Posterior Labral Repairs of the Shoulder Among Baseball Players: Results and Outcomes With Minimum 2-Year Follow-up

Management of Shoulder Instability in the Overhead Athletes

Overhead athletes with anterior, posterior, and multidirectional shoulder instability present with a wide range of symptoms, especially considering the injury mechanism and affected supportive structures. As such, the management of shoulder instability is widely variable and relies on rehabilitation, operative management, and sport-specific considerations, such as positional and seasonal demands on the athlete. Biomechanical analysis may further aid in the recovery process or serve as a predictive tool to identify an increased risk for injury.

Current Concepts on the Management of Shoulder Instability in Throwing Athletes

PURPOSE OF REVIEW

The management of shoulder instability in throwing athletes remains a challenge given the delicate balance between physiologic shoulder laxity facilitating performance and the inherent need for shoulder stability. This review will discuss the evaluation and management of a throwing athlete with suspected instability with a focus on recent findings and developments.

RECENT FINDINGS

The vast majority of throwing athletes with shoulder instability experience subtle microinstability as a result of repetitive microtrauma rather than episodes of gross instability. These athletes may present with arm pain, dead arms or reduced throwing velocity. Recent literature reinforces the fact that there is no "silver bullet" for the management of these athletes and an individualized, tailored approach to treatment is required. While initial nonoperative management remains the hallmark for treatment, the results of rehabilitation protocols are mixed, and some patients will ultimately undergo surgical stabilization. In these cases, it is imperative that the surgeon be judicious with the extent of surgical stabilization as overtightening of the glenohumeral joint is possible, which can adversely affect athlete performance. Managing shoulder instability in throwing athletes requires a thorough understanding of its physiologic and biomechanical underpinnings. Inconsistent results seen with surgical stabilization has led to a focus on nonoperative management for these athletes with surgery reserved for cases that fail to improve non-surgically. Overall, more high quality studies into the management of this challenging condition are warranted.

Batter's Shoulder: Diagnosis, Management, and Outcomes

Batter's shoulder is characterized by posterior shoulder instability in the lead (front) shoulder of a batting athlete. This most commonly occurs as a discrete event, particularly a swing and miss at an outside pitch, which leads to an episode of shoulder subluxation. A thorough history and physical examination is key to diagnosis, with patients feeling pain and instability of the lead shoulder when attempting the baseball swing or during pushing-type activities, as well as positive posterior labral signs in tests such as the Kim, jerk, and modified dynamic labral shear tests. Magnetic resonance imaging can confirm the diagnosis of posterior labral tear and may show concomitant pathologies such as a reverse Hill-Sachs lesion. Nonsurgical treatment is directed at rotator cuff and scapular strengthening; however, arthroscopic posterior labral repair is often required for definitive stabilization. Overall, this is a relatively rare diagnosis, but outcomes of surgical repair are favorable with high satisfaction and rates of return to competition.

Evolution of the throwing shoulder: why apes don't throw well and how that applies to throwing athletes

BACKGROUND

Humans have unique characteristics making us the only primate that can throw well while most other primates throw predominately underhand with poor speed and accuracy. The purpose of this study is to illuminate the uniquely human characteristics that allow us to throw so well. When treating an injury such as a labral tear or capsule tear, this study hopes the reader can gain a better understanding of the issues that lead to the tear and those that may determine the success of treatment besides the actual repair.

METHODS

In addition to a review of scientific and medical literature, information was obtained from interviews and experience with primate veterinarians, anthropologists, archeologists, and professional baseball players. These sources were used to study the connection between evolutionary throwing activities and current sports medicine issues.

RESULTS

Arm acceleration requires a functional kinetic chain, rapid motor sequences, and the ability to absorb elastic energy in the shoulder. Successful treatment of the throwing shoulder requires awareness of the shoulder's position in the kinetic chain and correction of defects in the ability to execute the kinetic chain. Some problems in the shoulder could reflect regression to a more primitive anatomy or dyskinesis. Return of performance requires regaining the elasticity in the tissues of the shoulder to temporarily store kinetic energy. For example, tissue remodeling after rotator cuff repair continues for months to years; however, the newly formed tissue lacks the same elasticity of the native tendon. This suggests why throwing performance typically does not return for 7 or more months after repair even though there may be structural integrity at 3-4 months.

CONCLUSION

The shoulder has developed uniquely in modern man for the act of throwing. The anatomic deficiencies in primates for throwing provide an illustration of the more subtle changes that a throwing athlete might have that are detrimental to throwing. Nonhuman primates have been unable to demonstrate the kinetic chain sequence for throwing secondary to the lack of neurologic pathways required. Humans are more sophisticated and precise in their movements but lack robusticity in their bone and muscle architecture, seen especially in the human rotator cuff. Successful treatment of a throwing injury requires familiarity with the conditions that cause the injury or affect the rehabilitation process. The return of performance following injury or surgery requires regaining the elasticity in the tissues of the shoulder to temporarily store kinetic energy from the kinetic chain.

