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Thacher RR, Varady NH, Khilnani T, Camp CL, Dines JS. Current Concepts on the Management of Shoulder Instability in Throwing Athletes. Curr Rev Musculoskelet Med 2024:10.1007/s12178-024-09910-1. [PMID: 38918331 DOI: 10.1007/s12178-024-09910-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE OF REVIEW The management of shoulder instability in throwing athletes remains a challenge given the delicate balance between physiologic shoulder laxity facilitating performance and the inherent need for shoulder stability. This review will discuss the evaluation and management of a throwing athlete with suspected instability with a focus on recent findings and developments. RECENT FINDINGS The vast majority of throwing athletes with shoulder instability experience subtle microinstability as a result of repetitive microtrauma rather than episodes of gross instability. These athletes may present with arm pain, dead arms or reduced throwing velocity. Recent literature reinforces the fact that there is no "silver bullet" for the management of these athletes and an individualized, tailored approach to treatment is required. While initial nonoperative management remains the hallmark for treatment, the results of rehabilitation protocols are mixed, and some patients will ultimately undergo surgical stabilization. In these cases, it is imperative that the surgeon be judicious with the extent of surgical stabilization as overtightening of the glenohumeral joint is possible, which can adversely affect athlete performance. Managing shoulder instability in throwing athletes requires a thorough understanding of its physiologic and biomechanical underpinnings. Inconsistent results seen with surgical stabilization has led to a focus on nonoperative management for these athletes with surgery reserved for cases that fail to improve non-surgically. Overall, more high quality studies into the management of this challenging condition are warranted.
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Affiliation(s)
- Ryan R Thacher
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
| | - Nathan H Varady
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Tyler Khilnani
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | | | - Joshua S Dines
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
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Herman ZJ, Nazzal EM, Engler ID, Kaarre J, Drain NP, Sebastiani R, Tisherman RT, Rai A, Greiner JJ, Hughes JD, Lesniak BP, Lin A. Overhead athletes have comparable intraoperative injury patterns and clinical outcomes to non-overhead athletes following surgical stabilization for first-time anterior shoulder instability at average 6-year follow-up. J Shoulder Elbow Surg 2024; 33:1219-1227. [PMID: 38081472 DOI: 10.1016/j.jse.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/18/2023] [Accepted: 10/24/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND AND HYPOTHESIS Anterior shoulder instability is a common problem affecting young, athletic populations that results in potential career-altering functional limitations. However, little is known regarding the differences in clinical outcomes after operative management of overhead vs. non-overhead athletes presenting with first-time anterior shoulder instability. We hypothesized that overhead athletes would have milder clinical presentations, similar surgical characteristics, and diminished postoperative outcomes when compared with non-overhead athletes after surgical stabilization following first-time anterior shoulder instability episodes. METHODS Patients with first-time anterior shoulder instability events (subluxations and dislocations) undergoing operative management between 2013 and 2020 were included. The exclusion criteria included multiple dislocations and multidirectional shoulder instability. Baseline demographic characteristics, imaging data, examination findings, and intraoperative findings were retrospectively collected. Patients were contacted to collect postoperative patient-reported outcomes including American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy activity index score, and Subjective Shoulder Value, in addition to return-to-work and -sport, recurrent dislocation, and revision rates. RESULTS A total of 256 patients met the inclusion criteria, of whom 178 (70%) were non-overhead athletes. The mean age of the entire population was 23.1 years. There was no significant difference in concomitant shoulder pathology, preoperative range of motion, or preoperative strength between cohorts. A greater proportion of overhead athletes presented with instability events not requiring manual reduction (defined as subluxations; 64.1% vs. 50.6%; P < .001) and underwent arthroscopic surgery (97% vs. 76%, P < .001) compared with non-overhead athletes. A smaller proportion of overhead athletes underwent open soft-tissue stabilization compared with non-overhead athletes (1% vs. 19%, P < .001). Outcome data were available for 60 patients with an average follow-up period of 6.7 years. No significant differences were found between groups with respect to recurrent postoperative instability event rate (13.0% for overhead athletes vs. 16.8% for non-overhead athletes), revision rate (13.0% for overhead athletes vs. 11.1% for non-overhead athletes), American Shoulder and Elbow Surgeons score, Western Ontario Shoulder Instability Index score, Brophy score, Subjective Shoulder Value, or rates of return to work or sport. CONCLUSION Overhead athletes who underwent surgery after an initial instability event were more likely to present with subluxations compared with non-overhead athletes. With limited follow-up subject to biases, this study found no differences in recurrence or revision rates, postoperative patient-reported outcomes, or return-to-work or -sport rates between overhead and non-overhead athletes undergoing shoulder stabilization surgery following first-time instability events. Although larger prospective studies are necessary to draw firmer conclusions, the findings of this study suggest that overhead athletes can be considered in the same treatment pathway for first-time dislocation as non-overhead athletes.
