Return to play and recurrent instability after in-season anterior shoulder instability: a prospective multicenter study.
Dickens JF, Owens BD, Cameron KL, Kilcoyne K, Allred CD, Svoboda SJ, Sullivan R, Tokish JM, Peck KY, Rue JP. Am J Sports Med. 2014 Dec;42(12):2842-50. doi: 10.1177/0363546514553181. Epub 2014 Nov 5.
Take Home Message: Returning the same season from a traumatic anterior shoulder dislocation or subluxation likely results in additional episodes of instability even after undergoing a strengthening and stability protocol. Self-report questionnaires immediately after initial injury may be useful in determining a return to play timeline.
Recommendations for the management of shoulder instability vary greatly, with no consensus among clinicians on the ideal treatment guidelines and return to play criteria. Therefore, the authors sought to identify outcomes after an acute bout of shoulder instability including the ability of an athlete to return-to-play, the amount of time lost, and the recurrence of shoulder instability upon returning to play in the same season as the initial injury. Researchers tracked three Division 1 NCAA institutions over a two year period. Participants were enrolled in the study if they suffered an in-season traumatic anterior instability injury and wanted to undergo a non-operative treatment protocol to compete. 45 athletes (42 male, 3 female, ~age = 21 years) were examined and categorized by the type of injury sustained, a subluxation or dislocation. All participants completed four different questionnaires that assessed shoulder function immediately after injury. Athletes then underwent an accelerated rehabilitation program previously described by Owens et al. An athlete who was asymptomatic, completed all prescribed rehabilitation, and able to perform sport-specific drills at full strength were cleared to return to full participation. Ultimately, thirty-three athletes returned to their sport for either all or part of the remainder of the season. Some surgeons recommended a functional shoulder brace but bracing failed to prevent additional in-season episodes of instability. Only 27% of the injured athletes returned without another episode of instability, regardless of the injury type (subluxation or dislocation). Athletes with a subluxation returned to play an average of 3 days and athletes with a dislocation returned to play an average of 7 days. 12 athletes failed to return to their sport after the first episode of instability and an additional 11 failed to finish the season after returning. The investigators found that questionnaire scores about shoulder function or symptoms immediately after an injury predicted return during the same season and how long it took them to return to play.
Although, this study had a relatively small cohort, the insight gained may be useful for clinicians. Despite having full strength after completing a rehabilitation protocol only 27% of participants returned to activity the same season with no additional episodes of instability. Surprisingly, the rate of recurrence was also similar whether it was a complete shoulder dislocation or subluxation. Dislocations are often regarded as more severe injuries when compared to subluxations. However, based on these results clinicians should be equally cautious of early return to play in cases with both dislocations or subluxations due to the high reoccurrence rates. Additionally, trauma has been shown to be a significant risk factor for early onset osteoarthritis. Multiple episodes of instability of the shoulder may leave it susceptible to premature development of osteoarthritis, making this finding more noteworthy. Another primary goal of this study was to assess the ability of questionnaires to successfully predict time-lost following initial injury. While, they were fairly successful in predicting time-loss following the injury through the self-report questionnaires, one has to question whether it’s worth the risk of the athlete suffering more traumatic events by returning them so quickly after initial injury, which the authors acknowledged. Although, we may want to balance both athlete and coaches wishes for early return to play, their future health should be taken into consideration. Athletes should be fully informed of the risks they may incur with early participation following a traumatic anterior instability event.
Questions for Discussion: Do you use a specific protocol for anterior shoulder instability rehabilitation? Which one? How long after a traumatic anterior instability event do you feel comfortable letting an athlete return back to play?
Written by: Catherine E. Lewis and Adam B. Rosen, PhD, ATC
Reviewed by: Jeffrey Driban
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