Shoulder Surgery and the Athlete

For many competitive and/or professional athletes, injury is unforeseeable and in some cases, the decision to continue on with their sport comes into question. More specifically, for those athletes who have developed, or even, were born with instable shoulders and have undergone physical therapy, are inevitably plagued with the notion, when therapy fails to work, to either have surgery to fix their shoulder(s) and to continue participating in their sport, or to quit their sport.

In this sense, for the athletes who want to carry on in their sport, it appears that an open or arthroscopic Bankart Repair is the most plausible solution in correcting on-going shoulder instability in athletes who have not improved through therapy and want to continue with their sport. In competitive or professional athletes, a stable shoulder is imperative for peak performance, especially for those athletes involved in sports that use persistent overhead motions, such as swimming, or throwing a baseball.

In understanding a stable shoulder, the shoulder is a joint that contains three primary bones: the shoulder blade, or scapula, the collarbone, or clavicle, and the upper arm bone, also known as the humerus. In addition, the American Academy of Orthopaedic Surgeons (2001), dictate that the head of the humerus bone (the humeral head) rests in a shallow socket within the shoulder blade called the glenoid and is held into the socket by the lining of the joint called the capsule.

Moreover, the humeral head is quite larger than that of the socket, and a soft fibrous tissue rim, known as the labrum, surrounds the socket, which helps keep the joint stabilized (Shoulder joint tear). Furthermore, the American Academy of Orthopaedic Surgeons (2001) states the rim in the socket deepens by up to 50 percent, therefore allowing the humeral head to fit better. What’s more is that the rim also serves as an attachment site for several ligaments (Shoulder joint tear).

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Additionally, the shoulder is referenced as being a ball and socket type joint that permits for a wide range of movement. Although the shoulder joint is intended to be stabilized, in many cases while athletes participate in their sports, they receive injuries to their shoulders that allows for their shoulder(s) to become instable, or even, it has been found that in some competitive athletes who might experience pain whilst enduring continuous overhead motions, may have inherited instable shoulders and have repeatedly gitated the joint. In this sense, it is possible that injuries to the tissue rim that surrounds the socket of the shoulder can occur from acute trauma or repetitive shoulder motion like swimming or throwing and/or pitching, according to the American Academy of Orthopaedic Surgeons (2001), (Shoulder joint tear). More so, in its discovery, while the shoulder joint has a wide range of motion, instability can occur when the humeral head moves out of the socket, or glenoid cavity.

The humeral head, considered as the ball portion of the ball and socket joint, “can move either partially (sublux) or completely (dislocate) out of the socket” (Sports medicine & shoulder surgery). Moreover, the humeral head can sublux or dislocate itself in three different directions: anteriorly, or forward, out of the bottom of the joint (inferior), or backward (posterior). Additionally, with any trauma to a stable shoulder, not only can the humeral head be forcefully dislocated or sublux, but the ligaments, capsule, or labrum can be torn, detached, or stretched from the shoulder bone as well.

Conversely, McFarland and Petersen declare that although the humeral head is capable of being put back in place, the ligaments, labrum, or capsule may heal in a stretched or loose position, thus increasing the chance of subluxation or dislocation to occur again (Sports medicine & shoulder surgery). In addition, there are wide ranges of problems that are contributed to shoulder instability that of which can take on many different forms in a competitive athletes shoulder(s).

More so, according to Wahl and Slaney (2005), these different factors influence how the shoulder should be treated, nonetheless each of these factors needs to be considered (Arthroscopic shoulder surgery). One of these forms is the severity of the instability where the severity can range anywhere from being subtle, to mild or moderate, or severe. Furthermore, the direction and mechanism of instability can also be a contributing factor.

As argued by Wahl and Slaney (2005), with direction, the instability of a shoulder can be due from anterior, posterior, or multi-directional dislocation or subluxation, and in the mechanism of instability, it can either be traumatic or a-traumatic (Arthroscopic shoulder surgery). Furthermore, Wahl and Slaney (2005) have also inquired that when a young athlete suffers from subluxation or dislocation, “it is statistically likely that they will dislocate again.

