Return to Play and Outcomes in Baseball Players After Superior Labral Anterior-Posterior Repairs

Ultrasound-Guided Hydrodissection of the Thoracodorsal Nerve and Axillary Nerve in a Gymnast With Shoulder Pain Associated With Superior Labral Anterior-Posterior Lesions: A Case Report

A 20-year-old male national-level gymnast presented with left shoulder pain attributed to a superior labral anterior-posterior (SLAP) lesion. Physical examination revealed pain in the anterosuperior area at maximum shoulder elevation, with a positive combined abduction test and horizontal flexion test indicating a restriction in glenohumeral joint motion. Rather than directly addressing the SLAP lesion, ultrasound-guided hydrodissections of the thoracodorsal and axillary nerves were performed, leading to immediate alleviation of pain and mobility constraints. This innovative approach, emphasizing shoulder function, offers a novel therapeutic strategy for SLAP-associated shoulder pain in athletes.

Return to Sport at Preinjury Level is Common After Surgical Treatment of SLAP Lesions: A Systematic Review and a Meta-analysis

BACKGROUND

Patients undergoing surgery for Superior-Labrum-anterior-to-posterior (SLAP) lesions are often worried about their return to sport performance. This systematic review determined the rate of return to sport and return to sport at the previous level (RTSP) after surgery for SLAP lesion.

MATERIALS AND METHODS

The PRISMA guidelines were followed. Meta-analysis of data through forest plot projections was conducted. Studies were divided and analyzed according to the type of interventions (isolated slap repair or SLAP repair with rotator cuff debridement and biceps tenodesis).

RESULTS

The mean overall rate of return to sport after the procedures was 90.6% and the mean overall rate of return to sport at the previous level after the procedures was 71.7%. RTSP rates of the whole population were 71% (95% CI: 60%-80%), 66% (95% CI: 49%-79%), and 78% (95% CI: 67%-87%) for isolated SLAP repair, SLAP repair with the rotator cuff debridement and biceps tenodesis, respectively. A lack of subgroup analysis for the specific performance demand or type of lesion related to the surgical technique used might induce a high risk of bias.

DISCUSSION

Return to sports at the previous level after surgically treated superior labrum anterior to posterior lesion is possible and highly frequent, with the highest rates of RTSP in patients treated with biceps tenodesis. More studies and better-designed trials are needed to enrich the evidence on indications of SLAP surgical treatment in relation to specific sports-level demand.

LEVEL OF EVIDENCE

Level-IV.

Outcomes and Return to Sport After Knee Osteochondral Allograft Transplant in Professional Athletes

Background

Limited data are available on the outcomes and return-to-sport rates after osteochondral allograft transplant in professional athletes.

Purpose

To evaluate the experience of a single senior surgeon in treating professional athletes with osteochondral allograft transplant, including analyzing clinical outcomes and return to sport.

Study Design

Case series; Level of evidence, 4.

Methods

The authors performed a retrospective review of professional athletes treated with primary osteochondral allograft to the knee between January 1, 2001, and January 1, 2021, by a single surgeon. Athletes were required to play at the professional level in their sport and have a minimum of 2 years of follow-up. Return-to-sport rates and timing were evaluated. Patient-reported outcomes were assessed preoperatively and at final follow-up. Reoperations and failures were also tabulated.

Results

The study included 15 professional athletes who represented a variety of sports, with follow-up at a mean of 4.91 ± 2.2 years (range, 2.0-9.4 years). The majority (8 athletes; 53%) had undergone prior surgeries to the operative knee. Eleven (73%) returned to sport at a mean of 1.22 ± 0.4 years (range, 0.75-2 years), and of the 8 undergoing isolated osteochondral allograft, 7 (87.5%) returned at 1.28 ± 0.3 years. Ten athletes (66.7% of total; 90.9% of those who returned) returned to sport at the same level or higher compared with before surgery. Significant improvements were seen in each assessed patient-reported outcome score at final follow-up. Two of the 3 (66.7%) patients who underwent concomitant meniscal allograft transplant were able to return to sport at the same level or higher than presurgery. Three (20%) underwent second-look arthroscopy, 1 (6.7%) of whom underwent cartilage debridement of the osteochondral allograft.

Conclusion

Osteochondral allograft transplant in professional athletes can result in a high rate of return to play at a similar or higher level as presurgery, even when performed with concomitant procedures such as meniscal allograft transplant. High-level athletes should expect significant postoperative improvement in clinical outcomes.

Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study

Background

Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors-such as age and sports played-affect the treatment algorithms, even across similarly classified SLAP tears.

Purpose

To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement.

Results

There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case.

Conclusion

This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.

Return to Play After Shoulder Arthroscopy in Major League Baseball Pitchers vs Position Players

Background

Recovery from shoulder arthroscopy may vary between professional pitchers and position players in Major League Baseball (MLB). The time that it takes to return to play (RTP) and the level of skills to be regained after surgery are important factors for an athlete to consider when making career decisions.

Purpose

To identify MLB players who had arthroscopic shoulder surgery and observe their rates of RTP to MLB and the minor league, as well as to compare pre- and postinjury performance statistics and career metrics.

Study Design

Descriptive epidemiology study.

Methods

Public records (press releases, http://www.prosportstransactions.com, http://www.baseball-reference.com) were searched and analyzed to determine the number of days from shoulder arthroscopy to RTP and pre- and postinjury statistics for pitchers and position players in the MLB and minor league from 1998 to 2018. To meet inclusion criteria, a player must have undergone shoulder arthroscopy after having played at least 1 game in the MLB and had no identifiable concomitant injuries.

Results

Of 134 players, 89 (66.4%) returned to MLB. Fifty-four of 89 pitchers (60.7%) and 35 of 45 position players (77.8%) returned to MLB (P = .048). Forty-nine of 54 pitchers (90.7%) and 23 of 35 position players (65.7%) who returned to MLB returned to the minor league first. The mean time to RTP was 469.6 days (range, 100-1079 days) for pitchers and 301.6 days (range, 94-1488) for position players (P = .002). The WAR statistic (wins above replacement) for the pitchers decreased significantly (P = .004) after shoulder arthroscopy.

Conclusion

MLB position players returned to play at higher rates and more quickly than did pitchers. The WAR statistic declined in pitchers during the first season of RTP. Players undergoing arthroscopic shoulder surgery should be aware of these possible outcomes in time to RTP and postoperative performance.

Return to Sport After Arthroscopic Capsular Repair in Elite Baseball Players

Background

Chronic attritional midsubstance capsular tears arising from repetitive throwing stress are a rare but important source of pain and dysfunction in elite baseball players; however, little is known regarding outcomes after arthroscopic capsular repair.

Purpose

To evaluate the patient-reported outcomes and return-to-sport (RTS) rates after arthroscopic capsular repair in elite baseball players.

Study Design

Case series; Level of evidence, 4.

