National Athletic Trainers' Association Position Statement: Evaluation, Management, and Outcomes of and Return-to- Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries

Preventive interventions for throwing injuries in baseball players: a scoping review

BACKGROUND

Shoulder and elbow pain are the common complaints associated with throwing injuries in baseball players. Prospective studies evaluating the effectiveness of stretching in increasing posterior shoulder flexibility or strengthening the external rotator muscles as preventive strategies for throwing injuries in baseball players have been published. However, there are limited reviews highlighting the role of preventive interventions for throwing injuries in baseball players. Therefore, this scoping review aimed to summarize the existing literature on preventive interventions for throwing injuries in baseball players.

METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Scopus databases on 3 March 2023. Two independent reviewers screened the studies based on the eligibility criteria. We extracted existing literature on preventive interventions and effectiveness for throwing injuries in baseball players, and participants' characteristics and results were extracted from the studies. This scoping review was performed in accordance with the Extended Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for Scoping Reviews.

RESULTS

The initial database search yielded 1170 articles, four of which met the eligibility criteria. Of the included studies, two were randomized controlled trials, and the remaining two were prospective cohort studies. Eligible studies targeted youth-to high school-level players and focused on preventive programs for throwing injuries that manifest in the upper extremities of baseball players. The outcome measure most commonly used to quantify the effectiveness of prevention programs was the incidence of shoulder and elbow injuries, although the definitions vary among studies. The prevention program included sleeper stretching, shoulder external rotation strengthening exercises, and comprehensive prevention programs (focusing on improving the elbow, shoulder, and hip range of motion; rotator cuff and periscapular muscle strength; posture; and lower extremity balance). Each prevention program was reported to have the potential to reduce the incidence of throwing injuries in baseball players, and two studies suggested that high compliance with the program led to a lower injury risk.

CONCLUSION

This scoping review confirmed the presence of studies that examined preventive interventions for throwing injuries in baseball players. Preventive interventions that may reduce throwing injuries in baseball players include sleeper stretching, shoulder external rotation strengthening exercises, and comprehensive prevention programs. However, the characteristics of participants (eg, age, sports level, and position) and the definition of injury varied among previous studies. Injury profiles and prevention strategies may differ according to age, sport level, and position of players, and more studies are needed to prove this issue.

Preparation For Flight: The Physical Profile of Pre-Professional and Professional Circus Artists in the United States

Background

Established norms for fitness and performance measures are lacking in circus arts. These would assist healthcare professionals and coaches to screen for readiness to participate in training or performance, determine post-injury return to performance, and develop targeted conditioning programs.

Purpose

The purpose of this research was to establish norms for trunk and extremity physical exam and performance measures in circus artists by professional status, assigned sex at birth (ASAB), and age.

Study Design

Descriptive laboratory study.

Methods

Circus artists (n=201; ages 13-69y; 172 females ASAB, 29 males ASAB) from 10 cities across the United States underwent a baseline physical examination including shoulder, hip and trunk measures of passive (PROM) and active (AROM) range of motion, measures of flexibility (shoulder and hip), strength (manual muscle tests, grip strength), cardiovascular fitness (3 minute-step test), balance (single limb and handstand), and performance, (pull-ups, and the closed kinetic chain upper extremity stability test [CKCUEST]). ANOVAs were used to determine between group differences by age and T-tests to discern differences by ASAB or professional status.

Results

Differences existed by professional status for shoulder external rotation PROM, hip PROM, hip flexibility, shoulder and abdominal strength, and cardiovascular fitness. Sex differences were seen in active scapular upward rotation, hip and shoulder PROM and flexibility, hip and grip strength, and for functional performance measures (pull-ups, CKCUEST). Differences by age were limited to active scapular upward rotation, shoulder PROM, flexibility and strength, cardiovascular fitness, and balance. Overall, professionals outperformed pre-professionals for lower abdominal strength, pull-ups, handstand balance, cardiovascular fitness, hamstring, and straddle flexibility. Generally, males ASAB demonstrated greater shoulder flexibility and upper body functional strength while females ASAB had greater hip and lumbar flexibility and hip strength. No measures showed consistent declines with increasing age, though some showed differences between adolescents and adults.

