'Batter's shoulder': can athletes return to play at the same level after operative treatment?

Jeor JD, Trasolini NA, Waterman BR. Batter's Shoulder: All-Knotless Posterior Labral Repair With Retensionable Anchors for Treatment of Batter's Shoulder

Batter's Shoulder is a unique injury that may be associated with recurrent microtrauma followed by acute subluxation of the humeral head on the posterior glenoid edge, leading to posterior labral tears. Early identification of this injury is critical, as it may be treated with conservative nonsurgical treatments prior to labral tear onset. If conservative treatment fails and pain persists, surgical options include arthroscopic fixation to reapproximate the posterior labrum to the glenoid and restore capsular tension. Previous studies have shown the benefit of using knotless suture anchors in arthroscopic shoulder fixation. This technical note demonstrates that Batter's Shoulder is a unique injury associated with posterior labral tears of the shoulder and provides a contemporary method of arthroscopic fixation of a posterior labral tear using retensionable knotless all-suture anchors.

Acute Batter's Shoulder With Concomitant Superior Labrum from Anterior to Posterior Injury in a Collegiate Baseball Player

An 18-year-old collegiate baseball player sustained an acute batter's shoulder injury causing a posterior shoulder dislocation with type IX 360° superior labrum from anterior to posterior tear. To the authors' knowledge, this description of batter's shoulder is not within the literature. The patient ultimately underwent arthroscopic labral repair and has fully returned to sport. In understanding the complexity of the shoulder during the batter's swing, this case demonstrates an expansion to the previously described pathophysiology of batter's shoulder.

Posterior Shoulder Instability in Tennis Players: Aetiology, Classification, Assessment and Management

Background

Micro-traumatic posterior shoulder instability (PSI) is an often missed and misdiagnosed pathology presenting in tennis players. The aetiology of micro-traumatic PSI in tennis players is multifactorial, including congenital factors, loss of strength and motor control, and sport-specific repetitive microtrauma. Repetitive forces placed on the dominant shoulder, particularly combinations of flexion, horizontal adduction, and internal rotation contribute to the microtrauma. These positions are characteristic for kick serves, backhand volleys, and the follow-through phase of forehands and serves. The aim of this clinical commentary is to present an overview of the aetiology, classification, clinical presentation, and treatment of micro-traumatic PSI, with a particular focus on tennis players.

Level of Evidence

5.

Return to Play After Shoulder Surgery in Professional Baseball Players: A Systematic Review and Meta-analysis

Background

The current literature lacks an updated review examining return to play (RTP) and return to prior performance (RTPP) after shoulder surgery in professional baseball players.

Purpose

To summarize the RTP rate, RTPP rate, and baseball-specific performance metrics among professional baseball players who underwent shoulder surgery.

Study Design

Systematic review; Level of evidence, 4.

Methods

A literature search was performed utilizing the PubMed, MEDLINE, and CINAHL databases and according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language studies reporting on postoperative RTP and/or RTPP in professional baseball players who underwent shoulder surgery between 1976 and 2016. RTP rates, RTPP rates, and baseball-specific performance metrics were extracted from qualifying studies. A total of 2034 articles were identified after the initial search. Meta-analysis was performed where applicable, yielding weighted averages of RTP and RTPP rates and comparisons between pitchers and nonpitchers for each type of surgery. Baseball-specific performance metrics were reported as a narrative summary.

Results

Overall, 26 studies featuring 1228 professional baseball players were included. Patient-level outcome data were available for 529 players. Surgical interventions included rotator cuff debridement (n = 197), rotator cuff repair (RCR; n = 43), superior labrum from anterior to posterior repair (n = 124), labral repair (n = 103), latissimus dorsi/teres major (LD/TM) repair (n = 21), biceps tenodesis (n = 17), coracoclavicular ligament reconstruction (n = 15), anterior capsular repair (n = 5), and scapulothoracic bursectomy (n = 4). Rotator cuff debridement was the most common surgical procedure, while scapulothoracic bursectomy was the least common (37.2% and 0.8% of interventions, respectively). Meta-analysis revealed that the RTP rate was highest for LD/TM repair (84.5%) and lowest for RCR (53.5%), while the RTPP rate was highest for LD/TM repair (100.0%) and lowest for RCR (27.9%). RTP and RTPP rates were generally higher for position players than for pitchers. Nonvolume performance metrics were unaffected by shoulder surgery, while volume statistics decreased or remained similar.

Conclusion

RTP and RTPP rates among professional baseball players were modest after most types of shoulder surgery. Among surgical procedures commonly performed on professional baseball players, RTP and RTPP rates were highest for LD/TM repair and lowest for RCR.

Evaluation, Treatment, and Outcomes of Batter's Shoulder

PURPOSE OF REVIEW

This article reviews the incidence of batter's shoulder, the relevant biomechanics that predispose the lead shoulder to a posterior instability event, the evaluation and workup of posterior labral injury, the surgical technique for arthroscopic posterior labral repair, the postoperative rehabilitation process, and the clinical outcomes and return to sport after treatment of batter's shoulder.

RECENT FINDINGS

New epidemiological studies have demonstrated the relatively low incidence of batter's shoulder at the professional baseball level with 85% of the injured players successfully returning to the sport with nonoperative management. However, recent studies have reinforced the limited historical literature that players requiring surgery are able to return to their prior sport at a high level. Batter's shoulder is a subtype of posterior glenohumeral instability caused by the significant forces experienced by the lead shoulder during the baseball swing. Although an uncommon injury, batter's shoulder is a source of significant time away from competition. In patients who do not improve with nonoperative management, arthroscopic posterior labral repair can reliably return players to sport. Future research studies should consider opportunities for injury prevention.

