The Athlete s Shoulder
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- Charla Owens
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1 The Athlete s Shoulder Lennard Funk lenfunk@shoulderdoc.co.uk Decision Making NORMATIVE evidence base COGNITIVE environmental PSYCHOLOGICAL individual needs, bias, preferences, values Three P s 1. Major 1. Bony 2. ALPSA 3. HAGL 4. FTCT 2. Minor 1. Labral 2. PTCT Patient 1. Age 2. Gender 3. Laxity 4. Fatigue 5. Sport 6. Position 1. Season 2. Events 3. Pressure 4. Age Pathology Case 1 17year old male Rugby centre for school (captain) & premiership club feeder team First Disloc shoulder in tackle Mid-season Relocated in A&E Presents 1 week Some pain; unable to return to training
2 Some Facts: What you gonna do? Recurrence rate > 70% under 20 contact sports male Significant lesions Large Hill-Sachs Bony Bankart ALPSA HAGL Simonet, 1984 Wheeler, 1989 Arciero, 1994 Burkhart, 2001 Larrain, 2006 Mologne, 2007 Porcellini, 2009 MR Arthrogram 1. Return to play as comfortable 2. Arthroscopic Stabilisation 3. Latarjet 4. Other Surgery Considerations NORMATIVE evidence base 1. Always 2. Convenient limited 3. < 48hrs 4. > 48hrs 5. Risky without imaging 6. Surgery! What you gonna do? ALPSA lesion Small Hill-Sachs PATHOLOGY 1. X-Ray series 2. Ultrasound 3. MRI 4. MR Arthrogram 5. Return to play as comfortable 6. Dx Arthroscopy COGNITIVE environmental PRESSURES PATIENT PSYCHOLOGICAL individual needs preferences, values Most of the athletes were able to return to their sport and complete their seasons after an episode of anterior shoulder instability, although 37% experienced at least 1 additional episode of instability during the season.
3 Repair / Latarjet? There were no differences in recurrence or complication rate among patients undergoing surgery after the primary dislocation when compared with those undergoing surgery after multiple recurrent episodes. Repair / Latarjet? Age: ISIS - Balg & Boileau, JBJS(Br), 2007 Major Minor Bony Bankart Undisplaced Labral Tear ALPSA Partial Cuff Tear HAGL Hill-Sachs Lesion 92 Adolescent stabilisations (under 18) 3 surgeons; 5 year follow-up 91% Male; 78% rugby Considerations Lesions Rotator Cuff Tear (Torrance et al. AJSM 2018) PATHOLOGY NORMATIVE evidence base COGNITIVE environmental PRESSURES PATIENT PSYCHOLOGICAL individual needs preferences, values
4 Surgery Early Surgery: Large structural lesions Late in Season Unable to Return Younger Rehab & Return: Minor lesions Early season Older Professional Footballer Fell in match ++Pain and limited movement 4 weeks before the World Cup Some Facts: What you gonna do? Surgical Stabilisation Rehab & return
5 We conclude that the classification of AC joint injuries using a radiograph alone has limited reliability and consistency in clinical practice. ACJ Grade vs Symptoms Lack of reliability of the Rockwood classification of AC joint dislocations and of decisions regarding their treatment. Especially poor agreement between experienced shoulder surgeons. The addition of 3D CT did not improve reliability. Bradley & Elkousy, Clin Sport Med, 2003 The only advantage to operative intervention consistently borne out in the literature is an increased probability of anatomic reduction. There is no correlation between reduction and improvement in pain, strength, or motion. Treatment? ACJ Injuries (11yrs) 589 cases Operative OR Non-operative 116 sprains 197 Acute ACJ Disloc 276 Chronic ACJ Disloc When? } 288 Surgery 49%
6 MY Indications Approach Acute Injury < 1 week Symptoms Patient Demands Work demands Society demands Overhead Athlete Review 3 weeks Coping Review 3 months Surgical procedures >100 PUBLISHED!! 20% FAILURE RATE LARS Ligament 3 weeks post-op Not Coping Surgery
7 ACJ recon with LARS Ligament Marchegianno, Wright & Funk, KSSTA, 2014 LARS Ligament Outcomes Marchegianno, Wright & Funk, KSSTA, cases over 3 years 22 professional athletes (19 rugby) All > 6weeks post-injury Mean = 3.5 months LARS Ligament Outcomes All patients returned to their previous level of work & sports in a mean time of 3 months Mean patient satisfaction 93% One failed early (handstands at 3 weeks). summary 1. Early surgery very rarely needed 2. Treat the patient - not the Grade! 3. Reassess 3 weeks & 3 months 4. Copers vs. Non-copers 5. Rigid surgical fixation reconstructing ALL stabilising structures THANK YOU lenfunk@shoulderdoc.co.uk
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