Shoulder instability: return to play

Transcription

1 Clin Sports Med 23 (2004) Shoulder instability: return to play Eric C. McCarty, MD a, *, Paul Ritchie, MD a, Harpreet S. Gill, MD b, Edward G. McFarland, MD b a Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, University of Colorado, 1745 South High Street, Denver, CO 80210, USA b Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Falls Road, Suite 215, Lutherville, MD 21093, USA Shoulder instability in the competitive athlete is a relatively common problem. The etiology of glenohumeral instability that can affect the athlete runs a wide spectrum, from an isolated traumatic dislocation to repeated microtrauma or congenital laxity. Although many athletes are able to adapt to a mild laxity that might only occasionally affect them, it can be much more difficult to adapt or return after a dislocation or repeated subluxation episodes. This article focuses on the return to play for competitive individuals after a glenohumeral dislocation or reconstructive surgery for shoulder instability. Anatomy The glenohumeral joint is inherently unstable. The bony anatomy of the glenoid is such that it only covers approximately 25% to 30% of the humeral head. An analogy often given of the mismatch of the humerus on the glenoid is that of a golf ball positioned on the tee. Additionally, the bony surface of the glenoid is almost flat. The depth of the glenoid cavity has been found to average only 2.5 mm in the transverse plane and 9.0 mm in the caudal-cranial plane [1]. Because of this paucity of coverage of the humeral head, other aspects of the anatomy around the glenohumeral joint are relied upon for stability. Both static and dynamic mechanisms have been cited as important contributing aspects to stability of the shoulder. An important static mechanism is the labrum. The labrum is a wedge-shaped, fibrous structure that is attached to the periphery of the glenoid. The labrum is typically firmly attached in the inferior * Corresponding author. C.U. Sports Medicine, 311 Mapleton Ave, Boulder, CO address: eric.mccarty@uchsc.edu (E.C. McCarty) /04/$ see front matter D 2004 Elsevier Inc. All rights reserved. doi: /j.csm

2 336 E.C. McCarty et al / Clin Sports Med 23 (2004) half of the glenoid and sometimes more loosely attached in the superior half, particularly anteriorly. The labrum serves as a site of attachment for the capsule, the glenohumeral ligaments, and the biceps. Also, the labrum assists in stability by increasing the contact area of the glenoid and the humeral head, and by increasing the depth of the glenoid by as much as doubling it [2]. By virtue of increasing the depth and by its shape, the labrum is often thought of as acting as a chock block that helps prevent the humeral head from rolling over the edge of the glenoid. The glenohumeral joint is surrounded by capsule. Thickening of the capsule comprises the glenohumeral ligaments. The role these structures have in providing stability depends on the position of the arm and direction of force applied to the shoulder. The inferior glenohumeral ligamentous (IGHL) complex is the main glenohumeral ligamentous stabilizer for inferior, anterior, and posterior stability. The complex reciprocally tightens and loosens as the 90 abducted humerus rotates on the glenoid. External rotation tightens the anterior band of the IGHL, whereas internal rotation tightens the posterior band. The superior glenohumeral ligament (SGHL) and the middle glenohumeral ligament (MGHL) both assist in providing some stability to inferior and anterior translation with the arm at the side (SGHL) and at 45 (MGHL). A region of capsule between the supraspinatus and subscapularis is called the rotator interval. This interval region is variable in size. A large interval area has been found to be associated with increased translation of the humeral head in the inferior, anterior, and posterior directions [3]. Other factors contributing to stability of the shoulder include the adhesioncohesion between the intra-articular fluid and joint surfaces and the version angle of the glenoid. The negative intra-articular pressure also plays a role, although how much this contributes is not completely understood. Dynamic stability of the glenohumeral joint is afforded by the musculature around the shoulder, including the rotator cuff, the deltoid, and the long head of the biceps. The coordinated muscular contraction provides joint compression that aids in stability by increasing the required force necessary to translate the humeral head. These are particularly helpful in alleviating potential force applied to the capsuloligamentous structures. Proprioceptive feedback during contraction likely also assists in providing some stability. The scapulothoracic musculature assist in glenohumeral joint stability by providing appropriate movement of the scapula and positioning of the glenoid under the humerus. Dislocation mechanism/incidence Dislocations of the glenohumeral joint occur during all types of athletic endeavors. Anterior dislocations account for approximately 95% of all shoulder dislocations. In a series of 57 patients, Baker et al found that 76% of the anterior dislocations occurred in an athletic activity [4]. Posterior dislocations are uncommon. An incidence of 4% of all dislocations has been reported [5]. Posterior subluxations, however, can frequently occur in athletic events. Even

