Return to play for rotator cuff injuries and superior labrum anterior posterior (SLAP) lesions

Return to Sport after Arthroscopic Rotator Cuff Repair of Full-Thickness Rotator Cuff Tears: A Systematic Review

OBJECTIVE

Perform a systematic literature review regarding return to sport (RTS) outcomes after arthroscopic rotator cuff repair (aRCR) for full-thickness rotator cuff tears (FTRCTs).

DATA SOURCES

Systematic review of all articles in PubMed, Medline, and Excerpta Medica Database (EMBASE) was conducted in April 2022 using a combination of keywords: "rotator cuff repair," "RCR," "complete," "full-thickness," "tear," "RCT," "injury," "shoulder," "arthroscopic," "return to sport," "RTS," "sport," "return to play," and "athlete." Cohorts were included from all articles reporting RTS after aRCR for FTRCTs. Studies that were non-English, failed to distinguish between partial and FTRCT outcomes, or treated FTRCTs by open RCR, mini-open RCR, debridement, or nonsurgical management were excluded. Abstracted data included study design, surgical techniques, concomitant procedures, demographics, FTRCT type and size, patient-reported outcomes, type of sport, competition level, time to return, and reasons for failing to RTS.

MAIN RESULTS

11 studies were reviewed, with inclusion of 463 patients (385 athletes; mean age 47.9). RTS varied considerably in rate and timing, with 50.0% to 100% of patients returning on average between 4.8 to 14 months. In addition, 31 patients returned to a higher level of sport, 107 returned to or near preinjury level, and 36 returned to a lower level of competition or failed to RTS entirely.

CONCLUSIONS

The ability for athletes to RTS after aRCR for FTRCTs is likely multifactorial, demonstrating high variability in return rates and time to RTS. Given the paucity of available literature, future studies are warranted to provide a more definitive consensus.

The Effects Of Obesity On 1 Year Functional Outcomes Following Arthroscopic Rotator Cuff Tear Repair

Background

The purpose of our study was to examine the impact that an increased body mass index (BMI) has on arthroscopic rotator cuff repair (aRCR) outcomes.

Methods

We identified a sample of 313 patients who underwent aRCR at our institution from 2017 to 2020. Patients were classified into cohorts by BMI: normal BMI (<25), overweight (25-30), and obese (≥30). Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Pain Interference, Pain Intensity, and Upper Extremity) and Clinical Global Impressions scale rating of pain and functional improvement after surgery were obtained at 1 year postoperatively. The significance of the BMI category as a predictor for outcomes was evaluated using multiple linear and multivariable logistic regressions. Receiver operating characteristic curve analysis with Youden’s J-statistic was used to determine optimal BMI cutoff for predicting likelihood of achieving minimum clinically important difference (MCID) and substantial clinical benefit (SCB) on the Clinical Global Impressions scales.

Results

Obesity was a significant predictor of reduced preoperative-to-postoperative improvement in the PROMIS Upper Extremity score (P = .04). However, BMI was not predictive of other preoperative-to-postoperative differences in outcome scores or the size and number of cuff tendons torn (P > .05). Optimal BMI cutoffs were determined for pain MCID (40.8), pain SCB (26.8), function MCID (27.4), and function SCB (26.8), but all cutoffs had low correct classification rates (≤13%).

Discussion and Conclusion

Obesity was not found to be an independent risk factor for increased rotator cuff tear size or tendon involvement but was nonetheless associated with worse upper extremity function and pain after aRCR.

Italian consensus statement (2020) on return to play after lower limb muscle injury in football (soccer)

Return to play (RTP) decisions in football are currently based on expert opinion. No consensus guideline has been published to demonstrate an evidence-based decision-making process in football (soccer). Our aim was to provide a framework for evidence-based decision-making in RTP following lower limb muscle injuries sustained in football. A 1-day consensus meeting was held in Milan, on 31 August 2018, involving 66 national and international experts from various academic backgrounds. A narrative review of the current evidence for RTP decision-making in football was provided to delegates. Assembled experts came to a consensus on the best practice for managing RTP following lower limb muscle injuries via the Delphi process. Consensus was reached on (1) the definitions of 'return to training' and 'return to play' in football. We agreed on 'return to training' and RTP in football, the appropriate use of clinical and imaging assessments, and laboratory and field tests for return to training following lower limb muscle injury, and identified objective criteria for RTP based on global positioning system technology. Level of evidence IV, grade of recommendation D.

Professional advancement, performance, and injury characteristics of baseball players entering the Major League Baseball draft after treatment for shoulder injuries

BACKGROUND

How shoulder injuries treated before the Major League Baseball (MLB) draft affect the player's performance over their career is unclear. The purpose of this study was to determine whether prior shoulder injuries were associated with a difference in the level of performance and advancement of MLB draftees.