Swinging injuries in competitive baseball players

Injuries are common in competitive baseball players and can occur in all facets of the game. The majority of the existing literature on injuries in baseball players has focused on injuries secondary to the overhead throw with very little attention given to injuries sustained while batting. The baseball swing is a complex, often violent, motion that predisposes batters to a variety of injuries affecting the spine, trunk, pelvis, and extremities. Knowledge of injury patterns that commonly occur during the baseball swing and radiologic findings important to the treating physician can help radiologists provide accurate imaging interpretations that appropriately guide patient management.

Understanding Batter's Shoulder: Diagnosis, Treatment, and Outcomes

PURPOSE OF REVIEW

Though most of the attention in recent literature on baseball injuries has been paid to throwers, one often overlooked aspect of the game is the effect of the batter's swing on the shoulder. It is well known that the batter's lead shoulder can experience significant translational forces during the player's swing, and that these are increased following a missed swing. The purpose of this paper is to review the background and pathophysiology as well as clinical presentation and treatment of players with Batter's shoulder.

RECENT FINDINGS

Recent studies demonstrate that while nonoperative treatment of Batter's shoulder is still a viable first line of treatment, favorable outcomes have been reported with arthroscopic posterior labral repair for high level athletes. Batter's injury can cause significant pain and dysfunction in baseball hitters, especially during the follow through phase of swing. While conservative care can be attempted early, outcomes following arthroscopic posterior labral repair are favorable with a high rate of return to play.

Number of Months of Baseball in the Previous Year and Preseason Olecranon Tenderness: Risk Factors for Shoulder and Elbow Injuries in High-School Baseball Players

OBJECTIVE

To identify risk factors for shoulder and elbow injuries in high-school baseball position players and pitchers in the preseason history and physical examination.

DESIGN

Retrospective cohort study.

SETTING

Community high-school baseball.

PARTICIPANTS

Three hundred seventy-one male baseball players' mean age 15.0 ± 1.8 years.

OUTCOME MEASURES

A preseason history and physical examination was performed on all athletes. Injury information was collected by weekly self-report and athletic trainer injury logs throughout the season. Comparisons between injured and noninjured players were performed using t tests and χ 2 analyses. Binary logistic regression models were developed to identify risk factors for injury.

RESULTS

Seventy-six injuries were recorded over the season. In univariate analysis, the injured group had greater months of baseball participation ( P = 0.007) and shoulder visual analog scale for the past year ( P = 0.003). The injured group also had more olecranon tenderness ( P < 0.0001, odds ratio [OR] 2.9) and decreased elbow arc of motion. All other factors were not significantly different ( P > 0.05). In multivariable logistic regression, months per year of baseball participation was the only factor significantly associated with injuries ( P = 0.010, OR = 1.21).

CONCLUSIONS

Baseball players who developed arm injuries during a season were more likely to play more months of baseball and report shoulder pain in the previous year. The presence of preseason olecranon tenderness was associated with nearly triple the risk of injury during the season. Every additional month of baseball participation in the previous year was associated with a 1.2× increased odds of injury. The presence of glenohumeral internal rotation deficit was not a predictor of injury.

Shoulder Injuries in Professional Baseball Batters: Analysis of 3,414 Injuries Over an 8-Year Period

Purpose

To characterize the shoulder injuries experienced by baseball batters and position players (nonpitchers); to quantify the outcomes of these injuries with respect to time out of play, recurrence, and surgery rates; and to identify any injury patterns that are associated with worse outcomes.

Methods

Between 2011 and 2017, all Major League Baseball (MLB) and Minor League Baseball (MiLB) players who sustained shoulder injuries were identified using the MLB Health and Injury Tracking System (HITS). Injuries were included if they were sustained during baseball activity, resulted in at least 1 day missed (DM), and occurred in position players (nonpitchers).

Results

Over the study period, a total of 3,414 shoulder injuries occurred in batters, resulting in a sum of 68,808 DM and a mean of 22 DM per injury. Most injuries were a result of acute trauma (n = 2125; 62.2%) with throwing as the predominant activity (n = 1292; 38%). Rotator cuff strain/tears was the most common diagnosis (n = 790; 23.1%), and SLAP tears had the highest season-ending rate (35.3%) and need for surgery (45.1%). There was a lower frequency of surgery (6.2% vs 9.2%; P = .002) and reinjury (2.03% vs 3.62%; P = .007) in the throwing shoulder vs the nonthrowing shoulder. There was an increased frequency of surgery for the front versus the back batting shoulder (8.2% vs 6.2%; P = .031) with similar DM (20.7 vs 22.2; P = .333) and return to play rates (94.0% vs 92.2%; P = .135).

Conclusions

During the 7-season study period, there were a total of 3,414 shoulder injuries that resulted in nearly 70,000 days of out of play in professional baseball position players/batters (nonpitchers). Although pitchers were intentionally excluded from the analysis, throwing was still the most common mechanism of injury, and rotator cuff injuries were the most common injury. Labral tears were the most likely injury to be season ending and require surgery.