3 E.C. McCarty et al / Clin Sports Med 23 (2004) rarer is luxatio erecta, or inferior dislocation. The last variation of shoulder instability is voluntary instability, in which the patient can demonstrate the dislocation [6]. When an anterior dislocation occurs, the position of the arm is typically in an abducted and externally rotated position. The arm is sometimes held out abducted away from the body, then a traumatic event forces the arm to extend, causing the humeral head to lever out of the glenohumeral joint anteriorly. Common athletic activities that this occurs in are tackling in football and sliding into base during baseball or softball. The posterior dislocation/subluxation in sporting events can occur in individuals with adducted outstretched arms that receive a posterior stress (ie, a lineman in football, a falling gymnast). Inferior dislocations typically require major trauma, such as a fall from a height or an automobile accident, and they typically occur when an arm that is abducted overhead is driven inferior and dislocates out the inferior aspect of the joint. Overhead athletes who develop pain and inflammation in their shoulders without overt instability episodes have been postulated to have increased laxity or occult instability. This theory was first promulgated by F. Jobe et al [7] and has widespread acceptance in the literature [8 11]. According to Jobe and others [7 11], due to the repetitive nature of the sport, the AIGH ligament stretches over time due to microtrauma. This creates increased laxity of the shoulder, with subsequent increased contact of the humeral head to the acromion or to the posterior-superior glenoid. This contact can eventually result in or contribute to partial-thickness rotator-cuff tears, superior labrum pathology or superior labrum anterior posterior (SLAP) lesions, and eventually Bankart and Hill-Sachs lesions. When the contact leads to posterior-superior labrum tears, this has been called internal impingement by Walch et al [9] and by others [8,12 14]. It is important to distinguish this type of instability from traumatic instability, because the recovery and return to play are different for these groups. Pathology Various authors have described the findings after an anterior shoulder dislocation occurs [4,15 18]. In the early twentieth century, both Perthes [17] and Bankart [18] described the detachment of the capsulolabral complex from the glenoid rim; thus the term Perthes-Bankart lesion or Bankart lesion. It was initially thought that this was the essential lesion leading to recurrent anterior shoulder dislocation. This disruption of the capsulolabral complex pulls the labrum away from the front of the glenoid, thus eliminating the chock-block effect of the labrum. The attachment point of the IGHL, and sometimes the MGHL, are also disrupted, leading to anterior laxity. A complete detachment of the labrum after an anterior dislocation has been found to occur 62% to 97% of the time. In a study of findings at arthroscopy in initial dislocations at the United States Military Academy at West Point, New York, Taylor and Arciero [15] found that 97% of the cadets had a complete