Outcomes of arthroscopic stabilization for posterior shoulder instability: a systematic review

BACKGROUND

Posterior shoulder instability makes up approximately 10% of all shoulder instability cases and its diagnosis and treatment is less well understood. Recently, however, there has been increased recognition of posterior instability and posterior stabilization. The purpose of this study was to systematically review the literature to ascertain the outcomes on arthroscopic stabilization of posterior shoulder instability.

METHODS

Two independent reviewers conducted a systematic literature search based on PRISMA guidelines, utilizing the MEDLINE database. Studies were eligible for inclusion if they reported postoperative outcomes for posterior shoulder instability following arthroscopic stabilization.

RESULTS

A total of 48 studies met inclusion criteria for review including 2307 shoulders. Majority of patients were male (83.3%), with an average age of 26.1 years and a mean follow-up of 46.8 months. The functional outcome score primarily utilized for postoperative assessment was the American Shoulder and Elbow Surgeons with an average of 84.77. Overall, 90.9% of patients reported being satisfied with their arthroscopic stabilization. Recurrent instability occurred in 7.4% of patients. The total revision rate was 5.2%. 16.6% of patients reported residual pain postoperatively. The rate of return to play was 86.4% with 68.0% of patients returning to play at the same or higher level of play.

CONCLUSION

Arthroscopic stabilization of posterior shoulder instability resulted in good outcomes with high patient satisfaction and low rates of recurrent instability, revisions, and residual pain.

Posterior Shoulder Instability, Part I-Diagnosis, Nonoperative Management, and Labral Repair for Posterior Shoulder Instability-An International Expert Delphi Consensus Statement

PURPOSE

To establish consensus statements on the diagnosis, nonoperative management, and labral repair for posterior shoulder instability.

METHODS

A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement.

RESULTS

Unanimous agreement was reached on the indications for nonoperative management and labral repair, which include whether patients had primary or recurrent instability, with symptoms/functional limitations, and whether there was other underlying pathology, or patient's preference to avoid or delay surgery. In addition, there was unanimous agreement that recurrence rates can be diminished by attention to detail, appropriate indication and assessment of risk factors, recognition of abnormalities in glenohumeral morphology, careful capsulolabral debridement and reattachment, small anchors with inferior placement and multiple fixation points that create a bumper with the labrum, treatment of concomitant pathologies, and a well-defined rehabilitation protocol with strict postoperative immobilization.

CONCLUSIONS

The study group achieved strong or unanimous consensus on 63% of statements related to the diagnosis, nonoperative treatment, and labrum repair for posterior shoulder instability. The statements that achieved unanimous consensus were the relative indications for nonoperative management, and the relative indications for labral repair, as well as the steps to minimize complications for labral repair. There was no consensus on whether an arthrogram is needed when performing advanced imaging, the role of corticosteroids/orthobiologics in nonoperative management, whether a posteroinferior portal is required.

LEVEL OF EVIDENCE

Level V, expert opinion.

Posterior Shoulder Instability, Part II-Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play-An International Expert Delphi Consensus Statement

PURPOSE

To establish consensus statements on glenoid bone grafting, glenoid osteotomy, rehabilitation, return to play, and follow-up for posterior shoulder instability.

METHODS

A consensus process on the treatment of posterior shoulder instability was conducted, with 71 shoulder/sports surgeons from 12 countries participating on the basis of their level of expertise in the field. Experts were assigned to 1 of 6 working groups defined by specific subtopics within posterior shoulder instability. Consensus was defined as achieving 80% to 89% agreement, whereas strong consensus was defined as 90% to 99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement.

RESULTS

All of the statements relating to rehabilitation, return to play, and follow-up achieved consensus. There was unanimous consensus that the following criteria should be considered: restoration of strength, range of motion, proprioception, and sport-specific skills, with a lack of symptoms. There is no minimum time point required to return to play. Collision athletes and military athletes may take longer to return because of their greater risk for recurrent instability, and more caution should be exercised in clearing them to return to play, with elite athletes potentially having different considerations in returning to play. The relative indications for revision surgery are symptomatic apprehension, multiple recurrent instability episodes, further intra-articular pathologies, hardware failure, and pain.

CONCLUSIONS

The study group achieved strong or unanimous consensus on 59% of statements. Unanimous consensus was reached regarding the criteria for return to play, collision/elite athletes having different considerations in return to play, indications for revision surgery, and imaging only required as routine for those with glenoid bone grafting/osteotomies at subsequent follow-ups. There was no consensus on optimal fixation method for a glenoid bone block, the relative indications for glenoid osteotomy, whether fluoroscopy is required or if the labrum should be concomitantly repaired.

LEVEL OF EVIDENCE

Level V, expert opinion.

Occult, Incomplete, and Complete Posterior Labral Tears Without Glenohumeral Instability on Imaging Underestimate Labral Detachment

PURPOSE

To introduce a classification of posterior labral tear and describe clinical characteristics, magnetic resonance imaging (MRI)/magnetic resonance arthrography (MRA) findings, arthroscopic findings, and outcomes after arthroscopic repair for patients with posterior labral tears without glenohumeral instability.

