Shoulder Instability in the Athlete: Management and Surgical Techniques for Optimized Return to Play [1 ed.] 2020034481, 2020034482, 9781630916640, 9781630916657, 9781630916664, 163091665X, 1630916668, 1630916641

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Dickens • Owens

SHOULDER INSTABILITY Management and Surgical Techniques for Optimized Return to Play Shoulder Instability in the Athlete: Management and Surgical Techniques for Optimized Return to Play is a groundbreaking text that covers all aspects of care for athletes with shoulder instability—from on-the-field management and treatment to successful return to play. Edited by Drs. Jonathan F. Dickens and Brett D. Owens and featuring the expertise of internationally recognized surgeons who specialize in shoulder instability in high-level athletes, Shoulder Instability in the Athlete is a unique collaboration applicable across a variety of professional areas. This will be the premier reference for physicians, surgeons, therapists, trainers, and students involved in the care of athletes. Each chapter of Shoulder Instability in the Athlete reviews cutting-edge clinical and surgical techniques, as well as outcomes and return-to-play criteria. In-depth analysis of appropriate literature and outcomes specific to the athlete population are also presented. Important sections within the text include:

Principles for the Team Physician Anterior Instability Posterior Instability Special Topics in Instability

By focusing specifically on the unique and challenging dilemma of caring for the athlete with shoulder instability, Shoulder Instability in the Athlete will be a valuable reference for all health professionals who manage athletes.

SHOULDER INSTABILITY IN THE ATHLETE Management and Surgical Techniques for Optimized Return to Play

IN THE ATHLETE

Jonathan F. Dickens Brett D. Owens

SHOULDER INSTABILITY

IN THE ATHLETE

Management and Surgical Techniques for Optimized Return to Play SLACK Incorporated

®

®

MEDICAL/Orthopedics

https://t.me/mebooksfree

Editors

Jonathan F. Dickens, MD Chief, Sports Medicine, Walter Reed National Military Medical Center Vice Chair (Research), Department of Surgery, Uniformed Services University Associate Professor of Surgery, Uniformed Services University Adjunct Faculty, John A. Feagin Jr. Sports Medicine Fellowship, USMA Bethesda, Maryland

Brett D. Owens, MD Professor of Orthopaedic Surgery Brown University Alpert Medical School Providence, Rhode Island

SLACK Incorporated 6900 Grove Road Thorofare, NJ 08086 USA 856-848-1000 Fax: 856-848-6091 www.healio.com/books © 2021 by SLACK Incorporated

Senior Vice President: Stephanie Arasim Portnoy Vice President, Editorial: Jennifer Kilpatrick Vice President, Marketing: Mary Sasso Acquisitions Editor: Julia Dolinger Managing Editor: Allegra Tiver Creative Director: Thomas Cavallaro Cover Artist: Stacy Marek Project Editor: Dani Malady

All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quotations embodied in critical articles and reviews. The procedures and practices described in this publication should be implemented in a manner consistent with the professional standards set for the circumstances that apply in each specific situation. Every effort has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices. The authors, editors, and publisher cannot accept responsibility for errors or exclusions or for the outcome of the material presented herein. There is no expressed or implied warranty of this book or information imparted by it. Care has been taken to ensure that drug selection and dosages are in accordance with currently accepted/recommended practice. Off-label uses of drugs may be discussed. Due to continuing research, changes in government policy and regulations, and various effects of drug reactions and interactions, it is recommended that the reader carefully review all materials and literature provided for each drug, especially those that are new or not frequently used. Some drugs or devices in this publication have clearance for use in a restricted research setting by the Food and Drug and Administration or FDA. Each professional should determine the FDA status of any drug or device prior to use in their practice. Any review or mention of specific companies or products is not intended as an endorsement by the author or publisher. SLACK Incorporated uses a review process to evaluate submitted material. Prior to publication, educators or clinicians provide important feedback on the content that we publish. We welcome feedback on this work. Library of Congress Cataloging-in-Publication Data Names: Dickens, Jonathan F., editor. | Owens, Brett D., 1972- editor. Title: Shoulder instability in the athlete : management and surgical techniques for optimized return to play / editors, Jonathan F. Dickens, Brett D. Owens. Description: Thorofare, NJ : SLACK Incorporated, [2021] | Includes bibliographical references and index. Identifiers: LCCN 2020034481 (print) | LCCN 2020034482 (ebook) | ISBN 9781630916640 (hardcover) | ISBN 9781630916657 (epub) | ISBN 9781630916664 Subjects: MESH: Joint Instability--therapy | Shoulder | Athletes | Shoulder Injuries--therapy | Athletic Injuries--therapy Classification: LCC RD557.5 (print) | LCC RD557.5 (ebook) | NLM WE 810 | DDC 617.5/72044--dc23 LC record available at https://lccn.loc.gov/2020034481 LC ebook record available at https://lccn.loc.gov/2020034482 For permission to reprint material in another publication, contact SLACK Incorporated. Authorization to photocopy items for internal, personal, or academic use is granted by SLACK Incorporated provided that the appropriate fee is paid directly to Copyright Clearance Center. Prior to photocopying items, please contact the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA 01923 USA; phone: 978-750-8400; website: www.copyright.com; email: [email protected]