4 338 E.C. McCarty et al / Clin Sports Med 23 (2004) detachment of the anterior labrum from the glenoid (Bankart lesion). A review of the literature by Lintner and Speer reported an 85% incidence of Bankart lesions in traumatic anterior dislocators [19]. A bony Bankart lesion (a small portion of glenoid bone avulses with the labrum) occurs less frequently. The larger the glenoid defect, the greater its contribution to anterior instability. When these defects are more than 25% of the glenoid surface, then some type of bone graft is typically used in reconstruction [20]. In posterior dislocations, the detachment of the labrum (reverse Bankart lesion) can occur, but it is not commonly seen. Lesions of the superior labrum can also occur as a result of traumatic dislocations. Unstable lesions, such as a detachment of the superior labral-biceps complex, Type II SLAP lesion, can additionally increase the amount of pathologic glenohumeral translation [21]. Another significant finding that occurs with an anterior dislocation is capsular tearing or stretching. In Baker et al s study of arthroscopic findings of 45 patients after acute anterior dislocation, all patients had at least some capsular tearing [4]. The injury to the capsule is very important, because this injury can cause additional laxity. Some surgeons feel that the plastic deformation of the capsule and resulting laxity is the primary reason for persistent instability. This injury is now recognized, and must be addressed at the time of surgical intervention. An avulsion of the lateral capsule from the humeral neck, humeral avulsion of the glenohumeral ligaments (HAGL) lesion, is rare, but must be recognized and surgically repaired [15,22 24]. Impression fractures of the posterolateral aspect of the humeral (Hill-Sachs lesions) are frequently evident (~80%) to varying degrees after anterior shoulder dislocations [25]. The fracture or divot in the humeral head occurs when the head displaces over and impacts on the anterior edge of the glenoid. This defect usually does not cause a problem; however, if the defect is more than 30% of the articular surface, it is thought be some authors to further contribute to the anterior instability [26,27]. With a posterior dislocation, an impression fracture on the anterior aspect of the humeral head is often present (reverse Hill-Sachs lesion). Rotator-cuff injuries can occur with dislocations. The incidence of tears seems to be related to age. Rotator-cuff tears are not common in younger patients after an anterior dislocation, but in patients above age 40 the incidence is approximately 30%, and by age 60 has been reported to be almost 80% [28 30]. Nerve and vascular injuries can occur after a dislocation. Vascular injuries are rare, but can occur in the elderly who have stiff vessels secondary to arthroscolerosis [31]. Axillary nerve injuries occur from 5% to 35% of the time, with increasing frequency based on age [31,32]. Management After an athlete dislocates a shoulder in practice or competition, the initial step in management is to recognize the injury. After an anterior shoulder dislocation, the athlete will typically be in moderate to significant discomfort. There is often a

5 fullness seen in the anterior portion of the shoulder, with a loss of the normal lateral deltoid contour. The arm is held in a slightly abducted and externally rotated position. The athlete with a posterior shoulder dislocation will hold the arm in an adducted and slightly internally rotated position. He or she will be unable to externally rotate the arm past a neutral position. Forward flexion past 90 is also difficult. The appearance of the shoulder reveals a prominent coracoid process anteriorly and a fullness posteriorly. With an inferior dislocation, the arm is usually held at about 110 to 160 of abduction. The humeral head can sometimes be palpated along the chest wall laterally. Reduction E.C. McCarty et al / Clin Sports Med 23 (2004) After dislocation, the next step in management is reduction. For an anterior dislocation, various techniques have been espoused. Leveraging techniques, such as the Kocher technique, may cause a fracture and should not be used. Gentle longitudinal traction will allow the humeral head to slide back into the joint as the surrounding musculature succumbs to the traction. The Stimson technique is accomplished by placing the athlete prone on a table and wrapping 10 lb to 15 lb of weight to the affected wrist. It may take several minutes, but this method is generally effective. On the field, a variation of this can be done with the athlete supine, by pulling on the athlete s wrist in forward flexion and placing countertraction with ones opposite hand onto the athlete s chest. If the athlete is large (ie, a 300-lb offensive lineman) then the same technique can be performed with two hands placed around the athlete s wrist and the knee placed onto the chest for countertraction (Fig. 1). Fig. 1. Technique for reducing shoulder in large athlete.

