Criteria, Timing, and Factors Associated With Return to Competitive Sport After Rotator Cuff Surgery.

Rotator cuff pathology in competitive athletes is common and may produce chronic symptoms and joint disability, impairing sports participation and leading to premature retirement. Athletes are a high-functioning patient population with unique characteristics. Decision-making for return to sport is a complex and multifactorial process. Literature is sparse and does not provide precise guidelines to assist physicians to make the right decision. This review aimed to highlight factors affecting outcome, timing, and criteria for return to competitive sport after rotator cuff surgery to help physicians to clearly counsel athletes and make high-quality decisions for return to sport.

Regional Anesthesia in the Elite Athlete.

Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.

Arthroscopically Assisted Treatment of Isolated Comminuted Trapezium Fracture: A Report of Two Cases.

CASES: Two competitive athletes with isolated comminuted trapezium fractures, sustained during American football and rugby, presented with pain and swelling of the first metacarpal base. Computed tomography confirmed isolated comminuted trapezium fractures. Arthroscopic reduction of displacement with screw fixation below the articular surface was performed through a small incision. Both patients returned to their preinjury sports levels within 2 months postoperatively. CONCLUSION: Arthroscopic treatment of isolated comminuted trapezium fractures achieved accurate reduction of articular surface displacement and preserved trapeziometacarpal joint stability with minimal soft-tissue invasion. This facilitated an early return to contact sports for the affected athletes.

Anterior Cruciate Ligament Repair-Here to Stay or History Repeating Itself?

Anterior cruciate ligament (ACL) injuries continue to be a prevalent concern among athletes and individuals with an active lifestyle. Traditionally, the standard of care for ACL tears has involved surgical reconstruction using autograft or allograft. This article aims to provide an overview of the evolving landscape of primary ACL repair, examining the current evidence, surgical techniques, patient selection criteria, outcomes, and potential future directions in this field.

Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction.

Rehabilitation after an anterior cruciate ligament (ACL) reconstruction requires patience, devotion, and discipline. Rehabilitation should be individualized to each patient's specific need and sport. Return to sport is a continuum throughout the rehabilitation, and patients should not return to performance before passing a battery of muscle function tests and patient-reported outcomes, as well as change of direction-specific tests. Return to full participation should be an agreement between the patient, physical therapist, surgeon, and coach. For minimal risk for second ACL injury, patients should continue with maintenance and prevention training even after returning to sport.

Precision Anterior Cruciate Ligament Reconstruction.

Precision anterior cruciate ligament reconstruction (ACLR) refers to the individualized approach to prerehabilitation, surgery (including anatomy, bony morphology, and repair/reconstruction of concomitant injuries), postrehabilitation, and functional recovery. This individualized approach is poised to revolutionize orthopedic sports medicine, aiming to improve patient outcomes. The purpose of this article is to provide a summary of precision ACLR, from the time of diagnosis to the time of return to play, with additional insight into the future of ACLR.

[Slipped vertebrae (Spondylolysis): the underestimated weak point of the (pre)professional football player-an algorithm]. / Der Gleitwirbel: unterschätzte Schwachstelle des (prä)professionellen Fußballspielers ­ ein Algorithmus.

BACKGROUND: Isthmic spondylolysis represents the most common cause of spinal pain in adolescent athletes. This article provides an overview of the classification, diagnosis, and treatment options for these conditions, including conservative and operative measures. It also provides a treatment pathway to how young athletes with spondylolysis should be treated. DIAGNOSTICS: Diagnostic imaging techniques are essential for an accurate diagnosis, with CT scans providing additional information for surgical planning. TREATMENT: Conservative treatment focuses on activity modification and physiotherapy, with a phased approach tailored to individual patient needs. Operative intervention may be considered if conservative measures fail, with minimally invasive techniques such as Buck's screw fixation showing promising results. The decision between conservative and operative management should consider factors of the patients' individual profile. In this paper, we present the first treatment algorithm for the treatment of isthmic spondylolysis. Long-term prognosis varies, with most athletes able to return to sport following treatment.