METHODS

Sixty patients with posterior labral tear who underwent arthroscopic repair were analyzed retrospectively. Patients with shoulder instability were excluded. Tear patterns were classified into 3 types; occult (type 1), incomplete (type 2), and complete (type 3) based on MRI/MRA studies. A visual analog scale score for pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score for satisfaction, and return to sports were evaluated at a minimum follow-up of 2 years. Computed tomography arthrography was performed at a year follow-up for assess labral healing. The diagnosis was confirmed in arthroscopy, and arthroscopic labral repair without capsular plication was performed.

RESULTS

The mean patient age was 30.4 ± 6.9 years, and all patients were male. Forty-four patients (73.3%) were participating in sports. MRI/MRA studies identified 10 patients with type 1, 18 with type 2, and 32 with type 3 tears. Type 1 tear patients showed a significantly longer symptom duration than those with type 3 (32.5 ± 17.2 vs 18.2 ± 17.1 months; P = .015). In arthroscopic findings, 70% of type 1 tear was confirmed as incomplete or complete tears. The American Shoulder and Elbow Surgeons score improved from 79.6 ± 10.3 to 98.1 ± 3.7, and pain was relieved from 2.4 ± 0.7 to 0.2 ± 0.5 at the last follow-up visit with high labral healing rate (95%). Thirty-nine (88.6%) patients returned to sports at preinjury levels.

CONCLUSIONS

In active young men with shoulder pain during daily activities or sports despite programmed conservative treatment, posterior labral tears should be considered even when MRI/MRA findings are ambiguous. Arthroscopic posterior labral repair without capsular plication provided satisfactory clinical outcomes and a high labral healing rate.

LEVEL OF EVIDENCE

Level Ⅳ, case series.

Acute Batter's Shoulder With Concomitant Superior Labrum from Anterior to Posterior Injury in a Collegiate Baseball Player

An 18-year-old collegiate baseball player sustained an acute batter's shoulder injury causing a posterior shoulder dislocation with type IX 360° superior labrum from anterior to posterior tear. To the authors' knowledge, this description of batter's shoulder is not within the literature. The patient ultimately underwent arthroscopic labral repair and has fully returned to sport. In understanding the complexity of the shoulder during the batter's swing, this case demonstrates an expansion to the previously described pathophysiology of batter's shoulder.

Posterior Labral Repair Using Knotless "All-Suture" Suture Anchors

Isolated posterior instability is well described but relatively uncommon, accounting for less than 10% of all shoulder instability cases. When nonoperative management fails, surgical outcomes demonstrate improved patient-reported outcomes with a high level of return to sport. Knotless suture anchor and "all-suture" suture anchor technology are now available and used for instability procedures in the shoulder. This technical description describes knotless "all-suture" suture anchor fixation for isolated posterior labral tears.

Return to Play After Shoulder Arthroscopy in Major League Baseball Pitchers vs Position Players

Background

Recovery from shoulder arthroscopy may vary between professional pitchers and position players in Major League Baseball (MLB). The time that it takes to return to play (RTP) and the level of skills to be regained after surgery are important factors for an athlete to consider when making career decisions.

Purpose

To identify MLB players who had arthroscopic shoulder surgery and observe their rates of RTP to MLB and the minor league, as well as to compare pre- and postinjury performance statistics and career metrics.

Study Design

Descriptive epidemiology study.

Methods

Public records (press releases, http://www.prosportstransactions.com, http://www.baseball-reference.com) were searched and analyzed to determine the number of days from shoulder arthroscopy to RTP and pre- and postinjury statistics for pitchers and position players in the MLB and minor league from 1998 to 2018. To meet inclusion criteria, a player must have undergone shoulder arthroscopy after having played at least 1 game in the MLB and had no identifiable concomitant injuries.

Results

Of 134 players, 89 (66.4%) returned to MLB. Fifty-four of 89 pitchers (60.7%) and 35 of 45 position players (77.8%) returned to MLB (P = .048). Forty-nine of 54 pitchers (90.7%) and 23 of 35 position players (65.7%) who returned to MLB returned to the minor league first. The mean time to RTP was 469.6 days (range, 100-1079 days) for pitchers and 301.6 days (range, 94-1488) for position players (P = .002). The WAR statistic (wins above replacement) for the pitchers decreased significantly (P = .004) after shoulder arthroscopy.

Conclusion

MLB position players returned to play at higher rates and more quickly than did pitchers. The WAR statistic declined in pitchers during the first season of RTP. Players undergoing arthroscopic shoulder surgery should be aware of these possible outcomes in time to RTP and postoperative performance.

Return to Sport After Arthroscopic Capsular Repair in Elite Baseball Players

Background

Chronic attritional midsubstance capsular tears arising from repetitive throwing stress are a rare but important source of pain and dysfunction in elite baseball players; however, little is known regarding outcomes after arthroscopic capsular repair.

Purpose

To evaluate the patient-reported outcomes and return-to-sport (RTS) rates after arthroscopic capsular repair in elite baseball players.