Conclusion

These normative values for physical characteristics and functional performance in pre-professional and professional circus artists may be used to guide screening for readiness to participate in advanced training or performance, return to performance after injury, and the development of targeted strength and conditioning programs.

Level of Evidence

3.

Rehabilitation of the painful shoulder

Managing the painful shoulder in overhead athletes can be difficult because of a lack of time-loss injuries in overhead sports and focusing primarily on either pathoanatomic causes or movement impairments. Although managing the painful shoulder can be challenging, the combination of identifying pathoanatomic causes with movement impairments can provide a more focused rehabilitation approach directed at the causes of shoulder pain. Understanding the potential influence of scapular positioning as well as mobility and/or strength impairments on shoulder pain can help clinicians develop more directed rehabilitation programs. Furthermore, sports-specific methods such as long toss or the use of weighted balls for achieving physiological or performance-based gains have limited empirical evidence regarding their clinical and performance-based benefits, which may impede the rehabilitation process. Applying a comprehensive evaluation approach prior to and throughout the treatment process can assist clinicians with selecting the most appropriate treatment based on patient need. Reconsidering traditional treatments based on existing evidence may help refine the treatment process for overhead athletes with shoulder pain.

Sink or Swim? Clinical Objective Tests and Measures Associated with Shoulder Pain in Swimmers of Varied Age Levels of Competition: A Systematic Review

BACKGROUND

Swimming is enjoyed by athletes of all ages, and shoulder pain is a common problem. Clinicians identify impairments which impact shoulder pain and these impairments may differ depending on the swimmer's age competition level.

PURPOSE

The purpose of this study was to investigate objective measures utilized to assess swimmers and assess the relationship of test values to shoulder pain in distinct age groups/competition levels. A secondary aim was to report normative/expected values for these tests.

DESIGN

Systematic review.

METHODS

PRISMA methodology was employed to assess studies evaluating clinical tests and measures associated with shoulder pain for swimmers in varied age competition levels. The Methodological Index for Non-Randomized Studies instrument was used to evaluate the quality of the included studies, and a qualitative synthesis of findings was conducted to determine the strength of the evidence in four age competition levels for nine objective measures. Distinct cut points for proposed measures were identified.

RESULTS

Twenty-seven studies were included in the analysis and the majority were of moderate quality in adolescent/adult swimmers. Youth swimmers had limited evidence for the development of shoulder pain associated with scapular position/dyskinesia, weakness of periscapular muscles, low endurance of core muscles, and moderate evidence for shoulder pain associated with laxity and altered range of motion (ROM). Adolescent/adult swimmers demonstrated limited evidence for a positive association between developing shoulder pain if there is a low eccentric ER:concentric IR ratio, and moderate evidence for pectoralis minor tightness and glenohumeral laxity. There were limited studies regarding masters swimmers to derive conclusive evidence. Cut points were identified from the included studies but these have not been validated in other studies.

CONCLUSION

Swimmers of various ages may have different objective clinical tests and measures associated with the risk for developing shoulder pain. More studies are needed to fully understand risk factors for shoulder pain in the masters swim competition level, and to validate recommended cut points for various tests and measures.

Key level of evidence

3, Systematic review of mostly Level 3 studies.

Long-term results of arthroscopic repair of type II SLAP lesions in sports: assessment of return to pre-injury playing level and critical risk factors for complication

PURPOSE

The management of isolated SLAP lesions is still debated especially in athletes. Aims of the study were: 1. to analyse our algorithm to treat SLAP lesions starting from the selection of patients for surgery and 2. to correlate the familiarity for diabetes and hypothyroid disorders with post-operative results.

METHODS

Seventy-eight patients with isolated SLAP lesion were arthroscopically treated using knotless anchors and microfractures. All patients had a pre-operative and post-operative clinical examination according to Walch-Duplay, Constant, Rowe and Dash scores and interviewed for familiarity to diabetes and hypothyroid disorders.

