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Editorial Commentary: Reviewing the Science of Our Unscientific Criteria for Return to Sports After Shoulder Stabilization
Editorial Commentary: Reviewing the Science of Our Unscientific Criteria for Return to Sports After Shoulder Stabilization Riley J. Williams III, M.D.
Abstract: In contrast to anterior cruciate ligament reconstruction, there is a paucity of primary studies that address the issue of return to play after anterior shoulder stabilization for glenohumeral instability. Most studies focused on clinical outcomes after anterior shoulder stabilization provide little detail on the authors’ assessment protocols used in determining return to sport readiness. In fact, many issues germane to the postoperative rehabilitation process (biologic healing, motion recovery, strength recovery, and sport-specific considerations) remain poorly defined, and are not typically addressed using validated shoulder outcomes instruments. Sports medicine surgeons need more objective criteria on which to base their clinical decision making with athletes treated for anterior glenohumeral instability.
See related article on page 903
F
ew things are as frustrating to an orthopaedic surgeon as a failed surgery. We accept that “success” after surgery is a multifaceted issue. Patient-related factors, surgical technique, biological healing, rehabilitation, unexpected trauma, or simple random chance all may play a role in the patient’s perception of how well they have done after an orthopaedic procedure. As surgeons, we are often faced with the unpleasant reality of a disappointed patient, and potentially, a difficult revision procedure, especially in cases of a failed shoulder stabilization. Consequently, modern orthopaedic practice has increasingly focused on minimizing the risk of surgical failure by optimizing postoperative rehabilitation protocols, avoiding environmental factors deleterious to healing, and delaying return to activity until patients are “ready” biologically and functionally. The last point is particularly important when dealing with young, physically active patients. A premature
New York, New York The author reports the following potential conflicts of interest or sources of funding: R.J.W. is shareholder and board member of Innovate Orthopaedics; receives grants from Smith and Nephew Endoscopy; and is the member of the Editorial Board of The Bone and Joint Journal. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2017 by the Arthroscopy Association of North America 0749-8063/171509/$36.00 https://doi.org/10.1016/j.arthro.2017.12.015
914
return to contact sports carries a substantial risk of reinjury and surgical failure regardless of the type of procedure performed. In light of these circumstances, it is surprising that we have not more clearly defined the optimal protocol for returning of athletes to sport after anterior shoulder stabilization. Return to sport has become a metric of success after surgery for anterior knee instability associated with an anterior cruciate ligament (ACL) tear. As such, there is a growing recognition of the importance of performing functional movement assessments after ACL reconstruction before allowing these patients to return to unrestricted athletics.1,2 According to National Collegiate Athletic Association data, shoulder dislocations occur at a slightly lower rate in college athletes compared with ACL ruptures (0.12 per 1,000 exposures vs 0.15 per 1,000 exposures).3,4 Yet standardized physical testing of the shoulder after stabilization has not been described. The consequences of nonoperative, early-operative, and delayed-operative treatment of shoulder instability have been debated extensively. However, very little has been written about how and when sports medicine surgeons should allow their patients to return to athletics after any of these treatment strategies. This is the context in which I considered the article by Ciccotti, Syed, Hoffman, Abboud, Ciccotti, and Freedman, “Return to Play Criteria Following Surgical Stabilization for Traumatic Anterior Shoulder Instability: A Systematic Review.”5 The authors conducted
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 3 (March), 2018: pp 914-916
EDITORIAL COMMENTARY
an extensive, systematic review of the return to play criteria used in both prospective and retrospective studies. The majority of included studies (75%) reported only a temporal criterion; most of those studies simply allowed patients to return to play 6 months after surgery. The remaining studies (25%) used assessments of strength, range of motion, pain levels, clinical stability, imaging, or some combination thereof. Dr. Ciccotti and his colleagues do not tell us why these criteria were employed. And, for that matter, how could they? These data are not put forth in the studies included in their review. In most of the studies, the authors typically put these criteria near the end of the Materials and Methods section. A description of the parameters used to assess functional progression is often buried