior surgical techniques and did not represent current fixation, which may have contributed to statistical differences. Return-to-play data for shoulder instability in National Collegiate Athletic Association football players published in 2017 had 168 arthroscopic procedures, with those who just had anterior procedures seeing an 82.4% return to sport.¹⁶

Bone augmentation procedures have been traditionally reserved for patients with bony insufficiency. This is important to consider whenever treating shoulder instability, especially with poor outcomes being associated with more than 25% bone loss and even as little as less than 13% bone loss being associated with worse outcomes.17,18 In this setting publications on return-to-sport rates have been published as 65% in rugby players and 96.4% in combined collision and noncollision sports.^19,20

POSTOPERATIVE REHABILITATION

Most postoperative rehabilitation protocols follow very similar principles that include return to normal ROM and flexibility as well as restoration of strength, all of which are pain free.²¹ An important aspect of return to play for the competitive athlete is functional rehabilitation, whose principles include restoring proprioceptive capacity and neuromuscular control of the shoulder joint after injury.²²

Arthroscopic stabilization procedures require a slower progression of rehabilitation.^21,23,24 The patient is usually protected for 4 for 6 weeks in a sling while initially working on passive and active-assisted ROM. This protected phase is important for initial healing of the soft tissues and has been proven important for postoperative instability.²⁵ Phases of rehabilitation then progress in approximately 4- to 6-week intervals to improve ROM, then strengthening, and finally functional rehabilitation and sport-specific activities. The goal for return to sport at full participation usually falls between months 7 and 9.

Open stabilization procedures such as capsular shift as well as Latarjet procedures can have a slightly accelerated time frame of rehabilitation.²⁴ ROM as well as strengthening exercises are performed slightly earlier than in an arthroscopic repair program with anticipation of return to sport at the 6-month mark. This again is predicated on functional rehabilitation as well as sport-specific activities symptom free.

The role of functional rehabilitation involves recreating the sensory motor pathways involved with proprioception. During rehabilitation, Myers and Oyama describe the 4 facets of functional rehabilitation: awareness of proprioception, dynamic stabilization restoration, preparatory and reactive muscle facilitation, and finally replication of functional activities.22 Each of these facets is completed at different stages during rehabilitation. Awareness of proprioception is started with initial ROM, dynamic stabilization restoration involves reestablishing muscular force couple contraction, reactive muscle facilitation begins the process of muscle activation with unexpected forces, and finally replication of functional activities return the patient to athletic activities within a controlled environment.

The senior author presents his current postoperative rehabilitation treatment course for arthroscopic Bankart repairs in Table 15-2. This includes the functional testing used in the return-to-play phase of treatment. The rehabilitation protocol is divided into phases I through V. Each phase has its own goals as well as expected outcomes. Phase I starts immediately postoperatively and is a protection phase. Goals include protecting the repair and limiting the negative effects of immobilization. This phase begins with passive and active-assisted ROM. The second half of phase I begins scapular stabilization, strengthening, and the beginning of proprioceptive training. In phase II there is increased emphasis on returning to normal ROM, proprioception, and core stabilization. Phase III is the initiation of strength and power, and stretching becomes more aggressive. A sport interval training program is integrated with functional exercises, which begin the process of sport-specific proprioceptive training. Phase IV represents the advance strengthening phase in which goals are returning to preinjury levels of strength, mobility, and endurance. Functional testing also begins during this phase outlined in Table 15-2. Phase V is return to sport. Passing appropriate criteria and functional testing, the athlete returns to unrestricted sporting activity and continues with a strengthening program.

FUNCTIONAL TESTING

An athlete’s ability to return to sport determined by objective measures of strength and ROM do not demonstrate the ability to perform sport-related skills effectively, efficiently, and confidently.

Performance-based testing is essential in evaluating movement deficits and dysfunction for identification of increased predisposition for injury. Functional tests measure the relationship between injured and uninjured side, determining “normal” and “abnormal” performance. It is important to recognize that following injury and surgical intervention, the athlete’s activity level will decrease. The effect can be global, affecting not only the postoperative extremity but involving the athlete’s overall strength, stability, and endurance.

