Effect of Posterior Glenoid Labral Tears at the NFL Combine on Future NFL Performance

High Incidence of Combined and Posterior Labral Tears in Military Patients With Operative Shoulder Instability

BACKGROUND

Anterior shoulder instability is the pattern most commonly reported in the civilian population, but military servicemembers may represent a unique population. At 1.7 per 1000 person-years, servicemembers not only have a higher incidence of instability events compared with civilians (reported rate of 0.2-0.8), but the distribution of labral tears in the military may differ significantly as well.

HYPOTHESIS

The incidence of combined and posterior labral tears in the military population will be greater than numbers previously reported.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

The Wounded, Ill, and Injured Registry, a Department of Defense patient reported outcomes data collection platform that includes all military branches, was queried retrospectively for all patients who had undergone a primary arthroscopic or open shoulder stabilization procedure (Current Procedural Terminology codes 29806, 23455, 23462) between October 2016 and January 2019. Demographic information was obtained through intake forms completed by patients at the time of enrollment into the Military Orthopaedics Tracking Injuries and Outcomes Network. Tear location was determined arthroscopically and labeled as anterior, inferior, posterior, superior, or any combination thereof. Chi-square analysis was used to compare the percentage of patients with isolated anterior, isolated posterior, isolated inferior, or combined labral tears in the current study cohort with those in a previously reported cohort of patients with operative shoulder instability at a single military treatment facility.

RESULTS

A total of 311 patients were included who had undergone primary shoulder stabilization during the study period. Of these patients, 94 (30.2%) had isolated anterior tears, 76 (24.4%) had isolated posterior tears, and 136 (43.7%) had combined tears. We observed a higher percentage of combined tears in our data set than in a data set from a single military treatment facility (χ²(2) = 48.2; P < .00001). Chi-square analysis demonstrated that significantly more female patients had an isolated anterior labral tear (51.2%) compared with male patients (27.1%; χ²(2) = 9.4; P = .009).

CONCLUSION

The incidence of combined and posterior labral tears in the military population is greater than numbers previously reported in both military and civilian populations.

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.

Recurrent Instability and Surgery Are Common After Nonoperative Treatment of Posterior Glenohumeral Instability in NCAA Division I FBS Football Players

BACKGROUND

In-season return to play after anterior glenohumeral instability is associated with high rates of recurrent instability and the need for surgical stabilization. We are not aware of previous studies that have investigated in-season return to play after posterior glenohumeral instability; furthermore, as posterior shoulder instability in collision athletes occurs frequently, understanding the expected outcome of in-season athletes may improve the ability of physicians to provide athletes with a better understanding of the expected outcome of their injury and their ability to return to sport.

QUESTIONS/PURPOSES

(1) What proportion of athletes returned to play during the season after posterior instability in collegiate football players? (2) How much time did athletes lose to injury, what proportion of athletes opted to undergo surgery, and what proportion of athletes experienced recurrent instability after a posterior instability episode during a collegiate football season?

METHODS

A multicenter, prospective, observational study of National Collegiate Athletic Association (NCAA) Division 1 Football Bowl Subdivision athletes was performed at three US Military Service Academies. Ten athletes who sustained a posterior instability event during the regular football season and who pursued a course of nonoperative treatment were identified and prospectively observed through the subsequent season. All athletes in the observed cohort attempted an initial course of nonoperative treatment during the season. All athletes sustained subluxation events initially identified through history and physical examination at the time of injury. None of the athletes sustained a dislocation event requiring a manual reduction. Intraarticular pathology consisting of posterior labral pathology was further subsequently identified in all subjects via MRI arthrogram. Return to play was the primary outcome of interest. Time lost to injury, surgical intervention, and subsequent instability were secondary outcomes.

RESULTS

Of the 10 athletes who opted for a trial of initial nonoperative management, seven athletes were able to return to play during the same season. Although these seven athletes returned within 1 week of their injury (median of 1 day), 5 of 7 athletes sustained recurrent subluxation events with a median (range) of four subluxation events per athlete (0 to 8) during the remainder of the season. Seven athletes were treated surgically after the completion of their season, four of whom returned to football.

CONCLUSION

This study suggests that although collegiate football players are able to return to in-season sport after a posterior glenohumeral instability event, they will likely sustain multiple recurrent instability events and undergo surgery after the season is completed. The results of this study can help guide in-season management of posterior shoulder instability by allowing more appropriate postinjury counseling and decision making through the identification of those athletes who may require additional attention from medical staff during the season and possible modifications to training regimens to minimize long-term disability. Further prospective studies involving a larger cohort over several seasons should be performed through collaborative studies across the NCAA that better assess function and injury risk factors before beginning collegiate athletics. This would better characterize the natural history and associated functional limitations that athletes may encounter during their collegiate careers.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Magnetic Resonance Arthrography in Rugby Players Undergoing Shoulder Stabilization for Glenohumeral Instability: Professionals Have Higher Frequencies of More Pathologies

Purpose

To quantify the magnetic resonance arthrography (MRA) findings in rugby players during preoperative workup for anterior surgical stabilization for glenohumeral instability.

Methods

All patients who underwent glenohumeral instability surgery in our institution between 2008 and 2018 were considered for inclusion. Rugby players were identified using the patient's medical notes, with subsequent identification of all professional players. All rugby player's preoperative MRA findings were recorded and analyzed.

Results

Overall, 267 rugby players were included, 261 of whom were male (97.8%), with a mean age of 22.7 years (range 13-55 years). There were 58 professional rugby players (21.7%). The mean number of pathologies in nonprofessional rugby players was 5.0 pathologies versus 6.2 pathologies in the professional rugby players, with a significant difference in nonprofessional rugby players with up to 3 pathologies versus professional rugby players (26.3% vs 10.3%, P = .01). Professional rugby players had a statistically significant increased incidence of bicipital tendon lesions (25.9% vs 13.9%, P = .009), acromioclavicular joint degeneration (60.3% vs 42.1%, P = .016), glenohumeral bone loss (87.9% vs 69.9%, P = .006), and degenerative changes (67.2% vs 44.0%, P = .002) on their MRAs.

Conclusions

Rugby players undergoing surgical stabilization for glenohumeral instability often have a significant number of pathologies identified on MRA at the time of surgery. Professional rugby players showed concerningly greater frequencies of early degenerative changes when compared with nonprofessional rugby players.

Level of Evidence

III; Retrospective Cohort Study.