RESULTS

About 68.8% of patients solved pain with rehabilitation. About 29% of patients returned to the sports activities. About 32% of patients were no responder to physiotherapy and were arthroscopically treated. About 53.9% of patients responded excellent, 34.7% good, 3.8% medium and 7.6% poor results according to Walch-Duplay score. The Constant score increased from 64 to 95, the Rowe score from 48 to 96. The outcomes were significantly worse in patients with familiarity for diabetes.

CONCLUSIONS

Microfractures and knotless anchor give long-term good results for the treatment of SLAP lesions in athletes. The familiarity for diabetes is an important risk factor that can lead to decreased outcomes.

Content reporting and effectiveness of therapeutic exercise in the management of massive rotator cuff tears: A systematic review with 490 patients

Background

Massive rotator cuff tears (MRCT) account for a substantial fraction of tears above the age of 60 years. However, there are no clear criteria for prescription parameters within therapeutic exercise treatments. The aim of this study was to evaluate the effects and characteristics of therapeutic exercise treatments in patients with MRCT.

Methods

A systematic search was conducted in MEDLINE/PubMed, Web of Science, SPORTDiscus, SciELO, Scopus and EMBASE from inception to August 2022. Studies were included if they evaluated the effects of exercise on patients with MRCT. The risk of bias was evaluated and the Consensus on Exercise Reporting Template (CERT) was also used. A narrative synthesis without meta-analysis was performed.

Results

One randomized controlled trial, two non-randomized studies, six non-controlled studies, one case series and four retrospective studies were included. They ranged from serious to moderate risk of bias. The CERT reflected a poor description of the exercise programmes. Studies showed a pattern of improvements in most patient-reported outcome measures (PROM) surpassing the MCID, and active elevation range of motion.

Conclusions

There is limited evidence that exercise and co-interventions are effective in the management of some patients with MRCT, based on a systematic review without meta-analysis. Future research should improve content reporting.

Level of evidence

IV.

Rehabilitation of Annular Pulley Injuries of the Fingers in Climbers: A Clinical Commentary

ABSTRACT

The annular pulley ligaments of the fingers are one of the most injured anatomical structures in those who participate in climbing. Despite this, there is a paucity of guidance clearly describing the rehabilitation and physical preparation parameters to return to sport following such injuries. The foundation of effective rehabilitation is the judicious application of progressive loading to increase the morphological and material properties of the damaged tissues. We maintain the optimal management of the climbing athlete after a traumatic annular flexor pulley system rupture should be grounded in the principles of strength and conditioning.

Postoperative Rehabilitation After Superior Labrum Anterior Posterior Repair

The 4-phase rehabilitation protocol outlined in this article provides a comprehensive 26-week program to return patients with superior labrum anterior posterior repairs to their preinjury states. It is guided by the principle of gradual return to preinjury function while preserving the integrity of the surgical repair. Objective criteria are present at the conclusion of each phase to ensure patients are progressing appropriately. The goal is to allow patients to return to their previous functional ability in their sport-specific or occupational-specific training.

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Two paleopathological cases suggestive of paralabral cysts of the shoulder

OBJECTIVE

To undertake differential diagnosis of scapular bone defects found in two medieval skeletons buried in different necropoles of Friuli Venezia Giulia (Italy) and to evaluate the clinical significance of paralabral cysts in the context of shoulder pathology.

MATERIALS

Individual JoT36 is an adult male exhumed from a necropolis belonging to a rural agricultural settlement dated to the 10th to 11th century A.D. Individual CIVT58 is an adult male from a Langobard necropolis dated to 630-670 A.D.

METHODS

Macroscopic examination of the skeletons was performed using standard osteological methods and review of pertinent clinical literature to assist differential diagnosis.

RESULTS

Between the glenoid cavity and the spinoglenoid notch of the right scapula of JoT36 there is a multilocular circular defect adjacent to the glenoid rim. On the neck of the left scapula of CIVT58, immediately above the spinoglenoid notch, there is a unilocular circular depression. In both cases, the cortical bone appears smooth without any evidence of erosion or sclerosis.

