History of shoulder instability and subsequent injury during four years of follow-up: a survival analysis

Risk Factors Associated with First Time and Recurrent Shoulder Instability: A Systematic Review

Background

Shoulder instabilities constitute a large proportion of shoulder injuries and have a wide range of presentations. While evidence regarding glenohumeral dislocations and associated risk factors has been reported, less is known regarding the full spectrum of instabilities and their risk factors.

Purpose

The purpose of this systematic review was to identify modifiable risk factors to guide patient management decisions with regards to implementation of interventions to prevent or reduce the risk of shoulder instability.

Study Design

Systematic Review.

Methods

A systematic, computerized search of electronic databases (CINAHL, Cochrane, Embase, PubMed, SportDiscus, and Web of Science) was performed. Inclusion criteria were: (1) a diagnosis of shoulder instability (2) the statistical association of at least one risk factor was reported, (3) study designs appropriate for risk factors, (4) written in English, and (5) used an acceptable reference standard for diagnosed shoulder instability. Titles and abstracts were independently screened by at least two reviewers. All reviewers examined the quality studies using the Newcastle-Ottawa Scale (NOS). At least two reviewers independently extracted information and data regarding author, year, study population, study design, criterion standard, and strength of association statistics with risk factors.

Results

Male sex, participation in sport, hypermobility in males, and glenoid index demonstrated moderate to large risk associated with first time shoulder instability. Male sex, age \<30 years, and history of glenohumeral instability with concomitant injury demonstrated moderate to large risk associated with recurrent shoulder instability.

Conclusion

There may be an opportunity for patient education in particular populations as to their increased risk for suffering shoulder instability, particularly in young males who appear to be at increased risk for recurrent shoulder instability.

Level of Evidence

Level III.

Glenoid Bone Loss in Recurrent Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review

BACKGROUND

Glenoid bone loss has been reported to occur in as many as 86% of patients with recurrent shoulder stability. This systematic review evaluated the amount of glenoid bone loss associated with recurrent shoulder dislocation or subluxation and with worse patient-reported outcomes after arthroscopic Bankart repair. We hypothesized that the percentage of glenoid bone loss associated with recurrent instability after arthroscopic Bankart repair is lower than the previously proposed critical value of 25%.

METHODS

The systematic review included 528 patients with glenoid bone loss from 3 clinical studies. The percentage of bone loss was the value quantified and reported in each study. Failure was defined as recurrent dislocation or subluxation. The percentage of glenoid bone loss associated with recurrent shoulder dislocation or subluxation after arthroscopic Bankart labral repair was analyzed with receiver operating characteristic (ROC) curve analysis.

RESULTS

Recurrent dislocation or subluxation occurred in 23.7% (125) of 528 patients in the pooled study cohort. There was a significant difference in age between those in whom the arthroscopic Bankart repair failed and those in whom it did not (22.9 versus 24.3 years; p = 0.009). The ROC curve analysis demonstrated that ≥16.0% glenoid bone loss was predictive of recurrent shoulder dislocation or subluxation (Youden index = 0.59, sensitivity = 80%, specificity = 80%). In patients who did not sustain a recurrent dislocation or subluxation, the ROC curve analysis demonstrated that 20.0% glenoid bone loss was predictive of a Single Assessment Numeric Evaluation (SANE) score of <85% (Youden index = 0.93, sensitivity = 93%, specificity = 100%).

CONCLUSIONS

The critical amount of glenoid bone loss associated with an increased risk of persistent instability was found to be less than previously reported. Glenoid bone loss of ≥16.0% was found to place patients at higher risk for recurrent shoulder dislocation or subluxation after treatment with arthroscopic Bankart repair alone.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Clinical Results of Knot-tying Versus Knotless Suture Anchors in Arthroscopic Anteroinferior Labral Repair

Background Arthroscopic repair of glenohumeral instability is becoming an increasingly common procedure. These repairs can be undertaken using knot-tying and knotless suture anchors; there is currently no clear consensus in the literature about what type of repair is most cost-effective and provides superior outcomes. The purpose of this study is to examine postoperative outcomes of patients undergoing arthroscopic anteroinferior labral repair (AALR) with either knot-tying or knotless anchors. Methods A single institution retrospective observational cohort study of 122 patients undergoing AALR from January 2014 to June 2021 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes between repair types; multivariate analysis was used to evaluate risk factors for recurrent instability and reoperation. Results Patients undergoing AALR with knotless anchors had a shorter case duration than those with knot-tying anchors (112.64 vs. 89.86 minutes, p<0.001). There were no significant differences between groups in the size of labral tear, presence of a glenoid bone defect, or Hill-Sachs lesion. After controlling for age, BMI, sex, glenoid bone defect, number of preoperative dislocations, and fixation type, only age (OR=0.896, p=0.010) and female sex (OR=5.341, p=0.008) were independent risk factors for recurrent instability and no factors were independent predictors of reoperation. Conclusion Patients undergoing AALR experienced similar rates of reoperation and recurrent instability regardless of whether a knot-tying or knotless repair was performed. The use of knotless suture anchors may improve cost-effectiveness due to decreased surgical time without diminishing postoperative outcomes.

Surgical treatment of shoulder instability in active-duty service members with subcritical glenoid bone loss: Bankart vs. Latarjet

INTRODUCTION

Subcritical bone loss has been identified as a risk factor for potentially inferior outcomes following typical arthroscopic soft tissue repair. One alternative that has been presented as an option for patients with bone loss is the Latarjet, an ipsilateral coracoid transfer to the anteroinferior glenoid. The purpose of this study is to compare the outcomes between the arthroscopic Bankart repair and the open Latarjet for the treatment of anterior shoulder instability in patients with subcritical bone loss. We hypothesize that the open Latarjet will provide higher patient-reported outcome measure scores and lower rates of dislocation.

METHODS

A retrospective cohort comparison of patients with anterior glenohumeral instability procedures was performed. Inclusion criteria included symptomatic anterior shoulder instability, subcritical glenoid bone loss (13.5%-24%), surgical treatment with arthroscopic Bankart repair or open Latarjet, and minimum follow-up of 2 years. Outcomes included recurrent instability (defined as postoperative dislocation or subjective subluxation), permanent physical restrictions, Western Ontario Shoulder Index (WOSI), and Single Assessment Numeric Evaluation (SANE) scores.

RESULTS

Forty-seven patients were included, 25 of whom underwent an arthroscopic Bankart repair and 23 patients an open Latarjet. The average bone loss was 17.8% and 19.3%, respectively. Overall, 8 patients experienced recurrent instability, 6 in the arthroscopic Bankart group and 2 in the open Latarjet group (P = .162). The average postoperative SANE score for arthroscopic Bankart group was 48% and for the open Latarjet group, 84% (P < .001). The average postoperative WOSI score for the arthroscopic Bankart group was 53.6% and for the open Latarjet group, 67.9% (P = .069). There were significantly more patients placed on permanent physical restrictions in the arthroscopic Bankart repair group (16) compared with open Latarjet (3) (P < .001).

CONCLUSION

In patients with subcritical glenoid bone loss (defined as 13.5%-24%), patients treated with an open Latarjet have insignificantly higher SANE and WOSI scores and lower permanent physical restrictions than patients treated with an arthroscopic Bankart repair. We found no statistically significant difference in recurrent instability rates between the open Latarjet and arthroscopic Bankart repair (P = .162).

Public Insurance Is Associated With Decreased Rates of Surgical Management for Glenohumeral Instability: An Analysis of the Rhode Island All-Payers Claims Database

Background

Socioeconomic status has been shown to influence patients' ability to access health care.

Purpose

To evaluate the socioeconomic status and/or insurance provider of patients and to determine whether these differences influence the management of shoulder instability.

Study Design

Descriptive epidemiology study.

Methods

The Rhode Island All-Payers Claims Database (APCD) was used to identify all patients between the ages of 5 and 64 years who made an insurance claim related to a shoulder instability event between January 1, 2011, and December 31, 2019. Chi-square analysis and multivariate logistic regression were utilized to determine whether insurance status, social deprivation index (SDI), or median income by zip code were significant predictors of treatment methodology and recurrent instability. Kaplan-Meier failure analysis and Cox regression were used to assess for variation in the cumulative rates of surgical intervention and recurrent instability over 20-year age groups (5-24, 25-44, and 45-64 years).

Results

There were 3310 patients from the APCD query included in the analysis. Bivariate analysis demonstrated significant variation in the rates of surgical stabilization between patients with public and commercial insurance providers (P < .001). Patients with public insurance received surgery 1.8% of the time compared with 5.8% of the time in patients with commercial insurance. After controlling for recurrent instability, age, instability type (subluxation or dislocation) and directionality, and sex, patients with public insurance were 79% less likely to receive surgery within 30 days (P = .035) and 64% less likely to receive surgery within 1 year (P = .002). This disparity was most notable in the 5- to 24-year (hazard ratio [HR] = 0.28; 95% CI, 0.13-0.61) and 25- to 44-year (HR = 0.26; 95% CI, 0.08-0.89) age groups. Neither SDI quartile nor income quartile based on patient primary zip code had a clinically significant influence on rates of surgery or recurrent instability.

Conclusion

These data demonstrate that patients with public insurance have a decreased likelihood of undergoing surgical stabilization to address glenohumeral instability compared with patients with commercial insurance.