'It's just my knee': a qualitative study investigating the process of reframing and young athletes' perceived quality of life between anterior cruciate ligament injury and surgery.

OBJECTIVES: To understand the factors influencing young athletes' perceptions of quality of life (QOL) following an anterior cruciate ligament (ACL) rupture, prior to reconstructive surgery. DESIGN: Qualitative descriptive study using semi-structured interviews and thematic analysis of data. SETTING: Tertiary sports medicine clinic with patients recruited from the practices of three specialist orthopaedic surgeons. PARTICIPANTS: Twenty athletes aged 14-25 provided consent to participate in the study and completed interviews prior to their ACL reconstruction surgery. Participants were eligible to participate if they were scheduled to undergo ACL reconstruction, were 25 years of age or younger, identified as athletes (participated in any level of organised sport), could communicate in English and agreed to be audio recorded. Participants were not eligible if they had experienced a multiligament injury or fracture. RESULTS: Young athletes shared common factors that made up their QOL; social connections and support, sport, health, and independence. However, participants' perceptions of their current QOL were quite variable (13-95/100 on a Visual Analogue Scale). Participants who were able to reframe their injury experience by shifting focus to the positive or unaffected aspects of their lives tended to have more favourable perceptions of their QOL than participants who shifted focus to the losses associated with injury. CONCLUSIONS: Young athletes who have experienced an ACL injury define their QOL based on social support, sport, health and independence. Individual processes of adaptation and cognitive reframing in response to an ACL injury may exert a greater influence on postinjury QOL than the physical ramifications of the injury itself. Understanding individual perceptions may help target potential interventions or supports to enhance athletes' adaptation to injury.

Clavicle fracture and triathlon performance: a case report.

BACKGROUND: Collarbone fracture is a common injury, particularly among athletes involved in contact sports and participating in endurance activities. Conventional treatment requires surgery and postoperative immobilization, resulting in an average return-to-sport timeframe of approximately 13 weeks. This case challenges the established treatment protocols, aiming to expedite recovery and enable a quicker resumption of high-intensity athletic activities. CASE PRESENTATION: A 24-year-old Caucasian athlete completed a Half-Ironman Triathlon (70.3) merely three weeks post-collarbone fracture. Utilizing Extracorporeal Magneto-Transduction Therapy (EMTT) alongside surgical intervention, the patient achieved accelerated healing and remarkable performance outcomes without encountering any adverse effects. CONCLUSIONS: The integration of EMTT into the treatment paradigm for bone fractures alters the traditional understanding of recovery timelines and rehabilitation strategies. This case highlights the potential benefits of electromagnetic wave therapy in expediting the healing process and enabling athletes to resume high-level sports activities at an earlier stage.

Return to Sports Rates in Pediatric Patients After Bilateral Versus Unilateral Medial Patellofemoral Ligament Reconstruction.