Methods

We identified 11 elite-level baseball players who were treated with arthroscopic repair for a midsubstance glenohumeral capsular tear by a single surgeon with a uniform approach and a standardized postoperative protocol between 2012 and 2019. All players had at least 2 years of follow-up data. Demographic data and concomitant surgical procedures were recorded. Preoperative and postoperative Kerlan-Jobe Orthopaedic Clinic (KJOC) scores and Single Assessment Numeric Evaluation (SANE) scores were collected in a subset of the cohort, and statistical comparisons were made. A telephone survey was conducted to determine the patients' RTS level and outcome scores. Statistical comparisons between preoperative and postoperative outcomes scores were made using t tests.

Results

Eight major league players, 1 minor league player, and 2 collegiate players were included. There were 9 pitchers, 1 catcher, and 1 outfielder. All patients had debridement of the posterosuperior labrum and rotator cuff. Two pitchers underwent a rotator cuff repair, and 1 outfielder underwent a posterior labral repair. The mean age at the time of surgery was 26.9 years (range, 20-34 years), with a mean follow-up of 3.5 years (range, 2.6-5.9 years). There were significant preoperative versus postoperative improvements in the mean KJOC (20.6 vs 89.8; P = .0002) and SANE (28.3 vs 86.7; P = .001) scores. All patients reported a high degree of satisfaction. At a mean of 16.3 months (range, 6.5-25.4 months), 10 of 11 (90.1%) players met the Conway-Jobe good or excellent criteria for RTS.

Conclusion

Arthroscopic capsular repair provided significant improvements in functional outcomes in elite baseball players, high levels of patient satisfaction, and high levels of RTS.

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.

Clinical outcomes and return to play in softball players following SLAP repair or biceps tenodesis

BACKGROUND

Shoulder pain due to labral tears and biceps tendonitis is commonly found in softball players. Surgical options include labral repair and biceps tenodesis. Although past studies are limited by heterogeneous study groups from multiple sports, this is the first study that assesses clinical outcomes and return to play rates for fast-pitch softball players.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the clinical outcomes and return to play for fast-pitch softball players treated for a superior labrum anterior posterior (SLAP) tear and recalcitrant biceps tendonitis with a biceps tenodesis compared with a traditional SLAP repair. We hypothesized that the biceps tenodesis would have comparable outcomes with a faster return to play compared with SLAP repair.

METHODS

We performed a retrospective analysis on fast-pitch softball players treated surgically for SLAP tear, recalcitrant biceps tendonitis, or a combination between 2001 and 2019 at our institution. Inclusion criteria were fast-pitch softball players who underwent biceps tenodesis or a SLAP repair with greater than 2-year follow-up. Exclusion criteria involved slow-pitch softball players, patients with less than 2-year follow-up, and patients who had undergone concomitant procedures on the ipsilateral shoulder at the time of SLAP repair or biceps tenodesis. Follow-up was either self-reported through OBERD, a patient-reported outcomes (PRO)-managing software, or achieved over the phone. Follow-up data included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Andrews Carson Score, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score, Numeric Rating Scale for Pain, and our institution-specific return-to-play questionnaire. We statistically compared players who underwent biceps tenodesis or a SLAP repair, and compared pitchers with position players using Student t tests and Fisher exact test with statistical significance determined to be P < .05.

RESULTS

From 60 eligible patients identified, follow-up outcome data were successfully captured for 47 (78%). Of the 18 SLAP repair patients, 17 (94%) returned to full competition at an average of 7.9 months. Of the 29 patients who underwent biceps tenodesis, 27 (93%) returned to full competition at an average of 7.1 months. Statistical analysis of PRO scores for each group found no significant differences between any of the measures used to evaluate patient outcomes, including no statistical difference in pitchers compared with position players.

CONCLUSION

In conclusion, this study demonstrated comparable outcomes between SLAP repairs and biceps tenodesis procedures among our study group of fast-pitch softball players. There was no significant difference between RTP times between the 2 groups.

Moderate Return to Play and Previous Performance After SLAP Repairs in Competitive Overhead Athletes: A Systematic Review

PURPOSE

To perform a systematic review of return to play (RTP) and return to previous level of performance (RPP) in competitive overhead athletes after SLAP repair to identify factors associated with failure to RTP.

METHODS

Systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Review was registered with PROSPERO International prospective register of systematic reviews (CRD42020215488). Inclusion criteria were literature reporting RTP or RPP following SLAP repair in overhead athletes were run in the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Categories for data collection for each full article included (1) article information; (2) patient demographics; (3) surgical techniques; (4) level of competition; (5) rotator cuff treatment; (6) player position; (7) patient-reported outcome measures; and (8) RTP and RPP rates. The Methodological Index for Non-randomized Studies checklist was used to evaluate quality of all included studies.

RESULTS

Eight studies with 333 subjects were identified. Overall RTP and RPP rates were 50% to 83.6% and 35.3% to 64%, respectively. Patients with surgically treated rotator cuff pathology had lower RTP (12.5%-64.7%) rates compared with those without (80.0%-83.6%). Professional athletes had similar RTP rates (62.5%-81.5%) compared with high-school (75.0%-90.0%) and college athletes (12.5%-83.3%). However, professional athletes demonstrated the lowest relative range of reported RPP rates (27.7%-55.6%). Pitchers had lower RTP (62.5%-80.0%) and RPP (52.0%-58.9%) compared with position players (91.3% RTP, 76.3%-78.2% RPP).

CONCLUSIONS

Studies reviewed reported moderate RTP and RPP rates following SLAP repairs in competitive overhead athletes. Those with associated rotator cuff tear requiring treatment, and baseball pitchers were less likely to RTP and RPP. Professional athletes had similar RTP to an amateur; however, they were less likely to RPP.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III-IV studies.

Analysis of common shoulder injuries in collegiate baseball players

OBJECTIVES

Baseball players are highly susceptible to shoulder injuries due to repetitive overhead throwing. The purpose of this study was to investigate men's collegiate baseball shoulder injury rates and associated risk factors.

METHODS

Using the NCAA Injury Surveillance Program (ISP) database, shoulder injury data for men's baseball players was analyzed from 2009-2010 through 2013-2014. Only the most common shoulder injuries were examined, including acromioclavicular (AC) sprain, anterior dislocation, biceps tear, biceps tendinitis, SLAP (superior labrum from anterior to posterior) tear, non-SLAP labral tear, rotator cuff tear, rotator cuff tendinitis, and shoulder impingement. Statistical analysis was performed using proportion ratios (PR). Statistical significance was initially defined as p < 0.05; a post-hoc Bonferroni adjustment was applied using a p < 0.005 threshold balancing the likelihood of false positive and false negative findings.

RESULTS

Overall, 138 shoulder injuries were identified of which 51.4% occurred during practice. Rotator cuff pathology represented 45.6% of all injuries, with rotator cuff tears significantly more likely to be season-ending injuries (PR 2.5, 95% CI 1.2-5.6, p = 0.019). Pitching or throwing was the mechanism of injury in 100% of players with rotator cuff tendonitis, 87.5% of SLAP tears, 70% of players with biceps tendinitis, and 67% of players with rotator cuff tears. Biceps tendinitis (PR 3.9, 95% CI 1.2-12.5, p = 0.024) and SLAP tears (PR 6.4, 95% CI 1.6-25.0, p = 0.008) were significantly more likely to be chronic. SLAP tears were significantly more likely to be recurrent (PR 5.5, 95% CI = 1.5-20.4, p = 0.010). Being a freshman or sophomore was significantly associated with a lower proportion of biceps tendinitis (PR = 0.2, 95% CI = 0.04-0.8, p = 0.028). All anterior shoulder dislocations occurred while running the bases or sliding, and AC sprains were significantly associated with contact (PR 20.6, 95% CI = 2.5-168.7, p = 0.0048).