CONCLUSIONS

Skeletal findings and historical/archaeological contexts of both cases are compatible with the diagnosis of paralabral cysts.

SIGNIFICANCE

Paralabral cysts are relatively frequently observed in clinical settings but very few examples have been documented in paleopathological literature. This study seeks to improve recognition and interpretation of this pathology in historical/archaeological contexts.

LIMITATIONS

Findings from a case report can neither generate epidemiological information nor be generalized.

SUGGESTIONS FOR FURTHER RESEARCH

Identification of new cases may add valuable information about lifestyles and related shoulder pathologies in ancient times.

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.

Cross-cultural adaptation and validation of the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score in Finnish-speaking overhead athletes

Background

The Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score (KJOC) is developed to evaluate the shoulder and elbow function in overhead athletes. To date, the score has not been adapted into Finnish language. The aim of this study was to perform a cross-cultural adaptation of the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow score (KJOC) into Finnish language and evaluate its validity, reliability, and responsiveness in overhead athletes.

Methods

Forward–backward translation method was followed in the cross-cultural adaptation process. Subsequently, 114 overhead athletes (52 males, 62 females, mean age 18.1 ± 2.8 years) completed the Finnish version of KJOC score, Disabilities of the Arm, Shoulder and Hand (DASH), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and RAND-36 to assess validity of the KJOC score. To evaluate reliability and responsiveness, the participants filled in the KJOC score 16 days and eight months after the first data collection. Validity, reliability, and responsiveness of the Finnish KJOC score were statistically tested.

Results

Minor modifications were made during the cross-cultural translation and adaptation process, which were related to culture specific terminology in sports and agreed by an expert committee. Construct validity of the KJOC score was moderate to high, based on the correlations with DASH (r = − 0.757); DASH sports module (r = − 0.667); ASES (r = 0.559); and RAND-36 (r = 0.397) questionnaires. Finnish KJOC score showed excellent internal consistency (α = 0.92) and good test–retest reliability (2-way mixed-effects model ICC = 0.77) with acceptable measurement error level (SEM 5.5; MDC 15.1). Ceiling effect was detected for asymptomatic athletes in each item (23.2–61.1%), and for symptomatic athletes in item 5 (47.4%). Responsiveness of the Finnish KJOC score could not be confirmed due to conflicting follow-up results.

Conclusion

The Finnish KJOC score was found to be a valid and reliable questionnaire measuring the self-reported upper arm status in Finnish-speaking overhead athletes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00581-4.

Longitudinal assessments of strength and dynamic balance from pre-injury baseline to 3 and 4 months after labrum repairs in collegiate athletes

BACKGROUND

There is a lack of quantitative assessments of athletes' functional strength and dynamic balance following labrum repairs.

PURPOSE

To compare the upper extremity strength and dynamic balance among pre-injury baseline and approximately 3 and 4 months after labrum surgeries in collegiate athletes to identify critical values to inform rehabilitation.

METHODS

Fifteen male and one female collegiate athletes between 18 and 22 years old were tested at pre-injury baseline (n = 14) and 2.7 (n = 16) and 3.8 months (n = 12) after labrum surgeries. Strength was assessed using the peak forces produced in a maximal push-up test. Dynamic balance was assessed using the reaching distances in a reaching test.

RESULTS

The injured side's peak forces significantly decreased from the baseline to the 3-month post-surgery and then significantly increased between the 3-month and 4-month post-surgery assessments but remained significantly less at the 4-month post-surgery compared to the baseline (p ≤ 0.024; Cohen's dz ≥ 0.75). Peak force asymmetries were greater at the 3-month and 4-month post-surgery assessments than the baseline (p ≤ 0.005; Cohen's dz ≥ 1.02).

CONCLUSION

With a relatively small sample size, the results support the use of objective functional assessments for rehabilitation and return-to-play decisions among collegiate athletes following labrum repairs.