Clinical Relevance

This study is meant to help determine characteristics of shoulder injuries that occur in non-pitchers by focusing on professional baseball batters and position players. This information could be helpful to sports medicine practitioners and shoulder specialists to better prognosticate injury recovery.

Posterior Glenoid Osteotomy With Capsulolabral Repair Improves Resistance Forces in a Critical Glenoid Bone Loss Model

Background:

There is no widespread consensus on the surgical treatment of posterior shoulder instability with critical posterior glenoid bone loss.

Hypothesis:

That opening posterior glenoid wedge osteotomy with soft tissue repair would improve the resistance forces of instability when compared with soft tissue repair alone in the setting of 20% critical bone lose.

Study Design:

Controlled laboratory study.

Methods:

Native glenoid retroversion was measured on 9 shoulders using computed tomography (CT) scans. The humerus was potted in 90° of forward flexion and 30° of internal rotation relative to the scapula, and a posterior dislocation was performed to create a posterior capsulolabral injury model. The specimens were each taken through a fixed sequence of testing: (1) posteroinferior capsulolabral tear, (2) no glenoid bone loss with posteroinferior capsulolabral repair, (3) 20% posterior glenoid bone loss with posteroinferior capsulolabral repair, and (4) 20% glenoid bone loss with posterior glenoid opening wedge osteotomy and posteroinferior capsulolabral repair. Bone loss was created using a sagittal saw. The resultant peak forces with 1 cm of posterior translation were measured. A 1-way repeated-measures analysis of variance was used to compare mean force values.

Results:

After the initial dislocation event, all shoulders had a resultant posterior capsulolabral injury. The resulting labral injury was extended from 6- to 9-o’clock in all specimens to homogenize the extent of injury. Repairing the capsulolabral complex in the 20% posterior glenoid bone loss group did not result in a statistically significant increase in resistance force compared with the labral deficient group (34.1 vs 22.2 N; P = .068). When 20% posterior bone loss was created, the posterior glenoid osteotomy with capsulolabral repair was significantly stronger (43.8 N) than the posterior repair alone both with (34.1 N) and without (31.8 N) bone loss (P = .008 and .045, respectively).

Conclusion:

In the setting of critical posterior glenoid bone loss, an opening wedge posterior glenoid osteotomy with capsulolabral repair improved resistance to posterior humeral translation significantly compared with capsulolabral repair alone.

Clinical Relevance:

The results of this biomechanical cadaveric study may aid in surgical planning for this complex patient population.

Return to Sport After Surgical Management of Posterior Shoulder Instability: A Systematic Review and Meta-analysis

BACKGROUND

Posterior shoulder instability accounts for a small proportion of all shoulder instability, although it can affect athletes of all types, from contact to overhead athletes. Surgical treatment is quite successful in these patients; however, the literature reports a wide range of rates of return to sport.

PURPOSE/HYPOTHESIS

The purpose was to determine the return-to-sport rates after surgical stabilization for posterior shoulder instability. It was hypothesized that patients would experience a high rate of return to sport.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Embase, PubMed, and MEDLINE were searched for relevant literature from database inception until April 2020, and studies were screened by 2 reviewers independently and in duplicate for studies reporting rates of return to sport after surgical management of posterior shoulder instability. Demographic data as well as data on return to sport and functional outcomes were recorded. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias was assessed for all included studies.

RESULTS

Overall, 32 studies met inclusion criteria and comprised 1100 patients (1153 shoulders) with a mean age of 22.8 years (range, 11-65) and a mean follow-up of 43.2 months (range, 10-228). The pooled rate of return to any level of sport was 88% (95% CI, 84%-92%; I² = 68.7%). In addition, the pooled rate of return to the preinjury level was 68% (95% CI, 60%-76%; I² = 79%). Moreover, the pooled return-to-sport rate for contact athletes was 94% (95% CI, 90%-97%; I² = 0%), while for throwing athletes it was 88% (95% CI, 83%-92%; I² = 0%).

CONCLUSION

Surgical management of posterior shoulder instability resulted in a high rate of return to sport, as well as significant pain reduction and functional improvement in most patients. However, only two-thirds of athletes can return to their preinjury levels of sport.

Management of common upper extremity injuries in throwing athletes: a critical review of current outcomes

Given the rising incidence and prevalence of shoulder injuries in throwing athletes, this review aims to evaluate management options and outcomes of common shoulder injuries in overhead throwers. Laxity of the glenohumeral joint is often adaptive for overhead athletes to achieve the velocity necessary to compete in the professional ranks. Surgical repair of the stabilizers of the humeral head-specifically the labrum and rotator cuff-often causes inflammation, scarring, and overtensioning of the glenohumeral joint which lead to poor postoperative performance. Thus, nonsurgical management should be exhausted in this population before considering surgical intervention.

Home Run Derby Participation in Major League Baseball Players: Is There Associated Injury Risk and Impact on Second-Half Performance?

Background:

The Major League Baseball (MLB) All-Star Game (ASG) Home Run Derby (HRD) remains a highly anticipated event, during which contestants can take hundreds of maximum-effort swings en route to hitting a multitude of home runs. Critics have openly questioned the risk-benefit of HRD participation as it pertains to injury, alterations in swing mechanics, and timing.