Prospective Evaluation of Posterior Glenoid Bone Loss After First-time and Recurrent Posterior Glenohumeral Instability Events

BACKGROUND

Although posterior glenohumeral instability is becoming an increasingly recognized cause of shoulder pain, the role of posterior glenoid bone loss on outcomes remains incompletely understood.

PURPOSES

To prospectively determine the amount of bone loss associated with posterior instability events and to determine predisposing factors based on preinstability imaging.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 1428 shoulders were evaluated prospectively for ≥4 years. At baseline, a subjective history of shoulder instability was ascertained for each patient, and bilateral noncontrast magnetic resonance imaging (MRI) scans of the shoulders were obtained regardless of any reported history of shoulder instability. The cohort was prospectively followed during the study period, and those who were diagnosed with posterior glenohumeral instability were identified. Postinjury MRI scans were obtained and compared with the screening MRI scans. Glenoid version, perfect-circle-based bone loss was measured for each patient's pre- and postinjury MRI scans using previously described methods.

RESULTS

Of the 1428 shoulders that were prospectively followed, 10 shoulders sustained a first-time posterior instability event and 3 shoulders sustained a recurrent posterior instability event. At baseline, 11 of 13 shoulders had some amount of glenoid dysplasia and/or bone loss. The change in glenoid bone loss was 5.4% along the axis of greatest loss (95% CI, 3.8%-7.0%; P = .009), 4.4% at the glenoid equator (95% CI, 2.7%-6.2%; P = .016), and 4.2% of total glenoid area (95% CI, 2.9%-5.3%; P = .002). Recurrent glenoid instability was associated with a greater amount of absolute bone loss along the axis of greatest loss compared with first-time instability (recurrent: 16.8% ± 1.1%; 95% CI, 14.6%-18.9%; first-time: 10.0% ± 1.5%; 95% CI, 7.0%-13.0%; P = .005). Baseline glenoid retroversion ≥10° was associated with a significantly greater percentage of bone loss along the axis of greatest loss (≥10° of retroversion: 13.5% ± 2.0%; 95% CI, 9.6%-17.4%; <10° of retroversion: 8.5% ± 0.8%; 95% CI, 7.0%-10.0%; P = .045).

CONCLUSIONS

Posterior glenohumeral instability events were associated with glenoid bone loss of 5%. The amount of glenoid bone loss after a recurrent posterior glenohumeral instability event was greater than that after first-time instability. Glenoid retroversion ≥10° was associated with a greater amount of posterior glenoid bone loss after a posterior instability event.

Clinical and Radiologic Outcomes of All-Arthroscopic Latarjet Procedure With Modified Suture Button Fixation: Excellent Bone Healing With a Low Complication Rate

PURPOSE

To investigate the clinical outcomes and radiologic evaluation of an all-arthroscopic Latarjet procedure with modified button fixation.

METHODS

Patients who received all-arthroscopic Latarjet procedure with modified suture button fixation between September 2015 to September 2016 were retrospectively reviewed. Indications for surgery were recurrent anterior shoulder dislocation with any 1 of these 3 conditions: glenoid defect >15%, contact-sport athlete, or failure after Bankart repair. Inclusion criteria included cases who received this surgery. Clinical outcomes were evaluated by University of California Los Angeles, ASES and Rowe score with a minimal follow-up of 3 years. Radiologic assessment on 3D computed tomography scan was performed preoperatively and postoperatively at different time points. Complications were also recorded.

RESULTS

A total of 30 patients were eventually included in this study. The mean follow-up time was 38.0 ± 2.5 months. There were 25 patients who performed contact sports. Of them, 10 patients were without glenoid defect >15% or failed Bankart repair. The remaining 20 patients had glenoid defect >15%, including 2 failed Bankart cases. Ten patients had glenoid defect < 13.5%, and the rest 20 patients had > 13.5%. UCLA, American Shoulder and Elbow Surgeons, and Rowe score significantly improved during follow-up, and the improvement exceeded MCID for all patients. No severe complications were noted. In total, 86.7% of the graft positioning was measured as flush and 13.3% as medial. The bone union rate was 96.7% at 3 months postoperatively and at final follow-up. The remodeling process for the restoration of the normal anatomy of the lower part of glenoid was noted.

CONCLUSIONS

All-arthroscopic Latarjet with modified suture button fixation can achieve stable fixation of the coracoid, good clinical outcomes (all patients with improvement exceeding MCID), low complications rate. Furthermore, the bone remodeling process contributes to the recovery of the normal anatomy of anteroinferior glenoid.

STUDY DESIGN

Case series; Level of evidence, 4.

Surgical treatment of anterior shoulder instability with glenoid bone loss with the Latarjet procedure in active-duty military service members

INTRODUCTION

The arthroscopic Bankart repair in the setting of glenoid bone loss has high rates of failure. In patients with anterior glenoid bone loss, the Latarjet provides glenohumeral stability through restoration of the glenoid bone, the conjoint tendon acting as a sling on the subscapularis, and anterior capsulolabral repair. Active-duty military personnel are at high risk for glenohumeral instability and have been equated to the contact athlete; most are young, male, and engage in contact sports. The purpose of this study is to assess the return to full-duty rates in active-duty military personnel following the Latarjet for anterior glenohumeral instability with glenoid bone loss.

METHODS

A retrospective review of all glenohumeral instability procedures were reviewed at a tertiary training hospital from June 2014 to June 2019. The patient population consisted of active-duty military personnel with glenoid bone loss and anterior glenohumeral instability, who were treated with a Latarjet. The primary outcome was return to full-duty status.

RESULTS

There were 50 patients identified for the study. Four patients were lost to follow-up, leaving 46 of 50 patients (92.0%) eligible for this study. The average age at the time of the index procedure was 23.1 years. The average percentage bone loss was 18.4%. Forty-one patients (89.1%) were able to return to full-duty status. Four patients (8.7%) sustained a recurrent dislocation following the Latarjet; all 4 dislocations occurred during a combat deployment. Four patients (8.7%) reported episodes of subluxation without dislocation. Forty-one patients (89.1%) reported that their shoulders felt stable, and we found an average return to full duty at 5.3 months CONCLUSION: In our active-duty military cohort, we found an 8.7% rate of recurrent instability after a Latarjet procedure, and 41 patients (89.1%) were able to return to full-duty status. In conclusion, the Latarjet procedure in the active-duty military population with anterior glenoid bone loss resulted in a high rate of return to duty, excellent functional outcomes, low rate of recurrent instability, and a low overall complication rate.

Treatment of anterior shoulder instability: a bibliometric analysis

PURPOSE

The treatment of anterior shoulder instability is a focus in the field of sports medicine. While much research has been conducted, few bibliometric studies have been performed in this field. This study analyzed the main characteristics and identified emerging research trends and hotspots related to the treatment of anterior shoulder instability over the past four decades.

METHODS

We searched for (anterior shoulder instability OR anterior shoulder dislocation) AND (treatment OR reconstruction) in ARTICLE (Mesh) in the Web of Science database from 1980 to 2020. We analyzed the keywords, author, institution, country, number of citations, average number of citations, publication year, and partnership of the identified articles. Information about annual publications was analyzed using Microsoft Excel 2019; the remaining data were analyzed using VOSviewer version 1.6.11 (Leiden University, Leiden, Netherlands) and CiteSpace version 5.7.R2 (Drexel University, Philadelphia, PA, USA).

RESULTS

A total of 1964 articles were published between 1980 and 2020. The American Journal of Sports Medicine, the United States, the United States Department of Defense, and Arcieio were journals, countries, institutions, and authors with the highest numbers of publications. The topic hotspots were instability, shoulder, and dislocation, while the research frontiers were arthroscopic, Bankart repair, Latarjet procedure, risk factors, recurrence, and complications.

CONCLUSION

The treatment of anterior shoulder instability has shown an increasing number of publications each year and achieved great progress. The United States made the most outstanding contributions to this important field. Arthroscopic, Bankart repair, and Latarjet procedures were research hotspots and risk factors, recurrence, and complications were likely to research frontiers.

Risk factors for musculoskeletal injuries in the military: a qualitative systematic review of the literature from the past two decades and a new prioritizing injury model

BACKGROUND

Musculoskeletal injuries (MSkIs) are a leading cause of health care utilization, as well as limited duty and disability in the US military and other armed forces. MSkIs affect members of the military during initial training, operational training, and deployment and have a direct negative impact on overall troop readiness. Currently, a systematic overview of all risk factors for MSkIs in the military is not available.

METHODS

A systematic literature search was carried out using the PubMed, Ovid/Medline, and Web of Science databases from January 1, 2000 to September 10, 2019. Additionally, a reference list scan was performed (using the "snowball method"). Thereafter, an international, multidisciplinary expert panel scored the level of evidence per risk factor, and a classification of modifiable/non-modifiable was made.

RESULTS

In total, 176 original papers and 3 meta-analyses were included in the review. A list of 57 reported potential risk factors was formed. For 21 risk factors, the level of evidence was considered moderate or strong. Based on this literature review and an in-depth analysis, the expert panel developed a model to display the most relevant risk factors identified, introducing the idea of the "order of importance" and including concepts that are modifiable/non-modifiable, as well as extrinsic/intrinsic risk factors.