BACKGROUND: Patellofemoral instability commonly occurs during sports activities. The return to sports (RTS) rate for pediatric patients after bilateral medial patellofemoral ligament reconstruction (MPFLR) is unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate RTS outcomes for pediatric patients undergoing bilateral MPFLR. It was hypothesized that (1) fewer pediatric patients would RTS after bilateral MPFLR compared with unilateral MPFLR and that (2) for those in the bilateral cohort who were able to RTS, fewer patients would attain the same level of play as or higher level than the preinjury level. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We prospectively collected RTS data on retrospectively identified matched cohorts of patients aged ≤18 years who underwent unilateral and bilateral MPFLR. We matched each participant with bilateral MPFLR at a 1 to 2 ratio with a participant with unilateral MPFLR by concomitant procedure, age, and sex. Postoperative complications and preoperative imaging measurements were collected from medical records. Patient-reported outcomes were obtained using a current Single Assessment Numeric Evaluation score collected at the time of primary outcome data. RESULTS: We matched 16 participants (mean age, 14 years) who underwent bilateral MPFLR to 32 participants (mean age, 14.3 years) in a corresponding unilateral MPFLR cohort. We found a significant decrease in RTS rates for pediatric patients after bilateral MPFLR when compared with unilateral MPFLR (69% vs 94%; P = .03). Among those who returned to sports, there was no difference in the level of play achieved. For participants who did not RTS or returned at a lower level of play after bilateral MPFLR, 57% cited fear of reinjury as the primary reason. There were no differences in postoperative complications or current Single Assessment Numeric Evaluation scores between cohorts. The bilateral cohort had a significantly higher Caton-Deschamps index compared with the unilateral cohort, although the absolute difference was small (1.3 vs 1.2; P = .005). CONCLUSION: We found that pediatric patients have a lower RTS rate after bilateral MPFLR when compared with a matched unilateral MPFLR cohort. No differences in the level of play were achieved among those who returned to sports. Fear of reinjury was a commonly cited reason for not returning to sports.

Shoulder dislocations in professional male football (soccer): A retrospective epidemiological analysis of the German Bundesliga from season 2012/2013 until 2022/2023.

PURPOSE: Injuries exert a detrimental impact on the team performance in professional football. Shoulder dislocations are known for their severity and often cause substantial lay-off times. However, there is a notable gap in the general understanding regarding the frequency and convalescence of these events in professional football. Thus, the aims of this study were (1) to determine the incidence, (2) to evaluate return to competition (RTC) and redislocation events (RDEs) and (3) to identify relevant player-, match- and injury-related parameters. METHODS: All shoulder dislocations within the highest three German football leagues (1.-3. Bundesliga) during the seasons 2012/2013 until 2022/2023 were identified. Player-, injury- and match-related data were obtained by performing a media analysis. Data were analysed using descriptive statistics. p Value was set at 0.05. RESULTS: A total of 90 first-time shoulder dislocations in 89 players with a median age of 25 years (interquartile range [IQR]: 23-28) were available for analysis. The incidence was 9.1 per 1000 Bundesliga matches played and increased over time. Forty-four (49%) shoulder dislocations were treated conservatively and 46 (51%) operatively. Median RTC was 24 days (IQR: 12-43) following conservative and 103 days (IQR: 85-135) following surgical treatment (p < 0.001). Twenty-two (24%) players suffered a redislocation, of whom 13 (59%) underwent initial conservative and nine (41%) initial surgical treatment (not significant [n.s.]). RDE following conservative treatment was after a median of 4 months (IQR: 2-22) and 7 months (IQR: 3-23) following surgical treatment (n.s.). CONCLUSION: The incidence of shoulder dislocation within professional football is increasing and currently amounts to 9.1 per 1000 matches played. A conservative treatment leads to a quicker RTC, while frequency and time to RDE were similar regardless of treatment. The increasing incidence of shoulder dislocations in professional football necessitates an analysis of relevant injury mechanisms and the implementation of specific preventive measures. LEVEL OF EVIDENCE: Level III.

Bone-patellar tendon-bone autograft is associated with a higher rate of return to preinjury levels of performance in high-level athletes than anterior cruciate ligament reconstruction using hamstring autograft.