DEDICATION This book is dedicated to my family: to my wife, Amy; my children, Mary Gray and Jonathan; and my loving and supportive parents, who taught me the value of hard work, a positive attitude, and perseverance. —Jonathan F. Dickens, MD I would like to dedicate this text to my family: my wife, Julie, and children, Cassidy, Ryan, Jocelyn, and Bennett. I thank my parents and brother for helping instill a foundation of integrity and service, and my mentors in orthopedics, many of whom I am proud to have contribute to this text. Finally, I dedicate this text to my patients, whom have taught me more than can be captured in a text. —Brett D. Owens, MD

The authors would like to further dedicate this book to Dr. John A. Feagin, Jr. He was the ultimate mentor who made everyone who knew him better. We are fortunate to have had the opportunity to walk by your side for a part of this journey.

CONTENTS Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

Section I

Principles for the Team Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1

Team Physician Principles for the Management of Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3 Jessica L. Brozek, MD and Bradley J. Nelson, MD

Chapter 2

Epidemiology of Shoulder Instability: Incidence, Risk Factors, and Prevention of Instability in the Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 David J. Tennent, MD; Matthew A. Posner, MD; and Kenneth L. Cameron, PhD, MPH, ATC

Chapter 3

Evaluation of Shoulder Instability on the Field and in the Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Francis P. Bustos, MD; Jeremy K. Rush, MD, FAAP; and Stephen F. Brockmeier, MD

Chapter 4

Clinical Anatomy and Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 David Eldringhoff, MD; Barry I. Shafer, PT, DPT, ATC; Gregory J. Adamson, MD; and Thay Q. Lee, PhD

Section II

Anterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Chapter 5

Management of In-Season Anterior Instability and Return-to-Play Outcomes . . . . . . . . . . . . . . . . . . . . . . . .43 Jonathan F. Dickens, MD and Maj. Michael A. Donohue, MD

Chapter 6

Decision Making in Surgical Treatment of Athletes With First-Time vs Recurrent Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Brian C. Lau, MD; Carolyn A. Hutyra, MMCi; and Dean C. Taylor, MD

Chapter 7

Radiographic and Advanced Imaging to Assess Anterior Glenohumeral Bone Loss . . . . . . . . . . . . . . . . . . .67 Lisa K. O’Brien, DO and Brian R. Waterman, MD

Chapter 8

Arthroscopic Anterior Shoulder Instability in the Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Lauren A. Szolomayer, MD and Robert Arciero, MD

Chapter 9

Open Treatment of Anterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Michael J. Pagnani, MD and Jason A. Jones, MD

Chapter 10

Latarjet and Coracoid Transfer in Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 Alexander Beletsky, BA; Ian J. Dempsey, MD, MBA; Brandon J. Manderle, MD; and Nikhil N. Verma, MD

Chapter 11

Glenoid Bone Loss Augmentation Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Matthew L. Vopat, MD; Liam A. Peebles, BA; Maj. Travis J. Dekker, MD, MC, USAF; and Matthew T. Provencher, MD, MC, USNR

Chapter 12

Arthroscopic Latarjet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129 Laurent LaFosse, MD; Christian Moody, MD; and Leonard Achenbach, MD

Chapter 13

Hill-Sachs Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139 Morad Chughtai, MD; Andrew Swiergosz, MD; Linsen T. Samuel, MD, MBA; and Anthony Miniaci, MD

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Contents

Chapter 14

Rehabilitation of the In-Season and Postoperative Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149 Kevin E. Wilk, PT, DPT and Lenny Macrina, MSPT, SCS, CSCS

Chapter 15

Return-to-Play Evaluation in the Postoperative Athlete for Anterior Shoulder Instability . . . . . . . . . . . . . 175 Brian Busconi, MD; Jonathon A. Hinz, DO; Benjamin J. Brill, DO; and Vickie Dills, PT, DPT, OCS, ITPT, CSAC

Section III

Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Chapter 16

History and Examination of Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187 Trey Colantonio, MD, CPT and CDR Lance LeClere, MD

Chapter 17

Imaging of Posterior Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197 Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, DO, FAAOS