CONCLUSIONS

Repetitive overhead throwing in college baseball is a common cause of overuse shoulder injuries. These athletes are especially susceptible to rotator cuff pathology, which is significantly more likely to cause season-ending injuries. While we have to interpret these results in light of both adjusted and unadjusted p-values, this information signifies the importance of shoulder injury prevention strategies by physicians and trainers taking care of collegiate baseball players.

Initial kinematic chain injuries increase hazard of subsequent arm injuries in professional baseball pitchers

BACKGROUND

Currently, there are few studies that have evaluated the relationship between a lower extremity or trunk injury (kinematic chain) and subsequent arm injury. The purpose of this study was (1) to investigate the relationship between initial kinematic chain (lower extremity or trunk) injury and subsequent arm injury; and (2) to investigate the relationship between initial shoulder or elbow injury and subsequent arm injury.

METHODS

A 7-year prospective injury risk study was conducted with Minor League Baseball pitchers. Pitches, pitching appearances, athlete exposures (AEs), and arm injuries (≥1-day time loss) were documented throughout the season. Cox survival analyses with 95% confidence intervals (95% CIs) were performed. Confounders controlled for included age, body mass index, arm dominance, pitching role, previous arm injury, number of pitching appearances, and seasonal pitch load.

RESULTS

A total of 297 pitchers participated (total player days = 85,270). Arm injury incidence was 11.4 arm injuries/10,000 AEs, and kinematic chain incidence was 5.2 injuries/10,000 AEs. Pitchers who sustained a kinematic chain injury demonstrated a greater hazard (2.6 [95% CI: 1.2, 5.6], P = .019) of sustaining an arm injury. Pitchers who sustained an initial shoulder injury demonstrated a greater hazard (9.3 [95% CI: 1.1, 83], P = .047) of sustaining a subsequent shoulder or elbow injury compared with pitchers who sustained an initial elbow injury.

CONCLUSIONS

Pitchers who sustained an initial lower extremity or trunk injury demonstrated an increased subsequent arm injury hazard compared with pitchers who did not. Pitchers who sustained an initial shoulder injury demonstrated a greater hazard of sustaining a subsequent arm injury compared with pitchers who sustained an initial elbow injury. However, this secondary analysis should be interpreted with caution. Clinicians should monitor risk with workload accumulation, which may be related to pitching compensatory strategies in a fatigued state. Pitchers who sustain a shoulder injury should be evaluated and perform both shoulder and elbow rehabilitation strategies before return to sport.

Can the Scapular Dyskinesis Test be Associated with Throwing Related Injuries During the Course of Collegiate Baseball Seasons?

Background

A pattern of scapular dyskinesis on the dominant side has been demonstrated to be associated with a decrease in throwing arm conditions identified by a self-report outcome assessment in collegiate baseball pitchers during the course of a single season. However, it is unclear if symptomatic shoulders in baseball pitchers may be associated with the presence of scapular dyskinesis.

Purpose

To study the relationship between the presence of scapular dyskinesis and throwing-related injury in collegiate baseball pitchers during each respective course of up to four subsequent seasons.

Methods

A single Division 1 National Collegiate Athletic Association team participated in this study over a four-year-period. The scapular dyskinesis test was implemented during the preseason for baseball pitchers. Players were followed throughout each respective season to track the incidence of throwing-related upper extremity injuries.

Results

A total of 36 collegiate baseball pitchers (height: 185.3 ± 5.6 cm, weight: 88.8 ± 7.8 kg, age: 20.0 ± 1.5 years) consisting of 57 pitcher seasons were followed in this study, in which 18 pitchers remained with the team for more than one year. Twenty-seven of the 57 pitchers were classified as having scapular dyskinesis demonstrated at around 90° of shoulder flexion on the throwing side. Five injuries (13.2% of a total of 38 injuries) were diagnosed as throwing-related shoulder injuries during the course of the intercollegiate baseball seasons. Four of the five throwing-related shoulder injuries occurred in pitchers who had scapular dyskinesis on their dominant side. Consequently, the odds ratio was 5.04 for the collegiate pitchers with scapular dyskinesis on the throwing arm side associated with a throwing-related shoulder injury compared to those with no scapular dyskinesis (p = 0.16). No relationship was identified between scapular dyskinesis on the throwing arm side and throwing-related elbow injury. Eighty-one percent of the scapular dyskinesis test results were not changed on the throwing side from the previous to the following year for those 18 pitchers who were followed for more than one season, whereas 42.9% of the results remained unchanged on the non-throwing side.

Conclusion

The results suggest that collegiate baseball pitchers with dominant arm scapular dyskinesis likely are at increased risk of throwing-related shoulder injury.

Level of evidence

Level 2, Prospective Cohort Study.

SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes

Background:

It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis.

Purpose:

To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported.

Results:

Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery.

Conclusion:

Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.

Performance Metrics and Economics of SLAP Repairs in Major League Baseball Pitchers

Background

Superior labrum anterior-posterior tears (SLAP) can be a career-altering injury for Major League Baseball (MLB) pitchers. Surgery and postoperative rehabilitation keep pitchers on the injured list (IL) for extended time, which results in a significant cost to a team. To date, no analyses have focused on the financial cost of SLAP repairs in MLB pitchers.

Methods

A retrospective review of MLB pitchers with SLAP repair from 2004 to 2019 was conducted utilizing IL and financial contract data from the MLB website. Cost of injury was calculated from salary of the player. Performance metrics including earned run average, walks + hits per innings pitched, and innings pitched (IP) were averaged for one and all seasons played before and after injury. Return to play and return to prior performance rates were calculated and reported.

Results

Of the 55 players identified, 22 players (40%) returned to play and 18 of these 22 players (82%) returned to prior performance. Annual cost increased over the study period (R² = 0.288) averaging $3.5 million, and a stable average of 172 days was spent on the IL (R² = 0.001). Performance was negligible except IP (106.95 vs. 50.85; P < .01) for 1 season before and after injury. For all seasons, earned run average and walks + hits per innings pitched significantly increased (4.13 vs. 5.19; P = .030, and 1.36 vs. 1.53; P = .033, respectively), while IP downtrended without significance (P = .058).

Conclusion

SLAP repairs in MLB pitchers have significant financial impact and time spent on the IL, which surprisingly has not changed over time. It is encouraging to know return-to-play pitchers return without profound decline in performance level following SLAP repair.