Studies have shown that when a dislocation occurs in a child with open growth plates, there is up to a 100 percent chance that they will dislocate again. ” Additionally, Wahl and Slaney (2005) claim that in young adults, typically under the age of 20, whose growth plates have just begun to close, “the re-dislocation rate is about 55 percent to 95 percent” (Arthroscopic shoulder surgery).

Therefore, it appears that without surgical repair, a young competitive athlete with instable shoulders may endure greater damage to their shoulder joint and develop other problems associated with instability. In those athletes with instable shoulder(s) looking to find the best course of treatment, it appears that in comparison to an open or arthroscopic Bankart Repair, an athlete has only minimal choices in treating their instability.

Some of these choices entail the use of anti-inflammatory medications such as Aleve, Naproxen, or simply Advil, modifying the activity that aggravates the injury, physical therapy, which helps increase the muscle strength of the shoulder(s), and/or stopping the activity overall. On the contrary however, for countless competitive athletes, these choices are sometimes not enough, or yet, do not help, and the decision to end their sport is out of the question. With surgery as the remaining option, there are many considerations that first need to be looked into.

For example, Matsen and Warme (2008), claim that athletes who should forego surgery will have had experienced persistent occurrences of “shoulder subluxation or dislocation, who continue to have instability despite an adequate trial of physical therapy” (Bankart Repair). Additionally, Matsen and Warme (2008) state that surgery is also an option for athletes with a-traumatic instability who “have not responded to a well-conducted rehabilitation program (Bankart repair). Nevertheless, the decision for an open or arthroscopic Bankart Repair is the best solution for athletes with instable shoulders who have sought out alternative treatments, that of which have failed, and wish to continue on with their sport. In shoulder instability surgery, the labrum, which is profoundly damaged, and the ligaments found in the shoulder, are recognized and then repaired back to the glenoid, or socket. More specifically, there are two separate surgical procedures that can be done in repairing instable shoulder(s).

The first procedure entails arthroscopy, which is a closed surgical technique that uses a small camera (an arthroscope) to be inserted through a small incision “to examine or repair the tissues inside or around the shoulder joint” as described by the Medline Plus Medical Encyclopedia (2007), and the second is an open surgical procedure called an open Bankart Repair. According to Matsen and Warme (2008), an open Bankart Repair “securely restores the attachment of the labrum and the ligaments to the edge of the glenoid socket” (Bankart repair).

Nonetheless, the Bankart procedure re-attaches the torn ligaments of the shoulder to the proper places, allowing for restoration of normal function. In comparing surgery with other treatments, such as physical therapy, anti-inflammatory medications, etc, it has been theorized by numerous Orthopaedic surgeons and as stated above, that with on-going instability in competitive athletes who have undergone other treatments, surgery is the best solution, especially if the athlete does not wish to give up their sport.

Matsen and Warme (2008) have asserted that with traumatic anterior shoulder instability, surgical stabilization has been found to have the most dependable results with the use of an open Bankart Repair. Moreover, it has been said that the use of surgery to stabilize the shoulder is the “most effective method to restore comfort and eliminate the symptoms” (Bankart repair). In addition, Matsen and Warme (2008) also state that repair for frequent traumatic instability has an “excellent chance of restoring much of the lost comfort and function to the unstable shoulder” (Bankart repair).

Furthermore, according to Mahaffey and Smith (1999), it is believed by countless Orthopedic surgeons that the option for surgical repair, whether through arthroscopy or by an open Bankart Repair, should be placed under great consideration for athletes under the age of 25 to prevent any further incidences of “anterior dislocation and arthritic changes” (Shoulder instability in young athletes).

What is more is that Mahaffey and Smith (1999), argued that early arthroscopic surgery represents a change in the approach, where results of studies have illustrated that arthroscopic repair has been beneficial in reducing the rate of recurrent dislocation (Shoulder instability in young athletes). Mahaffey and Smith (1999) also allege that even in athletes engaged in contact sports, “the incidence of recurrent dislocation is only ten to twenty percent following arthroscopic surgery. Re-dislocation occurs in some athletes, however, about five years after surgery” (Shoulder instability in young athletes).