Chapter 18

Management of In-Season Athletes With Posterior Glenohumeral Instability . . . . . . . . . . . . . . . . . . . . . . .205 Mark Slabaugh, MD, FAAOS and Christopher Gaunder, MD

Chapter 19

Arthroscopic Management of Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Fotios Paul Tjoumakaris, MD and James P. Bradley, MD

Chapter 20

Bone Augmentation for Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221 Jaymeson R. Arthur, MD and John M. Tokish, MD

Chapter 21

Postsurgical Rehabilitation of Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .233 Evan W. James, MD; Kenneth M. Lin, MD; Lawrence V. Gulotta, MD; and Samuel A. Taylor, MD

Chapter 22

Return to Play Following Posterior Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241 Tracey Didinger, MD; Jennifer Reed, NP; and Eric McCarty, MD

Section IV

Special Topics in Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .249

Chapter 23

Revision Arthroscopic Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251 Craig R. Bottoni, MD and Zackary Johnson, MD

Chapter 24

Instability in the Throwing Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265 Ashley J. Bassett, MD and Steven B. Cohen, MD

Chapter 25

Instability in the Pediatric and Adolescent Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .281 Joseph W. Galvin, DO, FAAOS and Xinning Li, MD

Chapter 26

Special Considerations for Multidirectional Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .291 Mark E. Cinque, MD and Geoffrey D. Abrams, MD

Chapter 27

Special Considerations for Return to Play in Collision Athletes (Hockey, Football, and Rugby) . . . . . . . .299 Bruce S. Miller, MD, MS; Asheesh Bedi, MD; and Jack W. Weick, MD

Chapter 28

Management of the Aging Athlete With the Sequelae of Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . .307 Lucca Lacheta, MD; Maj. Travis J. Dekker, MD, MC, USAF; and Peter J. Millett, MD, MSc

Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

ACKNOWLEDGMENTS The authors would like to acknowledge the indefatigable Julia Dolinger, Kayla Whittle, Dani Malady, and Allegra Tiver. Thank you to everyone with the SLACK Incorporated team for their dedication and commitment to this project. This journey began as a concept, and with the support and guidance from SLACK has been made into a reality. We are also deeply indebted to all of the world-renowned authors who have graciously contributed their time and expertise to make this into a cogent resource of extraordinary quality. Lastly, we want to acknowledge all those whose footsteps we have followed in service to our country. There has been no better source of comradery and friendship, no finer arena in which to practice, and most of all, no better patient for which to care.

ABOUT THE EDITORS

Jonathan F. Dickens, MD is Chief of the Orthopaedic Sports Medicine and Shoulder Service at Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland; Vice-Chair of Research for the Uniformed Services University Department of Surgery; and Adjunct Faculty at the John A. Feagin Jr. Sports Medicine Fellowship at the US Military Academy in West Point, New York. He is an Associate Professor of Surgery at the Uniformed Services University of the Health Sciences. Dr. Dickens earned his Bachelor of Science from Davidson College in North Carolina before entering the Army. He subsequently completed medical school at Indiana University in Bloomington, followed by Orthopaedic Surgery Residency at WRNMMC. He completed his Fellowship in Sports Medicine and Arthroscopy at the John A. Feagin Jr. Sports Medicine Fellowship at West Point. Dr. Dickens is a Lieutenant Colonel in the US Army and has served as a Consultant Physician for Special Operations Task Force–Afghanistan in 2015 and Commander of the Hamid Karzi International Airport NATO Role II Hospital in Kabul, Afghanistan in 2019.

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About the Editors

Brett D. Owens, MD is a Board-certified orthopedic sports medicine surgeon. Dr. Owens is currently a Professor in the Department of Orthopaedic Surgery at the Brown University Alpert Medical School and practices in Providence, Rhode Island. He is a retired Colonel in the US Army and previously served as Chief of Orthopaedics and Sports Medicine at Keller Army Hospital, West Point, New York. He is currently Team Physician for Brown University Athletics and the Providence Bruins (AHL). He attended the US Military Academy and Georgetown University School of Medicine. He completed his residency at the University of Massachusetts and the John A. Feagin Jr. Sports Medicine Fellowship at West Point. He was an AOA North American Traveling Fellow as well as an AOSSM-ESSKA Traveling Fellow. Dr. Owens has published more than 250 articles in orthopedics and sports medicine. This is his fourth textbook. His research has garnered the O’Donoghue Research Award, Aircast Award, and NCAA Research Awards from the American Orthopaedic Society for Sports Medicine and the AAOS Kappa Delta Award. Dr. Owens is proud to serve as Associate Editor of the American Journal of Sports Medicine since 2012.

