Return to Play and Prior Performance in Major League Baseball Pitchers After Repair of Superior Labral Anterior-Posterior Tears

Return to Sport at Preinjury Level is Common After Surgical Treatment of SLAP Lesions: A Systematic Review and a Meta-analysis

BACKGROUND

Patients undergoing surgery for Superior-Labrum-anterior-to-posterior (SLAP) lesions are often worried about their return to sport performance. This systematic review determined the rate of return to sport and return to sport at the previous level (RTSP) after surgery for SLAP lesion.

MATERIALS AND METHODS

The PRISMA guidelines were followed. Meta-analysis of data through forest plot projections was conducted. Studies were divided and analyzed according to the type of interventions (isolated slap repair or SLAP repair with rotator cuff debridement and biceps tenodesis).

RESULTS

The mean overall rate of return to sport after the procedures was 90.6% and the mean overall rate of return to sport at the previous level after the procedures was 71.7%. RTSP rates of the whole population were 71% (95% CI: 60%-80%), 66% (95% CI: 49%-79%), and 78% (95% CI: 67%-87%) for isolated SLAP repair, SLAP repair with the rotator cuff debridement and biceps tenodesis, respectively. A lack of subgroup analysis for the specific performance demand or type of lesion related to the surgical technique used might induce a high risk of bias.

DISCUSSION

Return to sports at the previous level after surgically treated superior labrum anterior to posterior lesion is possible and highly frequent, with the highest rates of RTSP in patients treated with biceps tenodesis. More studies and better-designed trials are needed to enrich the evidence on indications of SLAP surgical treatment in relation to specific sports-level demand.

LEVEL OF EVIDENCE

Level-IV.

Surgical Treatment of Superior Labral/Biceps Pathology in the Overhead Thrower

Symptomatic superior labral anterior and posterior (SLAP) tears have become an increasingly common diagnosis, particularly within the competitive overhead athlete population. Type II SLAP tears are the most encountered variant in overhead throwing athletes. Given the high incidence of false positives on advanced imaging, corroborating the history and physical examination with imaging is paramount to accurately establish a SLAP lesion diagnosis. Previous studies have reported conflicting success rates with conservative management, but the number of pitching athletes able to return to prior level of performance with nonsurgical management strategies has been unsatisfactory. Although there has historically been a notable disconnect between the incidence of SLAP tears in the literature and the number of SLAP repairs in recent investigations, high-grade or unstable tears may be candidates for débridement, labral repair, biceps tenodesis, or less frequently, biceps tenotomy. Biceps tenodesis has been increasingly used for the management of these lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes.

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.

High Rate of Return to Sporting Activity Among Overhead Athletes With Subpectoral Biceps Tenodesis for Type II SLAP Tear

PURPOSE

To evaluate the functional and athletic outcomes after primary subpectoral biceps tenodesis for type II SLAP tear in overhead athletes.

METHODS

All competitive elite athletes with type II SLAP tears undergoing biceps tenodesis by a single surgeon were isolated between 2007 and 2015. Exclusion criteria were applied to individuals not involved in overhead athletics, clinical follow-up <24 months, adjacent rotator cuff or labral repair, concomitant SLAP repair, and/or previous arthroscopic shoulder surgery. Patient-reported outcome measures included visual analog scale (VAS), Kerlan Jobe Orthopaedic Clinic shoulder score, and Single Assessment Numerical Assessment. Clinical and sporting outcomes were recorded using a sports-specific questionnaire.

RESULTS

Of 22 identified patients, 16 competitive overhead athletes (72.7%; 11 men, 5 women) with a mean age of 21.0 years were available at mean 4.5-year follow-up. Baseball or softball comprised the majority of patients (n = 9; 56.3%), followed by gymnastics (n = 2), swimming (n = 2), and other sports (n = 3). At mean 4.1 months postoperatively, 13 patients (81.3%) returned to previous level of athletic activity, whereas 2 patients (12.5%) failed to return to sporting activity and 1 (6.3%) returned at a lower level of competition. VAS pain significantly decreased from an average of 4.4 preoperatively to 1.7 postoperatively (P = .002), and mean Single Assessment Numerical Assessment scores also demonstrated significant improvement (55.4-76.7; P = .008). Final mean Kerlan Jobe Orthopaedic Clinic score was 74.0 (standard deviation 25.9), including 2 patients with suboptimal outcomes due to persistent pain. There were no significant differences in mean forward flexion or rotation in either the adducted or throwing position (P > .05), although small, significant decreases in postoperative active abduction were noted (165° vs 155°; P = .003).