6 340 E.C. McCarty et al / Clin Sports Med 23 (2004) Reduction of an acute posterior dislocation is often more difficult than doing an anterior reduction. With the athlete supine, traction can be applied in-line with the deformity; during traction the humeral head is manually placed into the joint. Lateral traction on the proximal arm may allow the locked posterior dislocated head to disengage. Forceful external rotation must be avoided. For the rare luxatio erecta, reduction is accomplished by traction and countertraction. Traction is initially placed with the arm in its dislocated position upward, and then the arm is gradually brought down into less abduction. During this maneuver, countertraction is placed by an assistant using a sheet across the superior aspect of the shoulder. If any of these reductions is difficult, it can be facilitated by intravenous sedation or 20 cc of intra-articular, short-acting local anesthetic. Immobilization Following reduction, sling immobilization has traditionally been the treatment of choice. Despite the popularity of its use, the overall value of traditional sling (arm in internal rotation across the front of the body) immobilization is controversial; the efficacy of using the traditional sling in preventing recurrence of dislocation remains unknown. A review of the literature reveals no consensus on use of a sling or on length of immobilization following an initial anterior shoulder dislocation. In the mid 1950s, Rowe [33] reviewed over 500 shoulder dislocations and found that overall immobilization seemed to reduce the incidence of recurrence by 10% to 15%, but there was no correlation between length of immobilization and recurrence. In 1980, Kiviluoto et al [34] found that in patients younger than 30, the recurrence rate was higher in 26 patients treated with immobilization of less than a week compared with those treated for 3 weeks. Henry and Genung [35] reviewed a population of 121 young athletes (average age 19) after initial dislocation. Ninety percent (56/62) of the athletes immobilized after dislocation incurred a recurrence within 18 months, whereas 85% (50/59) who were not immobilized had another dislocation. Additionally, the length of the immobilization had no effect on the rate of redislocation. Simonet and Cofield [36] reviewed 124 patients over a 9-year period, and found that activity restriction had a much greater role in reducing recurrence than immobilization after a first time anterior dislocation. Hovelius et al [37,38] studied over 240 patients treated after an initial primary anterior shoulder dislocation and found that essentially there was not a significant difference between those patients immobilized for 3 to 4 weeks and those allowed early motion. Wheeler and colleagues at West Point [39] demonstrated a high recurrence rate (92%) despite 3 weeks of immobilization after an initial dislocation. Kralinger et al [40] retrospectively analyzed the potential factors associated with recurrence of dislocation after a primary anterior shoulder dislocation. Their findings indicate that immobilization does not reduce the risk of recurrence. With a wide variance of outcomes regarding immobilization after an initial anterior shoulder dislocation, it is clear that this issue remains unresolved. Whether to immobilize or not and for how long remain questions.

7 E.C. McCarty et al / Clin Sports Med 23 (2004) Immobilization in external rotation? Some authors feel that immobilization in internal rotation may not allow anatomic healing of the labrum to the glenoid [41 43]. Recently there has been some compelling evidence from Japan that immobilizing the shoulder in external rotation after a first-time shoulder dislocation may be the answer to reducing the recurrence rate. Itoi et al [42 44] have demonstrated basic science evidence and clinical evidence that this position makes sense. In their initial study [42], they created simulated Bankart lesions in ten cadaveric shoulders devoid of muscle. The findings indicate that a coaptation zone exists where the edges of labrum in a simulated Bankart lesion are held in approximation to the glenoid. Without the surrounding musculature, this occurs chiefly with the arm in adduction and in a range of full internal rotation to 30 of external rotation. In a follow-up study, Itoi et al [43] used magnetic resonance imaging to examine the coaptation of the Bankart lesion in 18 patients shortly after an anterior shoulder dislocation. Patients had their shoulders imaged with the arm positioned first in internal rotation (mean, 29 ) and then imaged in external rotation (mean, 35 ). Their findings were significant in that there was a better approximation of the Bankart lesion to the glenoid with the arm in external rotation than in internal rotation. Finally, Itoi et al [44] have recently reported preliminary findings from a clinical study regarding the position of immobilization after a first-time dislocation. Forty patients with first-time anterior shoulder dislocation were prospectively followed. After an average follow-up of 15.9 months, the 20 patients immobilized in internal rotation demonstrated a 30% rate of recurrence, whereas the 20 patients treated in 30 of external rotation demonstrated 0% recurrence. In the younger patients (<29) the recurrence rate was 45% (5/11 patients) for the internal rotation group and 0% (0/11) for the external rotation group. The findings are provocative and may change the way first time dislocators are treated in the future. Current multicenter studies will help clarify this issue. An example of a sling to keep the arm in external rotation is shown in Fig. 2. Fig. 2. Example of shoulder sling that will immobilize arm in external rotation (Courtesy of DJOrtho, Vista, California).