CONCLUSIONS

This is the qualitative systematic review of studies on risk factors for MSkIs in the military that has attempted to be all-inclusive. A total of 57 different potential risk factors were identified, and a new, prioritizing injury model was developed. This model may help us to understand risk factors that can be addressed, and in which order they should be prioritized when planning intervention strategies within military groups.

Non-Operative Shoulder Dysfunction in the United States Military

INTRODUCTION

Recent epidemiological evidence shows that shoulder and upper-arm complaints impose a substantial burden on the armed forces of the United States and create significant challenges for all components of the physical fitness domain of total force fitness. Clinicians, epidemiologists, and health-services researchers interested in shoulder and upper-arm injuries and their functional limitations rarely have objective, validated criteria for rigorously evaluating diagnostic practices, prescribed treatments, or the outcomes of alternative approaches. We sought to establish and quantify patient volume, types of care, and costs within the Military Health System (MHS) in assessing and managing active duty members with nonoperative shoulder and upper-arm dysfunction.

MATERIALS AND METHODS

We performed a retrospective cohort study using data from the MHS Data Repository and MHS MART (M2) from fiscal year 2014 to identify active duty individuals with a diagnosis of shoulder and upper-arm injury or impairment defined by one of the International Classification of Disease Ninth Edition diagnosis codes that were selected to reflect nonoperative conditions such as fractures or infections. Statistical analyses include descriptive statistics on patient demographics and clinical visits, such as the range and frequency of diagnoses, number and types of appointments, and clinical procedure information following the diagnosis. We also examined treatment costs related to shoulder dysfunction and calculated the total cost to include medications, radiological, procedural, and laboratory test costs for all shoulder dysfunction visits in 2014 and the average cost for each visit. We further examined the category of each medication prescribed.

RESULTS

A total of 55,643 individuals met study criteria and accrued 193,455 shoulder-dysfunction-related clinical visits in fiscal year 2014. This cohort represents approximately 4.8% of the 1,155,183 active duty service members assigned to the United States and its territories during FY 2014. Most patients were male (85.32%), younger (85.25% were under 40 years old), and Caucasian/White (71.12%). The most common diagnosis code was 719.41 (pain in joint, shoulder region; 42.48%). The majority of the patients 42,750 (76.8%) had four or fewer medical visits during the study period and 12,893 (23.2%) had more than four visits. A total of 4,733 patients (8.5%) underwent arthrocentesis aspiration or injection. The total cost for all visits was $65,066,767.89. The average and median cost for each visit were $336.34 (standard deviation was $1,493.87) and $163.11 (range was from 0 to $84,183.88), respectively. Three out of four patients (75.3%) underwent radiological examinations, and 74.2% of these individuals had more than one radiological examination. Medications were prescribed to 50,610 (91.0%) patients with the three most common being IBUPROFEN (12.21%), NAPROXEN (8.51%), and OXYCODONE-ACETAMINOPHEN (5.04%), respectively.

CONCLUSIONS

Nearly 1 in 20 active duty military service members presented for nonoperative care of shoulder and/or upper-arm dysfunction during FY2014. Further examinations of the etiology and potential impact of shoulder/upper-arm dysfunction on force readiness are clearly warranted, as are additional studies directed at identifying best practices for preventing injury-related dysfunction and determining best practices for the treatment of shoulder dysfunction to optimize service member fitness and force readiness.

Biceps Brachii Alterations Following the Latarjet Procedure: A Prospective Multicenter Study

Purpose: To prospectively investigate the postoperative forearm supination and elbow flexion strength of both upper extremities and popeye deformity in patients who underwent a mini-open Latarjet procedure for anterior shoulder instability. Methods: Patients who underwent a mini-open Latarjet procedure at two specialized shoulder centers were prospectively evaluated preoperatively (T0) and at least 6 months (T1) after surgery. Subjects were tested for elbow flexion and forearm supination strength of both upper extremities using an isometric dynamometer and customized torque dynamometer. Clinical outcome was assessed by the Constant Score (CS), American Shoulder and Elbow Score (ASES) and Simple Shoulder test (SST). Popeye deformity was defined as a distalization of the greatest circumference of the biceps muscle belly towards the lateral epicondyle of the elbow. Results: A total of 20 patients with a mean age of 27 ± 6 years were included in the study. At a mean follow-up of 10 ± 3 months, the elbow flexion strength was restored to the preoperative state (p = 0.240). Forearm supination strength significantly decreased at final follow-up, to 88 % in the surgical arm (p = 0.015) vs. 90 % in the non-surgical arm (p = 0.023). There was no statistical difference when comparing both arms concerning elbow flexion strength (p = 0.510) and forearm supination strength (p = 0.495). No significant popeye deformity was observed in both arms (p = 0.111 vs. p = 0.508). Clinical outcome scores improved significantly from 73 ± 18 to 82 ± 13 (p = 0.014) for CS and 76 ± 22 to 89 ± 12 (p = 0.008) for ASES score preoperatively to final follow-up. No difference in the SST was documented (p = 0.10). Conclusion: The Latarjet procedure showed to preserve elbow flexion strength and provided comparable forearm supination strength compared to the uninjured arm with reliable clinical outcome in this study population. However, a decrease of forearm supination strength in both arms was persistent at a mean of 10 months postoperatively. No popeye deformity was noted in the postoperative examinations. Level of evidence: Case series, Level III.

The association between Y-balance test scores, injury, and physical performance in elite adolescent Australian footballers

OBJECTIVES

Identify how modified Lower-Quarter Y-Balance Test (mYBT-LQ) and Upper-Quarter Balance Test (mYBT-UQ) scores relate to injury risk and measures of physical performance in elite adolescent Australian Football (AF) athletes.

DESIGN

Prospective cohort study.

METHODS

Pre-season mYBT-LQ, mYBT-UQ, and physical performance measures (speed, jump height, and agility) were obtained in 257 elite adolescent male AF athletes. Injury status was tracked across the 18-game season to determine the relationship between mYBT scores and injury risk based on time-to-event analysis. Cross-sectional analysis of mYBT-LQ scores and performance measures determined the relationships between these variables.

RESULTS

There were no significant associations between injury risk and any single mYBT parameter. However, athletes with high posteromedial asymmetry and good agility performance (top 25% of the cohort) had moderately increased injury risk with and tended to without a previous injury history (Hazard Ratio = 3.26 [95% Confidence Interval: 1.01, 10.54; p = 0.048] and 2.69 [95% Confidence Interval = 0.92, 7.82; p = 0.069], respectively). There were significant correlations between faster agility times and higher composite limb-length normalised mYBT-LQ (r = -0.210; CI = -0.324, -0.090), limb-length normalised average posteromedial reach score (r = -0.227; CI = -0.340, -0.108), and limb-length normalised average posterolateral reach score (r = -0.250: CI = -0.361, -0.132).

CONCLUSION

In isolation, the mYBT is not useful for identifying injury risk in junior AF athletes, and only small correlations between mYBT-LQ and physical performance variables were identified. However, high mYBT-LQ posteromedial asymmetry is associated with increased injury risk for athletes with good agility performance. This should be considered within athlete preparation programs.

Joint hypermobility in athletes is associated with shoulder injuries: a systematic review and meta-analysis

BACKGROUND

Joint hypermobility in athletes is associated with increased risk of knee injuries, but its role in relation to shoulder injuries has not been scrutinized. Therefore, our aim was to synthesize the evidence on the association between joint hypermobility and shoulder injuries in athletes.

METHODS

Data sources were MEDLINE, CINAHL, EMBASE, and SPORTDiscus from inception to 27th February 2021. Eligibility criteria were observational studies of athletes (including military personnel), mean age ≥ 16 years, and with a transparent grouping of those with and without joint hypermobility. A broad definition of joint hypermobility as the exposure was accepted (i.e., generalised joint hypermobility (GJH), shoulder joint hypermobility including joint instability). Shoulder injuries included acute and overuse injuries, and self-reported pain was accepted as a proxy for shoulder injuries. The Odds Ratios (OR) for having shoulder injuries in exposed compared with non-exposed athletes were estimated using a random effects meta-analysis. Subgroup analyses were performed to explore the effect of sex, activity type, sports level, study type, risk of bias, and exposure definition. Risk of bias and the overall quality of evidence were assessed using, respectively, the Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Among 6207 records, six studies were included with 2335 (range 118-718) participants (34.1% females; athlete mean age 19.9 years). Athletes with joint hypermobility were more likely to have shoulder injuries compared with athletes without joint hypermobility (OR = 3.25, 95% CI 1.64, 6.43, I2 = 75.3%; p = 0.001). Exposure definition (GJH, OR = 1.97, 95% CI 1.32, 2.94; shoulder joint hypermobility, OR = 8.23, 95% CI 3.63, 18.66; p = 0.002) and risk of bias (low, OR = 5.25, 95% CI 2.56, 10.8; high, OR = 1.6, 95% CI 0.78, 3.29; p = 0.024) had large impacts on estimates, while the remaining subgroup analyses showed no differences. The overall quality of evidence was low.

CONCLUSION

Joint hypermobility in athletes is associated with a threefold higher odds of having shoulder injuries, highlighting the need for prevention strategies in this population. However, due to low quality of evidence, future research will likely change the estimated strength of the association.

PROTOCOL REGISTRATION

Open Science Framework registration osf.io/3wrn9.