Anterior Shoulder Instability in Throwers and Overhead Athletes: Long-term Outcomes in a Geographic Cohort

BACKGROUND

Athletes of all sports often have shoulder instability, most commonly as anterior shoulder instability (ASI). For overhead athletes (OHAs) and those participating in throwing sports, clinical and surgical decision making can be difficult owing to a lack of long-term outcome studies in this population of athletes.

PURPOSE/HYPOTHESIS

To report presentation characteristics, pathology, treatment strategies, and outcomes of ASI in OHAs and throwers in a geographic cohort. We hypothesized that OHAs and throwers would have similar presenting characteristics, management strategies, and clinical outcomes but lower rates of return to play (RTP) when compared with non-OHAs (NOHAs) and nonthrowers, respectively.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

An established geographic medical record system was used to identify OHAs diagnosed with ASI in the dominant shoulder. An overall 57 OHAs with ASI were matched 1:2 with 114 NOHAs with ASI. Of the OHAs, 40 were throwers. Sports considered overhead were volleyball, swimming, racquet sports, baseball, and softball, while baseball and softball composed the thrower subgroup. Records were reviewed for patient characteristics, type of sport, imaging findings, treatment strategies, and surgical details. Patients were contacted to collect Western Ontario Shoulder Instability index (WOSI) scores and RTP data. Statistical analysis compared throwers with nonthrowers and OHAs with NOHAs.

RESULTS

Four patients, 3 NOHAs and 1 thrower, were lost to follow-up at 6 months. Clinical follow-up for the remaining 167 patients (98%) was 11.9 ± 7.2 years (mean ± SD). Of the 171 patients included, an overall 41 (36%) NOHAs, 29 (51%) OHAs, and 22 (55%) throwers were able to be contacted for WOSI scores and RTP data. OHAs were more likely to initially present with subluxations (56%; P = .030). NOHAs were more likely to have dislocations (80%; P = .018). The number of instability events at presentation was similar. OHAs were more likely to undergo initial operative management. Differences in rates of recurrent instability were not significant after initial nonoperative management (NOHAs, 37.1% vs OHAs, 28.6% [P = .331] and throwers, 21.2% [P = .094]) and surgery (NOHAs, 20.5% vs OHAs, 13.0% [P = .516] and throwers, 9.1% [P = .662]). Rates of revision surgery were similar (NOHAs, 18.0% vs OHAs, 8.7% [P = .464] and throwers, 18.2% [P > .999]). RTP rates were 80.5% in NOHAs, as compared with 71.4% in OHAs (P = .381) and 63.6% in throwers (P = .143). Median WOSI scores were 40 for NOHAs, as compared with 28 in OHAs (P = .425) and 28 in throwers (P = .615).

CONCLUSION

In a 1:2 matched comparison of general population athletes, throwers and OHAs were more likely to have more subtle instability, as evidenced by higher rates of subluxations rather than frank dislocations, when compared with NOHAs. Despite differences in presentation and the unique sport demands of OHAs, rates of recurrent instability and revision surgery were similar across groups. Similar outcomes in terms of RTP, level of RTP, and WOSI scores were achieved for OHAs and NOHAs, but these results must be interpreted with caution given the limited sample size.

Variability in Rehabilitation Protocols after Superior Labrum Anterior Posterior Surgical Repair

Introduction

Rehabilitation after a superior labral anterior posterior (SLAP) repair is an important aspect of patient outcomes; however, no standardized rehabilitation protocol has been defined. The purpose of this paper is to assess the variability of rehabilitation after a SLAP repair to understand the need for standardization to improve patient outcomes.

Methods

Protocols for SLAP repairs were collected through a search for Academic Orthopedic Programs and a general Google search using the terms “[Program Name (if applicable)] SLAP Repair Rehab Protocol”. Protocols were compared by sling, range of motion (ROM), physical therapy, return to sport (RTS), return to throwing, and biceps engagement and tenodesis recommendations. Protocols for non-operative or generalized shoulders were excluded.

Results

Sixty protocols were included. A total of 61.7% (37/60) recommended a sling for four to six weeks and 90% (54/60) included a full ROM recommendation, but time was variable. There were different exercises recommended, but pendulum swings were recommended by 53% (32/60), submaximal isometrics by 55% (33/60), and scapular strengthening by 65% (39/60). Of the sixty protocols, 33% (20/60) recommended return to sports in 24 weeks and 38.3% (23/60) recommended allowing throwing in 16 weeks.

Conclusions

There was variability in protocols for SLAP repair, especially time until full ROM, RTS, and biceps strengthening. Time in sling and scapular strengthening were the least variable. A lack of specificity within protocols in what return to throwing meant for functional ability made it difficult to compare protocols. Considering the large number of orthopedic programs, a relatively small number had published protocols. Further studies are needed to evaluate a standardized post-operative rehabilitation for SLAP repairs to improve outcomes.

SLAP tears and return to sport and work: current concepts

Superior labrum, anterior and posterior (SLAP) lesions are common and identified in up to 26% of shoulder arthroscopies, with the greatest risk factor appearing to be overhead sporting activities. Symptomatic patients are treated with physical therapy and activity modification. However, after the failure of non-operative measures or when activity modification is precluded by athletic demands, SLAP tears have been managed with debridement, repair, biceps tenodesis or biceps tenotomy. Recently, there have been noticeable trends in the operative management of SLAP lesions with older patients receiving biceps tenodesis and younger patients undergoing SLAP repair, largely with suture anchors. For overhead athletes, particularly baseball players, SLAP lesions remain a difficult pathology to manage secondary to concomitant pathologies and unpredictable rates of return to play. As a consequence, the most appropriate surgical option in elite throwers is controversial. The objective of this current concepts review is to discuss the anatomy, mechanism of injury, presentation, diagnosis and treatment options of SLAP lesions and to present current literature on outcomes affecting return to sport and work.

Reported Technical Aspects of Type II SLAP Lesion Repairs in Athletes

Purpose

To systematically review the available literature to further describe and report the available data on SLAP repair techniques and the association with outcomes.

Methods

A systematic review of literature was performed on manuscripts describing type II SLAP repairs in athletes. Selection criteria included studies reporting exclusively type II SLAP tears without concomitant pathology, minimum 2-year postoperative follow-up, use of anchor fixation, and return to previous level of play data available. We extracted patient outcome as well as surgical construct details from each article. Average outcomes and return to play rates were calculated and substratified further by athlete type. Return to play rates were compared by repair constructs with the Student t test.

Results

Initial search resulted in 107 articles. After exclusion criteria were applied, 17 articles were included in the final analysis. Overall, 84% of patients had good-to-excellent results. Of all athletes, 66% returned to previous level of play. There was significant variation in reported technique in terms of anchor number, location, material, suture type, and knotless versus knotted constructs. No significant difference was reported in outcomes in comparison of suture type (P-value .96) or knotted versus knotless constructs (P-value .91). Given the significant variability in reporting, no statistical analysis was felt able to be performed on anchor location and number.

Conclusions

Repair of type II SLAP tears in athletes is a difficult problem to treat with overall low return to play despite a high rate of “good” outcomes when assessed by outcome measures. Significant variability exists in surgical technique, as well as reporting of surgical technique, potentially limiting the ability to define the best or most effective technique for SLAP repair.