CONTRIBUTING AUTHORS Geoffrey D. Abrams, MD (Chapter 26) Stanford University School of Medicine Department of Orthopedic Surgery Veterans Administration–Palo Alto Health Care System Palo Alto, California

James P. Bradley, MD (Chapter 19) Clinical Professor, Orthopaedic Surgery University of Pittsburgh Medical Center Head Team Physician, Pittsburgh Steelers Pittsburgh, Pennsylvania

Leonard Achenbach, MD (Chapter 12) Department of Trauma, Hand, Plastic and Reconstructive Surgery University Hospital Wuerzburg Wuerzburg, Germany

Benjamin J. Brill, DO (Chapter 15) Orthopaedic Surgeon Longview Orthopaedic Center, LLC Leominster, Massachusetts

Gregory J. Adamson, MD (Chapter 4) Congress Medical Foundation Pasadena, California Robert Arciero, MD (Chapter 8) Professor, Orthopaedics University of Connecticut UCONN Health Farmington, Connecticut Jaymeson R. Arthur, MD (Chapter 20) Department of Orthopedics Mayo Clinic, Scottsdale Phoenix, Arizona Ashley J. Bassett, MD (Chapter 24) The Orthopedic Institute of New Jersey Sparta, New Jersey Asheesh Bedi, MD (Chapter 27) Chief, Sports Medicine Gehring Professor of Orthopedic Surgery Michigan Medicine Ann Arbor, Michigan Alexander Beletsky, BA (Chapter 10) Division of Sports Medicine Midwest Orthopaedics at Rush Rush University Medical Center Chicago, Illinois Craig R. Bottoni, MD (Chapter 23) Professor of Surgery Uniformed Services University of the Health Sciences Chief, Sports Medicine Orthopaedic Surgery Department Tripler Army Medical Center Honolulu, Hawaii

Stephen F. Brockmeier, MD (Chapter 3) Sports Medicine and Shoulder Surgery Professor of Orthopaedic Surgery University of Virginia Director, UVA Sports Medicine Fellowship Program Team Physician, UVA Athletics Charlottesville, Virginia Jessica L. Brozek, MD (Chapter 1) Orthopedic Surgeon Newton Medical Center Newton, Kansas Brian Busconi, MD (Chapter 15) Chief of Sports Medicine and Arthroscopy University of Massachusetts UMass Memorial Health Care Division of Sports Medicine Worcester, Massachusetts Francis P. Bustos, MD (Chapter 3) Department of Orthopaedic Surgery University of Virginia Charlottesville, Virginia Kenneth L. Cameron, PhD, MPH, ATC (Chapter 2) John A. Feagin Jr. Sports Medicine Fellowship Keller Army Hospital US Military Academy West Point, New York Morad Chughtai, MD (Chapter 13) Department of Orthopaedic Surgery Cleveland Clinic Cleveland, Ohio Mark E. Cinque, MD (Chapter 26) Stanford University School of Medicine Department of Orthopedic Surgery Palo Alto, California

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Contributing Authors

Steven B. Cohen, MD (Chapter 24) Rothman Orthopaedic Institute Department of Orthopaedic Surgery Thomas Jefferson University Philadelphia, Pennsylvania Trey Colantonio, MD, CPT (Chapter 16) PGY-4, Research Resident Department of Orthopaedic Surgery Walter Reed National Military Medical Center Bethesda, Maryland Maj. Travis J. Dekker, MD, MC, USAF (Chapters 11 and 28) US Air Force Eglin Air Force Base, Florida Assistant Professor Uniformed Services University of the Health Sciences Bethesda, Maryland Ian J. Dempsey, MD, MBA (Chapter 10) Division of Sports Medicine Midwest Orthopaedics at Rush Rush University Medical Center Chicago, Illinois Tracey Didinger, MD (Chapter 22) LA Bone and Joint Institute Encino, California Vickie Dills, PT, DPT, OCS, ITPT, CSAC (Chapter 15) Department of Orthopedics University of Massachusetts Medical School Worcester, Massachusetts Maj. Michael A. Donohue, MD (Chapter 5) Assistant Professor of Surgery Uniformed Services University of the Health Sciences John A Feagin Jr. Sports Medicine Fellowship West Point, New York Josef K. Eichinger, MD, FAOA (Chapter 17) Sports Medicine, Shoulder and Elbow Surgery Professor of Orthopaedic Surgery Medical University of South Carolina Charleston, South Carolina David Eldringhoff, MD (Chapter 4) Congress Medical Foundation Pasadena, California Joseph W. Galvin, DO, FAAOS (Chapters 17 and 25) Assistant Professor of Surgery Uniformed Services University of the Health Sciences Department of Orthopaedic Surgery Shoulder and Elbow Surgery Madigan Army Medical Center Tacoma, Washington