Arthroscopic Latarjet Procedure: Indications, Techniques, and Outcomes

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The proposed advantages of the arthroscopic approach in the Latarjet procedure for shoulder dislocation include improved visualization for accurate positioning of the coracoid graft, the ability to address any associated intra-articular pathologies, and the diminished potential for the formation of postoperative scar tissue and stiffness associated with an open procedure.

»

Young age, the presence of glenoid and/or humeral bone loss, a history of dislocation, a history of failed arthroscopic stabilization surgery, and an active lifestyle are all associated with recurrent dislocation and are relative indications for an osseous augmentation procedure.

»

Both the open and arthroscopic Latarjet procedures result in substantial improvements in patient function, with comparable rates of recurrent instability and complication profiles.

Anterior glenohumeral instability: Current review with technical pearls and pitfalls of arthroscopic soft-tissue stabilization

The glenohumeral joint (GHJ) allows for a wide range of motion, but is also particularly vulnerable to episodes of instability. Anterior GHJ instability is especially frequent among young, athletic populations during contact sporting events. Many first time dislocators can be managed non-operatively with a period of immobilization and rehabilitation, however certain patient populations are at higher risk for recurrent instability and may require surgical intervention for adequate stabilization. Determination of the optimal treatment strategy should be made on a case-by-case basis while weighing both patient specific factors and injury patterns (i.e., bone loss). The purpose of this review is to describe the relevant anatomical stabilizers of the GHJ, risk factors for recurrent instability including bony lesions, indications for arthroscopic vs open surgical management, clinical history and physical examination techniques, imaging modalities, and pearls/pitfalls of arthroscopic soft-tissue stabilization for anterior glenohumeral instability.

Sex differences in outcomes after arthroscopic bankart repair

Objectives

Risk factors for anterior shoulder dislocation include young age, contact activities and male sex. The influence of sex on patient-reported outcomes of arthroscopic Bankart repair (ABR) is unclear, with few studies reporting potential differences. This study’s purpose was to compare patient-reported outcomes of males and females following ABR.

Methods

Prospectively collected data was analysed for 281 patients (males: 206, females: 75) after ABR with preoperative, 1-year and 2-year follow-up responses. The Wilcoxon signed-rank and χ² tests, preoperative, 1 year and 2 year follow-up results were examined to determine differences of scores in males versus females.

Results

No statistically significant sex differences were observed in Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), Visual Analogue Scale (VAS) or Single Assessment Numerical Evaluation (SANE) Scores at 1-year or 2-year follow-up. Females had lower Veterans RAND 12-item health survey (VR-12) mental health subscores at 2-year follow-up (females: 52.3±9.0, males: 55.8±7.6, p=0.0016). Females were more likely to report that treatment had ‘exceeded expectations’ at 2-year follow-up regarding motion, strength, function and normal sports activities.

Conclusion

Results of study demonstrate that ABR has similar outcomes for both males and females. There were no statistically significant sex-related differences in SST, ASES, VAS or SANE scores following ABR. VR-12 mental health subscores showed a minimal difference at 2-year follow-up, with lower scores in females.

Level of evidence

Retrospective cohort study; level II.

INFLUENCE OF LIMB DOMINANCE AND SHOULDER INJURY ON STRENGTH AND EXPLOSIVE FORCE IN US MARINES

Background

The specialized roles of many military personnel require specific skills and high physical demands, placing unique stresses on the shoulders and increasing risk of injury. As normal dominant/nondominant shoulder asymmetries have been established in military personnel, bilateral strength comparisons must be understood in context of daily physical demands to monitor patients' progress or readiness to return to duty.

Purpose

This study aims to assess bilateral differences in strength and explosive force in United States Marines with a history of dominant or nondominant shoulder pathology.

Study Design

Cross-Sectional.

Methods

A total of 52 full-duty, male US Marines with a shoulder injury within the prior year participated. Bilateral isokinetic shoulder internal (IR) and external (ER) rotation strength, and peak force (Peak Force) and average rate of force production (Avg Rate) during an explosive push-up were collected. Dominant versus nondominant side data were independently examined within each group (DOM: dominant injury, NOND: nondominant injury). Comparison between DOM and NOND, as well as previously published CON (no history of shoulder injury) was also completed.

Results

NOND (n = 26) demonstrated significantly less IR (p < 0.001) and ER (p = 0.003) strength and Peak Force (p = 0.001) and Avg Rate (p = 0.047) on the injured side, while DOM (n = 26) demonstrated no bilateral differences in strength or push-up performance. Comparison between the three groups showed that NOND demonstrated significantly less ER strength than CON (p = 0.022).

Conclusions

Military personnel demonstrate asymmetric strength patterns likely due to increased demand of the dominant shoulder. US Marines with a history of injury to the nondominant shoulder performed differently than those with a dominant side injury, presenting with both strength and push-up asymmetries. They also demonstrated significant ER strength deficits compared to CON. Common clinical practice and previous literature often compare injured and uninjured limbs or injured individuals to healthy controls, but further distinction of dominant or nondominant side may provide more accurate information needed to develop targeted treatment strategies.

Clinical Relevance

Recognizing unique occupational demands and how patients may present differently with dominant versus nondominant side shoulder injuries are important considerations for ensuring accurate assessment and effective individualized rehabilitation.

Level of Evidence

3.

Anterior Shoulder Instability in the Professional Athlete: Return to Competition, Time to Return, and Career Length

Background:

Anterior shoulder instability is a common condition in professional athletes, yet little is known about the success of surgery. Return to competition (RTC) is a metric indicative of a successful outcome for professional athletes who undergo anterior shoulder stabilization surgery.

Purpose:

To determine the rate of RTC, time to RTC, recurrence rate, and length of career after surgery in professional athletes who had undergone surgical treatment for anterior shoulder instability.

Study Design:

Case series; Level of evidence, 4.

Methods:

We evaluated professional athletes who underwent surgical treatment for anterior shoulder instability by a single surgeon between 2007 and 2018. Data from patients’ medical records, a patient data registry, basic search engines, sports websites, and individual team websites were used to determine length of professional play before injury, duration of career after surgery, and RTC level.

Results:

Overall, 23 professional athletes (25 shoulders from 12 contact and 13 noncontact athletes) were identified. The mean age at the time of surgery was 24.3 ± 4.9 years (range, 16-35 years). Primary procedures included arthroscopic Bankart repair (76%; 19/25), open Latarjet (20%; 5/25), and bony Bankart repair (4%; 1/25). Of the 23 athletes, 22 returned to their previous level of competition (96%; 95% CI, 78%-100%). The mean time between surgery and RTC was 4.5 months (range, 3-8 months). There was no difference in time to RTC between contact and noncontact athletes (4.1 vs 4.4 months). There was no difference in RTC rates and time to return for players who received a Bankart repair versus a Latarjet procedure (4.6 vs 4.2 months). A total of 12 participants were still actively engaged in their respective sport at an average of 4.3 years since surgery, while 11 athletes went on to retire at an average of 4.8 years. Duration of play after surgery was 3.8 years for contact athletes and 5.8 years for noncontact athletes (P > .05).

Conclusion:

In this series, professional athletes who underwent surgical shoulder stabilization for the treatment of anterior glenohumeral instability returned to their presurgical levels of competition at a high rate. No differences in RTC rate or time to RTC were observed for contact versus noncontact athletes or for those who received arthroscopic Bankart repair versus open Latarjet. However, contact athletes had shorter careers after surgery than did noncontact athletes.

Outcomes of the Latarjet procedure with minimum 5- and 10-year follow-up: A systematic review

BACKGROUND

The purpose of this study was to evaluate mid- and long-term outcomes following the Latarjet procedure for anterior shoulder instability.

METHODS

PubMed, MEDLINE, Embase, and Cochrane libraries were systematically searched, in line with PRISMA guidelines, for studies reporting on outcomes following the Latarjet procedure with minimum five-year follow-up. Outcomes of studies with follow-up between 5 and 10 years were compared to those with minimum follow-up of 10 years.

RESULTS

Fifteen studies reporting on 1052 Latarjet procedures were included. Recurrent instability occurred in 127 patients, with an overall random summary estimates in studies with a minimum five-year follow-up of 0-18% (I² = 90%) compared to 5-26% (I² = 59%) for studies with a minimum 10-year follow-up. Overall rates for return to sports, non-instability related complications, and progression of arthritis estimated at 65-100% (I² = 87%), 0-20% (I² = 85%), and 8-42% (I² = 89%) for the minimum five-year follow-up studies and 62-93% (I² = 86%), 0-9% (I² = 28%), and 9-71% (I² = 91%) for the minimum 10-year follow-up studies, respectively. All studies reported good-to-excellent mean PRO scores at final follow-up.

CONCLUSIONS

The Latarjet is a safe and effective procedure for patients with shoulder instability. The majority of patients return to sport, though at long-term follow-up, a trend towards an increased incidence of recurrent instability is appreciated, while a significant number may demonstrate arthritis progression.

Breaking the myths of competition: a cross-sectional analysis of injuries among CrossFit trained participants

Objectives

The purpose of this study was to examine the injury rates of individuals engaged in CrossFit training and examine the risk of injury associated with competition.

Study design

Cross-sectional analysis.

Methods

Descriptive statistics, including injury incidence and rates, were examined for individuals reporting participation in a CrossFit sanctioned competition between 2013 and 2017. To examine the odds of being injured, we considered logistic regression models, where the primary independent measure was participation length—individual measures of interest included age, sex, body mass index, CrossFit affiliation and competition status.