PURPOSE: Return to preinjury levels of performance (RTP) is the main goal after anterior cruciate ligament reconstruction (ACL-R) for athletes when ACL graft rupture is a career-threatening event. The purpose of this study was to elucidate the associated factors for RTP and subsequent ACL injury after ACL-R using bone-patellar tendon-bone (BPTB) or hamstring (HT) autograft in high-level athletes with a minimum postoperative follow-up of 24 months. METHODS: This retrospective study included 157 patients who had preinjury Tegner activity level of 9 and underwent primary ACL-R using BPTB (average age, 16.9 years; 35 males and 36 females) or HT (average age, 17.2 years; 49 males and 37 females). The mean follow-ups were 33.6 months in BPTB and 44.5 months in HT, respectively. The data were obtained based on routine clinical follow-ups and telephone interviews performed by the surgeon. Multivariate logistic regression analysis was conducted to determine the association of patient variables with RTP and subsequent ACL injury. RESULTS: Ninety-nine patients (63.1%) were able to RTP. The rate of RTP in BPTB (74.6%) was significantly higher than that of HT (53.5%) (p < 0.05). The overall average timing of RTP after ACL-R was 10.0 months while that was significantly earlier in BPTB (9.7 months) than in HT (10.5 months) (p < 0.05). Twenty-three (14.6%) and 21 patients (13.4%) had ACL graft ruptures and ACL injuries in the contralateral knees, respectively. Multivariate analyses showed that BPTB (odds ratio [OR], 2.590; 95% confidence interval [CI], 1.300-5.160; p = 0.007) was associated with a higher potential for RTP after ACL-R. The incidence of ACL graft rupture after ACL-R decreased with BPTB (OR, 0.861; 95% CI, 0.770-0.962; p = 0.009). CONCLUSIONS: The use of BPTB autograft was associated with a higher rate of RTP and a lower incidence of ACL graft rupture compared to ACL-R using HT autograft. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Preoperative factors associated with 180°, 270°, and 360° labral tears.

BACKGROUND: Large, circumferential glenoid labral tears are an uncommon injury affecting young, athletic patients. There are limited data describing the clinical presentation of patients with larger tears, especially 270° and 360° labral tears. Additionally, examination and imaging findings have poor reliability in diagnosing these tears. The purpose of this study was to determine the clinical presentation among patients presenting with small (less than 180°), medium (180°-270°), and large (270°-360°) labral tears. METHODS: This is a retrospective comparative study of consecutive patients surgically managed by a single shoulder surgeon for all glenoid labral tears from 2018-2022. The primary outcome was demographic and preoperative clinical risk factors. Demographic data including age, sex, hand dominance, body mass index, as well as clinical presentation (subluxation vs. dislocation, instability history, and participation in contact sports) were recorded. RESULTS: A total of 188 patients met the inclusion criteria: 101 of 188 (53.70%) patients with small tears, 43 of 188 (22.90%) patients with medium tears, and 44 of 188 (23.40%) patients with large tears. Individuals with large and medium-sized labral tears were more likely to have participated in contact sports compared to those with smaller labral tears (P = .003). Medium and smaller tears were more likely to present as dominant-side injury (P = .02). Furthermore, medium and large tears were more likely to present with anterior instability symptoms compared with smaller tears, which more frequently presented with posterior instability and pain (P = .003). CONCLUSION: Males participating in contact sports were the most common demographic population presenting with large, 270°-360° labral tears. Instability was the primary complaint rather than pain, and compared with small tears, medium and large tears were more likely to present with primary anterior instability. Although arthroscopic repair of 270°-360° labral tears can yield excellent clinical outcomes similar to smaller tears, identifying factors associated with larger glenoid labral tears may help in surgical planning and patient counseling.

Percutaneous Interventions for Injuries in Athletes: Implications on Return to Play.

For nonsurgical musculoskeletal (MSK) injuries in athletes, image-guided percutaneous intervention may aid in recovery and decrease return to play (RTP) time. These interventions fall into two major categories: to reduce inflammation (and therefore alleviate pain) or to promote healing. This review describes the risks and benefits of the various percutaneous interventions in MSK athletic injury and surveys the literature regarding the implication of these interventions on RTP.

Reinjury Following Return to Play.

Radiologists are frequently called on for guidance regarding return to play (RTP) for athletes and active individuals after sustaining a musculoskeletal injury. Avoidance of reinjury is of particular importance throughout the rehabilitative process and following resumption of competitive activity. Understanding reinjury risk estimation, imaging patterns, and correlation of clinical and surgical findings will help prepare the radiologist to identify reinjuries correctly on diagnostic imaging studies and optimize management for a safe RTP.