Study Design

Case series; Level of evidence, 4.

Methods

We identified 11 elite-level baseball players who were treated with arthroscopic repair for a midsubstance glenohumeral capsular tear by a single surgeon with a uniform approach and a standardized postoperative protocol between 2012 and 2019. All players had at least 2 years of follow-up data. Demographic data and concomitant surgical procedures were recorded. Preoperative and postoperative Kerlan-Jobe Orthopaedic Clinic (KJOC) scores and Single Assessment Numeric Evaluation (SANE) scores were collected in a subset of the cohort, and statistical comparisons were made. A telephone survey was conducted to determine the patients' RTS level and outcome scores. Statistical comparisons between preoperative and postoperative outcomes scores were made using t tests.

Results

Eight major league players, 1 minor league player, and 2 collegiate players were included. There were 9 pitchers, 1 catcher, and 1 outfielder. All patients had debridement of the posterosuperior labrum and rotator cuff. Two pitchers underwent a rotator cuff repair, and 1 outfielder underwent a posterior labral repair. The mean age at the time of surgery was 26.9 years (range, 20-34 years), with a mean follow-up of 3.5 years (range, 2.6-5.9 years). There were significant preoperative versus postoperative improvements in the mean KJOC (20.6 vs 89.8; P = .0002) and SANE (28.3 vs 86.7; P = .001) scores. All patients reported a high degree of satisfaction. At a mean of 16.3 months (range, 6.5-25.4 months), 10 of 11 (90.1%) players met the Conway-Jobe good or excellent criteria for RTS.

Conclusion

Arthroscopic capsular repair provided significant improvements in functional outcomes in elite baseball players, high levels of patient satisfaction, and high levels of RTS.

Return to Play After Shoulder Surgery in Professional Baseball Players: A Systematic Review and Meta-analysis

Background

The current literature lacks an updated review examining return to play (RTP) and return to prior performance (RTPP) after shoulder surgery in professional baseball players.

Purpose

To summarize the RTP rate, RTPP rate, and baseball-specific performance metrics among professional baseball players who underwent shoulder surgery.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search was performed utilizing the PubMed, MEDLINE, and CINAHL databases and according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language studies reporting on postoperative RTP and/or RTPP in professional baseball players who underwent shoulder surgery between 1976 and 2016. RTP rates, RTPP rates, and baseball-specific performance metrics were extracted from qualifying studies. A total of 2034 articles were identified after the initial search. Meta-analysis was performed where applicable, yielding weighted averages of RTP and RTPP rates and comparisons between pitchers and nonpitchers for each type of surgery. Baseball-specific performance metrics were reported as a narrative summary.

Results

Overall, 26 studies featuring 1228 professional baseball players were included. Patient-level outcome data were available for 529 players. Surgical interventions included rotator cuff debridement (n = 197), rotator cuff repair (RCR; n = 43), superior labrum from anterior to posterior repair (n = 124), labral repair (n = 103), latissimus dorsi/teres major (LD/TM) repair (n = 21), biceps tenodesis (n = 17), coracoclavicular ligament reconstruction (n = 15), anterior capsular repair (n = 5), and scapulothoracic bursectomy (n = 4). Rotator cuff debridement was the most common surgical procedure, while scapulothoracic bursectomy was the least common (37.2% and 0.8% of interventions, respectively). Meta-analysis revealed that the RTP rate was highest for LD/TM repair (84.5%) and lowest for RCR (53.5%), while the RTPP rate was highest for LD/TM repair (100.0%) and lowest for RCR (27.9%). RTP and RTPP rates were generally higher for position players than for pitchers. Nonvolume performance metrics were unaffected by shoulder surgery, while volume statistics decreased or remained similar.

Conclusion

RTP and RTPP rates among professional baseball players were modest after most types of shoulder surgery. Among surgical procedures commonly performed on professional baseball players, RTP and RTPP rates were highest for LD/TM repair and lowest for RCR.

Evaluation, Treatment, and Outcomes of Batter's Shoulder

PURPOSE OF REVIEW

This article reviews the incidence of batter's shoulder, the relevant biomechanics that predispose the lead shoulder to a posterior instability event, the evaluation and workup of posterior labral injury, the surgical technique for arthroscopic posterior labral repair, the postoperative rehabilitation process, and the clinical outcomes and return to sport after treatment of batter's shoulder.

RECENT FINDINGS

New epidemiological studies have demonstrated the relatively low incidence of batter's shoulder at the professional baseball level with 85% of the injured players successfully returning to the sport with nonoperative management. However, recent studies have reinforced the limited historical literature that players requiring surgery are able to return to their prior sport at a high level. Batter's shoulder is a subtype of posterior glenohumeral instability caused by the significant forces experienced by the lead shoulder during the baseball swing. Although an uncommon injury, batter's shoulder is a source of significant time away from competition. In patients who do not improve with nonoperative management, arthroscopic posterior labral repair can reliably return players to sport. Future research studies should consider opportunities for injury prevention.