in a short paragraph describing the postoperative rehabilitation protocols with no explanation of why the described criterion was applied. I am a coauthor on 2 of the studies included in Dr. Ciccotti’s review. I am honor-bound to admit that I too am guilty of having employed this approach in the past. Most sports medicine surgeons recognize that return to play criteria after shoulder stability are something of a gestalt phenomenon. I would argue that we surgeons “know readiness when we see it.” In my own practice, I consider all the elements identified in this article. I require athletes to have near-normal motion, but I will accept a small degree of residual stiffness as they work back into their sport. I also prefer that the patient be pain free. Yet, I am not bothered by a little discomfort at the end range of motion; this is acceptable in my mind. Strength is also important, but I tend to rely on my examination and the patients’ self-reports of increasing activity. I do not usually require quantitative measurements of shoulder strength and motion to ensure symmetry to the contralateral side. I consider my evaluation part and parcel of the “art” of medicine. My assessments work in clinical practice, but I would appreciate a more formal metric to help me make this very important decision with my patients. It is also important to remember that although we have made substantial progress in our understanding of anterior shoulder instability, gaps in our knowledge base remain. Bankart6 identified the essential lesion of shoulder instability in 1923 as the shearing off of “.the fibrous capsule of the joint from its attachment to the fibrocartilaginous glenoid ligament.” Since then, the anatomy of the static and dynamic stabilizers has been defined more precisely, as has the nature of the eponymous “Bankart lesion.” We understand the influence of the anterior glenoid bone stock in the setting of recurrent instability, the importance of secondary anterior soft-tissue stabilizers, and the concept of engaging bipolar lesions of the glenoid and humeral head. Arthroscopic versus open techniques remain a source of periodic controversy, and the indications for
915
anterior bone block procedures vary considerably by geographic region. We also do not know exactly how long the labrum takes to heal back to glenoid bone after soft tissue repair. It remains unclear as to whether we can modulate the timing of this healing process by the type of surgical repair employed. There is surprisingly little literature on this topic. Histologic analyses of labral healing have been conducted in rabbits7 and rats8,9; however, it is difficult to extrapolate healing times in these animals to humans. Many years ago, as a resident and fellow, I was taught that the labrum (after a stabilization procedure) required approximately 6 weeks to heal. After this interval, I was taught that it was “safe” to permit active motion and capsular stretching. Unsurprisingly, there is limited literature to support this approach. In fact, this historical 6-week approach may come from an experiment on a single primate; an unfortunate 1957 case report in which the authors created bilateral posterior labral tears in a rhesus monkey, and then dissected it 8 weeks later.10 The authors concluded that “reasonable repair would not be expected in less than 4 weeks, with sound repair at 6 weeks.” The dearth of information on functional recovery of the shoulder is even more stark. I am not aware of, nor was I able to find, any systematic investigation that addresses how long an interval is required to restore functional motion and strength after shoulder stabilization surgery. In truth, I am not wholly sure of what this means quantitatively. Is there a baseline measure of strength that I should be targeting for patients? Should I really consider the contralateral shoulder as “normal” to be used as the target for the operative limb? What about baseline differences based on hand dominance? I understand that the restoration of a functional upper extremity should include a consideration of contralateral shoulder girdle strength and motion, patient demand (including sports), and the level of competition. I believe that we all understand these factors intuitively, but struggle to objectively incorporate these issues into our decision-making process on return to play. In light of the current state of the shoulder instability literature, the review by Ciccotti et al.5 succinctly summarizes what the existing literature reports as return to play criteria. It is important to note that the study can offer no analysis of the appropriateness or relative importance of these criteria. In addition, it is unlikely that the return to play criteria in each of the reviewed papers fully describe clinicians’ decisionmaking process. Dr. Ciccotti rightly points this out when he says, “We acknowledge clinicians were likely more nuanced in determining the return to play of their individual patients.” We are then left with a summary of incomplete criteria whose appropriateness cannot be assessed.