METHODS

Before entering the draft, 119 professional baseball players from 2004 to 2010 were treated for a shoulder injury (73% treated surgically) as an amateur. A 3:1 matched case-control was performed to players without prior shoulder injuries by age, position, round selected, and signing bonus. Follow-up data were collected in 2016, and professional advancement, disabled list time, and in-game performance statistics for pitchers were analyzed and compared.

RESULTS

Players with a prior shoulder injury had a statistically higher chance to be assigned to the disabled list then controls (P = .03), but there was no difference in disabled list time or professional advancement. Pitchers with a prior shoulder injury pitched a statistically lower number of innings per game than controls (P = .04). All other in-game performance statistics were not statistically different. The type of treatment did not have any effect on future performance or advancement.

CONCLUSIONS

Professional baseball players treated for prior shoulder injuries at the amateur level were more likely to sustain future disability than their matched controls, but it did not affect professional advancement.

Functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair

AIM

To compare the functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair.

METHODS

Eighty-seven patients with rotator cuff tears following arthroscopic treatment were divided into traumatic and non-traumatic tear groups. Postoperative muscle strength and outcomes using the modified University of California, Los Angeles score were evaluated. Sex, age, affected limb and dominant limb were correlated between groups. Muscle strength of the repaired and unaffected shoulders was compared. Rotator cuff injury size was measured.

RESULTS

Of the 87 patients who underwent rotator cuff repairs, 35 had traumatic tears and 52 had non-traumatic tears. In patients with non-traumatic tears, the average age was 59 years, 74.5% were female, 96.1% were right-hand dominant and 92.3% had their dominant shoulder affected. Patients with traumatic tears were 59.5 years old on average, 51.4% were female, 91.4% were right-hand dominant and 88.5% had their dominant shoulder affected. No difference existed in the mean modified University of California, Los Angeles score between patients with traumatic tears (33.7) compared with those with non-traumatic tears (32.8). No strength differences were observed between groups: The strength difference between the non-affected and affected sides was 1.21 kg in the non-traumatic group and 1.39 kg in the traumatic group (P = 0.576), while the strength ratio between the non-affected/affected sides was 0.805 in the non-traumatic group and 0.729 in the traumatic group (P = 0.224).

CONCLUSION

The functional results of traumatic rotator cuff repairs are similar to non-traumatic tears. Both outcomes are satisfactory.

Understanding and evaluating shoulder pain in the throwing athlete

Shoulder pain in the throwing athlete can present at any age and in any level of sport and can lead to dysfunction. A thorough evaluation of the throwing athlete can often determine the cause of symptoms, which is frequently multifactorial. Although the pathophysiology leading to pain in the shoulder of the throwing athlete is not entirely known, nonoperative modalities remain the mainstay of treatment. In general, surgical intervention should be reserved as a last resort. Effective treatment often requires collaboration among trainers, players, physicians, and therapists to determine an appropriate course of action.

Return to play after treatment of superior labral tears in professional baseball players

BACKGROUND

The published return-to-play (RTP) rates for athletes who have undergone surgical repair of superior labrum anterior-posterior (SLAP) tears vary widely and are generally accepted to be lower in the subset of competitive throwers. The efficacy of nonsurgical treatment for this group is unknown.

HYPOTHESIS

Nonsurgical treatment of SLAP tears in professional baseball players leads to RTP before consideration of surgical treatment. Incorporating performance statistics and level of competition will result in lower calculated RTP rates than have been previously reported.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of 119 consecutive patients in a single professional baseball organization with persistent shoulder pain that limited the ability to compete was performed. Sixty-eight patients had magnetic resonance imaging-documented SLAP lesions. All patients had failed 1 attempt at rehabilitation but had continued with supervised physical therapy. Treatment was according to an algorithm focusing on the correction of scapular dyskinesia and posterior capsular contracture with glenohumeral internal rotation deficit (GIRD), followed by pain-free return to throwing. Those who failed 2 cycles of nonsurgical treatment were treated surgically. Success was defined by 2 different standards: (1) RTP, in accordance with previous studies; and (2) a more stringent standard of return to the same level/quality of professional competition (A, AA, AAA, etc) with the incorporation of a return to preinjury individual performance statistics (earned run average, walks plus hits per inning pitched), termed "return to prior performance" (RPP).

RESULTS

Sixty-eight athletes were identified with SLAP lesions. Twenty-one pitchers successfully completed the nonsurgical algorithm and attempted a return. Their RTP rate was 40%, and their RPP rate was 22%. The RTP rate for 27 pitchers who underwent 30 procedures was 48%, and the RPP rate was 7%. For 10 position players treated nonsurgically, the RTP rate was 39%, and the RPP rate was 26%. The RTP rate for 13 position players who underwent 15 procedures was 85%, with an RPP rate of 54%.

CONCLUSION

Nonsurgical treatment correcting scapular dyskinesia and GIRD had a reasonable success rate in professional baseball players with painful shoulders and documented SLAP lesions. The rate of return after surgical treatment of SLAP lesions was low for pitchers. The RTP and RPP rates were higher for position players than for pitchers. Nonsurgical treatment should be considered for professional baseball players with documented SLAP lesions, as it can lead to acceptable RTP and RPP rates.