Managing Shoulder Instability in the Overhead Athlete

PURPOSE OF REVIEW

Shoulder instability in the overhead athlete is a difficult problem because of the balance between necessary laxity for athletic movements and stability of the joint. The purpose of this review is to provide an overview of the clinical evaluation of shoulder instability in the overhead athlete and present evidence-based management strategies for each subtype of shoulder instability, including novel techniques and outcomes.

RECENT FINDINGS

Recent investigation has shown that throwers and other overhead athletes are more likely to present with subtle subluxation events rather than discrete dislocations as their primary symptom. While overhead athletes with discrete anterior dislocation events are likely to begin with non-operative management, many progress on to surgical intervention. Surgical management of glenohumeral joint instability continues to pose challenges due to the potential for over-tensioning for the sake of stability at the expense of the adaptive laxity that often confers performance benefits in the overhead athlete. Novel, individualized, and sport/position specific approaches are needed to address this complex issue. The optimal management of shoulder instability in the overhead athlete continues to be a controversial topic due to the complex work-up, an increasing number of surgical options with varying indications, and low volume of high-quality studies comparing any of the treatment options. The Anterior Shoulder Instability International Consensus Group guidelines from February 2022 offer the most updated guidelines on work-up and management. Overall, high-quality randomized controlled trials are required to determine the optimal treatment for specific pathologies and aid in creating patient-centered management plans.

Initial kinematic chain injuries increase hazard of subsequent arm injuries in professional baseball pitchers

BACKGROUND

Currently, there are few studies that have evaluated the relationship between a lower extremity or trunk injury (kinematic chain) and subsequent arm injury. The purpose of this study was (1) to investigate the relationship between initial kinematic chain (lower extremity or trunk) injury and subsequent arm injury; and (2) to investigate the relationship between initial shoulder or elbow injury and subsequent arm injury.

METHODS

A 7-year prospective injury risk study was conducted with Minor League Baseball pitchers. Pitches, pitching appearances, athlete exposures (AEs), and arm injuries (≥1-day time loss) were documented throughout the season. Cox survival analyses with 95% confidence intervals (95% CIs) were performed. Confounders controlled for included age, body mass index, arm dominance, pitching role, previous arm injury, number of pitching appearances, and seasonal pitch load.

RESULTS

A total of 297 pitchers participated (total player days = 85,270). Arm injury incidence was 11.4 arm injuries/10,000 AEs, and kinematic chain incidence was 5.2 injuries/10,000 AEs. Pitchers who sustained a kinematic chain injury demonstrated a greater hazard (2.6 [95% CI: 1.2, 5.6], P = .019) of sustaining an arm injury. Pitchers who sustained an initial shoulder injury demonstrated a greater hazard (9.3 [95% CI: 1.1, 83], P = .047) of sustaining a subsequent shoulder or elbow injury compared with pitchers who sustained an initial elbow injury.

CONCLUSIONS

Pitchers who sustained an initial lower extremity or trunk injury demonstrated an increased subsequent arm injury hazard compared with pitchers who did not. Pitchers who sustained an initial shoulder injury demonstrated a greater hazard of sustaining a subsequent arm injury compared with pitchers who sustained an initial elbow injury. However, this secondary analysis should be interpreted with caution. Clinicians should monitor risk with workload accumulation, which may be related to pitching compensatory strategies in a fatigued state. Pitchers who sustain a shoulder injury should be evaluated and perform both shoulder and elbow rehabilitation strategies before return to sport.

Arthroscopic Posterior Labral Repair in Active-Duty Military Patients: A Reliable Solution for an At-Risk Population, Regardless of Anchor Type

BACKGROUND

Active-duty servicemembers are a population at risk for the development of posterior shoulder instability. While short-term outcomes after arthroscopic posterior labral repair for posterior shoulder instability are promising, there is a paucity of longer term follow-up data for this procedure.

PURPOSES

The primary purpose was to report midterm outcomes after arthroscopic posterior labral repair in active-duty military patients for posterior shoulder instability without bone loss. The secondary purpose was to determine if outcomes varied between anchor types used.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Preoperative and postoperative outcomes, with a minimum 3-year follow-up, for a visual analog scale for pain, the Single Assessment Numeric Evaluation (SANE), the American Shoulder and Elbow Surgeons (ASES) score, and the Rowe score were collected and analyzed. A separate subgroup analysis was performed comparing the outcomes of patients who underwent repair with biocomposite anchors versus those who underwent repair with all-suture anchors.

RESULTS

A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months met the inclusion criteria and were available for analysis. As a whole, the cohort demonstrated statistically and clinically significant improvements in outcome scores at final follow-up. Preoperative and postoperative range of motion did not vary significantly. While the difference in final outcome scores between the 2 anchor types did not reach statistical significance, a statistically significantly larger proportion of patients who underwent repair with all-suture anchors versus those who underwent repair with biocomposite anchors met the Patient Acceptable Symptom State for the SANE (97.14% vs 78.95%, respectively; P = .0180) and the ASES score (88.57% vs 68.42%, respectively; P = .0171). The proportion of patients who achieved the substantial clinical benefit or surpassed the minimal clinically important difference, however, did not vary by anchor type. Overall, 70 patients (95.89%) remained on active duty and were able to return to preinjury work and recreational activity levels. There were 3 patients (4.11%) who had recurrent posterior instability.