Results

3049 individuals completed the survey (60% completion rate). All competitors, regardless of competition level, had similar incidence of injury (χ²=1.1, p=0.571). For those who reported competing, our calculated injury rate was 0.21–0.54 injuries per 1000 training hours, while for those not competing, the injury rate was calculated as 0.39–1.30 injuries per 1000 training hours. Logistic regression demonstrated short length of participation in CrossFit training as the main factor associated with the odds of being injured (OR=1.82; 95% CI: 1.15 to 2.92). Additionally, training at an official CrossFit affiliate appeared to have a protective effect from injury (OR=0.85; 95% CI: 0.65, 1.10).

Conclusion

Our findings provide evidence of the low risk of injury related to these events. Moreover, these findings support the notion that musculoskeletal injuries may be the result of poor progression plans, which may be minimised by participating in an official CrossFit affiliate.

Management of bone loss in recurrent traumatic anterior shoulder instability: a survey of North American surgeons

Background

Management of bone loss in recurrent traumatic anterior shoulder instability remains a topic of debate and controversy in the orthopedic community. The purpose of this study was to survey members of 4 North American orthopedic surgeon associations to assess management trends for bone loss in recurrent anterior shoulder instability.

Methods

An online survey was distributed to all members of the American Shoulder and Elbow Surgeons, American Orthopaedic Society for Sports Medicine, and Canadian Orthopaedic Association and to fellow members of the Arthroscopy Association of North America. The survey comprised 3 sections assessing the demographic characteristics of survey respondents, the influence of prognostic factors on surgical decision making, and the operative management of 12 clinical case scenarios of varying bone loss that may be encountered in clinical practice.

Results

A total of 150 survey responses were returned. The age of the patient and quantity of bone loss were consistently considered important prognostic criteria. However, little consensus was reached for critical thresholds of bone loss and how this affected the timing (ie, primary or revision surgery) and type of bony augmentation procedure to be performed once a critical threshold was reached, especially in the context of critical humeral and bipolar bone loss.

Conclusions

Consistent trends were found for the management of recurrent anterior shoulder instability in cases in which no bone loss existed and when isolated critical glenoid bone loss was present. However, inconsistencies were observed when isolated critical humeral bone loss and bipolar bone loss were present.

Humeral Head Osteochondral Allograft Reconstruction with Arthroscopic Anterior Shoulder Stabilization at a Long-Term Follow-Up: A Case Report

CASE

The authors report a case of recurrent anterior shoulder instability in a 19-year-old man. Intraoperative arthroscopic examination identified Bankart and engaging Hill-Sachs lesions. The patient was treated with humeral head osteochondral allograft reconstruction and concomitant arthroscopic anterior stabilization. At the 14-year follow-up, there was no recurrent instability.

CONCLUSION

Humeral head osteochondral allograft reconstruction combined with an arthroscopic anterior stabilization procedure can be successful for recurrent shoulder instability and engaging Hill-Sachs lesion.

Pathoanatomy of Shoulder Instability in Collegiate Female Athletes

BACKGROUND

Shoulder instability has been well described in young men; however, few studies have specifically evaluated the pathoanatomy and unique spectrum of injuries in women with shoulder instability.

PURPOSE

To describe the pathoanatomy of operative shoulder instability in a collegiate female cohort.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors performed a retrospective analysis of a consecutive series of female students at a National Collegiate Athletic Association Division I military service academy treated operatively for shoulder instability by a single surgeon between September 2008 and September 2014. Preoperative data collected included patient age, sport, mechanism of injury, number and frequency of dislocations, direction of instability, and co-occurring surgical abnormalities at the time of arthroscopy. Outcome variables included recurrent instability after surgery and need for revision.

RESULTS

Thirty-six female student athletes with an average age of 20 years (range, 18-22 years) were included. The majority of instability events were traumatic in nature (69%), and 61% of the total events were subluxations. Rugby was the most common sport for experiencing instability (7 patients), followed by obstacle course training (6 patients). Thirty-two patients (89%) reported multiple instability events, averaging 4 per shoulder. The primary direction of instability was anterior in 26, combined anterior and posterior in 7, and 3 met criteria for multidirectional instability. At the time of surgery, 26 patients (72%) had a Bankart tear, 9 (25%) had a posterior labral tear, and 5 (14%) had superior labrum anterior to posterior tears. Nine patients (25%) were found to have humeral avulsion of the glenohumeral ligament (HAGL) lesions, 7 (19%) had partial-thickness articular-sided rotator cuff tears, and only 1 patient (3%) had evidence of true attritional glenoid bone loss. Hill-Sachs lesions were found in 16 patients (44%). Recurrent instability occurred in 9 patients (25%) following arthroscopic stabilization, and revision surgery was performed in 6 (17%).

CONCLUSION

Shoulder instability in female athletes presents commonly as multiple subluxation events. While soft tissue Bankart lesions were found in numbers equal to those in previous studies include both sexes, bony Bankart lesions were less common in women. Finally, the presence of combined anterior and posterior labral tears and HAGLs in women was more common than previously reported.

Patterns and Associations of Shoulder Motion, Strength, and Function in MARSOC Personnel Without History of Shoulder Injury

Introduction

Military personnel are at an increased risk of shoulder injuries due to training and deployment demands, however, there is a lack of information on the tactical athlete's upper extremity profile. Therefore, the purpose of this study was to examine shoulder musculoskeletal characteristics, including range of motion (ROM), strength, and function, and the relationships between these measures in Marine Corps Forces Special Operations Command (MARSOC) personnel without history of shoulder injury.

Materials and Methods

Participants included 195 full-duty male MARSOC personnel (age: 25.38 ± 2.85 yr; height: 1.79 ± 0.06 m, mass: 82.79 ± 7.88 kg) without history of shoulder injury. Measurements of ROM, strength, and function were obtained bilaterally. Shoulder internal rotation (IR) and external rotation (ER) ROM were summed to calculate total arc of motion (ARC). Shoulder IR and ER strength were assessed using an isokinetic dynamometer. Function was evaluated with an explosive push-up.

Results

MARSOC personnel present with significantly increased ER ROM, and decreased IR ROM and ARC in their dominant shoulder. They demonstrated greater IR strength and peak force during the explosive push-up on the dominant side but no bilateral differences in average or peak rate were found. Correlation analyses suggest a weak inverse relationship between strength and ARC (r = -0.15 to -0.24). Positive relationships between strength and function were identified except for dominant IR strength and push-up variables. Those with the greatest ARC demonstrated significantly weaker IR and ER strength compared to those with less motion.

Conclusions

MARSOC personnel demonstrate shoulder ROM and strength symmetry patterns similar to overhead athletes. Increased dominant shoulder strength does appear to translate to a bilateral functional performance, but overall performance may be limited by the weaker nondominant upper extremity. As ARC increases, IR and ER rotation strength decrease. Repetitive, increased loading of the dominant shoulder during functional movements and training may increase risk of chronic, overuse-type injuries, common to the military. Unilateral exercises and movement analysis should be incorporated to encourage proper development of bilateral shoulder strength, which may be particularly important in those with high ranges of ARC.

Prospective Evaluation of Glenoid Bone Loss After First-time and Recurrent Anterior Glenohumeral Instability Events

BACKGROUND

Determining the amount of glenoid bone loss in patients after anterior glenohumeral instability events is critical to guiding appropriate treatment. One of the challenges in treating the shoulder instability of young athletes is the absence of clear data showing the effect of each event.

PURPOSE

To prospectively determine the amount of bone loss associated with a single instability event in the setting of first-time and recurrent instability.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

The authors conducted a prospective cohort study of 714 athletes surveilled for 4 years. Baseline assessment included a subjective history of shoulder instability. Bilateral noncontrast shoulder magnetic resonance imaging (MRI) was obtained for all participants with and without a history of previous shoulder instability. The cohort was prospectively followed during the study period, and those who sustained an anterior glenohumeral instability event were identified. Postinjury MRI with contrast was obtained and compared with the screening MRI. Glenoid width was measured for each patient's pre- and postinjury MRI. The projected total glenoid bone loss was calculated and compared for patients with a history of shoulder instability.

RESULTS

Of the 714 athletes (1428 shoulders) who were prospectively followed during the 4-year period, 22 athletes (23 shoulders) sustained a first-time anterior instability event (5 dislocations, 18 subluxations), and 6 athletes (6 shoulders) with a history of instability sustained a recurrent anterior instability event (1 dislocation, 5 subluxations). On average, there was statistically significant glenoid bone loss (1.84 ± 1.47 mm) after a single instability event ( P < .001), equivalent to 6.8% (95% CI, 4.46%-9.04%; range, 0.71%-17.6%) of the glenoid width. After a first-time instability event, 12 shoulders (52%) demonstrated glenoid bone loss ≥5% and 4 shoulders, ≥13.5%; no shoulders had ≥20% glenoid bone loss. Preexisting glenoid bone loss among patients with a history of instability was 10.2% (95% CI, 1.96%-18.35%; range, 0.6%-21.0%). This bone loss increased to 22.8% (95% CI, 20.53%-25.15%; range, 21.2%-26.0%) after additional instability ( P = .0117). All 6 shoulders with recurrent instability had ≥20% glenoid bone loss.

