Return to Sports After Shoulder Stabilization Surgery for Anterior Shoulder Instability

Substantial influence of psychological factors on return to sports after anterior shoulder instability surgery: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to (1) determine the proportion of patients who underwent anterior shoulder instability surgery and did not return to sports for psychological reasons and (2) estimate differences in psychological readiness scores between patients who did and did not return to sports.

METHODS

The EBSCOhost/SPORTDiscus, PubMed/Medline, Scopus, EMBASE and Cochrane Library databases were searched for relevant studies. The data synthesis included the proportion of patients who did not return to sports for psychological reasons and the mean differences in the psychological readiness of athletes who returned and those who did not return to sports. Non-binomial data were analysed using the inverse-variance approach and expressed as the mean difference with 95% confidence intervals.

RESULTS

The search yielded 700 records, of which 13 (1093 patients) were included. Fourteen psychological factors were identified as potential causes for not returning to sports. The rates of return to sports at any level or to the preinjury level were 79.3% and 61.9%, respectively. A total of 55.9% of the patients cited psychological factors as the primary reason for not returning to sports. The pooled estimate showed that patients who returned to sports had a significantly higher Shoulder Instability-Return to Sport After Injury score (P < 0.00001) than those who did not, with a mean difference of 30.24 (95% CI 24.95-35.53; I2 = 0%; n.s.).

CONCLUSIONS

Psychological factors have a substantial impact on the rate of return to sports after anterior shoulder instability surgery. Patients who returned to sports had significantly higher psychological readiness than those who did not return to sports. Based on these results, healthcare professionals should include psychological and functional measurements when assessing athletes' readiness to return to sports.

LEVEL OF EVIDENCE

Level IV.

Functional Performance Tests Reveal Promising Results at 6 Months After Shoulder Stabilization Surgery

BACKGROUND

Although athletes are mostly allowed to return to play 6 months after shoulder stabilization surgery, there are inadequate data about their functional status during this period.

HYPOTHESES

Performance tests would reveal insufficiency in the functional capacity of shoulder 6 months after stabilization surgery.

STUDY DESIGN

Prospective cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 32 male athletes with arthroscopic anterior capsulolabral repair (AACR) were included in the study. Shoulder internal and external rotator (IR-ER) strength was assessed using isokinetic dynamometer at 60°/s and 180°/s angular velocities preoperatively and 6 months postoperatively. Shoulder function was assessed with closed kinetic chain upper extremity stability (CKCUES) test, Y balance test-upper quarter (YBT-UQ), and unilateral seated shot-put test (USSPT) at 6 months postoperation. Western Ontario shoulder instability index (WOSI) and Tampa scale of kinesiophobia (TSK) were used for the self-assessment of the shoulder. Mixed-model ANOVA was used to analyze the changes in the IR-ER strength on both shoulders. Limb symmetry index (LSI) was calculated for the IR-ER strength, YBT-UQ, and USSPT scores.

RESULTS

Shoulder IR strength was higher at 6 months postoperatively compared with preoperatively. The LSI was 76.4% and 76.6% for ER strength, and 94.2% and 94% for IR strength at 60°/s and 180°/s angular velocities, respectively, at the postoperative 6 month timepoint. The mean CKCUES test score was 21.8 ± 2.6 touches and the LSI was 94.7% for the YBT-UQ and 102.5% for the USSPT. WOSI (P < 0.001) and TSK (P = 0.001) scores were significantly lower at 6 months postoperatively.

CONCLUSION

Functional status of the patients with shoulder stabilization surgery improved considerably 6 months after surgery, yet they did not fully recover function.

CLINICAL RELEVANCE

Exercise programs focusing on shoulder ER strength and shoulder performance should be emphasized after stabilization surgery.