CONCLUSION

This population of active-duty servicemembers undergoing posterior labral repair for posterior labral instability without bone loss demonstrated a statistically and clinically significant improvement in midterm outcomes, a low recurrence rate, and a rate of return to active duty of 95.89%, regardless of the anchor type used.

Arthroscopic Posterior Labral Repair and Capsular Closure via Single Working Portal for Posterior Shoulder Instability

Posterior shoulder instability (PSI) is a relatively less common form of instability that frequently affects young overhead or contact athletes. The etiology of PSI may be traumatic or atraumatic, with establishment of the diagnosis being more difficult in cases of atraumatic instability. Surgical management of PSI has evolved from open techniques to arthroscopic techniques. Posterior stabilization has commonly been performed with 2 posterior working portals with the patient in the lateral decubitus position. The objective of this Technical Note is to describe a technique for posterior labral repair using all-suture anchors with the patient in the beach-chair position via 1 working portal with capsular closure.

Return to Sport After Surgical Management of Posterior Shoulder Instability: A Systematic Review and Meta-analysis

BACKGROUND

Posterior shoulder instability accounts for a small proportion of all shoulder instability, although it can affect athletes of all types, from contact to overhead athletes. Surgical treatment is quite successful in these patients; however, the literature reports a wide range of rates of return to sport.

PURPOSE/HYPOTHESIS

The purpose was to determine the return-to-sport rates after surgical stabilization for posterior shoulder instability. It was hypothesized that patients would experience a high rate of return to sport.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Embase, PubMed, and MEDLINE were searched for relevant literature from database inception until April 2020, and studies were screened by 2 reviewers independently and in duplicate for studies reporting rates of return to sport after surgical management of posterior shoulder instability. Demographic data as well as data on return to sport and functional outcomes were recorded. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias was assessed for all included studies.

RESULTS

Overall, 32 studies met inclusion criteria and comprised 1100 patients (1153 shoulders) with a mean age of 22.8 years (range, 11-65) and a mean follow-up of 43.2 months (range, 10-228). The pooled rate of return to any level of sport was 88% (95% CI, 84%-92%; I² = 68.7%). In addition, the pooled rate of return to the preinjury level was 68% (95% CI, 60%-76%; I² = 79%). Moreover, the pooled return-to-sport rate for contact athletes was 94% (95% CI, 90%-97%; I² = 0%), while for throwing athletes it was 88% (95% CI, 83%-92%; I² = 0%).

CONCLUSION

Surgical management of posterior shoulder instability resulted in a high rate of return to sport, as well as significant pain reduction and functional improvement in most patients. However, only two-thirds of athletes can return to their preinjury levels of sport.

Single-Portal Arthroscopic Posterior Shoulder Stabilization

Posterior shoulder instability occurs when the labrum detaches posteriorly from the glenoid owing to significant trauma and is a relatively uncommon type of shoulder dislocation. Although posterior instability has often been treated with open shoulder stabilization, modern arthroscopic procedures are being rapidly pursued by surgeons as an improved option because of decreased invasiveness and reduced operative times. Arthroscopic stabilization of the posterior glenoid labrum typically involves 2 working portals, but the procedure still yields successful results when performed with a single posterior portal and a suture passer. Our technique involves 1 less portal to reduce invasiveness, lower the risk of nerve damage, and decrease the operative time and postoperative pain. The purpose of this article is to describe an arthroscopic posterior stabilization technique with a single working portal.

Variability of glenoid labral tear patterns: a study of 280 sequential surgical cases

BACKGROUND

Glenoid labrum tears are a common cause of shoulder pain and instability and tear patterns have historically been ascribed into categorical descriptions such as anterior, posterior, and superior labral tears (SLAP [superior labrum anterior and posterior]) with multiple subtypes. Although often quoted as representing no more than 10% of instabilities, posterior shoulder instability may be more common than previously recognized. The purpose of this study was to review observed labral tear patterns and compare incidence and morphologies to historical descriptions.

METHODS

All patients undergoing arthroscopic or open labral repair (Current Procedural Terminology codes 29806, 29807, 23455, 23460, 23462, 23465) by 2 fellowship-trained shoulder surgeons from July 2012 to May 2019 were retrospectively reviewed. Labral tears were categorized into 3 groups: exclusively anterior to the midline of the glenoid, exclusively posterior, and those crossing the midline of the glenoid. Chief complaint, mechanism of injury, hand dominance, preoperative MRI interpretation by surgeon, and independent radiologist were analyzed for each tear type.