CONCLUSIONS

In the current series of competitive overhead athletes, 81% of patients returned to previous level of play at an average of 4.1 months postoperatively after subpectoral biceps tenodesis for symptomatic SLAP tear. Athletes reliably experienced significant decreased activity-related pain with athletic function.

LEVEL OF EVIDENCE

IV, case series.

Biceps Tenodesis cannot be used as primary treatment option in baseball pitchers with intact rotator cuff muscles

Background Surgeons remain hesitant to perform biceps tenodesis in athletes with type II superior labrum anterior-to-posterior tears due to the lack of reported clinical outcomes for individual overhead throwing sports and associated concerns that this may predispose the joint to instability. This study aimed to assess the effect of biceps tenodesis on shoulder stability for major overhead throwing sports to aid sport-specific surgical decision-making for athletes with type II superior labrum anterior-to-posterior tears.

METHODS

This is a combined modelling and experimental study. Motion data and external forces were measured from 13 participants performing five overhead throwing motions. These data served as input into a musculoskeletal shoulder model that quantifies shoulder stability and muscle loading.

FINDINGS

The loading of the long head of the biceps brachii decreases significantly following biceps tenodesis in three overhead throwing motions (p = 0.02). The loss in joint stability following biceps tenodesis is compensated by a non-significant increase in rotator cuff muscle force which maintains shoulder stability across all overhead throwing motions, except baseball pitching (p = 0.01). The presence of a full-thickness supraspinatus tear post biceps tenodesis further decreases shoulder stability in four of the five overhead throwing motions (p = 0.01).

INTERPRETATION

The study findings demonstrate that an increase in rotator cuff muscle force maintains joint stability for all overhead throwing motions post biceps tenodesis, except baseball pitching. As the presence of a full-thickness tear of the supraspinatus significantly reduces joint stability, biceps tenodesis may be used as a primary treatment in overhead throwing athletes with intact rotator cuff muscles, except baseball pitchers.

LEVEL OF EVIDENCE

Controlled Laboratory Study; Level of Evidence 3.

Moderate Return to Play and Previous Performance After SLAP Repairs in Competitive Overhead Athletes: A Systematic Review

PURPOSE

To perform a systematic review of return to play (RTP) and return to previous level of performance (RPP) in competitive overhead athletes after SLAP repair to identify factors associated with failure to RTP.

METHODS

Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Review was registered with PROSPERO International prospective register of systematic reviews (CRD42020215488). Inclusion criteria were literature reporting RTP or RPP following SLAP repair in overhead athletes were run in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Categories for data collection for each full article included (1) article information; (2) patient demographics; (3) surgical techniques; (4) level of competition; (5) rotator cuff treatment; (6) player position; (7) patient-reported outcome measures; and (8) RTP and RPP rates. The Methodological Index for Non-randomized Studies checklist was used to evaluate quality of all included studies.

RESULTS

Eight studies with 333 subjects were identified. Overall RTP and RPP rates were 50% to 83.6% and 35.3% to 64%, respectively. Patients with surgically treated rotator cuff pathology had lower RTP (12.5%-64.7%) rates compared with those without (80.0%-83.6%). Professional athletes had similar RTP rates (62.5%-81.5%) compared with high-school (75.0%-90.0%) and college athletes (12.5%-83.3%). However, professional athletes demonstrated the lowest relative range of reported RPP rates (27.7%-55.6%). Pitchers had lower RTP (62.5%-80.0%) and RPP (52.0%-58.9%) compared with position players (91.3% RTP, 76.3%-78.2% RPP).

CONCLUSIONS

Studies reviewed reported moderate RTP and RPP rates following SLAP repairs in competitive overhead athletes. Those with associated rotator cuff tear requiring treatment, and baseball pitchers were less likely to RTP and RPP. Professional athletes had similar RTP to an amateur; however, they were less likely to RPP.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III-IV studies.