916
EDITORIAL COMMENTARY
As with much of orthopaedic surgery, it appears that our practice in this area is dictated by our training, cumulative clinical experience, limited clinical and basic science evidence, and a healthy dose of dogma. I will freely admit that my own requirement for 6 months of healing and rehabilitation before return to competitive sports comes from how I was trained by my surgeon mentors. The 6-month approach seems to work well, and my rates of recurrent dislocation are low relative to the published literature. As such, I continue to use this protocol for my shoulder stabilization patients. I will continue to employ this approach until we develop a validated return to play metric.
References 1. Abrams GD, Harris JD, Gupta AK, et al. Functional performance testing after anterior cruciate ligament reconstruction: A systematic review. Orthop J Sports Med 2014;2:2325967113518305, Ecollection. 2. van Melick N, van Cingel RE, Brooijmans F, et al. Evidence-based clinical practice update: Practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med 2016;50:1506-1515. 3. Owens BD, Agel J, Mountcastle SB, Cameron KL, Nelson BJ. Incidence of glenohumeral instability in
4.
5.
6. 7.
8.
9.
10.
collegiate athletics. Am J Sports Med 2009;37: 1750-1754. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. J Athl Train 2007;42: 311-319. Ciccotti MC, Syed U, Hoffman R, Abboud J, Ciccotti MG, Freedman K. Return to play criteria following surgical stabilization for traumatic anterior shoulder instability: A systematic review. Arthroscopy 2018;34:903-913. Bankart AS. Recurrent or habitual dislocation of the shoulder-joint. BMJ 1923;2:1132-1133. Abe H, Itoi E, Yamamoto N, et al. Healing processes of the glenoid labral lesion in a rabbit model of shoulder dislocation. Tohoku J Exp Med 2012;228:103-108. Packer JD, Varthi AG, Zhu DS, et al. Ibuprofen impairs capsulolabral healing in a rat model of anterior glenohumeral instability [published online November 29, 2017]. J Shoulder Elbow Surg. doi:10.1016/j.jse.2017.09. 027. Mulcahey MK, Marshall M, Gallacher SE, Kaback LA, Blaine TA. Factors expressed in an animal model of anteroinferior glenohumeral instability. Orthop J Sports Med 2015;3:2325967115599733, Ecollection. Scougall S. Posterior dislocation of the shoulder. J Bone Joint Surg Br 1957;39:726-732.
Abstract: In contrast to anterior cruciate ligament reconstruction, there is a paucity of primary studies that address the issue of return to play after anterior shoulder stabilization for glenohumeral instability. Most studies focused on clinical outcomes after anterior shoulder stabilization provide little detail on the authors’ assessment protocols used in determining return to sport readiness. In fact, many issues germane to the postoperative rehabilitation process (biologic healing, motion recovery, strength recovery, and sport-specific considerations) remain poorly defined, and are not typically addressed using validated shoulder outcomes instruments. Sports medicine surgeons need more objective criteria on which to base their clinical decision making with athletes treated for anterior glenohumeral instability.
See related article on page 903
F
ew things are as frustrating to an orthopaedic surgeon as a failed surgery. We accept that “success” after surgery is a multifaceted issue. Patient-related factors, surgical technique, biological healing, rehabilitation, unexpected trauma, or simple random chance all may play a role in the patient’s perception of how well they have done after an orthopaedic procedure. As surgeons, we are often faced with the unpleasant reality of a disappointed patient, and potentially, a difficult revision procedure, especially in cases of a failed shoulder stabilization. Consequently, modern orthopaedic practice has increasingly focused on minimizing the risk of surgical failure by optimizing postoperative rehabilitation protocols, avoiding environmental factors deleterious to healing, and delaying return to activity until patients are “ready” biologically and functionally. The last point is particularly important when dealing with young, physically active patients. A premature
New York, New York The author reports the following potential conflicts of interest or sources of funding: R.J.W. is shareholder and board member of Innovate Orthopaedics; receives grants from Smith and Nephew Endoscopy; and is the member of the Editorial Board of The Bone and Joint Journal. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2017 by the Arthroscopy Association of North America 0749-8063/171509/$36.00 https://doi.org/10.1016/j.arthro.2017.12.015
914