Is timing of superior labrum anterior to posterior (SLAP) repair important? A cohort study evaluating the effect of the duration of symptoms prior to surgery on the outcomes of patients who underwent type II SLAP repair

Background

The management of superior labrum anterior to posterior (SLAP) tears is somewhat controversial. It is unclear if the length of time between symptom onset and surgery affects SLAP repair outcomes.

Methods

Sixty-one SLAP repairs were retrospectively reviewed pre-operatively and post-operatively at 1, 6, 24 weeks, and > 2 years post-surgery. Patients were allocated to an 'early repair' or 'late repair' group based on time between symptom onset and surgery.

Results

Of the 61 patients, 22 patients had surgery within six months of symptom onset. Pre-operatively, 'late repair' patients played a higher level of sport than 'early repair' patients prior to injury. Post-operatively, both groups had similar outcomes up to six months, though at six months 'early repair' patients reported a higher level of work than 'late repair' patients (p = 0.01). At > 2 years after surgery, 'early repair' patients had reduced pain and difficulty with overhead activities (p = 0.002), less stiffness (p = 0.001) and were more satisfied than 'late repair' patients (p = 0.04).

Conclusions

Up to six months post-operatively, the time between symptom onset and surgery has limited effect on functional outcomes. However, at > 2 years after surgery, earlier repairs ( < 6 months) are interestingly associated with better functional outcomes. Further studies are required to determine if this is a causal relationship.

Risk factors and prevention strategies for shoulder injuries in overhead sports: an updated systematic review

PURPOSE

The aim of this systematic review was to update the knowledge on risk factors and prevention strategies for shoulder injuries in overhead sports with special emphasis on methodological quality.

METHODS

All methodological procedures were performed in line with a previous systematic review by Asker et al. (2018). The literature search was conducted in the PubMed, Google Scholar, Cochrane, and SPORT-Discuss databases. Due to the risk of bias assessment, only studies with at least an acceptable methodological quality were included. A best-evidence synthesis was performed to clarify the evidence and direction of the risk factors and prevention strategies.

RESULTS

A total of nine studies were included in the data extraction process. One study had a high and eight studies had an acceptable methodological quality. Seven cohort studies investigated risk factors and two randomised controlled trails evaluated prevention strategies. Moderate evidence was found for two non-modifiable (playing position, gender) and three modifiable factors (shoulder rotational strength, scapular dyskinesia, shoulder prevention programme) that were associated with the shoulder injury risk. All further risk factors had moderate and no association with risk (shoulder rotational ROM, joint position sense) or limited (history of shoulder/elbow pain, age, training experience, training volume, school grade, playing level), and conflicting evidence (setting).

CONCLUSIONS

There is moderate evidence for two non-modifiable (playing position, gender) and three modifiable factors (shoulder rotational strength, scapular dyskinesia, shoulder prevention programme) being associated with the shoulder injury risk in overhead sports.

2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels

There is an absence of high-quality evidence to support rehabilitation and return-to-sport decisions following shoulder injuries in athletes. The Athlete Shoulder Consensus Group was convened to lead a consensus process that aimed to produce best-practice guidance for clinicians, athletes, and coaches for managing shoulder injuries in sport. We developed the consensus via a 2-round Delphi process (involving more than 40 content and methods experts) and an in-person meeting. This consensus statement provides guidance with respect to load and risk management, supporting athlete shoulder rehabilitation, and decision making during the return-to-sport process. This statement is designed to offer clinicians the flexibility to apply principle-based approaches to managing the return-to-sport process within a variety of sporting backgrounds. The principles and consensus of experts working across multiple sports may provide a template for developing additional sport-specific guidance in the future. J Orthop Sports Phys Ther 2022;52(1):11-28. doi:10.2519/jospt.2022.10952.

Overview of Sport-Specific Injuries

Athletes are at risk for a variety of injuries not typically sustained in everyday life. The team physician must be capable of not only identifying and treating injuries as they occur, but he or she must be armed with the knowledge to minimize the risk of injuries before they occur. This review serves to provide an overview of the various sport-specific injuries typically encountered by team physicians. Injuries are grouped by body part and/or organ system, when possible. We do not aim to cover in detail the various treatments for these injuries; rather, we hope that this article provides a comprehensive overview of sport-specific injury, and demonstrate the well-roundedness in skills that must be possessed by team physicians.