8 342 E.C. McCarty et al / Clin Sports Med 23 (2004) Natural history As with the consideration of immobilization after a shoulder dislocation, when reviewing operative versus nonoperative treatment options, it is important to understand the literature regarding the natural history of an anterior shoulder dislocation. In 1950, McLaughlin and Cavallaro [45] reviewed 573 patients after an initial anterior shoulder dislocation. More than 90% of patients younger than age 20 experienced a repeat dislocation. Conversely, only 10% of patients greater than age 40 had a recurrence. In the group of patients aged 20 to 40, the recurrence rate was 60%. As mentioned previously, Rowe [33], reported his findings in Rowe found a 94% recurrence rate in patients younger than 20 and a 14% recurrence rate in those over 40. In the ages between, he reported repeat dislocations in 79% of those aged 21 to 30 and 50% of those aged 31 to 40. Henry and Genung s [35] study found an approximately 88% redislocation rate in their relatively young (average age 19) population of athletes. Also in a population of high-demand young athletes (hockey players), Hovelius observed a 90% redislocation rate in the players younger than 20 and 65% in those aged 20 to 25. In the Wheeler et al [39] study of young active cadets at West Point, the recurrence rate was 92%. It is clear from the previous three studies that in the younger athletic patient there is a high redislocation rate. This is further illustrated in the Simonet and Cofield [36] study, which demonstrated a recurrence rate of 82% in the athletes younger than 30 versus 30% in non-athletes of the same age. Other studies [37,46] have demonstrated varying recurrence rates, but the results are harder to interpret because the ages of the patients are not well stratified and the activity levels of the patients are not well defined. Little has been written on the natural history following a posterior dislocation. Reversal of natural history? It does appear that the natural history for a young athlete with a first-time anterior shoulder dislocation shows at least a 85% to 90% chance of recurrence. Because of the unfavorable numbers, several authors have prospectively investigated the possibility of operative management of this group of individuals [47 51]. These results are outlined in Table 1. The results of recurrence range from 4% to 15.9% after operative management, and from 27% to 94% after nonoperative treatment. These results seem to indicate that performing an anterior stabilization of a patient after a first-time anterior shoulder dislocation may in fact reverse the natural history of recurrence. Surgery If a decision for operative management is made in the athlete with shoulder instability, it must be decided whether an arthroscopic or open stabilization procedure will be performed. Traditionally, open stabilization of the shoulder has

9 E.C. McCarty et al / Clin Sports Med 23 (2004) Table 1 Results of prospective studies evaluating nonoperative treatment versus operative treatment of patients with a first-time anterior shoulder dislocation Author Type of study # Patients Treatment Results Arciero [47] Prospective nonrandomized 36 immobilize vs. arthoscopic transglenoid suturing Nonop: 80% recurrent instability Op: 14% recurrent instability Nonop: 94% recurrence Op: 4% recurrence Nonop: 47% recurrence Op: 15.9% recurrence Nonop: 75% recurrence Op: 11% recurrence Larrain [49] Prospective nonrandomized 46 immobilize vs. arthroscopic stabilization Kirkley [50] Prospective 40 immobilize vs. randomized arthroscopic stabilization Bottoni [48] Prospective 24 immobilize vs. arthroscopic randomized stabilization w/bioabsorb tack Jakobsen [51] Prospective 76 immobilize vs. open repair Nonop: 27% recurrence Op: 3 recurrence Abbreviations: Nonop, nonoperative; OP, operative; vs. versus. provided excellent overall results for stabilizing patients with recurrent anterior shoulder instability, similar to the results noted above. Recently, arthroscopic stabilization has produced better results than previously experienced, and in skilled surgical hands the results approach those found with open management. Contraindications for arthroscopic stabilization in the athlete include: HAGL lesion, large glenoid defects ( > 20%), large Hill-sachs defects (>30% 40%), and poor quality of the capsular tissue. Relative contraindications include arthroscopic stabilization in a contact athlete and failed arthroscopic stabilizations. Both of these two are debatable. As techniques and surgeons skills have improved, arthroscopic stabilization in the contact athlete has become acceptable. O Neill [52] prospectively studied arthroscopic anterior stabilization of first-time dislocators in a group of 41 athletes, including 17 football players. He demonstrated a 98% return to preoperative sport; 95% had no additional dislocation, and 90% had good-to-excellent results. Two subluxations did occur in the football players. Mair et al [53] reported on their experience of arthroscopic posterior stabilization of posterior labral detachments in contact athletes. All 9 athletes were able to make a successful return to their sports, football and lacrosse. Return to play without surgery If a decision is made not to perform surgery, then returning an athlete to the field of competition after a shoulder dislocation requires consideration of a multitude of factors. First and foremost, the question must be asked if a safe return is possible. Second, is there a risk of further injury? Third, can the athlete protect himself or herself? Last, do the athletes meet ideal criteria for return to the playing field Box 1? Other factors to be taken into consideration include: the type of sport the athlete is involved in, the season of the sport, timing during the year, age and year