RESULTS

During the 7-year period, 280 patients underwent arthroscopic or open labral repair. Sixty percent of tears were traumatic, with dislocation being the most common traumatic mechanism at 31.4%. Ten distinct tear patterns were identified: 3 types of 90° tears (anteroinferior, posteroinferior, and posterosuperior), 4 types of 180° tears (anterior, posterior, inferior, and SLAP), 2 types of 270° tears (anteroinferior and anterosuperior), and 360° labral tears. A total of 134 tears (47.9%) were classified as posterior, and 72 tears (25.7%) were anterior. Seventy-four tears (26.4%) were combined anterior-posterior tears. Labral tears involving some portion of the posterior labrum constituted 74% of tears. A significant association between tear location and primary complaint (P < .001) was noted. Patients with anterior tears complained of only instability in 62.5% of cases, and only pain in 22%. Patients with posterior labral tears complained primarily of pain in 68% of cases, and instability in 21%. There was an accurate preoperative diagnosis given by both radiologists and surgeons on 30% (n = 63) of the tears.

CONCLUSION

There is a wide variety of labral tear patterns identified at the time of surgery, and the incidence of posterior labral tears is higher than previously described. Isolated Bankart lesions are relatively rare and are often associated with more extensive labral lesions. Patients with posterior labral pathology more often complain of pain rather than instability, whereas patients with anterior labral tears more often complain of instability.

Management of common upper extremity injuries in throwing athletes: a critical review of current outcomes

Given the rising incidence and prevalence of shoulder injuries in throwing athletes, this review aims to evaluate management options and outcomes of common shoulder injuries in overhead throwers. Laxity of the glenohumeral joint is often adaptive for overhead athletes to achieve the velocity necessary to compete in the professional ranks. Surgical repair of the stabilizers of the humeral head-specifically the labrum and rotator cuff-often causes inflammation, scarring, and overtensioning of the glenohumeral joint which lead to poor postoperative performance. Thus, nonsurgical management should be exhausted in this population before considering surgical intervention.

Return-to-Sport Criteria After Upper Extremity Surgery in Athletes-A Scoping Review, Part 1: Rotator Cuff and Shoulder Stabilization Procedures

Background:

Standardized criteria are lacking to guide patient return to sport (RTS) after rotator cuff surgery (RCS) or shoulder stabilization surgery (SSS).

Purpose:

To describe RTS criteria used after RCS and SSS in athletic populations.

Study Design:

Scoping review; Level of evidence, 4.

Methods:

This scoping review was based on the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses–Scoping Review) guidelines. A total of 5 electronic databases (MEDLINE, Scopus, SPORTDiscus, Embase, Google Scholar Advanced search) and the gray literature were searched for English-language studies that reported at least 1 RTS criterion in athletes after shoulder surgery. Studies were assigned to the RCS or SSS subgroup based on the primary procedure performed. Data were extracted and summarized as frequencies or arithmetic mean and standard deviation.

Results:

Included were 52 studies and 2706 athletes (2206 male, 500 female, with a mean age of 28.8 ± 1.8 years). The RCS group consisted of 14 studies and the SSS group consisted of 38 studies. Time from surgery was the most common RTS criterion reported overall (37/52 studies; 71%) as well as within the RCS (93%) and SSS (63%) subgroups. Muscle strength (25/52 studies; 48%) and range of motion (23/52; 44%) were used by almost half of the included articles. RTS criteria reported less often were absence of pain, successful completion of sport-specific or position-specific test, proprioception, radiographic evaluation, patient-surgeon agreement, minimum time required to participate in pain-free throwing, and satisfactory scapulothoracic mechanics. All studies used 1 to 3 of the above RTS criteria; however, the definition of each criterion differed among the included articles.

Conclusion:

Time from surgery was the most commonly reported RTS criterion after RCS or SSS in athletes, whereas muscle strength and range of motion were used by almost half of the articles. There was high heterogeneity in the definition of each RTS criterion used among the included studies, which also used different combinations of 1 to 3 RTS criteria. These results suggest the need to better define quantitative and qualitative RTS criteria in athletes undergoing rotator cuff and shoulder stabilization procedures in order to safely return athletes to sport.

Return to Play After Arthroscopic Stabilization for Posterior Shoulder Instability-A Systematic Review

Purpose

To ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after arthroscopic posterior shoulder stabilization.

Methods

Medline, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies on arthroscopic posterior shoulder stabilization. Studies were included if they reported RTP data or rehabilitation protocols and excluded if concomitant procedures influenced the rehabilitation protocol. Rate and timing of RTP, along with rehabilitation protocols, were assessed.

Results

This review found 25 studies, including 895 cases, meeting the study’s inclusion criteria. The majority of patients were male (82.7%), with an age range of 14 to 66 years and a follow-up range of 4 to 148.8 months. The overall RTP rate ranged from 62.7% to 100.0%, and 50.0% to 100.0% returned to the same level of play. Among collision athletes, the overall rate of RTP was 80.0% to 100.0%, with 69.2%-100.0% returning to the same level of play. In overhead athletes, the overall rate of RTP was 85.2% to 100.0%, with 55.6% to 100.0% returning to the same level of play. Four studies (128 patients) specifically addressed the timing of RTP, and the range to RTP was 4.3 to 8.6 months. Specific RTP criteria were reported in a majority of studies (60%), with the most reported item being restoration of strength (44%).