Purpose:

To determine whether participation in the MLB ASG HRD was associated with both increased injury risk and decline in second-half performance in MLB players.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

MLB players who participated in the HRD between 2006 and 2019 were identified through publicly available internet databases. A control group of ASG participants who had the highest home run totals in the first half of the corresponding MLB season were selected as a control group. Multivariable linear regression was used to determine independent associations between HRD participation and batting metrics in the second half of the season. Multivariable logistic regression also assessed the impact of HRD participation on injured list placement during the second half of the concurrent MLB season.

Results:

A total of 114 HRD participants and 114 ASG participant controls competed during the study period. No statistically significant differences were seen in batting metrics in the second half of the MLB season between HRD participants and ASG controls, although HRD participants had a significantly lower wins-above-replacement statistic for the season compared with controls (4.69 ± 2.06 vs 5.33 ± 2.08; P = .021). HRD participation was not significantly associated with injury during the second half. The number of HRD rounds in which a player participated did not result in a statistically significant increased odds of injury during the second half of the MLB season.

Conclusion:

HRD participants did not have increased odds of being placed on the injured list during the second half of the MLB season compared with controls, nor did they experience second-half performance declines in offensive production versus controls when multivariable linear regression analysis was performed.

Return to Play After Arthroscopic Stabilization for Posterior Shoulder Instability-A Systematic Review

Purpose

To ascertain the rate and timing of return to play (RTP) and the availability of specific criteria for safe RTP after arthroscopic posterior shoulder stabilization.

Methods

Medline, EMBASE, and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to find studies on arthroscopic posterior shoulder stabilization. Studies were included if they reported RTP data or rehabilitation protocols and excluded if concomitant procedures influenced the rehabilitation protocol. Rate and timing of RTP, along with rehabilitation protocols, were assessed.

Results

This review found 25 studies, including 895 cases, meeting the study’s inclusion criteria. The majority of patients were male (82.7%), with an age range of 14 to 66 years and a follow-up range of 4 to 148.8 months. The overall RTP rate ranged from 62.7% to 100.0%, and 50.0% to 100.0% returned to the same level of play. Among collision athletes, the overall rate of RTP was 80.0% to 100.0%, with 69.2%-100.0% returning to the same level of play. In overhead athletes, the overall rate of RTP was 85.2% to 100.0%, with 55.6% to 100.0% returning to the same level of play. Four studies (128 patients) specifically addressed the timing of RTP, and the range to RTP was 4.3 to 8.6 months. Specific RTP criteria were reported in a majority of studies (60%), with the most reported item being restoration of strength (44%).

Conclusion

There is a high rate of return to sport after arthroscopic posterior shoulder stabilization, ranging from 4.3 to 8.6 months after surgery. Return to preinjury level is higher for collision athletes compared with overhead athletes. However, there is inadequate reporting of RTP criteria in the current literature, with no clear timeline for when it is safe to return to sport.

Level of Evidence

IV, systematic review of level II to IV studies

Return to sport after surgical treatment for posterior shoulder instability: a systematic review

Purpose

To report the rate of return to sport after surgical treatment for posterior shoulder instability among athletes.

Methods

A systematic review of the literature regarding rate of return to sport after surgical treatment for posterior shoulder instability was undertaken. The primary outcome measure was return to sport. The secondary outcome measures included rate of return to sport to preinjury level, time to return to sport, injury type, reoperations after primary surgery, and objective patient-reported outcome data. Data is summarized with ranges and tables.

Results

A total of 23 studies met inclusion criteria. The rate of return to sport ranged from 57.9%-100%. The rate of return to sport to the preinjury level ranged from 47.4%-100%. Time to return to sport ranged from 4.3-7.7 months. Furthermore, 66% of subjects had an acute traumatic injury and 34% were of insidious onset. The most commonly reported outcome measures were American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores and visual analog scale (VAS) pain scores. At a minimum of 1-year follow-up, ASES and VAS pain scores improved. Revision rates ranged from 0%-36.8%.

Conclusion

The systematic review demonstrated high rates of return to sport and relatively high rates of return to preinjury level of sport among all athletes who underwent surgical treatment for posterior shoulder instability. Objective patient-reported outcome metrics improved postoperatively whereas revision rates remained low.

Batter's Shoulder: Clinical Outcomes and Return to Sport

Background

Batter’s shoulder has been defined as an acute posterior subluxation of the lead shoulder during a baseball swing causing a traumatic tear of the posterior labrum. There are limited data correlating repair techniques with return-to-play information but none utilizing standardized outcome measures. The purpose of this study is to examine a case series of patients for postoperative return-to-play and obtain follow-up using standardized outcome measures.

Methods

We retrospectively identified 10 patients with a batter’s shoulder injury. Patients were included if they met the criteria for batter’s shoulder injury. We attempted contact via telephone to complete Western Ontario Shoulder Instability (WOSI) and Disability of Arm Shoulder and Hand (QuickDASH) evaluations. We successfully reached five of the patients. The minimum follow-up was one year and the maximum was 11 years.

Results

All five patients in our cohort were able to return to play at the previous level without limitation. Patients reported a very low percentage limitation on the WOSI and QuickDASH questionnaires and results are detailed further on. Range of motion (ROM) and strength were not affected.

Conclusion

Batter’s shoulder is an infrequent cause of posterior labral tearing, leading to a painful swing that can limit sports activity. In our limited series, all patients treated with arthroscopic repair were able to return to play at the previous level, confirming a significantly improved prognosis for a batter’s shoulder injury in contrast to return to play after other causes of posterior labral tears.

