Shoulder Instability: Return to Play 335 Eric C. McCarty, Paul Ritchie, Harpreet S. Gill, and Edward G. McFarland

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1 RETURN TO PLAY Foreword Mark D. Miller xiii Preface Edward G. McFarland xv Return to Play for Rotator Cuff Injuries and Superior Labrum Anterior Posterior (SLAP) Lesions 321 Hyung Bin Park, Sung Kai Lin, Atsushi Yokota, and Edward G. McFarland The shoulder is a frequently injured joint in athletes, and the most common injuries in active patients include instability, rotator cuff injuries, and superior labrum lesions. These three types of injuries often involve different mechanisms of injury, variable methods of surgical repair, and different considerations in rehabilitation and return to play. This article focuses upon rotator cuff injuries and superior labrum lesions, treated nonoperatively and operatively. Return to play with these injuries depends upon many factors including upon the age of the patient, the severity of the pathology, the type of treatment rendered, and the expectations of the patient. Shoulder Instability: Return to Play 335 Eric C. McCarty, Paul Ritchie, Harpreet S. Gill, and Edward G. McFarland 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 VOLUME 23 NUMBER 3 JULY 2004 vii

2 occasionally affect them, it can be much more difficult to adapt or return to play 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. Return to Sport Following Elbow Surgery 353 Leigh Ann Curl Although less common than injuries to the knee or shoulder, elbow injuries can be a substantial challenge to sports medicine providers. Many elbow problems respond to routine nonoperative measures including periods of activity modification and physical therapy, but others may ultimately require surgery. Following surgery, appropriate attention to rehabilitation is important to achieve optimal function. This article addresses some of the more common sports-related operative elbow pathology, basic principals of surgery (with an emphasis on techniques only where it may impact rehabilitation or return-to-sport decisions), and return-to-play decisions (including typical targeted time frames). The emphasis is on an understanding of sport-specific functional demands and the difficult assessment of reinjury risk following surgery. Return to Play after Lumbar Spine Conditions and Surgeries 367 Jason C. Eck and Lee H. Riley III Low back pain in athletes can result from a wide variety of conditions. A detailed history and physical examination supplemented by appropriate imaging studies can lead to an accurate diagnosis. The majority of cases will be self-limiting and resolve within 6 weeks regardless of treatment, but it is important to be able to identify conditions that require specific treatment. The decision of when an athlete can return to active competition is determined by the specific condition, associated symptoms, and treatment provided. Most athletes can return to full unrestricted play after sufficient resolution of pain and restoration of range of motion. Athletes undergoing spinal fusion are typically restricted from full-contact sports. Return to Play Following Surgical Treatment of Meniscal and Chondral Injuries to the Knee 381 Thomas R. Bowen, Daniel D. Feldmann, and Mark D. Miller Much has been written in the sports medicine literature regarding return to competition following anterior cruciate ligament reconstruction; however, little scientific work has been done regarding the return to competition following meniscal surgery or cartilage surgery. This article reviews the basic science of meniscal surgery viii