Critical reflection of the advanced rehabilitation of an elite rugby league player sustaining a posterior Bankart lesion

The following is a critical description and discussion of the successful assessment and rehabilitation of a right shoulder posterior Bankart repair in an elite rugby league player. The rehabilitation follows accelerated, goal based guidelines, widely adopted in current sports practice but not well documented in the literature (Funk & Snow, 2007; Park, Lin, Yokota, & McFarland, 2004). The study serves to be the first critical discussion of such a regime.

Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: Effect of concomitant partial-thickness rotator cuff tears

BACKGROUND

There are conflicting reports in the literature regarding the outcome of superior labral anterior posterior (SLAP) repairs in overhead athletes and a paucity of data demonstrating ability to return to prior level of competition.

HYPOTHESIS

Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score provides more accurate assessment of shoulder function and ability to return to previous level of athletic competition after SLAP lesion repair than does the conventional American Shoulder and Elbow Surgeons scoring system.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-three elite (collegiate or professional) overhead athletes who were more than 1-year status postarthroscopic repair of type II SLAP lesions were evaluated using both the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score and American Shoulder and Elbow Surgeons score. P values were computed using the analysis of variance model. Postoperative American Shoulder and Elbow Surgeons and Kerlan-Jobe Orthopaedic Clinic scores from subjects were compared with control values obtained from a healthy athletic cohort; the relationship between the scores was investigated using the linear regression model and assessed using Pearson correlations.

RESULTS

At a mean 38-month follow-up, 13 athletes were playing pain free at the time of the questionnaire administration, 6 were playing with pain, and 4 were not playing because of pain. Regarding American Shoulder and Elbow Surgeons scores, 22 athletes (96%) had good-excellent scores, whereas 1 (4%) had a fair score. The Kerlan-Jobe Orthopaedic Clinic scores revealed 9 excellent (39%), 3 good (13%), 4 fair (17%), and 7 poor (30%) results for the same study group. Of the 23 patients, 13 (57%) had returned to their pain-free preinjury levels of competition at final follow-up. The inability to return to this level of competition correlated with the presence of a partial-thickness rotator cuff tear (P = .0059). The Kerlan-Jobe Orthopaedic Clinic demonstrated better overall accuracy (85%) than did the American Shoulder and Elbow Surgeons (70%) in evaluating return to pain-free preinjury levels.

CONCLUSION

Return to preinjury level of competition for elite overhead athletes after type II SLAP lesion repairs was 57%, despite high American Shoulder and Elbow Surgeons scores. Return to play status correlated with the presence of a partial-thickness rotator cuff tear. The Kerlan-Jobe Orthopaedic Clinic score, designed specifically for the evaluation of the overhead athlete, was a more accurate assessment tool than was the American Shoulder and Elbow Surgeons in this population of elite overhead athletes with SLAP tears.

Current concepts in pediatric and adolescent arthroscopy

Arthroscopy continues to grow as a treatment modality for pediatric and adolescent orthopaedic pathologies. In recent years arthroscopic procedures previously reserved for adult patients have become more frequently used in the treatment of younger individuals. Advancements in arthroscopic instrumentation including smaller arthroscopes and tools have made the constraint of smaller joint spaces in the pediatric and adolescent populations less of a limiting factor when addressing surgical options for care. This is valuable considering the consistent increase in pediatric sports- and activity-related injuries, of which many are treatable arthroscopically. Currently, arthroscopy is indicated for the treatment of various chronic and acute injuries of the shoulder, elbow, wrist, hip, knee, and ankle. This review aims to highlight the current literature regarding arthroscopy in this population while also offering treatment algorithms, rehabilitation guidelines, and surgical tips for various pathologies in pediatric and adolescent patients.

Superior labral lesions anterior to posterior-evaluation and arthroscopic management

Lesions of the superior labrum are complex and difficult to both diagnose and treat effectively. The clinical diagnosis is challenging due to the nonspecific history and physical examination. MRI has substantially improved our ability to detect SLAP tears, although experience is necessary to distinguish pathologic findings from normal anatomic variants. Treatment is determined by patient age, functional demands, and the type of lesion identified.

Baseball and softball injuries

Baseball and softball injuries can be a result of both acute and overuse injuries. Soft tissue injuries include contusions, abrasions, and lacerations. Return to play is allowed when risk of further injury is minimized. Common shoulder injuries include those to the rotator cuff, biceps tendon, and glenoid labrum. Elbow injuries are common in baseball and softball and include medial epicondylitis, ulnar collateral ligament injury, and osteochondritis dissecans. Typically conservative treatment with relative rest, medication, and a rehabilitation program will allow return to play. Surgical intervention may be needed for certain injuries or conservative treatment failure.