Level of Evidence

IV, systematic review of level III and level IV studies.

Outcome Measures After Shoulder Stabilization in the Athletic Population: A Systematic Review of Clinical and Patient-Reported Metrics

Background:

Athletic endeavor can require the “athletic shoulder” to tolerate significant load through supraphysiological range and often under considerable repetition. Outcome measures are valuable when determining an athlete’s safe return to sport. Few data are available to guide a clinician’s choice from the variety of measures available.

Purpose:

To describe the use of quantifiable objective outcome measures and patient-reported outcome tools after glenohumeral joint stabilization, specifically in an athletic population. The secondary aim of our study was to assess whether the method of measurement used was clearly described and standardized to aid clinical interpretation.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of MEDLINE, Scopus, SPORTDiscus, and Web of Science databases was performed in December 2018 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After the application of selection criteria, a full review of identified papers, and screening of reference lists, a total of 62 studies were included in the review. All studies were independently appraised for quality, predefined data fields were populated and cross-checked for accuracy, and results were then summarized from these data fields.

Results:

Of the 62 included studies, 94% used a quantifiable objective clinical outcome. A majority (85%) of the studies measured range of motion, 21% recorded muscle strength, 5% measured electromyographic activity, 5% examined shoulder kinematics, and 3% assessed joint proprioception after surgery. However, only 18% of the studies clearly described a standardized method of measuring the outcome. Nearly all (95%) of the studies used at least 1 patient-reported outcome measure. The Rowe score was most commonly used (35%).

Conclusion:

We must standardize and clearly describe the use of quantifiable objective outcome measures to aid clinical interpretation. A concerted effort should also be made to standardize the use of patient-reported outcome tools after shoulder stabilization in the athletic population.

Superior Labral Injuries in Elite Gymnasts: Symptoms, Pathology, and Outcomes After Surgical Repair

Background:

Superior labral anterior-posterior (SLAP) lesions are common among elite gymnasts and throwing athletes. Although SLAP lesions in throwers are well-described in the literature, no study has described the characteristics of SLAP lesions in gymnasts. We aimed to reveal the characteristics of SLAP lesions in gymnasts by comparing the location and extension of these lesions between gymnasts and throwers.

Hypothesis:

The location and arc of SLAP lesions in gymnasts will be different from those in throwing athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included 27 shoulders in 20 males and 3 females with a mean ± SD age of 20 ± 2.5 years (range, 16-25 years). We performed debridement alone for shoulders with a stable lesion. Anterior and/or posterior labral repair was added for unstable SLAP lesions depending on the extension and stability of the lesions. We investigated symptoms, onset, return to sport (based on patient records), and subjective shoulder values. SLAP lesions were evaluated through use of the Snyder classification. The location and arc of SLAP lesions were determined from surgical records and videos and described by use of the right shoulder clockface method. During the same period, 65 baseball players (65 shoulders; all males; mean age, 23 ± 7.0 years; range, 16-44 years) underwent arthroscopic SLAP surgery. We compared the location and arc of SLAP lesions between gymnasts and baseball players.

Results:

Symptoms during gymnastics included pain (100%), apprehension (48%), or catching (11%). We found that 20 shoulders had symptom onset during gymnastics, most commonly during rings events. Type II SLAP lesions were found in 17 shoulders, type III in 2 shoulders, and type IV in 8 shoulders. The mean center of SLAP lesions was at the 11:40 clockface position in 27 gymnasts and 10:40 clockface position in 65 baseball players, and the difference was statistically significant (P < .001). The mean arc of SLAP lesions was 125° in gymnasts and 140° in baseball players, and the difference was not significant. We performed debridement in 2 shoulders (7%) and labral repair in 25 shoulders (93%). After surgery, all patients returned to gymnastics. The mean subjective shoulder value was 35 (range, 10-90) preoperatively and 76 (range, 40-100) postoperatively.

Conclusion:

SLAP lesions in gymnasts were significantly located anteriorly compared with those in baseball players. All patients returned to gymnastics after arthroscopic surgery. Secure repair of SLAP lesions may be important for good surgical outcomes, because 50% of patients experienced preoperative shoulder apprehension.

The Relationship Between Baseball Participation and Health: A Systematic Scoping Review

OBJECTIVE

To investigate the relationship between baseball participation and health (musculoskeletal, general, and psychological health) and to identify research gaps in the existing literature.

DESIGN

Systematic scoping review.

LITERATURE SEARCH

Medical databases and gray literature were systematically searched from inception to November 2018.

STUDY SELECTION CRITERIA

All studies that investigated constructs related to the health of current or former baseball players were included.

DATA SYNTHESIS

Data were extracted for thematic summaries.

RESULTS

Ten thousand five hundred seventy-four titles/abstracts were screened, and 678 studies were included. Ninety percent of articles included only baseball players playing in the United States, 34% of articles investigated professional baseball players, and 11% studied college baseball players. Five hundred eighty-three (86%) studies investigated musculoskeletal health, 77 (11%) general health, and 18 (3%) psychological health. Injury incidence (injuries per 1000 athlete exposures) ranged from 0.7 to 3.6 in professional, 4.7 to 5.8 in college, and 0.8 to 4.0 in high school baseball. Among baseball players, 31% to 50% reported regular tobacco use. There was limited research investigating psychological health in current or former baseball players at all competition levels.

CONCLUSION

Almost 90% of all articles investigated musculoskeletal health, with few articles studying general or psychological health. Baseball players have high tobacco, alcohol, and drug use compared to the general population, which may have negative health outcomes. Little is understood about the long-term musculoskeletal, general, and psychological health of baseball players. J Orthop Sports Phys Ther 2020;50(2):55-66. doi:10.2519/jospt.2020.9281.

Internal impingement of the shoulder: An international survey of 261 orthopaedic surgeons

BACKGROUND

Internal impingement of the shoulder (IIS) is a specific disorder of young overhead-throwing athletes that was first described in 1991. The many non-operative and surgical treatments suggested to date have produced mixed outcomes. The objective of this study was to compare the practices of surgeons in France versus other countries regarding the diagnosis and treatment of IIS.

HYPOTHESIS

Diagnostic and therapeutic practices regarding IIS differ between surgeons in France and in other countries.

MATERIAL AND METHODS

A 21-item questionnaire in French and English was emailed to the 1300 members of the French Arthroscopy Society and to surgeons from countries other than France. The questionnaire collected information on knowledge about IIS (2 items), the frequency of IIS in clinical practice (2 items), the diagnosis of IIS (6 items), the non-operative and surgical treatment of IIS (3 and 5 items, respectively), and return-to-sports rates after treatment for IIS (3 items).

RESULTS

The completed questionnaire was sent back by 261 surgeons, 206 in France and 55 in other countries, including 42 in Japan. Among the respondents, 90% knew about IIS. Experience with IIS in terms of number of patients seen or surgical treatments performed was greater in the international group (45% vs. 19% in France, p<0.001). Posterior shoulder pain in the arm cocking position was the most widely recognised symptom (99% in France, 74% internationally, p<0.001), followed by excessive external rotation during arm abduction (55% vs. 65%, p=0.23). The most commonly sought lesions were those of the postero-superior labrum and articular surface of the rotator cuff. Rotator cuff debridement was among the surgical options according to most respondents (74% vs. 70%). In contrast, postero-superior glenoidplasty was cited almost only by surgeons in France (67% vs. 4%, p<0.001). The proportion of patients who are able to return to sports was estimated at 50% to 75% by most respondents.