Criteria for Progression to Functional Testing Phase to Access Return to Play

• Full, pain-free shoulder ROM without substitutional patterns
  
• No shoulder instability
  
• Pain-free exercises
  
• Proper scapular posture with rest and dynamic scapular control with ROM and strengthening exercises
  
• Muscular strength of 75% to 80% of contralateral side
  
• Satisfactory scores on shoulder activity scores

Functional Tests

1. Trunk Stability Push-Up: Tests the ability to stabilize the spine and hips in a sagittal plane with closed kinetic chain (CKC) activity during upper body symmetrical pushing motions. A variety of sports require trunk stabilization while applying symmetrical forces between the upper and lower extremities
   
2. Closed Kinetic Chain Upper Extremity Stability Test: Measures speed, agility, and power. Along with the number of repetitions counted over a 15-second trial, the athlete should be monitored for instability with movement, thoracic kyphosis, scapular winging, lumbar lordosis, and pelvic rotation.
   
3. Upper Extremity Y Balance Test (Figure 15-3): Dynamic test to maximally challenge the mobility and stability of the upper extremity, shoulder complex, and trunk. Combines scapular stability and mobility, thoracic rotation, and core stability.
   
4. Posterior Shoulder Endurance Test: Test to assess scapular muscle endurance.
   
5. One-Arm Hop Test: Dynamic performance test to compare the injured upper extremity to the contralateral upper extremity.
   
6. Long Arm Plank Ball Tap: Assesses joint stability, endurance, and proprioception.
   
7. Plank Weight Stacking (Figure 15-4): Assesses dynamic stability of the core and scapula. Assesses right vs left stability and proprioception.
   
8. Overhead Band Reach: Assesses the athlete’s ability to maintain scapular and core stability while reaching in various directions. Demonstrates functional RTC activity throughout various ROMs. Athletes must maintain proper scapulothoracic alignment while avoiding upper trapezius dominance, trunk lean, and pelvic tilt/lumbar lordosis.

Table 15-2. Rehabilitation Protocol for Postoperative Anterior Shoulder Instability

PHASE I: IMMEDIATE POSTOPERATIVE

• Goals
  
  
  
  • Protect repair
    
  • Prevent negatives of immobilization
    
  • Promote dynamic stability/proprioception
    
  • Diminish pain and inflammation
    
  • No stretching
    
  • No active external rotation/abduction or extension
  
  
• Weeks 1 to 2
  
  
  
  • Sling
    
  • Sleep in immobilizer
    
  • Elbow/hand ROM
    
  • Passive/gentle AAROM
    
    
    
    • Flexion 70 degrees Week 1
      
    • Flexion 90 degrees Week 2
      
    • Scapular plane elevation 60 degrees
    
    
  • Ext/Int rotation with 30 degrees of abduction (P/AA)
    
    
    
    • Ext rotation 10 degrees
      
    • Int rotation 45 degrees
      
    • Scapular retraction
  
  
• Weeks 3 to 4
  
  
  
  • Discontinue sling
    
  • Passive/AAROM
    
    
    
    • Flexion 90 degrees
      
    • Elevation in scaptation 90 degrees
      
    • Ext/Int rotation in 45 degrees of abduction in scap. plane
      
      
      
      • Ext rotation 20 degrees
        
      • Int rotation 60 degrees
    
    
  • Proprioceptive training
    
    
    
    • Ball stabilization
      
    • Standing wobble board
      
    • Treadmill UE walking
    
    
  • Core stabilization
    
  • Scapular stabilization/strengthening
  
  
• Weeks 5 to 6
  
  
  
  • Progress from AAROM to AROM
    
    
    
    • Flexion 140 degrees
      
    • Ext/Int rotation in 45 degrees abduction in scap. plane
      
      
      
      • Ext 50°
        
      • Int 60°
    
    
  • Initiate stretching trap/levator and Lat
    
  • Side lying ER/IR at Week 6
    
  • Scapular strengthening
    
  • Deltoid/supraspinatus/serratus strengthening
    
  • Continue rhythmic stabilization
    
  • Bodyblade 1 hand/2 hand in neutral grip

PHASE II: INTERMEDIATE PHASE

• Goals
  
  
  