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Affiliation(s)
- Zachary J Herman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Ehab M Nazzal
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Janina Kaarre
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nicholas P Drain
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Romano Sebastiani
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert T Tisherman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ajinkya Rai
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Jonathan D Hughes
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bryson P Lesniak
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Albert Lin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Minelli M, Longo UG, Ranieri R, Pascucci F, Giunti F, Conti M, Catellani F, Castagna A. The Epidemiology of Shoulder Injuries in Water Polo Players: A Monocentric Descriptive Study on Clinical and Radiological Presentation. J Clin Med 2024; 13:1951. [PMID: 38610716 PMCID: PMC11012509 DOI: 10.3390/jcm13071951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/12/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
Water polo players' shoulders are exposed to repeated overhead and throwing motions as well as direct and indirect traumas. Shoulder injuries account for over half of all injuries sustained by water polo players. This is a monocentric descriptive epidemiological study on the clinical and radiological presentation of a consecutive series of water polo players from January 2002 to September 2022. All patients underwent clinical and physical examinations and an MRI arthrogram. A total of 92 water polo players were included in this study. Fifty-three patients (57.6%) reported at least one previous shoulder instability episode; 100% of patients in this group were diagnosed with a capsulolabral complex lesion, and 88.7% of these players complained of subjective symptoms of shoulder instability (RR: 4.4). A total of 39 out of 92 patients (42.4%) did not report previous shoulder dislocation episodes; the mean age at presentation in this group was significantly higher than the mean age of the patients who experienced previous instability episodes (p < 0.01), and the throwing arm was affected in 79.5% of patients (RR = 1.41).
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Affiliation(s)
- Marco Minelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (M.M.); (R.R.); (F.P.); (F.G.); (F.C.); (A.C.)
| | - Umile Giuseppe Longo
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Roma, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy
| | - Riccardo Ranieri
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (M.M.); (R.R.); (F.P.); (F.G.); (F.C.); (A.C.)
- Shoulder and Elbow Unit, Department of Orthopedic and Trauma Surgery, Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, 20089 Milan, Italy;
| | - Federico Pascucci
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (M.M.); (R.R.); (F.P.); (F.G.); (F.C.); (A.C.)
| | - Filippo Giunti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (M.M.); (R.R.); (F.P.); (F.G.); (F.C.); (A.C.)
| | - Marco Conti
- Shoulder and Elbow Unit, Department of Orthopedic and Trauma Surgery, Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, 20089 Milan, Italy;
| | - Francesco Catellani
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (M.M.); (R.R.); (F.P.); (F.G.); (F.C.); (A.C.)
- Humanitas Gavazzeni, 24125 Bergamo, Italy
| | - Alessandro Castagna
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090 Milan, Italy; (M.M.); (R.R.); (F.P.); (F.G.); (F.C.); (A.C.)