DISCUSSION

Most respondents had theoretical knowledge about IIS, but surgery was rarely performed in France. Only very few athletes in France play baseball, which is responsible for most sports injuries of the shoulder seen in Japan. This fact, combined with differences in the lesions or even the diagnoses, may have contributed to the differences in the responses to the survey items between the French and international groups.

Return to Sport After Arthroscopic Superior Labral Anterior-Posterior Repair: A Systematic Review

CONTEXT

Superior labral anterior-posterior (SLAP) lesions often result in significant sporting limitations for athletes. Return to sport is a significant outcome that often needs to be considered by athletes undergoing the procedure.

OBJECTIVE

To evaluate return to sport among individuals undergoing arthroscopic SLAP repair.

DATA SOURCES

Four databases (MEDLINE, EMBASE, PubMed, and Cochrane) were searched from database inception through January 29, 2018.

STUDY SELECTION

English-language articles reporting on return-to-activity rates after arthroscopic SLAP repairs were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data including patient demographics, surgical procedure, and return to activity were extracted. The methodological quality of included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool.

RESULTS

Of 1938 screened abstracts, 22 articles involving a total of 944 patients undergoing arthroscopic SLAP repair met inclusion criteria. Of the total included patients, 270 were identified as overhead athletes, with 146 pitchers. Across all patients, 69.6% (657/944 patients) of individuals undergoing arthroscopic SLAP repair returned to sport. There was a 69.0% (562/815 patients) return to previous level of play, with a mean time to return to sport of 8.9 ± 2.4 months (range, 6.0-11.7 months). The return-to-sport rate for pitchers compared with the return-to-activity rate for nonpitchers, encompassing return to work and return to sport, was 57.5% (84/146 patients) and 87.1% (572/657 patients), respectively, after arthroscopic SLAP repair.

CONCLUSION

Arthroscopic SLAP repair is associated with a fair return to sport, with 69.6% of individuals undergoing arthroscopic SLAP repair returning to sport. SLAP repair in pitchers has significantly decreased return to sport in comparison with nonpitching athletes. Athletes on average return to sport within 9 months postoperatively.

Arthroscopic Repair of Type II SLAP Lesions in Overhead Athletes

For overhead athletes and, in particular, baseball pitchers, the rates of success and return to play for those who have undergone arthroscopic repair of type II SLAP lesions are poor, ranging from 7% to 62%. The reasons for the poor results and high failure rates in overhead athletes with type II SLAP repairs are multifactorial and are a combination of many factors. These factors include the failure to establish the diagnosis and treat these athletes preoperatively; the inability of the operating surgeon to differentiate normal anatomic variants from pathologic SLAP lesions at the time of surgery; the surgical technique, which may violate the rotator cuff; or the placement of suture anchors, which restricts external rotation and alters overhead throwing mechanics. The proper diagnosis of SLAP lesions can be difficult because SLAP tears rarely occur in isolation and are often associated with other shoulder pathology. A proper history detailing the onset of symptoms and whether there was an acute episode of trauma or a history of repetitive use is critical. It is important to remember that no single physical examination finding is pathognomonic for SLAP tears. When seen in isolation, SLAP tears may mimic impingement syndrome (52%) or even anterior instability (39%). Surgical treatment of type II SLAP lesions should not be undertaken lightly in overhead athletes. If a 3-month rehabilitation period followed by a return to sports over the following 3 months does not allow the athlete to return to his or her preinjury level, diagnostic arthroscopy with SLAP repair is a reasonable option and can yield excellent results using the proper techniques. The technique described in detail in this article and our video can be technically demanding, but with the key points outlined, it can be reproduced and provide excellent results for overhead athletes undergoing SLAP repair. By not violating the rotator cuff, using a mattress configuration and keeping the suture knot away from the articular surface, and by not going anterior to the biceps tendon for repair, external rotation and strength can be preserved, leading to an excellent result with a predictable return to play for overhead athletes.

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.

Return to Sport After the Surgical Treatment of Superior Labrum Anterior to Posterior Tears: A Systematic Review

Background:

Controversy exists as to the optimal treatment of superior labrum anterior to posterior (SLAP) tears in athletes. There are no systematic reviews evaluating return-to-sport (RTS) rates after arthroscopic SLAP repair and biceps tenodesis.

Purpose:

To compare the overall RTS rates in patients with primary type 2 SLAP tears who were managed with arthroscopic SLAP repair versus biceps tenodesis.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching the MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library databases. Inclusion criteria were clinical studies that evaluated RTS rates after arthroscopic SLAP repair, arthroscopic SLAP repair with partial rotator cuff debridement, and biceps tenodesis. The studies were analyzed for quality and inclusion in the final analysis. Data relevant to RTS rates were then extracted and compiled, and outcomes were compared.

Results:

Of the 337 studies initially identified, 15 (501 patient-athletes) met inclusion criteria. These consisted of 195 patients who underwent isolated arthroscopic SLAP repair (mean age, 31 years; mean follow-up, 3.2 years), 222 patients who underwent arthroscopic SLAP repair with partial rotator cuff debridement (mean age, 22 years; mean follow-up, 5.1 years), and 84 patients who underwent biceps tenodesis (mean age, 42 years; mean follow-up, 3.3 years). The overall RTS rates were high for all 3 procedures (SLAP repair, 79.5%; SLAP repair with rotator cuff debridement, 76.6%; biceps tenodesis, 84.5%), with biceps tenodesis having the highest overall rate. Biceps tenodesis also had the highest RTS rate at the preinjury level (78.6%) compared with SLAP repair (63.6%) and SLAP repair with rotator cuff debridement (66.7%).

Conclusion:

Primary arthroscopic SLAP repair, arthroscopic SLAP repair with partial rotator cuff debridement, and biceps tenodesis all provide high RTS rates. Biceps tenodesis as an operative treatment of primary SLAP lesions may demonstrate an overall higher RTS rate when compared with traditional SLAP repair in older athletes. More, higher level studies are needed that control for age, level of activity, and type of sport (overhead vs nonoverhead) to determine the efficacy of biceps tenodesis as a primary alternative to arthroscopic SLAP repair in young athletes who present with type 2 SLAP tears.

Epidemiology of Shoulder Surgery Among Professional Baseball Players

BACKGROUND

Injuries remain a significant problem for professional baseball players. There is little information regarding the incidence and outcomes of shoulder surgical procedures among these athletes.

PURPOSE/HYPOTHESIS

To report the incidence, pathology, procedure type, demographics, and return-to-sport (RTS) rate of shoulder surgery among Major League Baseball (MLB) players. Most shoulder procedures would be performed on pitchers with a history of injury; the labrum would be the most commonly involved; and that the RTS rate would be >50%.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

All MLB players who underwent surgery between 2012 and 2016 were identified from a database prospectively maintained by MLB. Demographic information and details regarding the procedure were recorded and RTS rates determined. Only those players with a minimum 2-year follow-up were included.