Neuromuscular function of the shoulder girdle and upper extremity musculature in individuals with a history of glenohumeral labral repair

The purpose of this study was to compare neuromuscular function in the upper extremity musculature between individuals with glenohumeral labrum repair and uninjured controls. This cross-sectional study examined 16 individuals with a primary, unilateral glenohumeral labral repair (male/female: 13/3, age: 24.1 ± 5.0 years, time from surgery: 36.7 ± 33.3 months) and 14 uninjured individuals (male/female: 11/3, age: 23.8 ± 2.7 years) matched by age, sex, activity level, and limb dominance participated. Mass-normalized shoulder abduction and wrist flexion maximal voluntary isometric contraction (MVIC) torque, motoneuron pool excitability of the flexor carpi radialis (Hoffmann reflex), and corticospinal excitability of the upper trapezius, middle deltoid, and flexor carpi radialis (active motor threshold [AMT]) were evaluated. Dependent and independent t-tests were used to assess between-limb and between-group comparisons. Cohen's d effect sizes with 95% confidence intervals were used to quantify the magnitude of differences observed. Within the injured group, the involved limb had lesser shoulder abduction MVIC torque (p < 0.001, d = 1.16) and higher AMT for the upper trapezius (p = 0.01, d = 0.81) compared with the contralateral limb. The labral repair group had lesser shoulder abduction MVIC torque (p < 0.001, d = 1.17) and Hoffmann reflex (p = 0.01, d = 0.99), as well as higher AMT for the upper trapezius (p < 0.001, d = 1.23) in their involved limb compared with the control group. Large magnitude neuromuscular impairments are present beyond 6 months from glenohumeral labral repair, suggesting potential origins of impairments to be addressed during post-operative rehabilitation.

Return to Professional Australian Rules Football After Surgery for Traumatic Anterior Shoulder Instability

BACKGROUND

The treatment of traumatic anterior shoulder instability in professional Australian Football League (AFL) players is challenging, with an emphasis on early return to play and avoidance of instability recurrence.

PURPOSE

To investigate return-to-sport (RTS) outcomes and complications after 2 different procedures for traumatic anterior shoulder instability in professional AFL players.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively reviewed our surgical database for professional AFL players who underwent capsulolabral stabilization or open Latarjet procedure by a single surgeon between 2006 and 2017. Outcomes included RTS, on-field performance, and complications. Between-group analyses for RTS and complications were estimated using Kaplan-Meier survival analyses. Within-group analyses for on-field performance data were performed using paired t tests with significance set at .05.

RESULTS

A total of 58 capsulolabral stabilization procedures in 54 players and 32 Latarjet procedures in 29 players were included in the analysis; 93.1% of capsulolabral patients and 96.9% of Latarjet patients returned to professional AFL. The median RTS time was 6.8 months for the capsulolabral group and 7.3 months for the Latarjet group. There was no significant difference in RTS rates between the 2 groups (P = .270). Of those undergoing surgery early in the season, 75% of the capsulolabral and 71% of Latarjet group were able to RTS within the same season, at a mean time of 16.9 weeks and 18.8 weeks, respectively. There was a significant difference in instability recurrence, with 19% for the capsulolabral group and no recurrence in the Latarjet group (P = .017). There was no significant reduction in player on-field performance in either group (P < .05).

CONCLUSION

In this study, the median RTS in AFL players was approximately 7 months after capsulolabral and Latarjet surgery with no compromise to on-field performance. Instability-related complications occurred only in the capsulolabral group, and the incidence increased with time.

Outcomes After Arthroscopic Anterior Shoulder Stabilization in Professional Handball Players

Background:

Although numerous studies have reported on the redislocation rate and functional results of arthroscopic treatment for anterior shoulder instability in athletes, they have not disclosed outcomes in the high-risk group of elite handball players.

Purpose:

To investigate the postoperative outcomes of arthroscopic treatment for anterior shoulder instability as well as the return-to-sport (RTS) rate in professional handball players.

Study Design:

Case series; Level of evidence, 4.

Methods:

Involved in this study were 44 competitive handball players (47 shoulders) who underwent arthroscopic anterior capsulolabral reconstruction between 2010 and 2018 and had a minimum follow-up of 24 months. After surgery, patients completed a questionnaire that collected Rowe and American Shoulder and Elbow Surgeons (ASES) scores and RTS data, and we compared these results with their preoperative scores. We also compared results according to the following subgroups: true dislocations versus recurrent subluxations, younger (<20 years) versus older (≥20 years) age, male versus female sex, and shorter versus longer duration of instability. Statistical analysis included the paired-samples t test and nonparametric Fisher exact test.

