Okay. So I'm going to talk about upper extremity injury treatment and return to sport after shoulder surgery. My disclosures are available on the website and at AOS as well. So why do we care? Well if Vonda has not convinced you as to why you should care, you need to understand these patients are going to be showing up at your office in increasing numbers. 20% of the population is going to be over age 65 by 2030. And if you look on this map, purple represents the increase in the 65 plus population. It actually grew 34% in the last decade. And that's the fastest growing demographic in the U.S. And in fact, the 18 and under population is smaller now than it was in 2010. So with the aging population, there has been increased interest, as Dr. Wright explained, in taking care of yourself, increasing your activity in the 50s, 60s, and beyond. And we know that strength training is important, especially for older individuals, to reduce the risk of injury and prevent falls, to improve mental health, to limit and reverse age-related decline in muscle mass and in bone mass. So we already started to cover why you might care. Certain sports are very shoulder intensive. Pickleball is the fastest growing sport in the U.S., as we just heard. Other shoulder intensive sports include things like racquet sports, baseball and softball, weightlifting, swimming, and of course, golf, all require coordinated motion of the shoulder and strength in the rotator cuff. Sorry, I've got to move that little hand. Okay. So what kind of problems are we going to see in the aging athlete? Well, when it comes to shoulder, the most common problems that we encounter in the office every day are going to be rotator cuff tears, osteoarthritis. And in a lucky subset of patients, you're going to see both. So when we think about how we're going to treat these patients, we as sports medicine surgeons are uniquely qualified to manage the aging athlete and the shoulder conditions that are disabling for them. And for these patients, oftentimes the only way back to the field, the court, the fairway is going to be through our operating room. And so it's really important for everyone in this room to understand what can we do to take care of these patients? What do we know? So the questions I'm hoping to answer today are, what do we really know about return to sport in the master's athlete after shoulder surgery? What should we counsel patients regarding wanting to play sports after shoulder surgery? What do you tell them? What factors influence return to sport and even performance in the master's athlete? And then just like their younger counterparts, they want to know when, when am I going to get back to sport and activity and participation? So the short answer, it depends, right? So if we think about these shoulder problems, the most common surgeries they're going to encounter are going to be rotator cuff repair. So what's the recovery like after that? And then shoulder arthroplasty. So these are the types of procedures that shoulder problems, aging athletes are going to have to encounter. So when we look at what types of sports they're participating in, this was a study looking at two-year outcomes after cuff repair. We'll dive into cuff repair now. The sports were things like tennis, swimming, golf, weightlifting, bodybuilding. So those types of activities were shoulder-intensive for these patients. And what they found is that 88% returned to sport at an average of six months with most returning at the equivalent level. Factors influencing return to sport, hours of participation as well as duration of symptoms with shorter duration more likely to return to sport. When we look at patients over age 70, there's really not a lot out there. This is a Dr. Millett study. So the number one sport in this group was alpine skiing. But looking at this cohort of patients, they found that at a mean age of 73 years, 77% returned to sport at a similar level. And cuff repair was actually really highly effective in returning elderly patients to sport. But if they had limitations in terms of their activity, it did decrease satisfaction with the results of cuff repair. So I like this one. This is a systematic review from 23. So it includes 20 studies in the last decade looking at return to sport after rotator cuff repair. So 75% of patients overall in these studies were able to return to sport at an average of about six months. The majority returned at the pre-injury level and then a percentage did have to have reoperation. So overall pretty good results, three quarters of patients getting back to sport. If we look at what the literature shows for specific sports like swimming, this one looked at patients mean age 65, so master's level swimmers. The butterfly stroke which you see here is pretty shoulder-intensive, had the lowest return to sport. But this is pretty incredible, 97% returned to swimming. So that's pretty good for rotator cuff repair. And then the majority of them did return to the same level or higher by one year postoperatively. So golf. This is another sport in which there's some information sport-specific, requires coordination of the rotator cuff, the subscapularis is active on the downswing in the front arm and then follow through on the back arm. So what is there that we understand about rotator cuff repair and golf? Well this was a study again from this year looking at 200, almost 200 athletes. And