RESULTS

There were 581 shoulder procedures performed (542 players; pitchers, 60%; incidence, 1.48%). Overall, 19% of surgical procedures were performed on major league players and 81% on minor league players. Most players were between 20 and 25 years old. The majority of procedures were performed on the posterior and anterior labrum. Of these, 67% involved labral repair. Within rotator cuff surgery, 84% involved debridement; most tears were articular sided (87%); and 75% involved the supraspinatus. Overall, 11% of players had prior shoulder surgery, and 76% spent time on the disabled list before surgery. The overall rate of RTS was 63%. Of those who returned, 86% returned to at least the same level of play or higher as before surgery. Of those who returned to their prior level of play, 73% later ascended to a higher level of play or could not ascend to a higher level because they were already in the majors.

CONCLUSION

Shoulder surgery is uncommon among professional baseball players. Of those players who require surgery, the majority are pitchers and minor league players. Most procedures involve the labrum. Rotator cuff tears are mostly articular-sided supraspinatus tears. The overall RTS rate is 63%. Of those who return, 86% are able to return to the same or higher level of play as before surgery.

Trends in the Management of Isolated SLAP Tears in the United States

Background:

The management of superior labrum anterior and posterior (SLAP) tears remains controversial, with surgical treatment options including SLAP repair, debridement, and open or arthroscopic biceps tenodesis (BT), based on patient factors and the type of tear.

Hypothesis:

We hypothesized that SLAP repair has become less frequently performed over time, while BT is more frequently performed, particularly in patients ≥ 40 years.

Study Design:

Descriptive epidemiology study.

Methods:

A retrospective query was performed using the Humana insurance database from years 2007 to 2016. For the management of a SLAP tear diagnosis (International Classification of Diseases–Ninth Edition [ICD-9] code: 840.7), independent and exclusive cohorts were formed using Current Procedural Terminology (CPT) codes for debridement (29822, 29823), SLAP repair (29807), open or arthroscopic BT (29828, 23430), and SLAP repair combined with BT (29828 OR 23430 AND 29807).

Results:

Of 46,650 diagnoses of a SLAP tear, there were 3347 patients who underwent operative management for an isolated SLAP tear from 2007 to 2016. There was a linear increase of SLAP tear diagnoses per year (r² = 0.800, P < .001) during this period. Overall, SLAP repair was performed in 1629 patients (48.7%), debridement was performed in 1076 patients (32.1%), BT was performed in 552 patients (16.5%), and combined SLAP repair and BT was performed in 90 patients (2.7%). There was a 69.3% decrease in isolated SLAP repair from 2007 to 2016 (r² = 0.882, P < .001). BT for the diagnosis of an isolated SLAP tear increased by 370.0% over the same period (r² = 0.800, P < .001). SLAP repair had an equivalent percentage of being performed in patients both older and younger than 40 years (P = .218). There was a 1500.0% increase in BT performed in patients older than 40 years during the study period. There were no statistical differences in the postoperative incidence of stiffness, surgical site infections, and reoperations between all surgical treatment groups (P > .05).

Conclusion:

An analysis of a large private-payer database revealed that surgical treatment of isolated SLAP tears in the United States has shifted from 2007 to 2016, with an increase in the frequency of BT and a decline in the frequency of SLAP repair, particularly in patients older than 40 years.

Return to Play and Performance Perceptions of Baseball Players After Isolated SLAP Tear Repair

Background:

Variable return-to-play (RTP) rates have been reported after surgical repair of superior labral anterior-posterior (SLAP) tears in baseball players. Many studies, however, have not controlled for concomitant shoulder injuries.

Purpose/Hypothesis:

The purpose of this study was to evaluate rates of RTP and return to previous or higher performance level (RTPP) and long-term outcomes after isolated SLAP tear repair. The hypothesis was that improved outcomes would be identified compared with previous reports.

Study Design:

Case series; Level of evidence, 4.

Methods:

The records of 232 players who underwent isolated SLAP tear repair from 2004 to 2014 were reviewed. A total of 98 players who were at least 12 months out from surgery were identified. Through telephone interviews, participants completed the Western Ontario Shoulder Instability Index (WOSI) and Veterans RAND 12-Item Health Survey (VR-12) and answered scripted questions about RTP, RTPP, and current symptoms.

Results:

Of the 98 players who met the inclusion criteria, 73 (74.5%) participated. The mean age at the time of surgery was 19.8 ± 2.9 years. The mean follow-up time was 86.2 ± 25.1 months overall; it was 84.4 ± 24.4 months for pitchers and 90.3 ± 26.7 months for other position players, (P = .40). There were 10 professional, 36 collegiate, and 27 high school players. Most players perceived successful RTP (83.6%), including 80.0% of pitchers and 91.3% of other position players (P = .23). However, RTPP rates were lower, at 52.3% (n = 26) and 78.3% (n = 18) for pitchers and other position players, respectively (P = .03). Pitchers were younger at the time of surgery (19.3 ± 3.0 vs 20.8 ± 3.0 years, respectively; P = .03) and had greater perceived shoulder and general health impairments compared with other position players (P ≤ .02). Players who perceived successful RTPP had better WOSI of the healthy shoulder and individual physical, sports, lifestyle, and emotion scores compared with players who did not perceive successful RTPP.

Conclusion:

After the surgical repair of isolated type II or greater SLAP tears, other position players displayed superior RTP (91.3% vs 80.0%, respectively) and RTPP (78.3% vs 52.3%, respectively) rates than pitchers. Long-term follow-up suggests that pitchers may perceive greater long-term impairments than other position players and are less likely to return to their previous or higher performance level.

Professional advancement, performance, and injury characteristics of baseball players entering the Major League Baseball draft after treatment for shoulder injuries

BACKGROUND

How shoulder injuries treated before the Major League Baseball (MLB) draft affect the player's performance over their career is unclear. The purpose of this study was to determine whether prior shoulder injuries were associated with a difference in the level of performance and advancement of MLB draftees.

METHODS

Before entering the draft, 119 professional baseball players from 2004 to 2010 were treated for a shoulder injury (73% treated surgically) as an amateur. A 3:1 matched case-control was performed to players without prior shoulder injuries by age, position, round selected, and signing bonus. Follow-up data were collected in 2016, and professional advancement, disabled list time, and in-game performance statistics for pitchers were analyzed and compared.

RESULTS

Players with a prior shoulder injury had a statistically higher chance to be assigned to the disabled list then controls (P = .03), but there was no difference in disabled list time or professional advancement. Pitchers with a prior shoulder injury pitched a statistically lower number of innings per game than controls (P = .04). All other in-game performance statistics were not statistically different. The type of treatment did not have any effect on future performance or advancement.

CONCLUSIONS

Professional baseball players treated for prior shoulder injuries at the amateur level were more likely to sustain future disability than their matched controls, but it did not affect professional advancement.