Christopher Gaunder, MD (Chapter 18) Maj, USAF, MC Orthopaedic Surgeon Dayton, Ohio Lawrence V. Gulotta, MD (Chapter 21) Hospital for Special Surgery New York, New York Jonathon A. Hinz, DO (Chapter 15) Orthopaedic Surgeon Associated Orthopedists of Detroit St. Clair Shores, Michigan Carolyn A. Hutyra, MMCi (Chapter 6) Orthopaedic Surgery Duke University Durham, North Carolina Evan W. James, MD (Chapter 21) Hospital for Special Surgery New York, New York Zackary Johnson, MD (Chapter 23) Honolulu, Hawaii Jason A. Jones, MD (Chapter 9) Nashville Knee and Shoulder Center Music City Orthopaedics and Sports Medicine Nashville, Tennessee Lucca Lacheta, MD (Chapter 28) Steadman Philippon Research Institute Vail, Colorado Assistant Professor Center for Musculoskeletal Surgery Charitè—Universitaetsmedizin Berlin Berlin, Germany Laurent LaFosse, MD (Chapter 12) ALPS Surgery Institute Annecy, France Brian C. Lau, MD (Chapter 6) Duke Sport Science Institute Orthopaedic Surgery Duke University Durham, North Carolina CDR Lance LeClere, MD (Chapter 16) Sports Medicine and Shoulder Surgery Naval Health Clinic Annapolis Head Team Physician US Naval Academy Annapolis, Maryland

Contributing Authors Thay Q. Lee, PhD (Chapter 4) Congress Medical Foundation Pasadena, California Xinning Li, MD (Chapter 25) Associate Professor of Orthopaedic Surgery Department of Orthopaedic Surgery Sports Medicine and Shoulder Surgery Sports Medicine Fellowship Director Boston University School of Medicine Boston Medical Center Boston, Massachusetts Kenneth M. Lin, MD (Chapter 21) Hospital for Special Surgery New York, New York Lenny Macrina, MSPT, SCS, CSCS (Chapter 14) Physical Therapist Champion Physical Therapy and Performance Waltham, Massachusetts Brandon J. Manderle, MD (Chapter 10) Division of Sports Medicine Midwest Orthopaedics at Rush Rush University Medical Center Chicago, Illinois

Bradley J. Nelson, MD (Chapter 1) Associate Professor Department of Orthopaedic Surgery Medical Director Department of Intercollegiate Athletics University of Minnesota Team Physician, Minnesota Wild Hockey Club Minneapolis, Minnesota Lisa K. O’Brien, DO (Chapter 7) Lehigh Valley Health Network Department of Orthopaedic Surgery Scranton, Pennsylvania Michael J. Pagnani, MD (Chapter 9) Nashville Knee and Shoulder Center Music City Orthopaedics and Sports Medicine Nashville, Tennessee Liam A. Peebles, BA (Chapter 11) Tulane University School of Medicine New Orleans, Louisiana Matthew A. Posner, MD (Chapter 2) John A. Feagin Jr. Sports Medicine Fellowship Keller Army Hospital United States Military Academy West Point, New York

Eric McCarty, MD (Chapter 22) University of Colorado School of Medicine Professor, Chief of Sports Medicine and Shoulder Surgery Champions Center Boulder, Colorado

Matthew T. Provencher, MD, MC, USNR (Chapter 11) The Steadman Clinic Vail, Colorado

Bruce S. Miller, MD, MS (Chapter 27) Professor of Orthopedic Surgery Michigan Medicine Ann Arbor, Michigan

Jennifer Reed, NP (Chapter 22) CU Sports Medicine University of Colorado School of Medicine Team Provider University of Colorado–Boulder Athletics Aurora, Colorado

Peter J. Millett, MD, MSc (Chapter 28) Chief Medical Officer and Director of Shoulder Surgery Steadman Philippon Research Institute The Steadman Clinic Vail, Colorado Anthony Miniaci, MD (Chapter 13) Cleveland Clinic Sports Health Center Department of Orthopaedic Surgery Cleveland Clinic Cleveland, Ohio Christian Moody, MD (Chapter 12) Prisma Health System Department of Orthopaedic Surgery Division of Hand and Upper Extremity Greenville, South Carolina

Jeremy K. Rush, MD, FAAP (Chapter 3) Orthopaedic Sports Medicine Nemours Children’s Specialty Care Jacksonville, Florida Assistant Professor of Orthopedics Mayo Clinic College of Medicine and Science Rochester, Minnesota Linsen T. Samuel, MD, MBA (Chapter 13) Department of Orthopaedic Surgery Cleveland Clinic Cleveland, Ohio Barry I. Shafer, PT, DPT, ATC (Chapter 4) Congress Medical Foundation Pasadena, California