Worley J, Sherman SL, Leary E. Decreased Upward Vertical Movement for Fastballs After Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers

Purpose

Methods

Results

Conclusions

Level of Evidence

Using Advanced Data to Analyze the Impact of Injury on Performance of Major League Baseball Pitchers: A Narrative Review

Major league baseball (MLB) pitchers are at risk of numerous injuries during play, and there is an increasing focus on evaluating their performance in the context of injury. Historically, performance after return to play (RTP) from injury has focused on general descriptive statistics, such as innings or games played, or rate statistics with inherent variability (eg, earned run average, walks and hits per inning pitched, strikeouts per 9 innings, or walks per 9 innings). However, in recent years, MLB has incorporated advanced technology and tracking systems in every stadium, allowing for more in-depth analysis of pitcher-specific data that are captured with every pitch of every game. This technology allows for the ability to delve into the pitching performance on a basis that is more specific to each pitcher and allows for more in-depth analysis of different aspects of pitching performance. The purpose of this narrative review was to illustrate the current state of injury recording for professional baseball pitchers, highlight recent technological advances in MLB, and describe the advanced data available for analysis. We used advanced data in the literature to review the current state of performance analysis after RTP in MLB pitchers after injury. Finally, we strived to provide a framework for future studies to more meticulously assess RTP performance given the current available resources for analysis.

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes

Background:

It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis.

Purpose:

To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported.

Results:

Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery.

Conclusion:

Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.

Thoracic Outlet Syndrome in Major League Baseball Pitchers: Return to Sport and Performance Metrics After Rib Resection

Background:

Thoracic outlet syndrome (TOS) is a rare injury that affects Major League Baseball (MLB) pitchers and is often corrected with surgical resection of the first rib. There are limited return-to-play (RTP) data for this surgery in MLB pitchers.

Hypothesis:

It was hypothesized that MLB pitchers who undergo first rib resection for TOS will show (1) a high rate of RTP, (2) no difference in postoperative career length compared with controls, (3) no difference in pre- and postoperative performance, and (4) no difference in postoperative performance compared with controls.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective cohort study evaluated MLB pitchers with neurogenic or vascular TOS who underwent rib resection surgery between January 1, 2001, and December 31, 2019. Players were identified through public injury reports from press releases, the MLB website, MLB team injury reports, and blogs. A demographics- and performance-matched control group was generated for comparison. Each player in the control group was given an index year that corresponded to the surgery year of the case group. Performance data included innings pitched (IP), games played (GP), earned run average (ERA), complete GP, shutouts, saves, hits, runs, home runs (HR), walks, strikeouts (K), walks plus hits per IP (WHIP), and earned runs (ER).

Results:

We identified 26 MLB pitchers who underwent rib resection for neurogenic or vascular TOS; 21 players (81%) had a successful RTP. Pitchers were 30 ± 3.6 years old at the time of surgery and had played 6.2 ± 3.5 seasons before undergoing surgery. Average postoperative career length was 3.1 ± 2.0 seasons, with an average time from surgery to RTP being 10 ± 4.7 months. Pitchers who RTP showed no significant differences in performance metrics compared with controls. Players pitch 0.94 (P < .05) more IP/GP in the season directly following RTP compared with the season before surgical intervention.

Conclusion:

MLB pitchers undergoing rib resection for TOS demonstrated (1) high RTP rates following rib resection, (2) no difference in postoperative career length compared with controls, (3) improvement in postoperative performance, and (4) no difference in postoperative performance compared with controls.

Performance Metrics and Economics of SLAP Repairs in Major League Baseball Pitchers

Background

Superior labrum anterior-posterior tears (SLAP) can be a career-altering injury for Major League Baseball (MLB) pitchers. Surgery and postoperative rehabilitation keep pitchers on the injured list (IL) for extended time, which results in a significant cost to a team. To date, no analyses have focused on the financial cost of SLAP repairs in MLB pitchers.

Methods

A retrospective review of MLB pitchers with SLAP repair from 2004 to 2019 was conducted utilizing IL and financial contract data from the MLB website. Cost of injury was calculated from salary of the player. Performance metrics including earned run average, walks + hits per innings pitched, and innings pitched (IP) were averaged for one and all seasons played before and after injury. Return to play and return to prior performance rates were calculated and reported.

