Return to play and recurrent instability
after in-season anterior shoulder instability: a prospective multicenter study.

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.

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. 

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?

by: Catherine E. Lewis and Adam B. Rosen, PhD, ATC
by: Jeffrey Driban

Related Posts:

Dickens, J., Owens, B., Cameron, K., Kilcoyne, K., Allred, C., Svoboda, S., Sullivan, R., Tokish, J., Peck, K., & Rue, J. (2014). Return to Play and Recurrent Instability After In-Season Anterior Shoulder Instability: A Prospective Multicenter Study The American Journal of Sports Medicine, 42 (12), 2842-2850 DOI: 10.1177/0363546514553181