Conclusion

There is a high rate of return to sport after arthroscopic posterior shoulder stabilization, ranging from 4.3 to 8.6 months after surgery. Return to preinjury level is higher for collision athletes compared with overhead athletes. However, there is inadequate reporting of RTP criteria in the current literature, with no clear timeline for when it is safe to return to sport.

Level of Evidence

IV, systematic review of level II to IV studies

Risk Factors for Revision Posterior Shoulder Stabilization in Throwing Athletes

Background

Revision posterior shoulder capsulolabral repair has inferior outcomes compared with primary surgery. Risk factors for revision in throwing athletes are unknown.

Purpose/Hypothesis

The purpose of this study was to characterize the revision rate and risk factors for revision surgery in throwing athletes. It was hypothesized that female athletes and those with smaller glenoid bone width would be at higher risk for revision surgery.

Study Design

Case-control study; Level of evidence, 3.

Methods

A total of 105 throwing athletes who underwent arthroscopic posterior capsulolabral repair of their throwing shoulder were reviewed at a minimum of 2-year follow-up, and patients who required a revision were compared with those who did not. Collected data compared between the revision and no-revision groups included age, sex, contact sport participation, and return to sport (RTS). American Shoulder and Elbow Surgeons (ASES) score, Kerlan-Jobe Orthopaedic Clinic (KJOC) score, stability, pain, strength, range of motion (ROM), and patient satisfaction. Radiographic parameters including glenoid bone version, cartilage version, labral version, bone width, labral width, glenoid labral version and width weight were also compared between both groups.

Results

Nine throwers required revision (8.6%) at an average of 2.8 years postoperatively. There were more female athletes in the revision than no-revision group (55.5% vs 23.4%; P = .03). There was no significant difference in age, proportion of contact athletes, rotator cuff tears, glenoid bone version, cartilage version, labral version, labral version weight, bone width, labral width, or labral width weight. Both groups had similar preoperative, postoperative, and change in ASES, KJOC, pain, strength, stability, and ROM scores. The proportion of patients with full strength and with full ROM, as well as patients who were satisfied with outcomes was similar between groups. Fewer patients in the revision group returned to sports compared with those in the no-revision group (14.3% vs 83.6%; P < .001), although return to sports at same level was not significantly different between groups (14.3% vs 37.2%; P = .41).

Conclusion

The revision rate of arthroscopic posterior shoulder stabilization in throwers was 8.6%. Female athletes were at higher risk for revision, and return to sports was lower in patients who underwent revision surgery.

Return to sport after surgical treatment for posterior shoulder instability: a systematic review

Purpose

To report the rate of return to sport after surgical treatment for posterior shoulder instability among athletes.

Methods

A systematic review of the literature regarding rate of return to sport after surgical treatment for posterior shoulder instability was undertaken. The primary outcome measure was return to sport. The secondary outcome measures included rate of return to sport to preinjury level, time to return to sport, injury type, reoperations after primary surgery, and objective patient-reported outcome data. Data is summarized with ranges and tables.

Results

A total of 23 studies met inclusion criteria. The rate of return to sport ranged from 57.9%-100%. The rate of return to sport to the preinjury level ranged from 47.4%-100%. Time to return to sport ranged from 4.3-7.7 months. Furthermore, 66% of subjects had an acute traumatic injury and 34% were of insidious onset. The most commonly reported outcome measures were American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores and visual analog scale (VAS) pain scores. At a minimum of 1-year follow-up, ASES and VAS pain scores improved. Revision rates ranged from 0%-36.8%.

Conclusion

The systematic review demonstrated high rates of return to sport and relatively high rates of return to preinjury level of sport among all athletes who underwent surgical treatment for posterior shoulder instability. Objective patient-reported outcome metrics improved postoperatively whereas revision rates remained low.

Posterior Labral Injury and Glenohumeral Instability in Overhead Athletes: Current Concepts for Diagnosis and Management

Posterior glenohumeral instability in overhead athletes presents a unique set of challenges for both diagnosis and treatment. Although a great deal of attention has been focused on the management of injuries to the biceps-labrum complex and rotator cuff in throwers, comparatively less has been written about posterior glenohumeral instability within this unique cohort. Historically, posterior instability has been observed secondary to either acute trauma or repetitive microtrauma, usually among collision athletes, weight lifters, and rowers. However, posterior glenohumeral instability resulting from pathology of the posterior capsulolabral tissues in throwers is a different entity, and the clinical assessment begins with an accurate differentiation between adaptive capsular laxity and labral injury with pathologic instability. Some posterior capsule labrum tears confirmed on arthroscopy will require nothing more than débridement. However, for more extensive lesions, surgical treatment must balance the necessity to repair torn capsulolabral tissues with the tendency to over constrain the shoulder. The literature provides mixed results regarding the likelihood of overhead athletes with posterior glenohumeral instability and labral injury treated surgically returning to their preinjury level of sport performance.