Results:

The mean follow-up period was 52.2 ± 21.4 months. There were 4 shoulders (9%) with recurrent instability. There were significant preoperative to postoperative improvements in the mean Rowe score (from 45.2 to 91.8) and mean ASES score (from 70.6 to 95.7) (P < .001 for both). Overall, the RTS rate was 83%, and 64% (30/47 shoulders) were able to return to their preinjury level. The RTS rate was significantly lower in the younger players than in the older players (46% vs 86%, respectively; P = .005).

Conclusion:

The study results indicated that handball players with anterior shoulder instability can be treated using arthroscopic labral reconstruction successfully and 83% of the athletes were able to RTS activity. The handball players aged ≥20 years returned to their preinjury level of sport at a higher rate than did those aged <20 years.

Athletes diagnosed with anterior and posterior shoulder instability display different chief complaints and disability

BACKGROUND

Anterior shoulder instability is a common complaint of young athletes. Posterior instability in this population is less well understood, and the standard of care has not been defined. The purpose of the study is to compare index frequency, treatment choice, and athlete disability following an incident of anterior or posterior shoulder instability in high school and collegiate athletes.

METHODS

A total of 58 high school and collegiate athletes (n=30 athletes with anterior instability; n=28 athletes with posterior instability) were included. Athletes suffering from a traumatic sport-related shoulder instability episode during a team-sponsored practice or game were identified by their school athletic trainer. Athletes were referred to the sports medicine physician or orthopedic surgeon for diagnosis and initial treatment choice (operative vs. nonoperative). Athletes diagnosed with traumatic anterior or posterior instability who completed the full course of treatment and provided pre- and post-treatment patient-reported outcome measures were included in the study. The frequency of shoulder instability was compared by direction, mechanism of injury (MOI), and treatment choice through χ² analyses. A repeated measures analysis of variance was used to compare the functional outcomes by treatment type and direction of instability (α = 0.05).

RESULTS

Athletes diagnosed with anterior instability were more likely to report a chief complaint of instability (70%), whereas those diagnosed with posterior instability reported a primary complaint of pain interfering with function (96%) (P = .001). The primary MOI classified as a contact event was similar between anterior and posterior instability groups (77% vs. 54%, P = .06) as well as the decision to proceed with surgery (60% vs. 72%, P = .31). In patients with nonoperative care, athletes with anterior instability had significantly more initial disability than those with posterior instability (32±6.1 vs. 58±8.1, P = .001). Pre- and post-treatment Penn Shoulder Scores for athletes treated with early surgery were similar (P > .05). There were no differences in functional outcomes at discharge in those treated nonoperatively regardless of direction of instability (P = .24); however, change in Penn score was significantly greater in those with anterior (61±18.7) than those with posterior (27 ± 25.2) instability (P = .002).

CONCLUSION

Athletes with anterior instability appear to have different mechanisms and complaints than those with posterior instability. Among those that receive nonoperative treatment, athletes with anterior instability have significantly greater initial disability and change in disability than those with posterior disability during course of care.

Return to play and performance after shoulder instability in National Basketball Association athletes

HYPOTHESIS

We hypothesized that players in the National Basketball Association (NBA) who sustained a shoulder destabilizing injury could return to play (RTP) successfully at a high rate regardless of treatment type.

METHODS

We used publicly available data to identify and evaluate 50 players who sustained an in-season shoulder instability event (subluxation/dislocation) while playing in the NBA. Demographic variables, return to NBA gameplay, incidence of surgery, time to RTP, recurrent instability events, and player efficiency rating (PER) were collected. Overall RTP was determined, and players were compared by type of injury and mode of treatment.

RESULTS

All players (50/50) returned to game play after sustaining a shoulder instability event. In those treated nonoperatively, athletes who sustained shoulder subluxations returned after an average of 3.6 weeks, compared with 7.6 weeks in those who sustained a shoulder dislocation (P = .037). Players who underwent operative management returned after an average of 19 weeks. Athletes treated operatively were found to have a longer time interval between a recurrent instability event (70 weeks vs. 28.5 weeks, P = .001).

CONCLUSION

We found 100% rate of RTP after a shoulder instability event in an NBA athlete. Players who experience shoulder dislocations were found to miss more time before RTP and were more likely to undergo surgical intervention compared with those who experienced a subluxation. Surgical repair maintained a longer interval between recurrent instability. Future investigations should aim to evaluate outcomes based on surgical procedures and identify possible risk factors predictive of recurrent instability or failure to RTP.