Results

Of the 55 players identified, 22 players (40%) returned to play and 18 of these 22 players (82%) returned to prior performance. Annual cost increased over the study period (R² = 0.288) averaging $3.5 million, and a stable average of 172 days was spent on the IL (R² = 0.001). Performance was negligible except IP (106.95 vs. 50.85; P < .01) for 1 season before and after injury. For all seasons, earned run average and walks + hits per innings pitched significantly increased (4.13 vs. 5.19; P = .030, and 1.36 vs. 1.53; P = .033, respectively), while IP downtrended without significance (P = .058).

Conclusion

SLAP repairs in MLB pitchers have significant financial impact and time spent on the IL, which surprisingly has not changed over time. It is encouraging to know return-to-play pitchers return without profound decline in performance level following SLAP repair.

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.

Pitch break and performance metrics remain unchanged in pitchers who returned to the same level of play after ulnar collateral ligament reconstruction in Major League Baseball pitchers

BACKGROUND

The ulnar collateral ligament is commonly injured in overhead-throwing athletes, particularly baseball pitchers. Pitch movement (break) is a critical aspect to pitching performance. The primary purpose of this study was to determine the changes in pitch velocity, pitch break, angle of break, and pitch performance metrics before and after ulnar collateral ligament reconstruction (UCLR) in Major League Baseball (MLB) pitchers. The secondary purpose was to determine changes in pitch performance metrics before and after UCLR. We hypothesized that pitch break and pitch performance metrics would be unchanged following UCLR.

MATERIALS AND METHODS

This was a retrospective case-series study of pitchers who had undergone primary UCLR between 2008 and 2014. Velocity, horizontal movement (Hmov), and vertical movement (Vmov) of each pitch were collected from the PITCHf/x system for each pitcher 12-24 months before surgery, 12-24 months after surgery, and 24-36 months after surgery. Overall break was calculated by taking the Pythagorean sum of Hmov and Vmov. Angle of break was determined by taking the inverse tangent of Vmov divided by Hmov. Repeated-measures analysis of covariance was performed to determine differences in pitch velocity, movement, angle of movement, and performance metrics between preoperative and postoperative time frames. Performance metrics included balls, strikes, swings, fouls, swings and misses, ground balls, line drives, pop-ups, fly balls, and home runs. Covariates included age at surgery, time from MLB debut to surgery, innings pitched as a starter, innings pitched as a reliever, and total pitches thrown.

RESULTS

In a cohort of 46 pitchers who underwent UCLR between 2008 and 2014, pitch velocity, movement, and angle were not significantly changed with respect to preoperative or postoperative time frames. In addition, postoperative time frames had clinically insignificant differences in pitch performance metrics.

CONCLUSION

Pitch break and performance metrics are not significantly affected in pitchers who return after UCLR.

Complications and Return to Activity After Arthroscopic Repair of Isolated Type II SLAP Lesions: A Systematic Review Comparing Knotted Versus Knotless Suture Anchors

Background:

Superior labral anterior to posterior (SLAP) tears are one of the most common injuries to the shoulder, with the type II variant representing the most frequently encountered subtype.

Purpose:

To systematically review the literature to better understand outcomes after arthroscopic repair of isolated type II SLAP lesions using knotted versus knotless anchors based on implant number, implant location, patient position, and portal position.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review investigating all studies in the literature between January 2000 and June 2019 reporting on patients undergoing arthroscopic repair for isolated type II SLAP lesions using knotted versus knotless suture anchors was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the PubMed, BIOSIS Previews, SPORTDiscus, PEDro, and Embase databases.

Results:

A total of 234 patients undergoing isolated arthroscopic repair of type II SLAP lesions using suture anchors were identified, with 76% (179/234) treated using knotted anchors versus 24% (55/234) treated using knotless anchors. Complications were reported in 12% of patients treated using knotted anchors versus no patients treated using knotless anchors (P = .008). The incidence of complications for knotted anchor repair was not significantly affected by patient position (P = .22) or portal position (P = .19). Using multiple regression analysis, we found no significant association with the incidence of complications when analyzing for anchor design (R² = 0.02; P = .06) or anchor position (R² = 0.02; P = .92). No significant difference in return-to-activity timing was appreciated based on anchor type (P = .28), patient position (P = .98), or portal position (P = .97) in patients treated using knotted anchors.

