We Can Do Better

Abstract

Davis (not his real name) was a sophomore linebacker who made a tackle close to our sideline. When he emerged from the scrum holding his left arm, the trainer and I locked eyes ever so briefly, both instantly recognizing the injury and the near-term implications. After reducing Davis’s shoulder on the sideline, we had to hold his helmet so he wouldn’t go right back into the game. In the locker room, the first question came, ‘‘Doc, when can I play again?’’ This is a classic sports medicine scenario that we all deal with on a weekly basis. For Davis, the season only had one remaining game, and we decided to surgically stabilize his shoulder in order to maximize his return the following season. Although the return to football during the same season was in question, a return the following season was never in doubt from the athlete’s perspective. Our profession’s success with the surgical treatment of shoulder instability has enabled athletes to expect to return the next season. Although so much of the conversation on return to play with shoulder instability has focused on return in the same season with nonsurgical treatment and the risks of recurrent instability episodes, our profession has paid relatively less attention to the return to play considerations after surgical repair or reconstruction. However, renewed interest in this topic has recently arisen. Although many conclude that surgical stabilization in high-risk athletes with shoulder instability has superior outcomes compared with nonoperative management, the relative advantages of different stabilization techniques are open for discussion. In this issue, Hurley and colleagues present a systematic review on the subject of return to play after Latarjet coracoid transfer. They used pooled data to find that Latarjet coracoid transfer resulted in return of 89% of patients to sports at a mean of 5.8 months, with only 72% returning at the same level. Recently, Abdul-Rassoul and colleagues presented a similar study focusing on the return considerations following numerous stabilization techniques, including arthroscopic Bankart repair, arthroscopic Bankart with remplissage, open Bankart repair, open Latarjet, and arthroscopic Latarjet. They found that arthroscopic Bankart repair resulted in the highest rate of return to play—98% at 5.9 months—with 92% returning to preinjury levels. Although arthroscopic Bankart repair had the best athletic return numbers, it is clear that patient populations in different studies may not be identical, given that open and bone augmentation procedures are often performed on patients with more complex bone and soft tissue deficiencies and higher risk profiles. Not all reports on arthroscopic Bankart repair are as positive, including the recent report from the MOON Shoulder Instability Consortium, which found a return rate of 63%, with only 45% returning at a similar level of play. One of the challenges in measuring return to play is the absence of agreed-upon return criteria and metrics. Athletes around the world play different sports that place unique demands on the shoulder joint. Add to the mix different surgical techniques and implants, and one can appreciate why discerning the signal through the noise is challenging. Some have worked on standardizing metrics for athletic activity specific to the shoulder, including the Degree of Shoulder Involvement in Sports (DOSIS) and the Brophy shoulder activity score. Return to play criteria have been elusive, and a recent systematic review of return to play criteria after surgical shoulder stabilization in athletes showed that time from surgery was the most commonly used criterion, reported in 90% of papers, with strength and motion being used in less than 20% of reports. Three-quarters of studies used time from surgery as the sole return to play consideration. We can do better than this. We have been able to study return to play after surgical stabilization in another area—ACL reconstruction. Surgeons and rehabilitation professionals have moved away from using strictly timebased criteria for return to sport after ACL surgery, in favor of focusing on strength and lower extremity mechanics. The advancement of neuromuscular assessments in the shoulder may offer methods of assessment that provide insight into the upper extremity functional capacity for sport-specific tasks. In addition to physical readiness, psychological readiness has been shown to have a significant effect on athletic return after ACL reconstruction. Fortunately, some early work has been published in this arena relating to shoulder instability, showing a similar importance of psychological variables. Continued research in this area is critical to maximize the return to sport of our shoulder instability patients. Of course, returning an athlete to sport involves an inherent risk of reinjury. A successful return to sport may be a pyrrhic victory if that return is cut short by recurrent instability. This is an ever-present conflict for the athlete’s surgeon, who fears that the player will face a recurrent injury and wants to help balance the shortterm risks and benefits with long-term health concerns. This complex decision-making process is central to orthopaedic sports medicine and makes our practices both rewarding and demanding. Although we cannot eliminate these risks, our goal as a profession is to minimize the risks