10 344 E.C. McCarty et al / Clin Sports Med 23 (2004) Box 1. Ideal criteria for return to play Little/no pain Patient subjectivity Near normal range of motion (ROM) Near normal strength Normal functional ability Normal sports-specific skills of the athlete in school, position of the athlete, and associated pathology. For example a cross-country runner who dislocated while falling on a trail will likely be more apt to return than a kayaker who requires his arm to be in an abducted and externally rotated position. Also, in a sport such as football, a linebacker may have a harder time returning than a offensive lineman, because of the need to bring the arm out to tackle. In the period after the initial dislocation, regardless of immobilization, the athlete needs to begin some rehabilitation. Soon after the initial pain subsides, isometric exercises should begin. These focus on grip, and biceps, triceps, and deltoid muscle groups. As the athlete becomes more comfortable, isotonic exercises should begin, increasing resistance as the athlete tolerates. Range-ofmotion exercises should also begin around the same time, beginning with forward flexion and avoiding external rotation with abduction. Neuromuscular training is essential, as is scapulothoracic stabilization training. Depending on the treating physician s philosophy for treating an acute dislocation, the sling may be removed within a couple of weeks or it may stay on for 6 weeks. Most athletes can come out of the sling when their pain has subsided and the motion and strength is good, usually within 10 to 14 days. A return to the athletic arena, whether in practice or competition, does require some of the criteria mentioned in Box 1 to be met. Ideally, the athlete will have full strength and full motion, and no apprehension on examination, but often it takes months for this to occur. Realistically, someone with 80% to 90% strength and motion with slight apprehension can return to play, if protected from putting the shoulder in a position of risk (abduction, external rotation) for another anterior dislocation. There are several braces available to limit the motion of the glenohumeral joint and avert the shoulder from being put in the abducted and externally rotated position. Some examples of these are seen in Figs. 3 and 4. These braces can be worn by themselves or attached to protective equipment such as shoulder pads. These devices may be particularly helpful in sports such as football, but there are no studies demonstrating their efficacy. Dislocations in the braces have been seen by the authors, and the athlete should be advised that the braces may not prevent instability episodes. As an athlete returns to play and has no symptoms, the brace may become optional. Typically, this does not occur within the same sports season.

11 E.C. McCarty et al / Clin Sports Med 23 (2004) Fig. 3. Shoulder brace (harness) that will limit abduction and external rotation (Courtesy of DJOrtho, Vista, California). With posterior instability, there are currently no braces that can successfully be used to avoid a posterior stress. Some do limit the arm from coming into adduction. Patients often have difficulty returning after a posterior shoulder dislocation, especially in a sport such as gymnastics or football, in which the arm is often in front and outstretched, and thus susceptible to a posterior stress. In patients who wish to return to sports without surgery, however, there are few studies that substantiate the risk of further instability with or without a brace. Return to play after surgery It is apparent that there is a large amount of anatomical pathology encompassed in shoulder instability and dislocations. As can be expected, there are a Fig. 4. Attachment to shoulder pads that will limit abduction and external rotation (Courtesy of DJOrtho, Vista, California).