Conclusion:

Patients treated using knotted anchors were significantly more likely to experience a postoperative complication compared with patients treated using knotless anchors after arthroscopic repair of isolated type II SLAP lesions. Despite the increased incidence of a postoperative complication after knotted anchor fixation compared with knotless anchor fixation, multiple regression analysis showed that anchor design and anchor position were not significantly predictive of the incidence of complications. Given the increasing popularity of knotless anchor fixation, further study on the long-term outcomes after knotless repair for isolated type II SLAP lesions is warranted.

Adolescent Posterior-Superior Glenoid Labral Pathology: Does Involvement of the Biceps Anchor Make a Difference?

BACKGROUND

Adolescent athletes are at risk of sustaining an injury to the posterior and superior labrum of the glenoid. Limited information is available regarding the outcomes of surgical intervention in this specific age cohort.

PURPOSE

To compare those patients with pure posterior pathology and those with posterior labral tears that involve the biceps anchor (superior labrum anterior-posterior [SLAP] tears) to determine risks for failure in the surgical management.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review was performed on all patients under the age of 19 years over an 8-year period to identify those treated for superior and posterior labral pathology, followed by chart review, radiographic review, and arthroscopic findings. Patient characteristics and other variables were recorded, including cause (traumatic vs atraumatic), activity/sports (overhead vs nonoverhead), involvement of the biceps anchor-crossing the 12-o'clock position (posterior vs SLAP), associated pathologies, outcome scores (Single Assessment Numerical Evaluation [SANE] and Pediatric/Adolescent Shoulder Survey [PASS] scores), and complications.

RESULTS

Forty-eight patients (30 boys, 18 girls) with a mean age at surgery of 16.5 years (range, 13.5-19 years) were identified who met criteria, with a mean follow-up of 4.1 years (range, 1.3-6.9 years). Nineteen patients had SLAP tears and 29 patients had posterior tears. All but 2 regularly participated in sports at the time of their injury; of the athletes, 26 (56.5%) played an overhead sport and 20 (43.5%) played a nonoverhead sport. The cause of the injury was traumatic in 25 cases (52.1%) and atraumatic in 23 cases (47.9%). Outcome scores were not significantly different between cause or type of sports played; SANE scores were not significantly different by tear type (mean SLAP score, 88.4 compared with mean posterior score, 80.9; P = .124); but the mean PASS score in the SLAP group was 88.7, compared with 76.2 in the posterior group (P = .005) at final assessment. Only 1 SLAP patient had failed management (5.3%) compared with 5 patients in the posterior-only cohort (17.2%).

CONCLUSION

Posterior SLAP tears have better outcomes and lower failure rates than posterior-only tears in the adolescent population. Posterior-superior labral tears can occur in all sports types with multiple causes, but the only factor that appears to play a role in ultimate outcome is whether the tear crosses under the biceps anchor to the anterior side.

Return to Sport After Arthroscopic Superior Labral Anterior-Posterior Repair: A Systematic Review

CONTEXT

Superior labral anterior-posterior (SLAP) lesions often result in significant sporting limitations for athletes. Return to sport is a significant outcome that often needs to be considered by athletes undergoing the procedure.

OBJECTIVE

To evaluate return to sport among individuals undergoing arthroscopic SLAP repair.

DATA SOURCES

Four databases (MEDLINE, EMBASE, PubMed, and Cochrane) were searched from database inception through January 29, 2018.

STUDY SELECTION

English-language articles reporting on return-to-activity rates after arthroscopic SLAP repairs were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data including patient demographics, surgical procedure, and return to activity were extracted. The methodological quality of included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool.