  • Gradually restore full ROM
    
  • Preserve integrity of repair
    
  • Restore muscular strength and balance
    
  • Enhance neuromuscular control
  
  
• Weeks 7 to 9
  
  
  
  • Gradual advance ROM
    
    
    
    • Flexion 160 degrees
      
    • Abduction in the scapular plane 160 degrees
      
    • Initiate Ext/Int rotation at 90 degrees of abduction
      
    • Ext/Int rotation in 60 degrees of abduction in scap. plane
      
      
      
      • Ext rotation 70 degrees
        
      • Int rotation 75 degrees
    
    
  • Isotonic strengthening
    
    
    
    • Supine serratus press
      
    • Periscapular stabilization
    
    
  • Proprioceptive facilitation
    
    
    
    • Wall push-ups
      
    • PlyoBall on wall
      
    • BodyBlade progression
    
    
  • Rhythmic stabilization
    
  • Core stabilization
  
  
• Weeks 10 to 13
  
  
  
  • Progress strengthening exercises
    
    
    
    • Seated row, biceps curl, prone Ts and Ys, sidelying ER
    
    
  • Advance isotonic strengthening
    
  • Advance stretching exercises
    
  • Standing ER stretch
    
    
    
    • PlyoBall diagonal patterns, ball catching
      
    • Progress to regular push-up

PHASE III: MINIMAL PROTECTION PHASE

• Goals
  
  
  
  • Maintain full ROM
    
  • Improve muscular control, strength, power and endurance
    
  • Initiate functional activities
    
  • Core stabilization and conditioning
  
  
• Phase III Criteria
  
  
  
  • Full, painless ROM
    
  • Satisfactory stability
    
  • Muscular strength
    
  • No pain or tenderness
  
  
• Weeks 15 to 18
  
  
  
  • Continue stretching
    
  • Continue core strengthening
    
  • Continue shoulder strengthening
    
  • Functional exercise and restricted sport activities
    
  • Initiate sport interval program Week 16
  
  
• Weeks 18 to 21
  
  
  
  • Advance interval sport program

PHASE IV: ADVANCE TO STRENGTHENING PHASE

• Goals
  
  
  
  • Maintain full ROM
    
  • Improve strength, power, and endurance
    
  • Advance functional activities
  
  
• Phase IV criteria
  
  
  
  • Full, painless ROM
    
  • Satisfactory stability
    
  • Muscular strength 80% contralateral side
    
  • No pain or tenderness
  
  
• Weeks 22 to 26
  
  
  
  • Continue flexibility exercises
    
  • Continue isotonic strengthening
    
  • Neuromuscular control drills
    
  • Plyometrics
    
  • Advance interval sport program
    
  • Pass functional testing
    
    
    
    • Trunk stability push-up
      
      
      
      • 3 reps with control
      
      
    • Closed Kinetic Chain Extremity Stability Test
      
      
      
      • 21 touches, 15 s
      
      
    • Upper extremity Y balance
      
      
      
      • 3 consecutive progressions

PHASE V: RETURN-TO-SPORT PHASE

• Goals
  
  
  
  • Enhance strength, power, and endurance
    
  • Pass all functional testing
    
  • Maintain mobility
  
  
• Phase V criteria
  
  
  
  • Full, painless ROM
    
  • Satisfactory static stability
    
  • Muscular strength 80% contralateral side
    
  • No pain or tenderness
  
  
• Weeks 26 to 32
  
  
  
  • Advance sport activity to unrestricted participation
    
  • Pass functional testing
    
  • Continue stretching and strengthening
    
  • Posterior shoulder endurance
    
    
    
    • 85% of contralateral arm
    
    
  • One-arm hop test
    
    
    
    • 5 repetitions
    
    
  • Long arm plank ball tap
    
    
    
    • 10 bidirectional taps with body control
    
    
  • Plank weight stacking
    
    
    
    • 4 × 1 pound
    
    
  • Overhand band reach
    
    
    
    • Maintain stability

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