3 and cartilage surgery in an attempt to promote rational rehabilitative protocols rooted in scientific investigation. A twofold approach is used. One approach is from a biologic standpoint; that is, when are the repaired tissues healed enough to withstand physiologic activity? The second approach is from a rehabilitative standpoint; when is the patient strong enough to play without recurrent injury? Return to Play after Anterior Cruciate Ligament Reconstruction 395 Brett M. Cascio, Lisa Culp, and Andrew J. Cosgarea The goal of knee ligament reconstruction is to return the athlete to the previous level of function as quickly and as safely as possible. The appropriate level of aggressiveness in returning the athlete to sport remains controversial. Information in the literature regarding safe return to play has been dominated by the anterior cruciate ligament (ACL) reconstruction literature. The basic concepts that hold true for returning the ACL-reconstructed athlete to play can be generalized to injuries treated nonoperatively as well. This article presents a review of the principles of rehabilitation following knee ligament reconstruction, with an emphasis on criteria for return to play. Transient Quadriplegia and Return-to-Play Criteria 409 Kim Fagan There will always be an inherent risk to participation in contact sports. Appropriate education of coaches, players, and parents is important. Recurrence rate is high in the athlete who has experienced transient quadriplegia or any neck injury, The athlete and his family should be made aware of this risk. Counseling is even more important, both from a medical and legal standpoint, in the patient with underlying spinal stenosis, found either incidentally or following an episode of transient quadriplegia. In these situations, consideration of consultation with a neurologist or neurosurgeon is prudent. Return to Play Following Sports-Related Concussion 421 Mark Lovell, Micky Collins, and James Bradley This article provides a review of current important issues in the management of athletes who have sustained a concussion during athletic competition. Recent research in the area of concussion management is reviewed with specific reference to the sideline evaluation of concussion and the follow-up of the athlete during the recovery period. The use of neuropsychological testing in sports is also reviewed. A systematic protocol for the management of sports related concussion is presented. ix

4 Pneumothorax and Pneumomediastinum 443 Margot Putukian Pneumothorax and pneumomediastinum occur uncommonly in association with athletic participation. Although they are rare, when they occur they can be life-threatening, requiring immediate diagnosis and treatment. These injuries also present difficult return-toplay decisions for the sports medicine physician. There are sparse data to help determine the incidence of these injuries in sport, as well as their optimal treatment. Although most sports physicians have seen these injuries, not many have seen enough to publish a large series discussing optimal management or make return-toplay recommendations. Cardiovascular Disease in Athletes 455 Chandrasekhar R. Vasamreddy, Daniyal Ahmed, Ty Gluckman, and Roger S. Blumenthal Cardiovascular disease (CVD) is the leading cause of death in the United States, resulting in increased awareness of the preventive importance of regular physical activity. Because athletes are considered physically fit, occurrence of sudden athlete death from CVD is perplexing. Regular intense physical activity can cause changes to the cardiovascular system that mimic known CVD processes. Therefore, screening of athletes for conditions that may increase risk for sudden cardiac death (SCD) is challenging. This article focuses on this problem, discussing the athlete s heart, SCD and associated CV conditions, and preparticipation screening. We also review recommendations of the 26th Bethesda Conference on determining eligibility for competition in athletes with known CV abnormalities, and how the recommendations relate to individual disease processes. Herpes Gladiatorum and Other Skin Diseases 473 Rob Johnson Musculoskeletal injury, appropriately, is the focus of time-loss from practice and competition. Nevertheless, skin infections are responsible for between 10% and 15% of time-loss injuries at the collegiate level. The risk of contagion has resulted in specific treatments dictated by the National Collegiate Athletic Association (NCAA) and National Federation of State High School Associations (NFHS) before an athlete can participate. These guidelines make identification and treatment by the athlete s physician imperative. This article provides the clinician with specific direction in addressing these dermatologic disorders. x

5 Infectious Mononucleosis: Return to Play 485 Paul G. Auwaerter Infectious mononucleosis most commonly affects adolescents and young adults with a febrile illness accompanied by pharyngitis, lymph node enlargement, and transient fatigue. The diagnosis is usually confirmed with demonstration of heterophile antibodies. Typical signs and symptoms are reviewed, along with pitfalls in diagnosis and management. The rare complication of splenic rupture serves to focus recommendations for returning athletes to strenuous physical activities. Because careful prospective studies of infectious mononucleosis in athletes are lacking, review of available literature suggests that clinicians may recommend a return to all sports in those without spleen enlargement 4 weeks after the onset of illness. Index 499 xi

Physical Examination of the Shoulder in the Primary Care Setting 783 John M. McShane, Michael J. Graveley, and Bruce D. Hopper

SPORTS MEDICINE, PART I Preface Vincent Morelli xiii Physical Examination of the Shoulder in the Primary Care Setting 783 John M. McShane, Michael J. Graveley, and Bruce D. Hopper Shoulder problems are