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Contributing Authors

Mark Slabaugh, MD, FAAOS (Chapter 18) Col, USAF, MC Sports Medicine Orthopaedic Surgeon Chief, Sports Medicine Service USAFA Team Physician USAFA Associate Professor of Surgery F. Edward Hébert School of Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland Andrew Swiergosz, MD (Chapter 13) Department of Orthopaedic Surgery Cleveland Clinic Cleveland, Ohio Lauren A. Szolomayer, MD (Chapter 8) Excel Orthopaedic Specialists Woburn, Massachusetts Dean C. Taylor, MD (Chapter 6) Duke Sport Science Institute Orthopaedic Surgery Duke University Durham, North Carolina Samuel A. Taylor, MD (Chapter 21) Hospital for Special Surgery New York, New York David J. Tennent, MD (Chapter 2) John A. Feagin Jr. Sports Medicine Fellowship Keller Army Hospital United States Military Academy West Point, New York Fotios Paul Tjoumakaris, MD (Chapter 19) Professor, Orthopaedic Surgery Sidney Kimmel College of Medicine Thomas Jefferson University Rothman Institute Egg Harbor Township, New Jersey

John M. Tokish, MD (Chapter 20) Consultant, Orthopedic Sports Medicine Professor, Orthopedic Surgery Orthopedic Surgeon, Arizona Coyotes Director, Orthopaedic Sports Medicine Fellowship Mayo Clinic Arizona Phoenix, Arizona Nikhil N. Verma, MD (Chapter 10) Division of Sports Medicine Midwest Orthopaedics at Rush Rush University Medical Center Chicago, Illinois Matthew L. Vopat, MD (Chapter 11) University of Kansas School of Medicine–Wichita Wichita, Kansas Brian R. Waterman, MD (Chapter 7) Chief and Fellowship Director Sports Medicine Associate Professor Department of Orthopaedic Surgery School of Medicine Team Physician Wake Forest University Athletics Team Physician, Winston-Salem Dash (Chicago White Sox) Team Physician, US Ski & Snowboard Associate Editor, Arthroscopy Journal Winston-Salem, North Carolina Jack W. Weick, MD (Chapter 27) Department of Orthopaedic Surgery University of Michigan Ann Arbor, Michigan Kevin E. Wilk, PT, DPT (Chapter 14) Associate Clinical Director Champion Sports Medicine Select Medical American Sports Medicine Institute Birmingham, Alabama

PREFACE “If I have seen further it is by standing on the shoulders of giants.” —Isaac Newton c. 1675 Shoulder instability in the athlete is an important topic, often with high stakes, and filled with nuances in diagnosis, treatment, and rehabilitation. The human shoulder joint allows the greatest range of motion of any joint, making it possible for the pitcher to throw a fastball at 95 mph, the gymnast to perform a rings routine, or the linebacker to make a tackle. While the “cause” of instability can come in many forms, its presence eliminates the athlete’s foundation of trust in their shoulder, and their performance suffers. Since the first historical description of shoulder surgery, the unique complexities of shoulder instability have been an important focus. Into this context, we set out to produce a textbook focusing on the unstable shoulder in athletes. Throughout our orthopedic surgery careers, and in our exploration of shoulder instability in particular, we have been blessed by incredible mentors. It is because of these “giants” and their willingness to mentor and teach us that we have been able to assemble this textbook. We are forever grateful for the opportunity to bring together many of the world’s experts on shoulder instability with the hopes of providing clearer guidance to clinicians treating athletes. This has been a rapidly advancing field, and our hope was to document the current state of scientific knowledge in this field. Shoulder instability has been a passion for both of us, and our attempts to progressively improve the understanding of certain aspects have proven to be among the most rewarding of our careers. This book, therefore, represents a summation of our clinical, laboratory, and team physician experience. Importantly, it reflects the thoughts, accomplishments, and insights of world-renowned colleagues and mentors whose teachings have influenced all of us. We are thankful for the research teams we have worked with and the relationships we have nourished with these collaborators and colleagues. We are mostly thankful for our patients who have entrusted us with the care of their shoulders. —Brett D. Owens, MD —Jonathan F. Dickens, MD