RESULTS

Of 1938 screened abstracts, 22 articles involving a total of 944 patients undergoing arthroscopic SLAP repair met inclusion criteria. Of the total included patients, 270 were identified as overhead athletes, with 146 pitchers. Across all patients, 69.6% (657/944 patients) of individuals undergoing arthroscopic SLAP repair returned to sport. There was a 69.0% (562/815 patients) return to previous level of play, with a mean time to return to sport of 8.9 ± 2.4 months (range, 6.0-11.7 months). The return-to-sport rate for pitchers compared with the return-to-activity rate for nonpitchers, encompassing return to work and return to sport, was 57.5% (84/146 patients) and 87.1% (572/657 patients), respectively, after arthroscopic SLAP repair.

CONCLUSION

Arthroscopic SLAP repair is associated with a fair return to sport, with 69.6% of individuals undergoing arthroscopic SLAP repair returning to sport. SLAP repair in pitchers has significantly decreased return to sport in comparison with nonpitching athletes. Athletes on average return to sport within 9 months postoperatively.

Injuries of the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes.

RECENT FINDINGS

The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40 years old. Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40 years of age, while biceps tenodesis and tenotomy are preferred for older patients.

Editorial Commentary: Silly Biceps, Tenodesis Is for Kids!

There is now a strong consensus that the best surgical treatment of a SLAP lesion is often something different from a primary direct repair, especially in older patients in whom postoperative stiffness and persistent pain have led most of us to perform a biceps tenodesis instead. However, treatment of younger patients and especially the overhead athlete group is more problematic and thus controversial. This study demonstrates that biceps tenodesis in these patients can be more successful and have a higher return to sport than SLAP repair alone. There may also be a role for biceps tenodesis AND a SLAP repair but the numbers presented in this paper preclude an analysis of exactly who that group is. When it comes to the treatment of patients with SLAP lesions for whom a very well executed rehabilitation program has failed, understanding the symptoms and demographics of your patients is critical to surgical decision making. The pendulum may swing toward tenodesis, but beware: The correct answer is usually near the center of the arc!

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.

Type VIII SLAP Repair at Midterm Follow-Up: Throwers Have Greater Pain, Decreased Function, and Poorer Return to Play

PURPOSE

To evaluate and compare midterm outcomes and return to play (RTP) of throwers and nonthrowers who underwent type VIII SLAP repair.

METHODS

With 4-year minimum follow-up, stability, pain, range of motion (ROM), Kerlan-Jobe Orthopaedic Clinic (KJOC), and American Shoulder and Elbow Surgeons (ASES) scores; surgical satisfaction; and RTP were compared between throwing and nonthrowing athletes who underwent repair of type VIII SLAP lesions between 2003 and 2014.

RESULTS

46 patients (27 throwers and 19 nonthrowers) were included. The athletes were aged 24.2 ± 9.2 years at the time of surgery. The mean follow-up period was 6.6 ± 2.0 years. A significant improvement in stability, pain, ROM, KJOC, and ASES scores was seen after surgery in both throwers and nonthrowers (P < .05). When postoperative outcomes were compared, throwers had more pain (P = .047), decreased ROM (P = .03), lower KJOC scores (52.2 ± 24.0 in throwers vs 87.5 ± 18.8 in nonthrowers, P < .0001), and lower ASES scores (43.5 ± 7.1 in throwers vs 48.3 ± 3.0 nonthrowers, P = .02). There was no difference in stability (P = .06), surgical satisfaction (96.3% in throwers vs 100% in nonthrowers, P > .99), or overall RTP (70.4% in throwers vs 94.7% in nonthrowers, P = .06). However, throwers were less likely to RTP at their preoperative level (37.0% in throwers vs 73.7% in nonthrowers, P = .02).

CONCLUSIONS

Surgical repair of type VIII SLAP tears led to significant improvements in stability, pain, ROM, and outcome scores at midterm follow-up. Compared with nonthrowers, throwers had significantly more pain, less ROM, and worse function. Throwers were also less likely to RTP at their preoperative level. These findings suggest that type VIII SLAP tears should be repaired in all athletes because outcomes do improve, although throwers require specific counseling and expectation management regarding their ability to RTP at their preinjury level.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Editorial Commentary: Buyer Beware-Throwers Undergoing Type VIII SLAP Repair Should Do So With Very Reasonable Expectations

SLAP repair in throwing athletes should be approached with caution. Surgery may help improve symptoms but may not guarantee a return to the preinjury level of competition. Even in the most expert of hands, the rate of return to the preinjury level of performance ranges from 38% to 60% and is as low as 10% for pitchers.

