Athletes with Multidirectional Instability of the Shoulder: Surgical Outcomes
Athletes with Multidirectional Instability of the Shoulder: Surgical Outcomes
abstract & commentary
Synopsis: An inferior capsular shift can be successful at restoring high level function in athletes who have failed a trial of physical therapy and rehabilitation.
Source: Bak K, et al. Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy. Am J Sports Med 2000;28(4):466-471.
This study by bak and colleagues evaluates 25 athletes with a total of 26 symptomatic shoulders from multidirectional instability. They performed an open inferior capsular shift on all patients and evaluated the patients using standard outcome measures at a median of 54 months post operatively. Their technique was a Jobe subscapularis split and cruciate type inferior capsular shift. Bak et al report that 84% of 21 athletes who were able to be located at follow-up returned to their pre-injury activity level at a median of five months. However, they also report that only 57% of athletes involved in overhead sports were still active in their sport at the pre-injury level at final follow-up. One patient had a spontaneous dislocation, and one developed recurrent subluxations. Of the 14 shoulders examined at follow-up, 93% showed 5° or less loss of external rotation. According to the Rowe outcome analysis, 88% of the patients had excellent or good results at final follow-up, two had fair scores, and one had a poor score. The UCLA scoring system showed slightly better scores, with 92% of patients in the good to excellent category. Bak et al conclude that "athletes who have multi directional instability based on isolated capsular and ligamentous redundancy can be successfully treated by an inferior capsular shift preserving the subscapularis tendon insertion."
COMMENT BY STEPHEN B. GUNTHER, MD
Rehabilitation with home exercises and physical therapy is the standard treatment for multi directional instability of the shoulder.1 An inferior capsular shift can be successful in restoring function and stability in those patients who have recurrent symptoms after a six-month course of physical therapy. Previous reports have shown acceptable surgical results in non athletes, and some studies have also shown good surgical results in athletes.2,3 This study examines the outcome of an inferior capsular shift procedure in an athletic population with many high-level overhead athletes. Bak et al report only two failures, and there was a very high (84%) return to pre-injury activity level. However, one must realize that only 76% of the overhead athletes returned to their previous sport after the operation, and only 57% were still active in their sport at the pre-injury level at final follow-up. Thus, not all athletes regained their previous level of function.
These results indicate that overhead athletes can return to their previous sport after an inferior capsular shift from multi directional instability with little loss of motion and excellent function. However, this population of overhead athletes should be cautioned preoperatively that this operation may cause loss of motion, and they may not be able to return to their previous level of sport.
References
1. Schenk TJ, Brems JJ. Multidirectional instability of the shoulder: Pathophysiology, diagnosis, and management. J Am Acad Orthop Surg 1998;6(1):65-72.
2. Bigliani LU, et al. Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med 1994;22(5):578-584.
3. Pollock RG, et al. Operative results of the inferior capsular shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg 2000;82:919-928.
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