Variability in Rehabilitation Protocols after Superior Labrum Anterior Posterior Surgical Repair

Introduction

Rehabilitation after a superior labral anterior posterior (SLAP) repair is an important aspect of patient outcomes; however, no standardized rehabilitation protocol has been defined. The purpose of this paper is to assess the variability of rehabilitation after a SLAP repair to understand the need for standardization to improve patient outcomes.

Methods

Protocols for SLAP repairs were collected through a search for Academic Orthopedic Programs and a general Google search using the terms “[Program Name (if applicable)] SLAP Repair Rehab Protocol”. Protocols were compared by sling, range of motion (ROM), physical therapy, return to sport (RTS), return to throwing, and biceps engagement and tenodesis recommendations. Protocols for non-operative or generalized shoulders were excluded.

Results

Sixty protocols were included. A total of 61.7% (37/60) recommended a sling for four to six weeks and 90% (54/60) included a full ROM recommendation, but time was variable. There were different exercises recommended, but pendulum swings were recommended by 53% (32/60), submaximal isometrics by 55% (33/60), and scapular strengthening by 65% (39/60). Of the sixty protocols, 33% (20/60) recommended return to sports in 24 weeks and 38.3% (23/60) recommended allowing throwing in 16 weeks.

Conclusions

There was variability in protocols for SLAP repair, especially time until full ROM, RTS, and biceps strengthening. Time in sling and scapular strengthening were the least variable. A lack of specificity within protocols in what return to throwing meant for functional ability made it difficult to compare protocols. Considering the large number of orthopedic programs, a relatively small number had published protocols. Further studies are needed to evaluate a standardized post-operative rehabilitation for SLAP repairs to improve outcomes.

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.

USE of CLINICAL TEST CLUSTERS VERSUS ADVANCED IMAGING STUDIES in the MANAGEMENT of PATIENTS with a SUSPECTED SLAP TEAR

Background and Purpose

The Magnetic Resonance Arthrogram (MRA) has served as the gold standard for identifying patients with possible Superior Labrum Anterior-Posterior (SLAP) lesions and are often required by orthopaedic surgeons prior to clinical evaluation. However, as the literature shows MRA sensitivity as 0.65-0.98, and specificity between 0.80-1.00, there is still room for misinterpretation of the imaging study, and potential mismanagement of a patient who may or may not exhibit a true SLAP lesion. It is proposed that by grouping a series of clinical special tests it may be possible to develop greater sensitivity in identifying a SLAP lesion, resulting in the ability to better manage this patient population, thus avoiding unnecessary and costly imaging studies and decreased referrals to surgical specialists. The purpose of this study is to examine specific combinations of SLAP lesion special tests and identify which clusters of tests have the highest sensitivity and specificities. This may allow therapists to improve the management of their patients by reliably diagnosing a SLAP lesion and referring only those who may need surgery to a physician.

Study Design

Literature review, diagnostic sensitivity/specificity outcomes.

Methods

A retrospective search of the current peer-reviewed literature was performed in an effort to identify the clinical special tests with the greatest sensitivity and specificity in identifying SLAP lesions. Based upon that search, the study was limited to five special tests: Biceps Load I, Biceps Load II, Speed's, Passive Compression, and O'Brien's tests. A multiple regression analysis was performed that looked at grouping of the tests to determine the diagnostic sensitivity/specificity when grouped.

Results

Obtaining positive results on three of the five special tests resulted in a sensitivity of 0.992-0.999 and a specificity of 0.992-0.999. The combination of the Biceps Load I/II and O'Brien's showed the highest sensitivity and specificity.

Conclusion

The results indicate that a combination of at least three positive SLAP lesion tests may be clinically useful in diagnosing a shoulder SLAP lesion with greater diagnostic accuracy than those reported for MRI/MRA, thus improving patient management by referring only those who may require surgical intervention to a physician.

Level of Evidence

2c, "Outcomes" Research.