Posterior Labral Repairs of the Shoulder Among Baseball Players: Results and Outcomes With Minimum 2-Year Follow-up

BACKGROUND

There is a paucity of information regarding the treatment of posterior labral tears of the shoulder for baseball players. Reports regarding treatment and postoperative outcomes are more limited than its anterior and superior counterparts.

PURPOSE

To evaluate the clinical presentation, surgical findings, postoperative outcomes, and rate of return to sport after arthroscopic repair of posterior labral injuries of the shoulder among baseball players.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Retrospective review was performed of baseball players who underwent arthroscopic posterior labral repair between 2009 and 2015 by a single surgeon, with a minimum 2-year follow-up. The group was composed of 32 male patients involved in recreational (6.3%), high school (43.8%), college (31.3%), and professional (18.8%) baseball, with a mean age of 20.5 years. Patients were categorized by chief complaint, clinical findings, surgical findings, and concomitant procedures performed. Pre- and postoperative measures included pain scale, range of motion, American Shoulder and Elbow Surgeons shoulder score, return to play, and patient satisfaction.

RESULTS

A variety of tear patterns were identified; 32% involved 90° of the posterior superior labrum; 35% involved the posterior 180°; and 32% involved 90° of the posterior inferior labrum. The dominant mechanism of injury was throwing (34.4%). The most common chief complaint was pain (n = 25, 78%), followed by pain and instability symptoms (n = 6, 18.8%), with only 3% citing isolated sensation of instability. Magnetic resonance imaging clearly identified tear patterns in 75% of cases. American Shoulder and Elbow Surgeons scores significantly improved ( P < .0001), increasing on average 30.9 points from the preoperative mean of 65.4 to a postoperative mean of 96.3. No significant range of motion deficits were noted. Tear size and number of anchors utilized did not influence outcomes. Ninety-four percent of athletes returned to play, 61% at previous levels, and 6% did not return. Pitchers had a lower return to previous level of play than position players (41% vs 86%, P = .0113).

CONCLUSION

Arthroscopic treatment of posterior labral tears of baseball players was effective in improving pain and function, resulting in 94% patient satisfaction and 94% return to sport, with 61% returning to previous level of play. Patient presentation is variable, with a majority of patients citing pain rather than instability.

On-field Management of Shoulder and Elbow Injuries in Baseball Athletes

PURPOSE OF REVIEW

The goal of this review article is to help medical personnel of all levels and backgrounds identify and appropriately manage on-field acute shoulder and elbow injuries in the baseball athlete. This article discusses the most common acute shoulder and elbow injuries in baseball players along with recommendations for appropriate on-field management.

RECENT FINDINGS

Shoulder and elbow injuries are very common in baseball players and can be problematic because of the unique demands placed on the shoulder and elbow during the throwing and swinging motions. While many shoulder and elbow injuries in baseball players are chronic, some acute injuries, including dislocations and fractures, require urgent on-field management. Evaluation should begin with a broad assessment to rule out life-threatening emergencies prior to performing a neurovascular evaluation of the affected extremity. Red-flag signs during examination, such as difficulty breathing, asymmetric pulses, weakness, and limb discoloration, require emergent treatment. In the absence of an emergency, the evaluating medical team should complete a basic neurovascular exam before performing any further on-field care. Contusions, dislocations, and fractures are the most commonly seen acute shoulder and elbow injuries in baseball athletes. Athletic trainers and physicians caring for these athletes should be familiar with these injuries and their appropriate on-field management.

Outcomes of Arthroscopic Posterior Shoulder Stabilization in the Beach-Chair Versus Lateral Decubitus Position: A Systematic Review

Background:

Arthroscopic posterior shoulder stabilization can be performed with patients in the beach-chair (BC) and the lateral decubitus (LD) positions; however, the impact of patient positioning on clinical outcomes has not been evaluated.

Purpose:

To compare clinical outcomes and recurrence rates after arthroscopic posterior shoulder stabilization performed in the BC and LD positions.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines was performed by searching PubMed, Embase, and the Cochrane Library for studies reporting the clinical outcomes of patients undergoing arthroscopic posterior shoulder stabilization in either the BC or LD position. All English-language studies from 1990 to 2017 reporting clinical outcomes after arthroscopic posterior shoulder stabilization with a minimum 2-year follow-up were reviewed by 2 independent reviewers. Data on the recurrent instability rate, return to activity or sport, range of motion, and patient-reported outcome scores were collected. Study methodological quality was evaluated using the Modified Coleman Methodology Score (MCMS) and Quality Appraisal Tool (QAT).

Results:

A total of 15 studies (11 LD, 4 BC) with 731 shoulders met the inclusion criteria, including 626 shoulders in the LD position (mean patient age, 23.9 ± 4.1 years; mean follow-up, 37.5 ± 10.0 months) and 105 shoulders in the BC position (mean patient age, 27.8 ± 2.2 years; mean follow-up, 37.9 ± 16.6 months). There was no significant difference in the overall mean recurrent instability rate between the LD and BC groups (4.9% ± 3.6% vs 4.4% ± 5.1%, respectively; P = .83), with similar results in a subanalysis of studies utilizing only suture anchor fixation (4.9% ± 3.6% vs 3.2% ± 5.6%, respectively; P = .54). There was no significant difference in the return-to-sport rate between the BC and LD groups (96.2% ± 5.4% vs 88.6% ± 9.1%, respectively; P = .30). Range of motion and other patient-reported outcome scores were not provided consistently across studies to allow for statistical comparisons.