Even more so, Mahaffey and Smith (1999) state that the recurrence of instability after an open Bankart repair is “three to seven percent,” and “four to twenty-five percent” with arthroscopic surgery. Additionally, Wahl and Slaney (2005) declare that without surgery, competitive athletes who persistently sublux or dislocate their shoulder(s) on a regular basis, could potentially lose valuable time in their sport, and/or worse: cause permanent damage to their shoulder joint or risk the development of premature arthritis (Arthroscopic shoulder surgery).

More so, according to King, he alleged that many studies have displayed that competitive athletes with unstable shoulder(s) or those athletes who have dislocated or sublux their shoulder at a younger age, “are much more likely to continue to have problems with instability without surgical treatment” (Shoulder instability), which also agrees with earlier references made by Mahaffey and Smith (1999).

Moreover, Wahl and Slaney (2005) argue that with the use of medications, when in comparison to surgery, that there have been no medications found that are capable of treating excess instability of the shoulder joint that athletes can develop with frequent dislocation or subluxation. Nevertheless, the only roles that any medication plays with shoulder instability is its capability of masking the pain that coincides with shoulder instability and unrelenting dislocations and to make the athlete more comfortable.

What’s more is that with surgery, such as arthroscopic surgery, an Orthopaedic surgeon is able to specifically isolate the contributing factors of instability. These factors can include “tears of the glenoid socket ‘lip’ (or ‘labrum’), tears of the shoulder capsule and ligaments, bony fractures of the glenoid socket or humeral head, the integrity of the rotator cuff tendons, or excessive laxity or volume of the shoulder capsule” (Arthroscopic shoulder surgery), where other techniques such as physical therapy, works only with the surrounding muscles of the shoulder joint.

More so, physical therapy may only help with control of an instable shoulder, and not allow for the shoulder to become completely stabilized. In addition, Matsen and Warme (2008) also asserted that for competitive athletes with traumatic instability, a surgical repair enables an Orthopaedic surgeon to distinctively repair the location of injury, therefore giving the shoulder joint restoration to proper functioning for the athlete.

Lastly, according to McFarland and Petersen, they declare that given the options of either modifying the activity that provokes a competitive athletes injury, or subsiding the activity overall, surgical treatment is the better alternative for those individuals “not willing to give up the activities or sports which provoke their episodes” (Sports medicine & shoulder surgery). Moreover, McFarland and Peterson also state that with surgery, the recurrence of instability “is low (three to five percent),” which is an agreement with the findings from Mahaffey and Smith (1999).

Additionally, Khalfayan claims since a labral tear cannot heal normally and the joint capsule is stretched, surgery is recommended when non-surgical treatment, like physical therapy, is not successful. Furthermore, Khalfayan also emphasizes that with young athletes, “the risk of re-dislocation can be as high as 90 percent with non-operative treatment. Therefore, in select patients or athletes, surgery may be recommended after a first-time dislocation. The re-dislocation rate after surgery is as low as five percent as compared to as high as 90 percent without surgery” (OPA Ortho).

All in all, many competitive and/or professional athletes are prone to, or have inherited, instable shoulder(s) and are repeatedly faced with the decision to either quit their sport or undergo elective surgery if other treatments, such as physical therapy, anti-inflammatory medications, etc, have failed. It is apparent that through much evidence, that an open or arthroscopic Bankart Repair is the most conceivable resolution in correcting on-going shoulder instability in competitive athletes who have not improved through therapy and want to continue with their sport.

It has been greatly substantiated that without surgical repair, professional and/or competitive athletes, especially those who are young and still growing, will continue to sublux or dislocate their shoulders and cause greater damage to the shoulder joint itself and even allow for premature arthritis to develop. Nevertheless, surgery is needed for those athletes suffering from instability and who want to continue participating in their sport. By either choosing arthroscopic surgery, or an open Bankart Repair, the use of stabilized shoulders can endure a competitive and/or professional athlete to grow and excel in their sport.

References

http://www.pamf.org/sports/king/ShoulderInstability.pdf

http://www.aafp.org/afp/990515ap/2773.html

http://www.nlm.nih.gov/medlineplus/ency/article/007206.htm

http://orthoinfo.aaos.org/topic.cfm?topic=A00426

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