return to contact sports carries a substantial risk of reinjury and surgical failure regardless of the type of procedure performed. In light of these circumstances, it is surprising that we have not more clearly defined the optimal protocol for returning of athletes to sport after anterior shoulder stabilization. Return to sport has become a metric of success after surgery for anterior knee instability associated with an anterior cruciate ligament (ACL) tear. As such, there is a growing recognition of the importance of performing functional movement assessments after ACL reconstruction before allowing these patients to return to unrestricted athletics.1,2 According to National Collegiate Athletic Association data, shoulder dislocations occur at a slightly lower rate in college athletes compared with ACL ruptures (0.12 per 1,000 exposures vs 0.15 per 1,000 exposures).3,4 Yet standardized physical testing of the shoulder after stabilization has not been described. The consequences of nonoperative, early-operative, and delayed-operative treatment of shoulder instability have been debated extensively. However, very little has been written about how and when sports medicine surgeons should allow their patients to return to athletics after any of these treatment strategies. This is the context in which I considered the article by Ciccotti, Syed, Hoffman, Abboud, Ciccotti, and Freedman, “Return to Play Criteria Following Surgical Stabilization for Traumatic Anterior Shoulder Instability: A Systematic Review.”5 The authors conducted
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 3 (March), 2018: pp 914-916
EDITORIAL COMMENTARY
an extensive, systematic review of the return to play criteria used in both prospective and retrospective studies. The majority of included studies (75%) reported only a temporal criterion; most of those studies simply allowed patients to return to play 6 months after surgery. The remaining studies (25%) used assessments of strength, range of motion, pain levels, clinical stability, imaging, or some combination thereof. Dr. Ciccotti and his colleagues do not tell us why these criteria were employed. And, for that matter, how could they? These data are not put forth in the studies included in their review. In most of the studies, the authors typically put these criteria near the end of the Materials and Methods section. A description of the parameters used to assess functional progression is often buried in a short paragraph describing the postoperative rehabilitation protocols with no explanation of why the described criterion was applied. I am a coauthor on 2 of the studies included in Dr. Ciccotti’s review. I am honor-bound to admit that I too am guilty of having employed this approach in the past. Most sports medicine surgeons recognize that return to play criteria after shoulder stability are something of a gestalt phenomenon. I would argue that we surgeons “know readiness when we see it.” In my own practice, I consider all the elements identified in this article. I require athletes to have near-normal motion, but I will accept a small degree of residual stiffness as they work back into their sport. I also prefer that the patient be pain free. Yet, I am not bothered by a little discomfort at the end range of motion; this is acceptable in my mind. Strength is also important, but I tend to rely on my examination and the patients’ self-reports of increasing activity. I do not usually require quantitative measurements of shoulder strength and motion to ensure symmetry to the contralateral side. I consider my evaluation part and parcel of the “art” of medicine. My assessments work in clinical practice, but I would appreciate a more formal metric to help me make this very important decision with my patients. It is also important to remember that although we have made substantial progress in our understanding of anterior shoulder instability, gaps in our knowledge base remain. Bankart6 identified the essential lesion of shoulder instability in 1923 as the shearing off of “.the fibrous capsule of the joint from its attachment to the fibrocartilaginous glenoid ligament.” Since then, the anatomy of the static and dynamic stabilizers has been defined more precisely, as has the nature of the eponymous “Bankart lesion.” We understand the influence of the anterior glenoid bone stock in the setting of recurrent instability, the importance of secondary anterior soft-tissue stabilizers, and the concept of engaging bipolar lesions of the glenoid and humeral head. Arthroscopic versus open techniques remain a source of periodic controversy, and the indications for
915
