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In-season anterior shoulder instability: What is the risk in returning to play?
Shoulder instability is a common injury in contact and collision athletes. While the acute management is relatively straight forward, the controversy arises when considering the risks associated with return to play in athletes.
Shoulder instability encompasses a wide spectrum of injury from microinstability, through subluxations all the way to complete locked dislocations that require a manual reduction. To treat the in-season athlete with shoulder instability, one must understand the subtle differences in the types of anterior shoulder instability, the associated injury patterns, and the recurrence rates that are associated with return to play.
Jonathan F. Dickens
Brett D. Owens
Diagnosis
A shoulder dislocation is often obvious on the playing field and requires formal reduction by a provider. A shoulder subluxation, however, is often more subtle and presents as a transient instability event that does not require formal reduction by a healthcare provider. A high index of suspicion for instability is warranted in the young athlete with a shoulder complaint. Similar to a patient with a dislocation, an athlete with a subluxation may demonstrate a positive apprehension and relocation sign on exam.
Early advanced imaging is recommended to quickly identify labral tears or Hill-Sachs lesions. While a shoulder subluxation may appear more benign than a dislocation, the pathoanatomy of a traumatic, acute first-time anterior glenohumeral subluxation is remarkably similar to the first-time dislocation with a Bankart lesion observed more than 90% of the time.
Figure 1. Non-gadolinium enhanced MRI within 3 days of injury demonstrates a clear Bankart lesion, the visualization of which is enhanced by the hemarthrosis.
Source: Dickens JF; Owens BD.
Figure 2. Shoulder arthroscopy in the beach-chair position shows the Bankart lesion.
Source: Dickens JF; Owens BD.
Figure 3. Shown is arthroscopic Bankart repair with suture anchors.
Source: Dickens JF; Owens BD.
Return to play and recurrence
Return to play of the mid-season athlete with anterior glenohumeral instability is feasible and often in line with the athletes desired goals; however he or she must demonstrate full and symmetric range of motion and strength. Before full return to competition the athlete should complete a graduated reconditioning program that includes sport and position-specific exercises. While return to play is possible and has been accomplished in as many as 90% of athletes, recurrence is common and is the primary risk associated with early return to sport. More than one-third of athletes are expected to have a recurrent instability episode when returning to in-season sports, and on average athletes have more than one recurrent instability event per season. The long-term consequences of recurrent instability in the in-season athlete, however, are unclear but it seems likely that such trauma may lead to early shoulder arthritis and perhaps increased glenoid bone loss.
Case example
U.L. is a 22-year-old collegiate rugby player who sustained a first-time anterior glenohumeral dislocation event during play. He was reduced on the sideline emergently. His MRI was obtained within a few days and demonstrated a clear Bankart lesion (Figure 1). He returned to rugby at 1 week in a motion-restricting brace and played the remainder of the season, experiencing no recurrent dislocations but one subluxation event. At season’s end, he was treated with arthroscopic Bankart repair (Figures 2 and 3).
Discussion
In this case of a college rugby team captain, the additional trauma of one subluxation event over the remaining 2 months of the season was believed to be appropriate management. However, this patient could have just as easily experienced a recurrent dislocation despite the bracing, with additional pathologic changes to his cartilage, bone, and capsulolabral complex. It is becoming clear that each subsequent instability event results in attritional damage to these structures, however where we “draw the line” for an acceptable number of events as clinicians remains unclear.
References:
Owens BD. J Bone Joint Surg Am. 2010;doi:10.2106/JBJS.I.00851.
Taylor DC. Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med. 1997;25(3):306-311.
Owens BD. J Am Acad Orthop Surg. 2012;doi:10.5435/JAAOS-20-08-518.
Buss DD. Nonoperative management for in-season athletes with anterior shoulder instability. Am J Sports Med. 2004;32(6):1430-1433.