Type VIII SLAP Repair at Midterm Follow-Up: Throwers Have Greater Pain, Decreased Function, and Poorer Return to Play

PURPOSE

To evaluate and compare midterm outcomes and return to play (RTP) of throwers and nonthrowers who underwent type VIII SLAP repair.

METHODS

With 4-year minimum follow-up, stability, pain, range of motion (ROM), Kerlan-Jobe Orthopaedic Clinic (KJOC), and American Shoulder and Elbow Surgeons (ASES) scores; surgical satisfaction; and RTP were compared between throwing and nonthrowing athletes who underwent repair of type VIII SLAP lesions between 2003 and 2014.

RESULTS

46 patients (27 throwers and 19 nonthrowers) were included. The athletes were aged 24.2 ± 9.2 years at the time of surgery. The mean follow-up period was 6.6 ± 2.0 years. A significant improvement in stability, pain, ROM, KJOC, and ASES scores was seen after surgery in both throwers and nonthrowers (P < .05). When postoperative outcomes were compared, throwers had more pain (P = .047), decreased ROM (P = .03), lower KJOC scores (52.2 ± 24.0 in throwers vs 87.5 ± 18.8 in nonthrowers, P < .0001), and lower ASES scores (43.5 ± 7.1 in throwers vs 48.3 ± 3.0 nonthrowers, P = .02). There was no difference in stability (P = .06), surgical satisfaction (96.3% in throwers vs 100% in nonthrowers, P > .99), or overall RTP (70.4% in throwers vs 94.7% in nonthrowers, P = .06). However, throwers were less likely to RTP at their preoperative level (37.0% in throwers vs 73.7% in nonthrowers, P = .02).

CONCLUSIONS

Surgical repair of type VIII SLAP tears led to significant improvements in stability, pain, ROM, and outcome scores at midterm follow-up. Compared with nonthrowers, throwers had significantly more pain, less ROM, and worse function. Throwers were also less likely to RTP at their preoperative level. These findings suggest that type VIII SLAP tears should be repaired in all athletes because outcomes do improve, although throwers require specific counseling and expectation management regarding their ability to RTP at their preinjury level.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Editorial Commentary: Buyer Beware-Throwers Undergoing Type VIII SLAP Repair Should Do So With Very Reasonable Expectations

SLAP repair in throwing athletes should be approached with caution. Surgery may help improve symptoms but may not guarantee a return to the preinjury level of competition. Even in the most expert of hands, the rate of return to the preinjury level of performance ranges from 38% to 60% and is as low as 10% for pitchers.

Outcomes and factors of elbow arthroscopy upon returning to sports for throwing athletes with osteoarthritis

Background

Elbow arthroscopy had good functional outcome for throwing athletes. Returning to sports is a major concern for all athletes, but only a few reports have investigated the clinical factors related to the duration of returning to sports. The present study evaluates the efficacy of elbow arthroscopic surgery on throwing elbows with osteoarthritis and defines the clinical factors related to the duration of the returning to sports.

Methods

This was a retrospective study with fifteen active baseball throwing athletes with elbow osteoarthritis who were treated with elbow arthroscopy. Perioperative clinical factors were analyzed for functional outcomes. A multiple linear regression analysis was used to analyze the clinical factors associated with the duration of returning to training and sports.

Results

The 15 patients’ mean age was 27 years. The mean follow-up time was 2.6 years. The mean procedural complexity was 3.1 ± 1.6 (range 1–6). The elbow total range of motion (ROM) improved significantly from 100.7 ± 28.7° to 125.7 ± 18.5° (p = 0.001). The terminal flexion range of the elbow increased significantly from 116.0 ± 22.6° to 130.0 ± 13.2° (p = 0.001), and the terminal extension range improved from 15.3 ± 11.1° to 4.3 ± 5.9° (p = 0.001). Before the operation, the average subjective patient outcome for return to sports (SPORTS) score was 3.4 ± 1.5, which increased significantly to 9.67 ± 0.45 (p = 0.003) at the last follow-up. The multiple linear regression analysis revealed that higher procedural complexity hinders the athletes from returning to competition.

Conclusions

Elbow arthroscopy offered highly satisfactory results in the throwing elbows of elite athletes and significantly improved the range of motion and SPORTS score. The procedural complexity was significantly related to the duration of returning to competition. Early and aggressive arthroscopic intervention is recommended for elite throwing athletes with elbow osteoarthritis who fail to respond to conservative treatment.

Kerlan-Jobe Orthopaedic Clinic (KJOC) score and scapular dyskinesis test in collegiate baseball players

BACKGROUND

The Kerlan-Jobe Orthopaedic Clinic (KJOC) score has been used to describe various parameters of throwing shoulder and elbow function for the return to play after a long period of rehabilitation, such as after ulnar collateral ligament reconstruction. No study has yet to identify how scapular dyskinesis (SD) in baseball players affects the KJOC score. This study investigated the relationship of the KJOC score to SD evaluated in collegiate baseball players with and without upper extremity injury.

MATERIALS AND METHODS

The study participants were 30 male collegiate baseball players (13 pitchers) belonging to the National Collegiate Athletic Association D-I conference. Participants were assessed with the KJOC instrument in the beginning (PRE) and end (POST) of the season. The SD test was conducted (PRE) in shoulder flexion to identify SD RESULTS: The mean value of KJOC score was significantly less in POST than that of PRE for the pitchers with SD (89.3 and 60.5, respectively; P = .001), whereas no difference was found in the KJOC score between PRE and POST for the pitchers without SD. For the position players, no difference in the mean value of KJOC score was found between PRE and POST, regardless of SD.

CONCLUSION

The results of this study provide evidence that collegiate baseball pitchers with mild SD may have lower KJOC scores, particularly setup or relief pitchers.

Can the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score Be Reliably Administered Over the Phone?: A Randomized Study

Background:

The Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow outcome score is a functional assessment tool for the upper extremity of the overhead athlete, which is currently validated for administration in person.

Purpose/Hypothesis:

The purpose of this study was to validate the KJOC score for administration over the phone. The hypothesis was that no difference will exist in KJOC scores for the same patient between administration in person versus over the phone.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

Fifty patients were randomized to fill out the KJOC questionnaire either over the phone first (25 patients) or in person first (25 patients) based on an a priori power analysis. One week after the patients completed the initial KJOC on the phone or in person, they then filled out the score via the opposite method. Results were compared per question and for overall score.

Results:

There was a mean ± SD of 8 ± 5 days between when patients completed the first and second questionnaires. There were no significant differences in the overall KJOC score between the phone and paper groups (P = .139). The intraclass correlation coefficient comparing paper and phone scores was 0.802 (95% CI, 0.767-0.883; P < .001), with a Cronbach alpha of 0.89. On comparison of individual questions, there were significant differences for questions 1, 3, and 8 (P = .013, .023, and .042, respectively).

Conclusion:

The KJOC questionnaire can be administered over the phone with no significant difference in overall score as compared with that from in-person administration.

Diagnosis and Treatment of Injuries to the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex.

RECENT FINDINGS

A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.