12 346 E.C. McCarty et al / Clin Sports Med 23 (2004) myriad of protocols and guidelines that have evolved after these various shoulder stabilization surgeries to allow a timely return by the athlete to activity and sport. Despite the differences in surgical techniques, there are some general principles to consider in the rehabilitation process. Many of the same criteria mentioned in Box 1 for return to sports after nonoperative treatment apply to athletes trying to return to their sport after a surgical stabilization. Whether the stabilization is performed arthroscopically or open, the athlete likely will need a minimum of 14 to 16 weeks before being ready to return. Typically, the time range for return is from 4 to 6 months, and it may take as long 9 to 12 months (Table 2). Protocols vary for sling use after surgical stabilization, but most use a time frame of about 6 weeks. During this time, the athlete begins on range-of-motion and some strengthening exercises; again this is dependent on surgeon preference. As soon as the athlete is out of the sling, more aggressive rehabilitation begins, and neuromuscular training is instituted. The rehabilitation process must be individualized, because each patient will progress at different levels due to quality of tissue health, speed of healing response, adequacy of fixation at the time of surgery (ie, suture anchors, bioabsorbable tacks, or sutures), surgical technique employed (open versus arthroscopic), and type of procedure performed (Bankart repair, anterior or posterior capsular shift, or thermal plication). The type and cause of the patient s instability must also be considered in designing and implementing the appropriate protocol. Generally, the postoperative rehabilitation can be divided into four phases. Phase I is a protection phase that generally spans to the 6th postoperative week. The goals of this period are to allow healing of sutured and repaired tissues such as the capsule, labrum, and subscapularis tendon. There is always a delicate balance of appropriate immobilization and early range-of-motion work to reduce the effects of prolonged immobilization. The negative effects of immobilization can be limited with gentle, supervised ROM exercises, protecting from excessive abduction as well as external/internal rotation. This early motion will help to retard muscular atrophy, improve tissue circulation, promote healing, and decrease inflammation. During the early phases of rehabilitation, great care is taken to protect healing tissue from becoming overstressed. Exercises employed include gentle ROM and wand exercises, followed by the initiation of isometric flexion and extension. Early-phase exercises are also critical to maintain strength and motion in the uninvolved joints, such as the elbow and wrist, and to maintain strong, supple hand and fingers. Exercises for elbow and wrist are initially performed in the sling, followed by maintaining the extremity in an appropriately safe position during elbow exercises. A squeeze-therapy ball can be used for the hand. Phase II, an intermediate phase, generally spans the 6th to 12th weeks of rehabilitation. Goals during this period generally consist of achieving full painfree ROM. To this end, active assisted ROM and more aggressive ROM exercises are used. During this phase, the patient works on normalization of arthrokinematics, increase in strength, and gaining neuromuscular control. Previous Phase I exercises are continued, with the addition of theraband and isotonic dumbbell

13 Table 2 Return to sports (overhead athletes) after shoulder surgery Study Year No. of Pts. Patient description Diagnosis Surgery Return to sport Sports/interval throwing program Return to competition Montgomery et al [56] Overhead athletes Recurrent anterior subluxation/dislocation Anterior capsulo-labral reconstruction 94% 3 6 mos 3 20 mos, Av 12 mos Morgan et al [57] Baseball pitchers SLAP Type II Arthroscopic Repair 84% 4 mos 7 mos Ellenbecker Athletes Instability Arthroscopic repair with No comment 3 4 mos 7 12 mos et al [58] thermal capsulorrhaphy Gartsman et al [59] Overhead athletes Instability Arthroscopic repair 89% No comment No comment Levitz et al [60] Baseball players Internal impingement Traditional arthroscopic 80% No comment 7.2 mos With thermal capsulorrhaphy 93% No comment 8.4 mos Dugas et al [61] Overhead athletes Laxity Thermal shrinkage 81% No comment 8.5 mos E.C. McCarty et al / Clin Sports Med 23 (2004)