anterior bone block procedures vary considerably by geographic region. We also do not know exactly how long the labrum takes to heal back to glenoid bone after soft tissue repair. It remains unclear as to whether we can modulate the timing of this healing process by the type of surgical repair employed. There is surprisingly little literature on this topic. Histologic analyses of labral healing have been conducted in rabbits7 and rats8,9; however, it is difficult to extrapolate healing times in these animals to humans. Many years ago, as a resident and fellow, I was taught that the labrum (after a stabilization procedure) required approximately 6 weeks to heal. After this interval, I was taught that it was “safe” to permit active motion and capsular stretching. Unsurprisingly, there is limited literature to support this approach. In fact, this historical 6-week approach may come from an experiment on a single primate; an unfortunate 1957 case report in which the authors created bilateral posterior labral tears in a rhesus monkey, and then dissected it 8 weeks later.10 The authors concluded that “reasonable repair would not be expected in less than 4 weeks, with sound repair at 6 weeks.” The dearth of information on functional recovery of the shoulder is even more stark. I am not aware of, nor was I able to find, any systematic investigation that addresses how long an interval is required to restore functional motion and strength after shoulder stabilization surgery. In truth, I am not wholly sure of what this means quantitatively. Is there a baseline measure of strength that I should be targeting for patients? Should I really consider the contralateral shoulder as “normal” to be used as the target for the operative limb? What about baseline differences based on hand dominance? I understand that the restoration of a functional upper extremity should include a consideration of contralateral shoulder girdle strength and motion, patient demand (including sports), and the level of competition. I believe that we all understand these factors intuitively, but struggle to objectively incorporate these issues into our decision-making process on return to play. In light of the current state of the shoulder instability literature, the review by Ciccotti et al.5 succinctly summarizes what the existing literature reports as return to play criteria. It is important to note that the study can offer no analysis of the appropriateness or relative importance of these criteria. In addition, it is unlikely that the return to play criteria in each of the reviewed papers fully describe clinicians’ decisionmaking process. Dr. Ciccotti rightly points this out when he says, “We acknowledge clinicians were likely more nuanced in determining the return to play of their individual patients.” We are then left with a summary of incomplete criteria whose appropriateness cannot be assessed.
916
EDITORIAL COMMENTARY
As with much of orthopaedic surgery, it appears that our practice in this area is dictated by our training, cumulative clinical experience, limited clinical and basic science evidence, and a healthy dose of dogma. I will freely admit that my own requirement for 6 months of healing and rehabilitation before return to competitive sports comes from how I was trained by my surgeon mentors. The 6-month approach seems to work well, and my rates of recurrent dislocation are low relative to the published literature. As such, I continue to use this protocol for my shoulder stabilization patients. I will continue to employ this approach until we develop a validated return to play metric.
References 1. Abrams GD, Harris JD, Gupta AK, et al. Functional performance testing after anterior cruciate ligament reconstruction: A systematic review. Orthop J Sports Med 2014;2:2325967113518305, Ecollection. 2. van Melick N, van Cingel RE, Brooijmans F, et al. Evidence-based clinical practice update: Practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med 2016;50:1506-1515. 3. Owens BD, Agel J, Mountcastle SB, Cameron KL, Nelson BJ. Incidence of glenohumeral instability in
4.
5.
6. 7.
8.
9.
10.
collegiate athletics. Am J Sports Med 2009;37: 1750-1754. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. J Athl Train 2007;42: 311-319. Ciccotti MC, Syed U, Hoffman R, Abboud J, Ciccotti MG, Freedman K. Return to play criteria following surgical stabilization for traumatic anterior shoulder instability: A systematic review. Arthroscopy 2018;34:903-913. Bankart AS. Recurrent or habitual dislocation of the shoulder-joint. BMJ 1923;2:1132-1133. Abe H, Itoi E, Yamamoto N, et al. Healing processes of the glenoid labral lesion in a rabbit model of shoulder dislocation. Tohoku J Exp Med 2012;228:103-108. Packer JD, Varthi AG, Zhu DS, et al. Ibuprofen impairs capsulolabral healing in a rat model of anterior glenohumeral instability [published online November 29, 2017]. J Shoulder Elbow Surg. doi:10.1016/j.jse.2017.09. 027. Mulcahey MK, Marshall M, Gallacher SE, Kaback LA, Blaine TA. Factors expressed in an animal model of anteroinferior glenohumeral instability. Orthop J Sports Med 2015;3:2325967115599733, Ecollection. Scougall S. Posterior dislocation of the shoulder. J Bone Joint Surg Br 1957;39:726-732.