INTRODUCTION The ambitious goal of this textbook was to assemble in one location a definitive and comprehensive guide for the treatment of shoulder instability in athletes. We are proud to have compiled an amazing list of internationally recognized authors from around the world and encompassing all aspects of care for the athlete’s injured shoulder. Our authors are surgeons and therapists, scientists and biomechanical engineers; they care for military, collegiate, and professional athletes, and have an unmatched expertise of shoulder instability. They have graciously been willing to participate in this text because of our shared passion for this worthy area of scientific pursuit. The textbook is subdivided into 4 sections for ease of consumption and each topic is uniquely constructed to address the challenges and tips to successfully treat our most demanding athletes. With in-depth analysis and expert authors, this text covers all aspects of the care of the athlete with shoulder instability, from on-the-field management, operative and nonoperative treatment, to successful return to play. Our first section is titled “Principles for the Team Physician” and details basic anatomic and biomechanical concepts that lay the foundation for the entire textbook. We review the epidemiology and also dive into the on-field management of the dislocated shoulder. The second section addresses anterior instability in athletes, reviews the unique consideration for in-season management, and addresses—in detail—the surgical management options starting with arthroscopic management and including all open stabilization indications and techniques. In the third section, we examine posterior instability, starting with initial evaluation, surgical treatment, rehabilitation, and return-to-play decision making. Lastly, we address special topics unique to the athlete’s shoulder, including throwers with instability, instability in collision athletes, and revision surgery, among others. Starting with the patient history, physical examination, and radiographic evaluation, each shoulder instability diagnosis is explored in detail. Surgical techniques are heavily emphasized with a thorough and stepwise description for all relevant procedures, interspersed with the expert’s own technical pearls. This has produced a level of detail that we hope will make this book useful not only to team physicians and providers, but to all those who care for athletes. Lastly, we are eternally indebted to our world-renowned authors who invested significant time and effort to ensure their knowledge is captured and shared in clinically useful and user-friendly text. We hope that you find Shoulder Instability in the Athlete: Management and Surgical Techniques for Optimized Return to Play a valuable aid in your care of the athlete with shoulder instability.

SECTION I Principles for the Team Physician https://t.me/mebooksfree

1 Team Physician Principles for the Management of Athletes Jessica L. Brozek, MD and Bradley J. Nelson, MD

Serving as a team physician can be a challenging but rewarding aspect of medical practice for a sports medicine physician. Although it is, at its core, no dif ferent from any other type of medicine—that is, providing expert knowledge and ser vice to improve and maintain optimal health for an individual—there are many other considerations that can complicate the ultimate achievement of that goal. When a “patient” becomes an “athlete”—or rather, an athlete becomes a patient—this is much more than a simple change in terminology. It brings with it connotations of the impact and goals of treatment, as well as the potential involvement of many other individuals who may have an investment in (and therefore affect) the decision-making process and final outcomes of treatment. The following chapter will discuss many of the nuances integral to acting as a team physician, including being prepared for many various medical scenarios, serving as leader of a diverse medical team, adhering to the ethical principles necessary to providing appropriate medical care to an athlete, and navigating the complex array of individuals involved in an athlete’s care.

BEING A TEAM PHYSICIAN A team physician’s role is more than simply the medical care of athletes. This title also inherently includes the coordination of all aspects of the medical care from each of the many multidisciplinary professionals in the medical team (to be discussed later in this chapter), oversight of emergency action plans (EAPs) and event preparedness, management of preparticipation physicals, and communication with administrators and other personnel within the athletic organization regarding medical concerns or injuries. The American Academy of

Orthopaedic Surgeons (AAOS) defines a team physician as an MD or DO with a full license to practice medicine, knowledgeable in management of on-field medical emergencies, trained in basic life support, with knowledge of musculoskeletal injuries, medical conditions, and psychological issues affecting athletes. Beyond these requirements, the AAOS recommends team physicians also have specific training in sports medicine through specialty board certification, fellowship training, research, and continuing education and a clinical practice focused on sports medicine.1 Team physicians can come from several different training backgrounds, including orthopedic surgery, family medicine, internal medicine, and pediatrics. Even within these tracks, experience in sports coverage can vary widely between residency programs. In one recent survey2 of orthopedic residents, nearly 90% of programs allow or require team/event coverage but just more than half provided training before this coverage. Only one-quarter of those without specific training had direct attending supervision. Formal training provided a statistically significantly higher level of comfort in treating sideline injuries. Many physicians will graduate training and find themselves providing care for athletic events, whether in an official or unofficial capacity; particularly in more rural or underserved settings, this is often without specific fellowship training in sports medicine. Thus, if a team physician is part of an academic institution that trains residents, part of that role may (and arguably should) include development and execution of a sideline preparation training curriculum. A certainly nonexhaustive list of topics includes education on safe spine boarding/precautions, concussion diagnosis, management of common ocular and dental injuries, triage and stabilization of medical emergencies, and a review of basic musculoskeletal physical examination.

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Dickens JF, Owens BD, eds. Shoulder Instability in the Athlete: Techniques for Optimized Return to Play (pp 3-10). © 2021 SLACK Incorporated.