- Shoulder and Elbow Unit, Department of Orthopedic and Trauma Surgery, Humanitas Clinical and Research Center, IRCCS, Via Manzoni 56, 20089 Milan, Italy;
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Marigi EM, Lamba A, Boos A, Wang A, Okoroha KR, Barlow JD, Krych AJ, Camp CL. Outcomes of Shoulder Instability Surgery in Competitive Wrestlers: Outcomes, Reoperations, and Return to Play at 5 Years' Mean Follow-up. Am J Sports Med 2024; 52:586-593. [PMID: 38305257 DOI: 10.1177/03635465231218262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Wrestling is a physically demanding sport with young athletes prone to traumatic shoulder instability and a paucity of data evaluating the results of shoulder instability surgery (SIS). PURPOSE To assess reoperation rates, patient-reported outcomes, and return to wrestling (RTW) after SIS in a cohort of competitive wrestlers. STUDY DESIGN Case series; Level of evidence, 3. METHODS All competitive wrestlers with a history of shoulder instability and subsequent surgery at a single institution between 1996 and 2020 were identified. All directions of shoulder instability (anterior shoulder instability [ASI], posterior shoulder instability [PSI], and traumatic multidirectional shoulder instability [TMDI]) were analyzed. Exclusions included revision SIS and <2 years of follow-up. Athletes were contacted for determination of complications, RTW, and Western Ontario Shoulder Instability Index scores. RESULTS Ultimately, 104 wrestlers were included with a mean age at initial instability of 16.9 years (range, 12.0-22.7 years), mean age at surgery of 18.9 years (range, 14.0-29.0 years), and a mean follow-up of 5.2 years (range, 2.0-22.0 years). A total of 58 (55.8%) wrestlers were evaluated after a single shoulder instability event, while 46 (44.2%) sustained multiple events before evaluation. ASI was the most common direction (n = 79; 76.0%), followed by PSI (n = 14; 13.5%) and TMDI (n = 11; 10.6%). Surgical treatment was most commonly an arthroscopic soft tissue stabilization (n = 88; 84.6%), with open soft tissue repair (n = 13; 12.5%) and open bony augmentation (n = 3; 2.9%) performed less frequently. RTW occurred in 57.3% of wrestlers at a mean of 9.8 months. Recurrent instability was the most common complication, occurring in 18 (17.3%) wrestlers. Revision SIS was performed in 15 (14.4%) wrestlers. Across the entire cohort, survivorship rates free from recurrent instability and revision surgery were 90.4% and 92.5% at 2 years, 71.9% and 70.7% at 5 years, and 71.9% and 66.5% at 10 years, respectively. Preoperative recurrent instability was an independent risk factor for postoperative recurrent instability (hazard ratio, 3.8; 95% CI, 1.33-11.03; P = .012). CONCLUSION Competitive wrestlers with multiple dislocations before initial clinical evaluation were 3.8 times more likely to experience postoperative recurrent instability. Patients should be counseled that despite SIS, only 57.3% returned to wrestling after surgery.
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Affiliation(s)
- Erick M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Abhinav Lamba
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander Boos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen Wang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan D Barlow
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Velasquez Garcia A, Hsu KL, Marinakis K. Advancements in the diagnosis and management of rotator cuff tears. The role of artificial intelligence. J Orthop 2024; 47:87-93. [PMID: 38059047 PMCID: PMC10696306 DOI: 10.1016/j.jor.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 12/08/2023] Open
Abstract
Background This review examined the role of artificial intelligence (AI) in the diagnosis and management of rotator cuff tears (RCTs). Methods A literature search was conducted in October 2023 using PubMed (MEDLINE), SCOPUS, and EMBASE databases, included only peer-reviewed studies. Relevant articles on AI technology in RCTs. A critical analysis of the relevant literature was conducted. Results AI is transforming RCTs management through faster and more precise identification and assessment using algorithms that facilitate segmentation, quantification, and classification of the RCTs across various imaging modalities. Precise algorithms focusing on preoperative factors to assess RCTs reparability have been developed for personalized treatment planning and outcome prediction. AI also aids in exercise classification and promotes patient adherence during at-home physiotherapy. Despite promising advancements, challenges in data quality and symptom integration persist. Future research should include refining AI algorithms, expanding their integration into various imaging techniques, and exploring their roles in postoperative care and surgical decision-making. Conclusions AI-driven solutions improve diagnostic accuracy and have the potential to influence treatment planning and postoperative outcomes through the automated RCTs analysis of medical imaging. Integration of high-quality datasets and clinical symptoms into AI models can enhance their reliability. Current AI algorithms can also be refined, integrated into other imaging techniques, and explored further in surgical decision-making and postoperative care.