CONCLUSION

Glenoid bone loss of 6.8% was observed after a first-time anterior instability event. In the setting of recurrent instability, the total calculated glenoid bone loss was 22.8%, with a high prevalence of bony Bankart lesions (5 of 6). The findings of this study support early stabilization of young active patients after a first-time anterior glenohumeral instability event.

An Updated Subsequent Injury Categorisation Model (SIC-2.0): Data-Driven Categorisation of Subsequent Injuries in Sport

BACKGROUND

Accounting for subsequent injuries is critical for sports injury epidemiology. The subsequent injury categorisation (SIC-1.0) model was developed to create a framework for accurate categorisation of subsequent injuries but its operationalisation has been challenging.

OBJECTIVES

The objective of this study was to update the subsequent injury categorisation (SIC-1.0 to SIC-2.0) model to improve its utility and application to sports injury datasets, and to test its applicability to a sports injury dataset.

METHODS

The SIC-1.0 model was expanded to include two levels of categorisation describing how previous injuries relate to subsequent events. A data-driven classification level was established containing eight discrete injury categories identifiable without clinical input. A sequential classification level that sub-categorised the data-driven categories according to their level of clinical relatedness has 16 distinct subsequent injury types. Manual and automated SIC-2.0 model categorisation were applied to a prospective injury dataset collected for elite rugby sevens players over a 2-year period. Absolute agreement between the two coding methods was assessed.

RESULTS

An automated script for automatic data-driven categorisation and a flowchart for manual coding were developed for the SIC-2.0 model. The SIC-2.0 model was applied to 246 injuries sustained by 55 players (median four injuries, range 1-12), 46 (83.6%) of whom experienced more than one injury. The majority of subsequent injuries (78.7%) were sustained to a different site and were of a different nature. Absolute agreement between the manual coding and automated statistical script category allocation was 100%.

CONCLUSIONS

The updated SIC-2.0 model provides a simple flowchart and automated electronic script to allow both an accurate and efficient method of categorising subsequent injury data in sport.

Surgical stabilization for first-time shoulder dislocators: a multicenter analysis

BACKGROUND

Anterior shoulder dislocations in young patients are associated with high rates of recurrent instability. Although some surgeons advocate for surgical stabilization after a single dislocation event in this population, there is sparse research evaluating surgical treatment for first-time dislocators.

METHODS

Patients undergoing surgical stabilization for anterior shoulder instability were prospectively enrolled at multiple institutions from 2015-2017 and stratified by number of dislocations before surgery. Demographic data, preoperative patient-reported outcomes, imaging findings, surgical findings, and procedures performed were compared between groups. Analysis of variance, χ², and multivariate logistic regression were used for statistical analysis.

RESULTS

The study included 172 patients (mean age, 25.3 years; 79.1% male patients) for analysis (58 patients with 1 dislocation, 69 with 2-5 dislocations, 45 with >5 dislocations). There were no intergroup differences in demographic characteristics, preoperative patient-reported outcomes, or physical examination findings. Preoperative imaging revealed increased glenoid bone loss in patients with multiple dislocation events (P = .043). Intraoperatively, recurrent dislocators were more likely to have bony Bankart lesions (odds ratio [OR], 3.26; P = .024) and biceps pathology (OR, 6.27; P = .013). First-time dislocators more frequently underwent arthroscopic Bankart repair and/or capsular plication (OR, 2.22; P = .016), while recurrent dislocators were more likely to undergo open Bristow-Latarjet procedures (OR, 2.80; P = .049) and surgical treatment for biceps pathology (OR, 5.03; P = .032).

CONCLUSIONS

First-time shoulder dislocators who undergo stabilization are more likely to undergo an arthroscopic procedure and less likely to have bone loss or biceps pathology compared with recurrent dislocators. Future studies are needed to ascertain long-term outcomes of surgical stabilization based on preoperative dislocation events.

Non-modifiable Risk Factors Associated with Sternoclavicular Joint Dislocations in the U.S. Military

INTRODUCTION

Sternoclavicular joint (SCJ) dislocations, although uncommon, are observed in patients with ligamentous laxity as well as those who experience traumatic injuries. The incidence and epidemiology of this costly and debilitating injury to our relatively young and active military population have not previously been reported. The purpose of this study is to consider and quantify the non-modifiable risk factors associated with this injury.

METHODS

Using Defense Medical Epidemiological Database, first-time occurrences, from 2006 to 2015 for the ICD-9-CM code 839.61 (closed dislocation of the SCJ), were obtained and further categorized by gender, race, age, rank, and branch of service. Race was classified based on self-reporting of patients into White, Black, or other categories. Age was divided into the categories of less than 20 yr, 20–24 yr, 25–29 yr, 30–34 yr, 35–39 yr, and greater than 40 yr. Rank was categorized as junior enlisted (E-1 to E-4), senior enlisted (E-5 to E-9), junior officer (O-1 to O-3), and senior officer (O-4 to O-10). Branch of service includes Army, Navy, Air Force, and Marines. Multivariate data analysis was performed to obtain rate per 1,000 person-years as well as adjusted rate (adjusted for age group, gender, race, rank, and service) to isolate risk factors.

RESULTS

Between 2006 and 2015, 427 cases of closed SCJ dislocations occurred among an at-risk population of 13,772,342 person-years for an unadjusted incidence rate (IR) of 0.031 per 1,000 person-years. The annual unadjusted IR ranged from 0.017 in 2006 to 0.059 in 2014 with the greatest increase occurring between 2006 and 2007 representing 61% increase in the rate of injuries. Males were almost twice as likely to sustain these injuries compared with females (adjusted rate ratio 1.73; 95% confidence interval [CI] 1.23, 2.43). Age was not found to be a risk factor for the development of these injuries with IRs for each age group overlapping with 95% CI for all other age groups. Similarly, the other category for race was also not found to be a statistically significant risk factor. Junior Officers (adjusted rate 0.017; 95% CI 0.011, 0.025) were found least likely to suffer from these injuries with Junior Enlisted (0.034; 95% CI 0.030, 0.040) and Senior Enlisted (0.032; 95% CI 0.028, 0.037) most at risk. Being in the Navy (0.019; 95% CI 0.015, 0.025) was found to be most protective compared with Air Force (0.032; 95% CI 0.026, 0.039), Army (0.036; 95% CI 0.031, 0.041), and Marines (0.036; 95% CI 0.028, 0.045).

DISCUSSION and CONCLUSION

Annual unadjusted IR of SCJ dislocations readily increased from 2006 to 2014. Statistically significant risk factors, for suffering a closed SCJ dislocation, identified by our study, were male sex, enlisted rank, and branch of service other than Navy. Age and race were not found to have a statistically significant risk. These results can shed light on non-modifiable risk factors for dislocations of the SCJ and can be used in other studies to aid in reducing injury burden on the U.S. Military.

Does Study Design Affect Redislocation Rates After Primary Shoulder Dislocations? A Systematic Review Comparing Prospective and Retrospective Studies

PURPOSE

To compare recurrence rates between prospectively collected and retrospectively collected data on primary anterior shoulder dislocations, as this could influence the timing of surgical decision making.

METHODS

A comprehensive literature search of Medline, Embase, CINAHL, and hand searches was performed. Recurrence rates of anterior shoulder dislocations were collected from relevant articles, along with follow-up length, age, and gender. An independent sample t test was conducted to evaluate our hypothesis. A multiple linear regression model was used to examine the variance in recurrence rates while controlling for covariates.

RESULTS

A total of 1,379 articles were identified, of which 25 were relevant to our study-16 prospective and 9 retrospective. The average rate of recurrence of anterior shoulder dislocations in retrospective studies (mean [M] = 45.2, standard deviation [SD] = 31.67) was not significantly different from that in prospective studies (M = 56.7, SD = 22.55). The 95% confidence interval for the difference of the means ranged from -34.05 to 10.91. After controlling for covariates with the multiple linear regression, only 1.9% of the variance in recurrence rates was due to study type and was not significant (P = .42). The t test performed to evaluate our hypothesis was also not significant t(23) = -1.07, P = .298.

CONCLUSIONS

When comparing prospective and retrospective studies, there was no significant difference in recurrence rates of primary anterior shoulder dislocations treated nonoperatively. The average redislocation rate was 56.7% in prospective studies and 45.2% in retrospective studies. Furthermore, the majority of this difference was accounted for by varying rates between age groups. Further research is needed to determine the risk of redislocation in specific age groups, to guide treatment decisions based on varying risk.

LEVEL OF EVIDENCE

Systematic review of Level II and III studies.

Successful Return to Sport After Arthroscopic Shoulder Stabilization Versus Nonoperative Management in Contact Athletes With Anterior Shoulder Instability: A Prospective Multicenter Study

BACKGROUND

The debate continues regarding the optimal treatment of intercollegiate contact athletes with in-season anterior shoulder instability.

PURPOSE

To examine return to sport and recurrent instability in the season after the index in-season anterior instability event.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Forty-five contact intercollegiate athletes treated nonoperatively or with arthroscopic stabilization were prospectively followed in a multicenter observational study to evaluate return to play (RTP) and recurrent instability in the season after an initial in-season anterior glenohumeral instability event. Baseline data collection included sport played, previous instability events, direction of instability, type of instability (subluxation or dislocation), and treatment method (nonoperative management or arthroscopic stabilization). All nonoperatively treated athletes underwent a standardized accelerated rehabilitation program without shoulder immobilization. Surgical stabilization was performed arthroscopically in all cases, and successful RTP was evaluated during the next competitive season after complete rehabilitation.