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Chapter 1

Table 1-1. American Academy of Orthopaedic Surgeons Recommendations for On-Site Supplies, Equipment, and Medication ADMINISTRATIVE

●

●

CARDIOPULMONARY

EXTREMITIES

GENERAL

Copy of athlete emergency form Copy of emergency action plan and emergency contact numbers

●

Prescription pad and pen

●

Medication log

●

Sideline concussion assessment protocol

●

Injury and illness care instruction sheets for patient

●

Airway

●

Mouth-to-mouth mask

●

Blood pressure cuff

●

Short-acting β agonist inhaler

●

Epinephrine 1:1000 in prepackaged unit

●

Stethoscope

●

Athletic tape

●

Sling

●

Crutches

●

Splints and braces

●

Elastic bandages

●

Tape cutter

●

Blanket

●

Antihistamine

●

Cotton-tip applicators

●

Antiemetic

●

Gloves (sterile/nonsterile)

●

Glucagon

●

Forceps

●

Aspirin

●

Ice

●

Cortisone

●

Oral glucose

●

Intravenous fluids and administration set and tourniquet

●

Large bore angiocatheter (14- to 16-gauge)

●

Local anesthetic, syringes, needles

●

Other medication ●

●

Topical/oral antibiotics

●

Oral fluid replacement

●

Plastic bags

●

Rectal thermometer and covers

●

Scissors

●

Sharps box and red bag

Anti-inflammatories (continued )

Although caring for an athlete is ultimately no more than caring for any patient, providing medical care at an athletic venue is inherently dif ferent from providing care in a clinic or hospital. The physician must be prepared for many potential scenarios and come equipped with supplies for such. This frequently takes the form of a medical bag. Like with definitions for the term team physician, the AAOS3 has provided recommendations for what supplies should be available when covering sports events; these are listed in Table  1-1. This is certainly not all inclusive but it does provide a basic idea of some of the medical equipment and supplies that may be required during an athletic event. Although it also does not necessarily represent what is frequently found physically within the team doctor’s bag, the availability and location of these items should ideally be known at each venue. Certain athletic events will include the presence of emergency medical personnel on site, and they can provide some of this equipment (the availability of such emergency medical services support should be included in the EAP, a topic which will be discussed later).

The team physician on the sidelines may encounter and thus must be prepared to handle medical emergencies including cardiac events (eg, hypertrophic cardiomyopathy, commotion cordis), pulmonary distress (eg, asthma, anaphylaxis, traumatic pneumothorax), heat-related injury (eg, heat stroke), and head/neck injuries (eg, subdural hematoma, spinal cord injury).4 As always in an emergency situation, the “A, B, Cs” of trauma evaluation (Airway, Breathing, Circulation) should be the initial focus, followed by a more specific secondary survey of the entire body once medical stability has been established. As leader of the team’s medical care, the team physician is ultimately responsible for the EAP. This should be a sitespecific written description completed before the season that delineates location of an automated external defibrillator and other emergency equipment, facility access for first responders, basic chain of command, and communication strategies. This EAP should be distributed to physicians, athletic trainers, safety personnel, coaches, and other administrative staff, and should also be reviewed annually.3 Examples of a basic EAP are provided in Figure 1-1.

Team Physician Principles for the Management of Athletes

5

Table 1-1. American Academy of Orthopaedic Surgeons Recommendations for On-Site Supplies, Equipment, and Medication (continued) HEAD AND NECK / NEUROLOGICAL

●

Cervical collar

●

Ocular anesthetic and antibiotics

●

Contact lens case and solution

●

Contact remover

●

Dental kit

●

Eye wash

●

Eye chart

●

SKIN

●

Dental wax

●

Mouth guard

●

Face mask removal tool

●

Cyanoacrylate glue

●

Flashlight

●

Hank’s solution

●

Mirror

●

Nasal packing material

Eye kit ●

Blue light

●

Oto-ophthalmoscope

●

Fluorescein stain strips

●

Spine board and attachments

●

Eye patch/shield

●

Tongue depressors

●

Alcohol swabs, povidone iodine swabs

●

Silver nitrate sticks

●

Benzoin

●

Skin lubricant

●

Blister care materials

●

●

Nail clippers

●

Razor and shaving cream

●

Scalpel

Although the rate of injuries during games is 3.5 times higher than those during practices, averaging 1 injury for every 2 games for National Collegiate Athletic Association athletes,5 serving as a team physician also entails medical care of the athletes outside the specific realm of competition. This often includes preparticipation physical exams (and postseason physicals, depending on level of competition) and “training room” (ie, providing on-site clinic services throughout the season). Although preparticipation physical exams are often required for athletic competition, the exact components are up for debate. A comprehensive discussion of this is beyond the scope of this chapter, but preparticipation physical exams