Conclusion:

Low rates of recurrent shoulder instability and high rates of return to sport can be achieved after arthroscopic posterior shoulder stabilization in either the LD or the BC position. Additional long-term randomized trials comparing these positions are needed to better understand the potential advantages and disadvantages of surgical positioning for posterior shoulder stabilization.

Patient Positioning in Arthroscopic Management of Posterior-Inferior Shoulder Instability: A Systematic Review Comparing Beach Chair and Lateral Decubitus Approaches

PURPOSE

To analyze the available literature pertaining to clinical outcomes and complications of posterior-inferior shoulder stabilization performed arthroscopically in either the beach chair (BC) or lateral decubitus (LD) position.

METHODS

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 3 databases (PubMed, EMBASE, and Medline) were searched up to January 2018 for English-language studies on posterior shoulder instability. Descriptive statistics are presented. The Methodological Index for Non-Randomized Studies (MINORS) scale was used to assess quality.

RESULTS

Twenty-five studies were included, examining 1,085 patients (n = 140 BC; n = 945 LD), of mean age 25.0 years, 27.1% female, and mean 3.1 years of follow-up. MINORS scores for BC and LD were 11.2 and 9.8, respectively. Regardless of positioning, patients did not differ across numerous outcomes and various surgical factors (e.g., number of portals, anchors, anchor types, concomitant pathology, or postoperative rehabilitation protocol). Postoperative patient satisfaction ranged from 85% to 87.5% and 93% to 100% for patients treated in BC and LD positions, respectively. Although not reported for BC, overall and preinjury return-to-play (RTP) rates in LD patients ranged from 72% to 100% and 55% to 100%, respectively, returning from 3 to 7.6 months postoperatively. Failure rates in the BC and LD positions ranged from 0% to 9.4% and 0% to 29%, respectively. There were no differences in reported incidences of neuropraxia, stroke, nonfatal pulmonary embolus, vision loss, cardiac arrest, or other positioning-related complications.

CONCLUSIONS

Arthroscopic management of posterior-inferior shoulder instability has a successful track record and minimal complication profile. Although patient positioning appears to influence results, with those treated in the LD position experiencing marginally higher patient satisfaction and failure rates, the current data prevent any conclusions being made regarding the superiority of one approach over another. As the clinical relevance of patient positioning remains to be determined, larger, higher-level study designs with long-term follow-up are required.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Systematic Review of Outcomes Reporting in Professional Baseball: A Call for Increased Validation and Consistency

BACKGROUND

Historically, treatment efficacy of professional baseball injuries has been determined by assessing the return-to-play (RTP) rate or using patient-reported functional outcomes scores; however, these methods may not be sensitive and specific enough for elite athletes. As a consequence, performance-based statistics are increasingly being reported in the medical literature.

PURPOSE

To (1) assess how treatment efficacy is currently reported in professional baseball players; (2) examine the variability in the reporting of these measures in terms of frequency, length of time followed, and units of measure; and (3) identify any attempts to validate these performance-based statistics.

STUDY DESIGN

Systematic review.

METHODS

All studies reporting treatment efficacy in professional baseball in PubMed, Embase, and Cochrane were identified. Data collected included frequency and method of reporting: RTP, functional outcomes, and performance-based statistics.

RESULTS

Fifty-four studies met all inclusion criteria. Of these, 51 (94%) reported RTP, 12 (22%) utilized functional outcomes, and 18 (33%) provided baseball-specific performance-based statistics to assess treatment efficacy. Great variability was seen in how follow-up was defined (games, seasons, months), duration of follow-up, and which performance-based statistics were utilized. None of the studies validated these performance-based statistics, determined minimal time of follow-up needed, or assessed the baseline variability in these statistics among noninjured players.

CONCLUSION

Most studies reported RTP to determine treatment efficacy, but significant variability was seen in how players were followed. Similarly, great variability was noted in the type and number of performance-based statistics utilized. Additional studies are necessary to validate these measures and determine the appropriate length of time that they should be followed.

CLINICAL RELEVANCE

This study provides a clear overview of the current methods that are used to determine treatment efficacy in professional baseball players.

Arthroscopic Labral Repair in the Setting of Recurrent Posterior Shoulder Instability

Posterior shoulder instability, although relatively rare in the general population, is more commonly seen in athletes, especially those in contact sports. Although nonoperative treatment has been associated with satisfactory results in the setting of posterior shoulder instability, conservative management may ultimately fail and lead to recurrence particularly in young, male patients. Both arthroscopic and open repair techniques to address posterior instability have been described, with each showing positive patient-reported outcomes, low risk of recurrence, and considerably high return-to-sport rates. In particular, arthroscopic treatment includes the following: capsular plication and knotted and/or knotless suture anchor fixation. The purpose of this technique is to describe our preferred technique to treat recurrent posterior shoulder instability through arthroscopic labral repair using knotless suture anchor fixation.

Arthroscopic Shoulder Surgery in Female Professional Tennis Players: Ability and Timing to Return to Play

OBJECTIVE

To assess the outcome and time to return to previous level of competitive play after shoulder surgery in professional tennis players.

DESIGN

Retrospective case series.

SETTING

Tertiary academic centre.