RESULTS

Thirty-nine of 45 intercollegiate contact athletes had remaining National Collegiate Athletic Association eligibility and were followed through the subsequent competitive season after the index instability event. Of the 10 athletes electing nonoperative treatment, 4 (40%) successfully returned to play without recurrence during the subsequent season. Of the 29 athletes treated surgically, 26 (90%) were able to successfully return to play without recurrence the following season (recurrence: n = 1; inadequate function: n = 2). Athletes who underwent surgical reconstruction before the next season were 5.8 times (95% CI, 1.77-18.97; P = .004) more likely to complete the subsequent season without recurrent instability. Of the 29 athletes electing surgical stabilization, there was no difference (risk ratio, 0.95; 95% CI, 0.10-9.24; P > .99) in RTP between the 9 stabilized after a single instability event (90% RTP rate) and the 20 stabilized after multiple in-season recurrent instability events (89% RTP rate).

CONCLUSION

Collegiate contact and collision athletes with in-season anterior shoulder instability are significantly more likely to successfully return to sport without subsequent instability events the next season if they undergo surgical repair in the off-season.

Recurrent Shoulder Instability in a Young, Active, Military Population and Its Professional Implications

Background:

Shoulder instability is a topic of significant interest within the sports medicine literature, particularly regarding recurrence rates and the ideal treatment indications and techniques. Little has been published specifically addressing the occupational implications of symptomatic recurrent shoulder instability.

Hypothesis:

Previous arthroscopic repair will continue to be a significant predisposing factor for recurrent instability in a young, active population, and that recurrent instability may have a negative effect on college graduation and postgraduate occupational selection.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

We conducted a retrospective review of approved medical waivers for surgical treatment of anterior shoulder dislocation or instability prior to matriculation at the US Military Academy or the US Naval Academy for the graduating classes of 2010 to 2013. Statistical analysis was performed to determine the incidence and risk factors for recurrence and to determine the impact on graduation rate and occupation selection.

Results:

Fifty-nine patients were evaluated; 34% developed recurrent anterior instability. Patients with previous arthroscopic repair had a significantly higher incidence of recurrence (38%, P = 0.044). Recurrent shoulder instability did not significantly affect graduation rates or self-selected occupation (P ≥ 0.05).

Conclusion:

There is a significant rate of recurrent shoulder instability after primary surgical repair, particularly among young, active individuals. In addition, arthroscopic repair resulted in a significantly higher recurrence rate compared with open repair in our population. Surgical repair for shoulder instability should not necessarily preclude young individuals from pursuing (or being considered for) occupations that may place them at greater risk of recurrence.

Clinical Relevance:

The risk of recurrent instability is greater than the rate typically described, which may suggest that some subpopulations are at greater risk than others. A unique data point regarding instability is the effect on occupation selection.

Traditional Versus Congruent Arc Latarjet Technique: Effect on Surface Area for Union and Bone Width Surrounding Screws

PURPOSE

To compare the surface area available for bony contact and the width of bone on each side of the Latarjet fixation screws in the traditional Latarjet technique versus the congruent arc modification of the Latarjet technique.

METHODS

Computed tomographic scans of 24 shoulders in patients with glenohumeral instability who underwent multiplanar reconstruction measurements with multiple dimensions of the coracoid. The surface area of the coracoid available for bony contact with the anterior glenoid and width of bone on each side of a 3.5-mm screw was compared for the traditional Latarjet technique versus the congruent arc modification.

RESULTS

The surface area available for bony contact to the anterior glenoid was 5.65 ± 1.08 cm² using the traditional Latarjet technique compared with 3.64 ± 0.93 cm² using the congruent arc modification of the Latarjet technique (P < .001). The mean width of bone on each side of a 3.5-mm screw was 7.1 ± 1.0 mm using the traditional Latarjet technique compared with 4.1 ± 1.0 mm using the congruent arc modification (P < .001).

CONCLUSIONS

The traditional Latarjet technique has greater bony contact with the glenoid and greater bone width on each side of the screws compared with the congruent arc modification of the Latarjet technique. This potentially allows for a larger surface for healing in the traditional Latarjet technique. Moreover, because of smaller width of the bone around the screw, the congruent arc modification is potentially less tolerant of screw-positioning error compared with the traditional Latarjet technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Association Between Serum Relaxin and Subsequent Shoulder Instability

Ligamentous laxity correlates with shoulder instability. Relaxin is a hormone that has been linked to laxity in the knee and has been shown to be a risk factor for anterior cruciate ligament (ACL) injury. This study prospectively evaluated the association between relaxin and acute shoulder instability. A prospective cohort study of 1050 young athletes was performed between 2006 and 2010. The authors conducted a nested case-control analysis within this cohort to evaluate the association between preinjury serum relaxin concentration and the likelihood of subsequent shoulder instability. The study compared 53 patients who had shoulder instability and 53 control subjects who were matched for sex, age, height, and weight. The serum relaxin concentration in preinjury baseline samples was tested with enzyme-linked immunosorbent assay analysis in duplicate. Independent t tests were performed to identify differences in mean serum relaxin concentration between patients with shoulder instability and uninjured control subjects. Logistic regression was used to evaluate whether preinjury baseline serum relaxin concentration was associated with the subsequent likelihood of shoulder instability. Of the 53 patients with instability, 13 (25%) had a detectable serum relaxin concentration compared with 9 (17%) of uninjured control subjects (P=.34). Mean serum relaxin concentration in the injury group was 3.69±1.78 pg/mL and 2.20±0.97 pg/mL in uninjured control subjects (P=.02). Increased serum relaxin concentration was associated with the subsequent likelihood of acute shoulder instability. Subjects were 2.18 times (odds ratio, 2.18; 95% confidence interval, 1.01-4.76) more likely to have acute shoulder instability during the follow-up period for every 1-pg/mL increase in serum relaxin concentration at baseline. The findings suggest that serum relaxin concentration is associated with a risk of subsequent shoulder instability in young athletes. Further research on the role of relaxin in shoulder instability is warranted. [Orthopedics. 2016; 39(4):e724-e728.].

Predictors for Surgery in Shoulder Instability: A Retrospective Cohort Study Using the FEDS System

BACKGROUND

Shoulder instability is a common cause of pain and dysfunction in young, active patients. While studies have analyzed risk factors for recurrent instability and failure after instability surgery, few have examined which variables are associated with initial surgery in this patient population.

PURPOSE

To identify variables that may be associated with surgical intervention in patients with shoulder instability in the context of the FEDS (frequency, etiology, direction, severity) classification, a system that may be useful in the surgical treatment of shoulder instability patients.

STUDY DESIGN

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

METHODS

A database of patients treated for shoulder instability from 3 separate institutions from 2005 to 2010 was generated using International Classification of Diseases-9th Revision data. Data were collected via retrospective review. Injury data were categorized according to the FEDS system. Data were analyzed for significance, with the primary outcome of surgical intervention. Summary statistics were used to assess which variables were associated with eventual surgery. To test the unadjusted bivariate associations between shoulder surgery and each data point, Pearson chi-square tests were used for categorical variables and Wilcoxon tests were used for continuous variables.

RESULTS

Over the study time period, 377 patients were treated for shoulder instability. Patients who had surgery were more likely younger, had recurrent instability, and had their initial injury while playing a sport. Most patients had anterior instability; however, there was a greater proportion of posterior instability patients in the operative group. Severity of dislocation, measured by whether the patient required help to relocate the shoulder, was not significantly associated with eventual surgery. While imaging was not available for all patients, surgical patients were more likely to have magnetic resonance imaging findings of anterior labral injury and less likely to have a supraspinatus or subscapularis tear.

CONCLUSION

Patients who underwent surgery for shoulder instability were younger, more likely to have experienced recurrent instability, and more likely to have sustained their original injury while playing sports. The FEDS classification, particularly the frequency and etiology of the patient's shoulder instability, may be helpful in identifying patients with a higher likelihood of undergoing surgical treatment.

Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: a systematic review and meta-analysis

BACKGROUND

Recurrent instability following a first-time anterior traumatic shoulder dislocation may exceed 26%. We systematically reviewed risk factors which predispose this population to events of recurrence.

METHODS

A systematic review of studies published before 1 July 2014. Risk factors which predispose recurrence following a first-time traumatic anterior shoulder dislocation were documented and rates of recurrence were compared. Pooled ORs were analysed using random-effects meta-analysis.

RESULTS

Ten studies comprising 1324 participants met the criteria for inclusion. Recurrent instability following a first-time traumatic anterior shoulder dislocation was 39%. Increased risk of recurrent instability was reported in people aged 40 years and under (OR=13.46), in men (OR=3.18) and in people with hyperlaxity (OR=2.68). Decreased risk of recurrent instability was reported in people with a greater tuberosity fracture (OR=0.13). The rate of recurrent instability decreased as time from the initial dislocation increased. Other factors such as a bony Bankart lesion, nerve palsy and occupation influenced rates of recurrent instability.

CONCLUSIONS

Sex, age at initial dislocation, time from initial dislocation, hyperlaxity and greater tuberosity fractures were key risk factors in at least two good quality cohort studies resulting in strong evidence as concluded in the GRADE criteria. Although bony Bankart lesions, Hill Sachs lesions, occupation, physiotherapy treatment and nerve palsy were risk factors for recurrent instability, the evidence was weak using the GRADE criteria-these findings relied on poorer quality studies or were inconsistent among studies.