A Comprehensive Return-to-Play Analysis of National Basketball Association Players With Operative Patellar Tendon Tears

Background:

Patellar tendon tears impart potentially debilitating sequelae among professional basketball athletes.

Hypothesis:

Professional basketball athletes with patellar tendon tears have decreased return-to-play performance in seasons after injury compared with preinjury statistics.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patellar tendon tears among National Basketball Association (NBA) athletes from the 1999-2000 to 2014-2015 seasons were identified. Player performance statistics for players who underwent operative patellar tendon repair were compared from 1 season before injury to 1 season after injury and 2 seasons before injury to 2 seasons after injury using the primary outcome of player efficiency rating (PER). Secondary performance outcomes were also analyzed.

Results:

A total of 13 patellar tendon tears (10 complete, 3 partial) were identified among 12 NBA athletes. Three players (25%) did not return to play in the NBA. No significant differences were found in PER in comparisons of 1 season before and after injury (16.6 ± 1.5 vs 14.3 ± 1.7; P = .20) or in comparisons of 2 seasons before and after injury (15.8 ± 0.8 vs 6.3 ± 2.3; P = .49). Diminished performance outcomes were noted for total minutes played (2598 ± 100 vs 1695 ± 78; P = .01), games played (74.8 ± 1.9 vs 60.5 ± 1.4; P = .04), and minutes per game (34.8 ± 1.5 vs 28.2 ± 1.8; P = .02) in comparisons of 1 season before and after injury. Total minutes played per season (2491 ± 190 vs 799 ± 280; P = .045) decreased in comparisons of 2 seasons before and after injury.

Conclusion:

Patellar tendon tears were not associated with diminished efficiency-adjusted performance, as measured by PER, games played, minutes per game played, points per 36 minutes, and rebounds per 36 minutes. However, decreases in total minutes played were observed following patellar tendon tear. Orthopaedic surgeons may be better prepared to counsel basketball athlete patients with patellar tendon tear given these findings.

Biceps tenodesis versus labral repair for superior labrum anterior-to-posterior tears: a systematic review and meta-analysis

BACKGROUND

This study systematically reviewed the comparative studies in the literature to ascertain whether biceps tenodesis or labral repair results in superior clinical outcomes in the treatment of superior labrum anterior-to-posterior (SLAP) tears.

METHODS

A systematic search of articles in PubMed, EMBASE and The Cochrane Library databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Cohort studies of biceps tenodesis compared with labral repair of SLAP tears were included. Statistical analysis was performed using Review Manager software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). A P value of <.05 was considered to be statistically significant.

RESULTS

Included were 5 studies with 234 patients. Biceps tenodesis resulted in improved rates of patient satisfaction (95.6% vs. 76.2%, P = .01) and rate of return to sport (81.3% vs, 64.3%, P = .02), compared with SLAP repair. Although the difference in reoperation rates was not statistically significant, there was a trend toward higher reoperation rates in patients treated with SLAP repair (14.2% vs 6.5%, P = .09). In addition, there was no difference in complication rates or functional outcomes.

CONCLUSION

Our study found that biceps tenodesis resulted in higher rates of patient satisfaction and return to sport in the studies published in the literature and that biceps tenodesis and SLAP repair resulted in similar functional outcome scores.

An Age and Activity Algorithm for Treatment of Type II SLAP Tears

Background

Type II SLAP tears predominantly occur in males between their third and fifth decades of life. The mechanism of injury is often repeated overheard activity but can also occur due to direct compression loads and traction injuries. The treatment options have changed over the years and include non-operative therapy, direct labral-biceps complex repair, and labral debridement with biceps tenodesis or tenotomy.

Objective

To review the existing literature on the management of Type II SLAP tears and provide clinical recommendations based on patient age and activity level.

Methods

A review of the existing literature through October 2017 investigating the management of Type II SLAP tears was performed. Emphasis was placed on distinguishing the outcomes based on age and activity level to provide an appropriate treatment algorithm.