PATIENTS AND INTERVENTIONS

The records of all female tennis players on the Women's Tennis Association (WTA) professional circuit between January 2008 and June 2010 were reviewed to identify players who underwent shoulder surgery on their dominant (serving) shoulder.

MAIN OUTCOME MEASURES

Primary outcomes were the ability and time to return to professional play and if they were able to return to their previous level of function as determined by singles ranking. Preoperative and postoperative singles rankings were used to determine rate and completeness of return to preoperative function.

RESULTS

During the study period, 8 professional women tennis players from the WTA tour underwent shoulder surgery on their dominant arm. Indications included rotator cuff debridement or repair, labral reconstruction for instability or superior labral anterior posterior lesion, and neurolysis of the suprascapular nerve. Seven players (88%) returned to professional play. The mean time to return to play was 7 months after surgery. However, only 25% (2 of 8) players achieved their preinjury singles rank or better by 18 months postoperatively. In total, 4 players returned to their preinjury singles ranking, with their peak singles ranking being attained at a mean of 2.4 years postoperatively.

CONCLUSIONS

In professional female tennis players, a high return to play rate after arthroscopic shoulder surgery is associated with a prolonged and often incomplete return to previous level of performance. Thus, counseling the patient to this fact is important to manage expectations.

LEVEL OF EVIDENCE

Level IV-Case Series.

Outcomes Following Arthroscopic Repair of Posterior Labral Tears in Patients Older Than 35 Years

Although the results of arthroscopic management of posterior labral pathology in young athletes have been reported extensively in the literature, the clinical outcomes in older patients are unknown. This retrospective review included patients older than 35 years who underwent arthroscopic posterior labral repair. Functional outcome scores were collected, and subgroup analyses were performed to evaluate the impact of patient-specific factors. Forty-three patients met the inclusion criteria; average follow-up was 36.9 months (range, 24-54 months). Mean patient age at the time of surgery was 40.9 years (range, 35-57 years). Average outcome scores at final follow-up were Quick Disabilities of the Arm, Shoulder and Hand Scale (QuickDASH), 19±22; Simple Shoulder Test (SST), 9.9±3; Western Ontario Shoulder Instability Index (WOSI), 601±546; and Single Assessment Numeric Evaluation (SANE), 79.6%±23.4%. No significant differences in outcomes were observed in patients with preoperative symptomatic instability, active workers' compensation claims, or traumatic injury (P>.05). The presence of intraoperatively definable chondral damage (Outerbridge grade III or higher) was associated with significantly worse final functional outcomes (QuickDASH: 29 vs 11.9, P=.03; SST: 8.5 vs 10.9, P=.02; WOSI: 875 vs 407, P=.01; and SANE: 70.6% vs 86%, P=.05). One patient (2%) experienced a minor postoperative complication, and 3 patients (7%) required subsequent procedures: 2 total shoulder arthroplasties and 1 revision labral repair. The results of arthroscopic posterior labral repair in patients older than 35 years were variable and worse than those previously reported in younger patients. The presence of chondral damage at the time of the index procedure was a negative predictive factor. [Orthopedics. 2017; 40(2):e305-e311.].

Posterior Shoulder Instability

CONTEXT

Posterior shoulder instability has become more frequently recognized and treated as a unique subset of shoulder instability, especially in the military. Posterior shoulder pathology may be more difficult to accurately diagnose than its anterior counterpart, and commonly, patients present with complaints of pain rather than instability. "Posterior instability" may encompass both dislocation and subluxation, and the most common presentation is recurrent posterior subluxation. Arthroscopic and open treatment techniques have improved as understanding of posterior shoulder instability has evolved.

EVIDENCE ACQUISITION

Electronic databases including PubMed and MEDLINE were queried for articles relating to posterior shoulder instability.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

In low-demand patients, nonoperative treatment of posterior shoulder instability should be considered a first line of treatment and is typically successful. Conservative treatment, however, is commonly unsuccessful in active patients, such as military members. Those patients with persistent shoulder pain, instability, or functional limitations after a trial of conservative treatment may be considered surgical candidates. Arthroscopic posterior shoulder stabilization has demonstrated excellent clinical outcomes, high patient satisfaction, and low complication rates. Advanced techniques may be required in select cases to address bone loss, glenoid dysplasia, or revision.

CONCLUSION

Posterior instability represents about 10% of shoulder instability and has become increasingly recognized and treated in military members. Nonoperative treatment is commonly unsuccessful in active patients, and surgical stabilization can be considered in patients who do not respond. Isolated posterior labral repairs constitute up to 24% of operatively treated labral repairs in a military population. Arthroscopic posterior stabilization is typically considered as first-line surgical treatment, while open techniques may be required in complex or revision settings.

The Porcellini test: a novel test for accurate diagnosis of posterior labral tears of the shoulder: comparative analysis with the established tests

QUESTIONS/PURPOSES

Although the posterior labral tears of the shoulder are known for their disabling clinical course, especially in overhead athletes, no clinical test used in isolation can diagnose it accurately in the preoperative period. We wanted to: (1) introduce "Porcellini test" with its radiological verification furnishing the anatomical basis of its mechanism; (2) determine its accuracy; and (3) compare its accuracy with that of the other established tests for diagnosing posterior labral tears of the shoulder.