Evolution of the throwing shoulder: why apes don't throw well and how that applies to throwing athletes.

BACKGROUND: Humans have unique characteristics making us the only primate that can throw well while most other primates throw predominately underhand with poor speed and accuracy. The purpose of this study is to illuminate the uniquely human characteristics that allow us to throw so well. When treating an injury such as a labral tear or capsule tear, this study hopes the reader can gain a better understanding of the issues that lead to the tear and those that may determine the success of treatment besides the actual repair. METHODS: In addition to a review of scientific and medical literature, information was obtained from interviews and experience with primate veterinarians, anthropologists, archeologists, and professional baseball players. These sources were used to study the connection between evolutionary throwing activities and current sports medicine issues. RESULTS: Arm acceleration requires a functional kinetic chain, rapid motor sequences, and the ability to absorb elastic energy in the shoulder. Successful treatment of the throwing shoulder requires awareness of the shoulder's position in the kinetic chain and correction of defects in the ability to execute the kinetic chain. Some problems in the shoulder could reflect regression to a more primitive anatomy or dyskinesis. Return of performance requires regaining the elasticity in the tissues of the shoulder to temporarily store kinetic energy. For example, tissue remodeling after rotator cuff repair continues for months to years; however, the newly formed tissue lacks the same elasticity of the native tendon. This suggests why throwing performance typically does not return for 7 or more months after repair even though there may be structural integrity at 3-4 months. CONCLUSION: The shoulder has developed uniquely in modern man for the act of throwing. The anatomic deficiencies in primates for throwing provide an illustration of the more subtle changes that a throwing athlete might have that are detrimental to throwing. Nonhuman primates have been unable to demonstrate the kinetic chain sequence for throwing secondary to the lack of neurologic pathways required. Humans are more sophisticated and precise in their movements but lack robusticity in their bone and muscle architecture, seen especially in the human rotator cuff. Successful treatment of a throwing injury requires familiarity with the conditions that cause the injury or affect the rehabilitation process. The return of performance following injury or surgery requires regaining the elasticity in the tissues of the shoulder to temporarily store kinetic energy from the kinetic chain.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Criteria.

BACKGROUND: Postoperative rehabilitation is an important component of recovery after anterior cruciate ligament (ACL) reconstruction (ACLR), facilitating successful return to sport (RTS) by reducing risk factors for repeat injury. PURPOSE: This systematic review aimed to determine the best protocol for RTS after ACLR in children. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: PubMed, Embase, PEDro, SPORTDiscus, and Web of Science databases were searched from October 3, 2014, to November 3, 2022. The inclusion criteria were the pediatric population (<18 years old) after ACLR with clear RTS criteria and/or mean/median time to RTS. Multiligament knee injuries were excluded from this study. The methodologic quality of the included articles was assessed using the methodological index for non-randomized studies (MINORS). The highest possible score was 24 points for comparative studies (ie, a study comparing 2 protocols or more). Noncomparative studies or studies with a single protocol could score a maximum of 16 points as assessed by the MINORS score. RESULTS: The search yielded 1816 titles, and 24 were retained based on the inclusion and exclusion criteria. Every study was published between 2015 and 2022. Among the 24 studies included, 13 were retrospective and 11 were prospective. The mean MINORS score for the noncomparative studies was 13 of 16 (n = 23) and 23 of 24 for the comparative study (n = 1). The studies were categorized into unspecified clearance (n = 10), milestone based (n = 13), and combined time and milestone (n = 1). A total of 1978 patients (57% female) were included in the review. The mean age at ACLR was 14.7 years. The most common endpoint used was graft rupture (0% to 35%). In the unspecified group, the quickest RTS was 5.8 months and the longest was 9.6 months. Statistically significant risk factors for ACL reinjury included younger age and earlier RTS. The latter was a significant contributor to graft failure for combined time-based and milestone-based RTS. In the milestone-based group, the most common criteria were ≥90% limb symmetry measured using hamstring strength, quadriceps strength, and/or hop tests. The mean RTS time was 6.8 to 13.5 months. CONCLUSION: RTS should be delayed, when possible, especially in the younger population. A combination of quantitative tests and qualitative tests is also recommended. However, optimal RTS criteria have yet to be determined. Future prospective studies should focus on comparing the different times and milestones currently available.