14 348 E.C. McCarty et al / Clin Sports Med 23 (2004) exercises. Programs for the rhythmic stabilization of the glenohumeral joint and scapulothoracic stabilization protocols are important parts of this phase. Phase III, usually encompassing the 12th through the 20th weeks of rehabilitation, consists of both advanced and dynamic strengthening protocols. It requires more aggressive exercises, based on the type of patient and the ultimate goal for therapy. Goals during this period include the improvement of strength, power, endurance, and neuromuscular control. There are several criteria that must be met by the patient before the initiation of Phase III exercises. The patient must have full or nearly full pain-free ROM, and must have achieved strength measuring at least 70% of that on the contralateral side. Rehabilitation during this phase emphasizes dynamic stabilization, eccentric exercises, and strength in functional movements. Specific exercises are added for athletes in their various specialties during this time, to further prepare the athlete for return to sport. Phase IV represents return to activity, and generally encompasses the time period from 4 to 8 months postoperative. Criteria to enter Phase IV include full ROM without pain, tenderness, or apprehension. Exercises are continued from previous phases, and work-simulating and activity-related programs are followed to satisfactory conclusion. The overhead athlete must progress through an intervalthrowing program before advancement into an aggressive pitcher s program if appropriate. It is also important that the physician determine that all patients have achieved appropriate isokinetic strength, as well as mental preparedness. Ultimately, a careful clinical examination of the patient by the physician is essential before giving clearance for the return to sport, work, or vigorous activity. The importance of the appropriate rehabilitation cannot be overemphasized. It is critical for the surgeon to realize that many hours of careful exquisite surgery culminating in an excellent repair can be rapidly destroyed in a few minutes of careless rehabilitation. Two excellent resources with lengthy descriptions of various protocols are found in a section by Warren et al in The Unstable Shoulder [54], and in a section by Cohen et al in Clinical Orthopaedic Rehabilitation [55]. Generally, open procedures involving a takedown of the subscapularis require a longer period of avoidance of external rotation, to allow healing of the violated soft tissues, and to allow adequate healing of the subscapularis tendon before greater movement and arcs of motion. Open subscapularis splitting approaches to anterior instability allow for more aggressive early motion. Posterior procedures require a longer period of healing, due to the inherent nature of the posterior tissue quality and structures, as well as lack of a large tendinous buttress. After a posterior stabilization, an extended period of immobilization is often required, with the arm in a neutral position. Additionally, when returning to play, there must be greater protection from posterior-directed forces for longer periods of time, to allow maximum tissue healing. Often the rehabilitation for the athlete progresses at an advanced pace, and after the initial period of immobilization, overhead athletes need to progress in ROM activities at a quicker pace to regain important motion for their sports. Ultimately, it is important to recognize that a team approach among the surgeon, therapist, and patient is essential to achieve optimal results.

15 E.C. McCarty et al / Clin Sports Med 23 (2004) As the athlete progresses in rehabilitation, goals for return to play are: full pain-free functional range of motion, normal strength and endurance, and no apprehension. Once an athlete demonstrates that he or she is physically and mentally ready, then return may take place. If athletes have met these criteria and are able to participate without problems, a brace is not necessary. Summary A return to sports after a shoulder dislocation involves many factors. An understanding of the pathoanatomy and the natural history of shoulder dislocations is important when deciding upon treatment after a dislocation. As an athlete recovers from a dislocation, there are several factors that need to be looked at when considering a return to play. There are ideal criteria that give some guidelines for return; however, frequently the athlete will return after meeting some but not all criteria. Protective braces may help in the early return. After surgical stabilization, many of the same principles apply, but return to play should only occur after attainment of full strength, motion, stability, and confidence. References [1] Galinat BJ, Howell SM. The containment mechanism: the primary stabilizer of the glenohumeral joint. Orthop Trans 1987;11:458. [2] Howell SM, Galinat BJ. The glenoid-labral socket: a constrained articular surface. Clin Orthop 1989;243: [3] Harryman DT, Sidles JA, Harris SL, et al. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74: [4] Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 1990;18(1):25 8. [5] McLaughlin HL. Posterior dislocation of the shoulder. J Bone Joint Surg Am 1952;34: [6] McFarland EG. Voluntary glenohumeral instability. In: Jobe FW, editor. Operative techniques in upper extremity sports injuries. St. Louis (MO): Mosby; p [7] Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain in the overhand or throwing athlete. The relationship of anterior instability and rotator cuff impingement. Orthop Rev 1989;18(9): [8] Davidson PA, Elattrache NS, Jobe CM, et al. Rotator cuff and posterior-superior glenoid labrum injury associated with increased glenohumeral motion: a new site of impingement. J Shoulder Elbow Surg 1995;4(5): [9] Walch G, Boileau P, Noel E, et al. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg 1992;1: [10] Doukas WC, Speer KP. Anatomy, pathophysiology, and biomechanics of shoulder instability. Orthop Clin North Am 2001;32(3): [11] Tibone JE. Glenohumeral instability in overhead athletes. In: Bigliani L, editor. The unstable shoulder. Rosemont (IL): American Academy of Orthopaedic Surgeons; p [12] Jobe CM. Posterior superior glenoid impingement: expanded spectrum. Arthroscopy 1995;11(5): [13] Jobe CM. Superior glenoid impingement. Current concepts. Clin Orthop 1996;(330): [14] Tirman PF, Bost FW, Garvin GJ, et al. Posterosuperior glenoid impingement of the shoulder:

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