1. Treatment and return to play considerations following primary anterior shoulder dislocation Fred Hoover Symposium July 23, 2016

2. Disclosure I have no disclosures

3. Objectives Discuss current evidence regarding treatment and RTP decisions for in-season primary anterior shoulder dislocations Discuss outcomes regarding operative vs non-operative treatment Review generally agreed upon criteria for in-season RTP Review absolute and relative indications for early surgery Highlight areas that need additional future studies

4. Current Evidence Lack of well designed studies Most current guidelines derived from expert opinion and clinical experience No general consensus on ideal in-season treatment or RTP guidelines Managed on individual basis depending on mult variables age contact/overhead vs non-contact sport early vs late season injury Athletes future plans associated gleno-humeral joint pathology

5. Clinical Review in Sports Health Journal Reviewed literature database from 1980 to 2015

6. Non-operative protocol Week 1: Immobilization with simple sling use Gentle ROM exercises Cryotherapy Week 2: PT Protocol: Strengthening RC and scapular stabilizers Sport specific drills initiated once ROM and strength similar to contralateral side Typical time frame for RTP is approximately 2-3weeks but may be accelerated based on specific circumstances Instances of RTP as soon as 5-10days

7. Immobilization: Duration remains controversial Recommendations range from no immobilization to sling immobilization either in internal vs. external rotation for 1-6weeks Most regimens aiming for rapid return to sport recommend 3- 10days in a simple sling

8. Shoulder Stabilization Brace Limits overhead motion and extreme abduction and ER Athletes report improved sense of stability compared to playing without a brace Only 1 study to evaluate effectiveness in preventing recurrence found no difference in competitive contact athletes with and without brace Need future studies

9. Operative Treatment Depends on several factors Failed course of non-surgical management persistent symptoms/pain Limitation in sports specific activity recurrent instability episodes (esp with lower energy mech) Age Timing during the season (early vs late) Extent of injury Type of sport/position Athletes future plans

10. Indications for Early Surgery Absolute: Glenoid osseous defect >25% Humeral head art surface defect >25% Large >50% rotator cuff tear Failed trial of rehab/non-op management Inability to perform sport specific drills without pain, limitation, and recurrent instability Relative >2 dislocations during the same season Overhead/throwing athletes Injury near end of season Age < 20years

11. RTP following surgery Typical time-frame is 4-6 months following surgery Progressive physical therapy rehab program Phase 1: Sling immobilization, Codmans, isometric muscle contraction (4wks) Phase 2: Progressive pROM (4wks) Phase 3: Restore full aROM and resistance exercises (4wks) Phase 4: Plyometric and sports specific exercises Return to full sport activity restricted until at least 4months Applies many of the same principles used to guide RTP in non- surgical management

12. Important considerations Re-dislocation rate Health care cost effectiveness Age Type of Sport Timing During Season Does surgical delay = worse pathology and outcome

13. Re-dislocation rate Athletes with in-season shoulder instability who return to sport non-op demonstrate recurrence rates from 37-90% Particularly high among young athletes <25yo Athletes pursuing non-op RTP should be counseled that recurrence rates are high

14. Which treatment yields lower re-dislocation rates?

15. Health Care Cost Effectiveness Crall et al Arth 2012: Early surgery more cost effective to age 25 in men. For older men (35) and women(25) surgery is more costly After one recurrence, surgery is more cost effective in all scenarios Robinson JBJS 2008: Non-op 20% higher direct costs at 2 yrs due to treatment for recurrence

16. “Successful”NON OPS vs. OPs OP Tx: better WOSIs than NON OP shoulders that never came out again! Western Ontario Shoulder Instability Index (WOSI) Were your expectations met? -OP:94% -NON OP w/o RR: 75%

17. Influence of Age High recurrence rate in younger population particularly <25yo Multiple studies have demonstrated relationship between age and risk of recurrence Up to >90% RR in second decade (particularly with contact sports) Drops to as low a 12% after age 50 Does operative management make more sense in younger population?

18. Activity: Type of Sport May depend on sport: Particularly contact and overhead/throwing sport Larrain (Arth 2001): Rugby players 95% RR with Nonop mgt High risk sports include rugby, hockey, wrestling, football Push you to operative mgt?

19. In-season return to play Buss AJSM 2004 30 In-season high school aged athletes 26/30 (87%) returned to complete season at 10 days 41% had additional in-season instability episode 20/30 required surgical correction at end of season But this is primarily a HS based population- mixed athletes

20. Will delay/non-op treatment lead to further shoulder injury? Will you make the labral tear worse? Habermeyer et al. JSES 1999 Patients with higher numbers of recurrences had worse pathology Hantes AJSM 2009: Combined SLAP/Bankart had more dislocations than Isolated Bankart

21. Will delay/non-op treatment lead to further shoulder injury? Will you make the Hill-Sachs bigger? Cetik, Acta Orthop Belg 2007 More dislocations = more head involvement (12% vs. 26%) More dislocations = deeper Hill-Sachs (4.1 vs. 5.1mm) Will you get worse arthritis down the road? Cameron, Hawkins, AJSM 2003 Longer time from injury to surgery = worse OA Hovelius JSES 2008 (Neer Award): Shoulders that had recurrence had more arthropathy than those that did not recur But even shoulders that did not recur had 55% arthropathy

22. Does pathology differ between primary and recurrent injuries AJSM 2010 Statistically significant higher rate of Hill-Sachs and bankart lesions

23. Conclusion Remains a very common yet challenging entity in the realm or sports Many athletes able to achieve in-season return to sport within 2-3 wks of initial event Need to understand high risk for recurrence Does appear to be related risk of worsening pathology (worse labral pathology/mechanical symptoms, larger Hill Sachs, long- term OA) Majority of cases do result in surgical stabilization Optimal timing remains controversial and varies case-by –case Numerous variables to consider More well-designed studies/research needed.

24. References A Clinical Review of Return to Play Considerations After Anterior Shoulder Dislocation. Watson, Allen, Grant. Sports Health Journal. July-Aug 2016. Volume 8 No. 4.