they found that the majority of patients, again three quarters, that's kind of the magic number with cuff, returned to sport. Most of them returning by one year. What factors influence return to sport? Well years of golfing, obviously the more they golf the more likely they were to return. Younger age, interestingly in this cohort, male sex actually returned at seven times the rate of women. And then tissue quality also played a role. So this was one of the studies I saw that looked at tissue quality. So tissue quality is somewhat subjective but we all kind of know it when we see it. Thinner tissue quality versus thicker, healthier tissue quality. And what they found was that thicker tissue quality actually improved odds of return to sport. And interestingly, with regard to driving distance, patients either maintained or improved their driving distance if they had thicker tissue quality. So what should we tell our golfers who want to get back to sport? Well we can tell them that they are likely to go back to sport, especially if they have good tissue quality. They're going to get their driving distance back and maybe even improve it. So let's talk about arthroplasty now. If you don't do arthroplasty, you have a partner who does shoulder arthroplasty or you know someone who does because this operation is being performed with increasing frequency in the U.S. A quarter of a million arthroplasty is being performed. And right now there's actually very little consensus on what patients should do with return to sport after anatomic, reverse, or hemi arthroplasty. So what do... Oh, I'm sorry. I went backwards. So let's go forwards. Okay. So this was a systematic review looking at 76 studies with a mean age of 65. And they found that the overall return to sport rate was about 83%. There was a little bit lower level of play in almost 10% of patients, but overall pretty good odds for return to sport. Another meta-analysis broke it out by anatomic versus reverse. And this is kind of interesting, but anatomic did return at higher rates than reverse, with 90% return versus 77%. And they also found differential by the type of sport, with again swimming being most likely to return to sport, followed by general fitness, golf, and then tennis. So this was an HSS study. They found again about 85% of people returned to sport, but it was differentiated by anatomic versus reverse, with anatomic returning at about 92, 93%, and reverse at 75%. And hemiarthroplasty came in last at about 71%. So why is this? Why is there a differential with return to sport? We certainly don't know all the answers yet. But Peter Millett's group looked at this and found that a repairable subscapularis definitely improved the odds of patients returning to sport. And he also found that with reversal arthroplasty, older patients were generally more satisfied with their results in return to sport than younger patients. In their paper, they found even with the reverse, though, that at least a third of patients returned to sport and felt like their sport was completely normal. And there was definitely improvement in the postoperative state compared to the preoperative state. This was a small cohort of patients, 37 patients, and they looked at return to sport. And they found kind of a dramatic difference between anatomic and reverse. So again, reverse was much less likely to return to sport at 56%. And overall return rate, again, the magic number, if you want to remember anything when patients ask you, about three quarters of patients will get back to sport. They had similar performance but decreased frequency of participation after shoulder arthroplasty. I loved this particular, from this paper, this particular graph. Look at reverse, though. Although reverse was less likely to return, a significant percentage of patients actually got back at zero to three months. So they were going back to golf pretty much right away. And those of you who do arthroplasty could probably attest to that. These patients, the ones who do get better and feel better, get better quickly. So what about weightlifting? A lot of surgeons have concern about weightlifting. Most surgeons recommend against returning to weightlifting despite all the benefits that we just heard about for weightlifting. And so this cohort of about 42 shoulders, against surgeon's advice, returning to weightlifting. This was a group of high-demand weightlifters. They looked at their return to sport after shoulder arthroplasty 3.6 years out. And what they found was although the patients, the majority of patients went back to weightlifting despite surgeons advising against it, they did not return to their pre-injury levels of activity for shoulder press, bench press or lat pulldown. So knowing all this, what are my takeaway points? What do we tell our patients? I recommend we tell them that they just do it. Because there's nothing in the literature that shows that physicians advising against return to sport are beneficial or even effective. And what we do know is that return to sport for patients has significant psychological, social and physical benefits. And so I recommend that we let the patients participate. They self-limit and self-select. And so let them figure out what's okay for them and what they can do. So thank you so much. I appreciate your time.

shoulder surgery

aging population

strength training

rotator cuff tears

return to sport