METHODS

To determine the anatomical basis, we initially performed radiological verification of our test. Then, we evaluated its accuracy in a retrospective case-controlled study on 310 consecutive patients who underwent shoulder arthroscopic procedures at our hospital between January 2013 and December 2013. All patients were examined preoperatively for Porcellini test, and the presence of posterior labral tear was confirmed on arthroscopy. Later, in a cohort study on 91 consecutive patients who underwent shoulder arthroscopic procedures, we compared its accuracy with O'Brien's test, the Kim test, the Jerk test, and the Load and Shift test. The accuracy was interpreted in terms of sensitivity, specificity, and predictive values.

RESULTS

The radiological verification conferred the anatomical basis for the mechanism of the Porcellini test. This new test showed high accuracy for posterior labral tears with sensitivity of 100 %, specificity of 99.3 %, the positive and negative predictive values of 92.6 and 100 %, respectively. Also, it had superior accuracy results than every other test. The interexaminer reliability for all test results was found to be >0.80.

CONCLUSIONS

We propose "Porcellini test" as a simple, accurate, reproducible, and reliable test for the preoperative diagnosis of posterior labral tears of shoulder.

Posterior shoulder instability in the athletic population: Variations in assessment, clinical outcomes, and return to sport

Posterior instability of the shoulder is becoming an increasingly recognized shoulder injury in the athletic population. Diagnostic elements, such as etiology, directionality, and degree of instability are essential factors to assess in the unstable athletic shoulder. Concomitant injuries and associated pathologic lesions continue to be a significant challenge in the surgical management of posterior shoulder instability. Return to sport and previous level of play is ultimately the goal for every committed athlete and surgeon, thus subpopulations of athletes should be recognized as distinct entities requiring unique diagnostic, functional outcome measures, and surgical approaches.

Posterior Instability of the Shoulder: A Systematic Review and Meta-analysis of Clinical Outcomes

BACKGROUND

To date, there are no reports in the literature of a systematic review and meta-analysis for posterior instability of the shoulder.

PURPOSE

The primary objective was to systematically capture, critically evaluate, and perform a meta-analysis of all available literature on arthroscopic clinical outcomes to provide insight and clinical recommendations for unilateral posterior shoulder instability. The secondary objective was to use the same means to assess clinical outcome literature for open treatment, of which a subset of highly reported outcome measures were used to determine superiority of arthroscopic versus open procedures for unilateral posterior shoulder.

STUDY DESIGN

Systematic review, meta-analysis.

METHODS

A systematic search to obtain every available, published, level of evidence study reporting patient data for unidirectional posterior shoulder instability was performed by use of the Cochrane Database of Systematic Reviews, PubMed/Medline database, manual searches of high impact factor journals and conference proceedings, and secondary references appraised for studies meeting inclusion criteria.

RESULTS

The systematic search captured a total of 1035 publications. After initial exclusion criteria were applied, 607 abstracts were assessed for eligibility. Full-text articles were obtained for 324 articles, and a total of 53 unique publications (27 arthroscopic studies, 26 open studies) reporting clinical outcomes for unidirectional posterior shoulder instability met inclusion criteria and were included in the systematic review and meta-analysis.

CONCLUSION

Well-defined and uniform shoulder outcome measures to assess posterior shoulder instability are lacking throughout the literature. However, arthroscopic procedures are shown to be an effective and reliable treatment for unidirectional posterior glenohumeral instability with respect to outcome scores, patient satisfaction, and return to play. Despite similar results of outcome measures to the overall athletic population, throwing athletes are less likely to return to their preinjury levels of sport compared with contact athletes or the overall athletic population. Evidence also indicates that arthroscopic stabilization procedures using suture anchors result in fewer recurrences and revisions than anchorless repairs in young adults engaging in highly demanding physical activity. Furthermore, the literature suggests that patients treated arthroscopically have superior outcomes compared with patients who undergo open procedures with respect to stability, recurrence of instability, patient satisfaction, return to sport, and return to previous level of play.

"Motionyms": activity-related musculoskeletal and medical problems (or "not an eponym!!")

Many common conditions in sports medicine are eponymous; that is, they are named for the person first describing or popularizing the diagnosis. But other medical conditions are named for the action or activity that is associated with the pathology. This article lists and references these conditions, and suggests that this group of conditions should be called "motionyms".

Spectrum of shoulder injuries in skeletally immature patients

This article evaluates the spectrum of epidemiology and treatment of children presenting with shoulder pain. These injuries are discussed to further understand the mechanism of injury, the variation of these injuries with age, treatment options, and outcomes and complications that may arise. A retrospective clinical review was performed to compliment the findings of the literature review.

Posterior instability caused by batter's shoulder

In summary, batter’s shoulder is a rare and only recently recognized entity. This condition is posterior shoulder instability caused by a missed attempt at hitting a pitch, especially with an outside pitch. The lack of counterforce from hitting a ball produces increased forces imparted on the posterior capsulolabral complex of the lead shoulder during batting. If the player fails conservative management, she or he can undergo an arthroscopic posterior labral repair instead of debridement. After treatment, the player can expect to return to play after approximately 6 to 7 months. Initial results from a small, retrospective series demonstrate greater than 90% excellent results. These findings are similar to current literature for arthroscopic treatment of posterior instability, which reports success rates that range from 75% to 91%. Longer-term follow-up will be needed to determine the natural history and prognosis or batter’s shoulder. Based on initial results, the authors predict good to excellent results for most players with batter’s shoulder who undergo proper treatment. Additionally, with the exception of switch hitters, the nonthrowing arm is affected. This can also improve the athlete’s return to play.