Approach to the treatment of primary anterior shoulder dislocation: A review

Glenohumeral joint dislocation is common among younger, active patients. Anterior dislocation is the most common direction of instability following a traumatic event. Due to a high rate of recurrence following primary traumatic anterior shoulder dislocation, an evidence-based approach is necessary to determine the best treatment regime for a patient presenting with this problem. A history, physical examination, and radiographic imaging can help guide treatment recommendations by determining the extent of soft tissue damage following dislocation. Controversies in the treatment of the first-time dislocator include the length and position of immobilization following dislocation, and the role of initial surgical stabilization. This article outlines the treatment options for the first-time glenohumeral dislocator, with an emphasis on the available evidence in the literature. Where applicable, the criteria known as the Strength of Recommendation Taxonomy were used to summarize the strength of evidence available for recommendations.

Shoulder instability with concomitant bone loss in the athlete

Thorough evaluation of the athlete with persistent shoulder instability and appropriate use of imaging modalities, such as 3-dimensional computed tomography, can help quantify the severity of bony deficiency. Based on obtained imaging and examination, surgical and nonsurgical methods can be considered. In many situations both the humeral- and glenoid-sided bone loss must be addressed. Depending on the extent of bone loss, athletic demands, and surgeon experience, arthroscopic or open surgical options can provide shoulder stability and return athletes to their prior level of activity.

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

BACKGROUND

There is no consensus on the optimal treatment of in-season athletes with anterior shoulder instability, and limited data are available to guide return to play.

PURPOSE

To examine the likelihood of return to sport and the recurrence of instability after an in-season anterior shoulder instability event based on the type of instability (subluxation vs dislocation). Additionally, injury factors and patient-reported outcome scores administered at the time of injury were evaluated to assess the predictability of eventual successful return to sport and time to return to sport during the competitive season.

STUDY DESIGN

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

METHODS

Over 2 academic years, 45 contact intercollegiate athletes were prospectively enrolled in a multicenter observational study to assess return to play after in-season anterior glenohumeral instability. Baseline data collection included shoulder injury characteristics and shoulder-specific patient-reported outcome scores at the time of injury. All athletes underwent an accelerated rehabilitation program without shoulder immobilization and were followed during their competitive season to assess the success of return to play and recurrent instability.

RESULTS

Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition (interquartile range, 13). Twelve athletes (27%) successfully completed the season without recurrence. Twenty-one athletes (64%) returned to in-season play and had subsequent recurrent instability including 11 recurrent dislocations and 10 recurrent subluxations. Of the 33 athletes returning to in-season sport after an instability event, 67% (22/33) completed the season. Athletes with a subluxation were 5.3 times more likely (odds ratio [OR], 5.32; 95% CI, 1.00-28.07; P = .049) to return to sport during the same season when compared with those with dislocations. Logistic regression analysis suggests that the Western Ontario Shoulder Instability Index (OR, 1.05; 95% CI, 1.00-1.09; P = .037) and Simple Shoulder Test (OR, 1.03; 95% CI, 1.00-1.05; P = .044) administered after the initial instability event are predictive of the ability to return to play. Time loss from sport after a shoulder instability event was most strongly and inversely correlated with the Simple Shoulder Test (P = .007) at the time of initial injury.

CONCLUSION

In the largest prospective study evaluating shoulder instability in in-season contact athletes, 27% of athletes returned to play and completed the season without subsequent instability. While the majority of athletes who return to sport complete the season, recurrent instability events are common regardless of whether the initial injury was a subluxation or dislocation.

Recurrent anterior shoulder instability: Review of the literature and current concepts

The purpose of this review article is to discuss the clinical spectrum of recurrent traumatic anterior shoulder instability with the current concepts and controversies at the scientific level. Because of increasing participation of people from any age group of the population in sports activities, health care professionals dealing with the care of trauma patients must have a thorough understanding of the anatomy, patho-physiology, risk factors, and management of anterior shoulder instability. The risk factors for recurrent shoulder dislocation are young age, participation in high demand contact sports activities, presence of Hill-Sachs or osseous Bankart lesion, previous history of ipsilateral traumatic dislocation, ipsilateral rotator cuff or deltoid muscle insufficiency, and underlying ligamentous laxity. Achieving the best result for any particular patient depends on the procedure that allows observation of the joint surfaces, provides the anatomical repair, maintains range of motion, and also can be applied with low rates of complications and recurrence. Although various surgical techniques have been described, a consensus does not exist and thus, orthopedic surgeons should follow and try to improve the current evidence-based treatment modalities for the patients.

Risk factors for anterior glenohumeral instability

BACKGROUND

While anterior glenohumeral instability has been shown to be common in young athletes, the risk factors for injury are poorly understood.

PURPOSE/HYPOTHESIS

To determine the modifiable and nonmodifiable risk factors for anterior shoulder instability in a high-risk cohort. The hypothesis was that specific baseline factors would be associated with the subsequent risk of injury.

STUDY DESIGN

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

METHODS

We conducted a prospective cohort study in which 714 young athletes were followed from June 2006 through May 2010. Baseline assessments included a subjective history of instability, physical examination by a sports medicine fellowship-trained orthopaedic surgeon, range of motion, strength with a handheld dynamometer, and bilateral noncontrast shoulder magnetic resonance imaging (MRI). A musculoskeletal radiologist measured glenoid version, glenoid height, glenoid width, glenoid index (height-to-width ratio), glenoid depth, rotator interval (RI) height, RI width, RI area, RI index, and the coracohumeral interval. Subjects were followed to document all acute anterior shoulder instability events during the 4-year follow-up period. The time to anterior shoulder instability event during the follow-up period was the primary outcome of interest. Univariate and multivariable Cox proportional hazards regression models were used to analyze the data.

RESULTS

Complete data were available for 714 subjects. During the 4-year surveillance period, there were 39 anterior instability events documented at a mean of 285 days. While we controlled for covariates, significant risk factors of physical examination were as follows: apprehension sign (hazard ratio [HR], 2.96; 95% CI, 1.48-5.90; P = .002) and relocation sign (HR, 4.83; 95% CI, 1.75-13.33; P = .002). Baseline range of motion and strength measures were not associated with subsequent injury. Significant anatomic risk factors on MRI measurement were glenoid index (HR, 8.12; 95% CI, 1.07-61.72; P = .043) and the coracohumeral interval (HR, 1.20; 95% CI, 1.08-1.34; P = .001).

CONCLUSION

This prospective cohort study revealed significant risk factors for shoulder instability in this high-risk population. Physical examination findings of apprehension and relocation were significant while controlling for history of injury. The anatomic variables of significance were not surprising-tall and thin glenoids were at higher risk compared with short and wide glenoids, and the risk of instability increased by 20% for every 1-mm increase in coracohumeral distance.

The arthroscopic latarjet procedure for anterior shoulder instability: 5-year minimum follow-up

BACKGROUND

The arthroscopic Latarjet procedure combines the benefits of arthroscopic surgery with the low rate of recurrent instability associated with the Latarjet procedure. Only short-term outcomes after arthroscopic Latarjet procedure have been reported.

PURPOSE

To evaluate the rate of recurrent instability and patient outcomes a minimum of 5 years after stabilization performed with the arthroscopic Latarjet procedure.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent the arthroscopic Latarjet procedure before June 2008 completed a questionnaire to determine whether they had experienced a dislocation, subluxation, or further surgery. The patients also completed the Western Ontario Shoulder Instability Index (WOSI).

RESULTS

A total of 62 of 87 patients (64/89 shoulders) were contacted for follow-up. Mean follow-up time was 76.4 months (range, 61.2-100.7 months). No patients had reported a dislocation since their surgery. One patient reported having subluxations since the surgery. Thus, 1 patient (1.59%) had recurrent instability after the procedure. The mean ± standard deviation aggregate WOSI score was 90.6% ± 9.4%. Mean WOSI domain scores were as follows: Physical Symptoms, 90.1% ± 8.7%; Sports/Recreation/Work, 90.3% ± 12.9%; Lifestyle, 93.7% ± 9.8%; and Emotions, 88.7% ± 17.3%.

CONCLUSION

The rate of recurrent instability after arthroscopic Latarjet procedure is low in this series of patients with a minimum 5-year follow-up. Patient outcomes as measured by the WOSI are good.

Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries

Ice hockey is a high contact sport where players are inherently at an increased risk for traumatic and time-loss injury. With its increasing popularity and high incidence of injury, further research is necessary to understand the risks and injuries associated with the sport and to develop performance-based outcome measures to guide return to play. This review, tailored to the practicing sports medicine team physician, focuses on the stepwise identification, treatment, time loss, return to play and subsequent risk of injury for the most common areas of injury: the head, shoulder, hip and knee. Injuries were categorised into upper and lower extremity with an emphasis on glenohumeral and acromioclavicular joint injuries, femoroacetabular impingement, medial collateral ligament tears, and high ankle sprains. With return to play a primary goal for these high-level athletes, recovery in ice hockey becomes a complex issue with efficient protocols tailored to the requirements of the sport vital to the athlete and clinician alike. By reviewing the treatments and sport-specific care, athletes can be better managed with the ultimate goal of returning to their preinjury level of play.

LEVEL OF EVIDENCE

Level IV.