Results

Patients with Type II SLAP tears should first be trialed with non-operative management and many patients will have a successful result with ability to return to their respective sports or activities. Surgical management should be considered if non-operative management does not provide symptomatic relief. Young, athletic, or high-demand patients should be treated with a SLAP repair while biceps tenodesis should be considered for older or worker's compensation patients. Patients undergoing revision surgery for a failed SLAP repair should be managed with biceps tenodesis.

Conclusion

Type II SLAP tears remain a difficult pathology to manage clinically, but the treatment indications are narrowing. The age and activity algorithm described in this review provides an effective method of managing this complex clinical condition.

Return to Play and Outcomes in Baseball Players After Superior Labral Anterior-Posterior Repairs

BACKGROUND

Few studies have documented the outcomes of superior labral anterior-posterior (SLAP) repairs in baseball players. Furthermore, the results of these previous studies varied widely and were based on small numbers of patients. Hypothesis/Purpose: The purpose was to report return-to-play (RTP) rates and validated subjective outcome scores for baseball players after SLAP repair. It was hypothesized that RTP rates and outcomes would be significantly different between pitchers and nonpitchers, as well as among baseball levels.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A series of 216 baseball players was identified who had isolated SLAP repair or SLAP repair with debridement of partial-thickness (<25%) rotator cuff tear at our surgical centers. Patients were contacted by phone a minimum of 2 years after surgery and asked questions about their ability to RTP. Patients were also asked questions to complete the Western Ontario Shoulder Instability Index (WOSI), Veteran's RAND 12-Item Health Survey (VR-12), and Kerlan-Jobe Orthopaedic Clinic (KJOC) questionnaires. Statistical equivalence in RTP rate, VR-12, and WOSI scores was determined between players with and without concomitant rotator cuff debridement using 2 one-sided tests and risk difference measures. Differences in RTP were tested among baseball levels (high school, college, professional) and positions (pitcher vs nonpitcher) using chi-square analyses ( P < .05). Differences in outcomes scores were compared using t tests and analyses of variance ( P < .05).

RESULTS

Of the 216 baseball players, 133 were reached by phone for follow-up interview (mean, 78 months; range, 27-146 months). Overall, 62% successfully returned to play. There were no differences in RTP rates or subjective outcomes among baseball levels or between procedures. RTP rates were 59% for pitchers and 76% for nonpitchers ( P = .060). Subjectively, the percentage of patients who felt the same or better at follow-up compared to preinjury was significantly higher among nonpitchers (66%) than pitchers (43%). There was no difference in KJOC scores between the pitchers (75.3 ± 19.4) and nonpitchers (76.2 ± 17.4) who successfully returned to play, although these scores were well below the minimum desired score of 90 for healthy baseball players.

CONCLUSION

SLAP repair should continue to be considered as an option for SLAP tear treatment only after nonsurgical management has failed. Some players may be able to return to baseball after SLAP repair, although regaining preinjury health and performance is challenging.

Top 50 cited journal articles on overhead throwing athletes: a bibliographic analysis

Background

The frequency of citations for a journal article is a reflection of its academic impact. The purpose of this study was to identify and characterize the top 50 cited journal articles related to overhead throwing athletes in the published literature.

Methods

The Web of Science database was searched on January 18, 2016, using the terms "throwing athlete," "baseball," and "pitcher" to identify the top 50 cited articles related to overhead throwing athletes using the all-database function. The type of study, country of origin, publishing journal, and year published were reviewed for each article.

Results

The top 50 articles identified were cited between 95 and 471 times and were published in 13 journals between 1969 and 2011. Most of the articles were small case series or nonsystematic literature reviews. The shoulder was the most common body region studied in the top 50 articles (33 of 50 [66%]). Among original studies (n = 43), there was a good representation of surgical management of shoulder and elbow pathology in overhead athletes (9 of 43 [20.9%]); however, most of the articles reported on shoulder and elbow kinematics (19 of 43 [44.2%]) and pathoanatomy (15 of 43 [34.9%]).

Conclusion

The greater prevalence of nonsurgical articles may reflect a continued effort to better understand the different pathologies specific to overhead throwing athletes. An understanding of the variable content and quality of frequently cited articles on overhead throwing athletes may serve as a stepping stone for future studies to advance the diagnosis and management of complex elbow and shoulder injuries in these high functional individuals.