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Affiliation(s)
- Ausberto Velasquez Garcia
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Clínica Universidad de los Andes, Department of Orthopedic Surgery, Santiago, Chile
| | - Kai-Lan Hsu
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
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Brown L, Tamburini LM. Traumatic Sternoclavicular Dislocations in Athletes: Diagnosis, Indications for Surgical Reconstruction, and Guide for Return to Play. Clin Sports Med 2023; 42:713-722. [PMID: 37716733 DOI: 10.1016/j.csm.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Injuries to the sternoclavicular (SC) joint are rare, however, when they occur prompt recognition, evaluation, and treatment are crucial. SC joint injuries can occur following high-energy mechanisms such as motor vehicle collisions and contact sports. Injury to the SC joint can be evaluated with the use of plain radiographs as well as computed tomography. If an injury to the SC joint is suspected, injury to vital mediastinal structures must be evaluated. SC joint dislocations can be treated by either closed reduction or open reduction and stabilization. Many stabilization methods have been described including plate stabilization and ligament reconstruction.
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Affiliation(s)
- Leah Brown
- Banner Orthopaedic Sports Medicine, University of Arizona College of Medicine-Phoenix, 7400 North Dobson Road, Scottsdale, AZ 85256, USA.
| | - Lisa M Tamburini
- Department of Orthopaedic Surgery, University of Connecticut, UConn Musculoskeletal Institute, 120 Dowling Way, Farmington, CT 06032, USA
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Olsen B, Gregory B. Diagnosis and Nonoperative Treatment of Acromioclavicular Joint Injuries in Athletes and Guide for Return to Play. Clin Sports Med 2023; 42:573-587. [PMID: 37716722 DOI: 10.1016/j.csm.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Injury to the acromioclavicular (AC) joint accounts for approximately 40% to 50% of all shoulder injuries. In contact sports, the prevalence of AC joint injury increases. This injury is frequently encountered and treated by fellowship-trained as well as general orthopedic surgeons. As such, it is important to understand the diagnostic and treatment pathways for AC joint disruption. The treatment pathways in athletes may be different from those in the general population. This article will focus on the diagnosis and nonoperative treatment of AC joint injuries in athletes. We will also comment on return-to-play guidelines after this nonoperative treatment.
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Affiliation(s)
- Brittany Olsen
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston/McGovern Medical School, 6400 Fannin Street, Suite 1700, Houston, TX 77030, USA
| | - Bonnie Gregory
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston/McGovern Medical School, 6400 Fannin Street, Suite 1700, Houston, TX 77030, USA.
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Arguello AM, Till SE, Reinholz AK, Okoroha KR, Barlow JD, Camp CL. Managing Shoulder Instability in the Overhead Athlete. Curr Rev Musculoskelet Med 2022; 15:552-560. [PMID: 36223035 PMCID: PMC9789295 DOI: 10.1007/s12178-022-09796-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Shoulder instability in the overhead athlete is a difficult problem because of the balance between necessary laxity for athletic movements and stability of the joint. The purpose of this review is to provide an overview of the clinical evaluation of shoulder instability in the overhead athlete and present evidence-based management strategies for each subtype of shoulder instability, including novel techniques and outcomes. RECENT FINDINGS Recent investigation has shown that throwers and other overhead athletes are more likely to present with subtle subluxation events rather than discrete dislocations as their primary symptom. While overhead athletes with discrete anterior dislocation events are likely to begin with non-operative management, many progress on to surgical intervention. Surgical management of glenohumeral joint instability continues to pose challenges due to the potential for over-tensioning for the sake of stability at the expense of the adaptive laxity that often confers performance benefits in the overhead athlete. Novel, individualized, and sport/position specific approaches are needed to address this complex issue. The optimal management of shoulder instability in the overhead athlete continues to be a controversial topic due to the complex work-up, an increasing number of surgical options with varying indications, and low volume of high-quality studies comparing any of the treatment options. The Anterior Shoulder Instability International Consensus Group guidelines from February 2022 offer the most updated guidelines on work-up and management. Overall, high-quality randomized controlled trials are required to determine the optimal treatment for specific pathologies and aid in creating patient-centered management plans.
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Affiliation(s)
- Alexandra M Arguello
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara E Till
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anna K Reinholz
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kelechi R Okoroha
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jonathan D Barlow
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christopher L Camp
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, MN, USA.
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