Editorial Commentary: Anterior Shoulder Stabilization Combining Arthroscopic Bankart and Inferior Capsular Shift Avoids Open Surgery in Athletes Without Critical Glenoid Bone Loss.

Traumatic anterior shoulder dislocations can cause a myriad of injuries, each with their own unique set of challenges with respect to surgical management. The debate of whether open or arthroscopic management is the superior approach is one that predates most currently practicing orthopaedic surgeons yet remains one of the most actively researched areas of orthopaedics. Current trends favor arthroscopic management for anterior instability secondary to a Bankart lesion in patients without other risk factors for instability, such as critical glenoid bone loss. However, excellent results are not guaranteed following arthroscopic Bankart repair, particularly in athletes, due to high rates of recurrence. While the technique of inferior to superior capsular shift is not new, transitioning a historically open technique to the arthroscopic world may represent another tool in the glenohumeral instability management toolbox. While perspectives are evolving, more evidence supporting arthroscopic techniques like the capsular shift are needed to better identify appropriate patient populations.

Editorial Commentary: Women Do Not Return to Sport at the Same Level After Anterior Cruciate Ligament Reconstruction as Often as Men: This May Be Associated With Lower Risk Tolerance-and Not Necessarily a Bad Thing!

It has been established that women do not return to preinjury sports (RTS) at the same level after anterior cruciate ligament reconstruction at the same rate as men. Normalization of strength parameters does influence the return to sports in men, but not women. Lower RTS rates may be associated with lower risk tolerance, and this is not necessarily a bad thing. Neither lower RTS rates nor lower risk tolerance is maladaptive or in need of correction. Awareness of the psychological diversity between the sexes does help in understanding this difference. Appreciation of this perspective will improve the relationship with the female athlete during her recovery.

The Surgical Management of NCAA Division 1 College Football Injuries Post COVID-19: A Single Institution Retrospective Review.

ABSTRACT: Cohen, JL, Cade, WH, Harrah, TC, Costello II, JP, and Kaplan, LD. The surgical management of NCAA Division 1 college football injuries post COVID-19: A single institution retrospective review. J Strength Cond Res 38(5): 906-911, 2024-The unprecedented COVID-19 pandemic had a significant impact on college football operations, including athletes' training regimens. As a result of these changes, concern for increased injury susceptibility post COVID-19 regulations has become a point of discussion. The current study sought to evaluate the incidence of surgical injury among NCAA Division 1 college football players at the authors' institution during the first full season after start of the COVID-19 pandemic compared with previous years. Retrospective chart review was performed for all players who sustained injuries requiring surgery while a member of the NCAA Division 1 football program during the 2009-2021 seasons. A p -value of ≤0.05 was used to determine significance. A total of 23 surgical injuries occurred in 22 players during the 2021 season compared with 121 in 118 players in the 12 previous seasons combined ( p = 0.0178; RR = 1.47). There was a significant increase in shoulder injuries ( n = 13 vs. n = 31; p = <0.0001; RR = 3.05) and specifically a significant increase in labral tears ( n = 10 vs. n = 30; p = 0.0003; RR = 2.74). No difference was seen in knee injuries ( n = 10 vs. n = 77; p = 0.27; RR = 1.35) and specifically no difference in anterior cruciate ligament injuries ( n = 3 vs. n = 31; p = 0.77; RR = 1.17). This phenomenon is multifactorial in nature, but alterations to players' training and preparations because of the COVID-19 pandemic likely resulted in suboptimal conditioning, leading to the increased incidence of surgical injuries emphasizing the importance of adequate strength training and conditioning.