With regard to some of the NC2A data, you know, it's the second time it was more likely in football to occur than any other collegiate activity second to wrestling. And we also see in the combine, you know, 10 percent of these guys that come in there have had a history of shoulder instability, and about half of those have already had shoulder stabilization surgery. This is data from the Patriots and Tom Gill. They showed a similar percentage of who had instability prior to coming into the NFL, but of those who have had no history of instability, 13.1 percent have a risk of dislocation within one and a half years. So this is something that you're going to really see quite frequently when you're taking care of these teams and football players from the youth to the NFL level. Anderson out of Columbia performed a study where he looked at six seasons of data, around 400 injury episodes of shoulder instability, found that it's quite common, 20 percent of all shoulder and elbow injuries, third highest burden of all injuries. Of these instability episodes, 70 percent of those were subluxations, 30 percent were dislocations, and of the subluxations, they were both anterior and posterior, but of the dislocations, 75 percent were anterior. Those are the ones that needed to be reduced manually, were not just popped back in. And there was significantly more missed time with a dislocation than with a subluxation. And anterior was most common for all positions except for offensive linemen, who commonly have the posterior dislocation like Dr. Bradley described, as well as quarterbacks. And when we're seeing these, particularly in these primary dislocators, we have two options, surgery versus not surgery, and particularly when we're in season, we're going to try to recommend non-surgical management. And so the first step of that is rehabilitation, trying to get their range of motion back, trying to get them strong enough to be able to protect themselves, and then return to play when they're ready. And stabilization with the brace is generally what we try to do. The issue with the brace is they can be cumbersome. It does limit their abduction, external rotation, and so it is position-specific. You know, obviously you can't put a quarterback and use a throw the ball in one of these solely braces. But the studies that are out there show that there are high return to play, but there really is no significant difference in recurrence versus bracing and non-braced athletes with regard to recurrent instability. So it probably does have a psychological factor. Most recently, just this year in 2023, a clinical review utilizing three studies, two of which I just had on the previous slide, showed that there was a good return to play, but again, no difference in recurrence rates. So when to manage these non-operatively? Well, we try to offer it in most cases, if this is a singular episode especially. The exceptions are going to be both medical and situational, though. And with regard to the medical reasons for performing surgery on these, these can be absolute, such as a big piece of glenoid bone fracture, you know, what we call the bony Bankart. And we've heard these numbers, you know, 20% bone loss with higher recurrence rate, but even probably lower with this subcritical bone loss of 13.5%. And I typically will be pretty aggressive with these from a bony procedure if it's, you know, 10% of bone loss. But if you see these acutely, you know, the outcomes of trying to repair these are going to be much better than waiting and seeing what happens. And then you have an osseous union that you're trying to deal with, you know, at the end of the season. In large bony Bankarts, it's good to fix those acutely. The relative indications for surgical treatment would be if this isn't a primary dislocation, this is a recurrent issue and the player just has had enough. If there is a large Hillsex lesion, Dr. Bradley talked about the on-track versus off-track. So if they have a large Hillsex lesion but no glenoid bone loss, this will be what we call off-track lesion and can lead to recurrent instability during the season. So that may push you one way versus the other. If they have a capsular injury such as a Hagel lesion or a reverse Hagel or an intrasubstance capsular injury, that can also lead you to perform surgery earlier than later. And then you can have other things such as loose bodies or prior failed surgery that could push you towards doing surgery also. And then there's a situational reasons to do this such as where are you in the season? Is this OTAs and if you can get them back in six months, then they are coming back in the middle of the season. Or is this the middle of the season where they really want to try to continue to play? And then what's their team record? You're late in the season and they're going to go to the Super Bowl. They clearly want to continue to play, so you're going to try to brace these guys versus if they have a really bad record, then they likely will opt for surgery. And then contract status and where they are with their agent always is going to play issue. And then the throwing shoulder of a quarterback is going to be an issue too. If they can't throw the ball clearly, they're going to opt for surgery than if trying to treat this conservatively. As far as the literature with regard to non-operative treatment, overall it's not that great. There is a 60% recurrence rate in all of the studies that we have. And so when you're treating these non-operatively during the season, the idea generally is that you're going to fix these at the end of the season. So this is a classic study by Robinson back in 2006, looked at 252 patients and found that there's a 60% recurrent dislocation rate. This is a systematic review where they looked at 24 cases, and again at the very bottom there you can see the number of 58% recurrence rate out of 1,337 primary dislocations. And then Dickens has done great work utilizing the military academies, West Point Air Force Academy as well as the Naval Academy, looking at athletes that had an instability episode during the season. He was able to return 73% of them back that season, but 64% recurrent instability rate. So this number of 60% is really what you can quote to these athletes, but he's able to get them back to sport in around 10 days. But then he looked at these the following season, and what he found is that of those that had surgery at the end of the season, the following season, 90% of them completed it. But if they did not have surgery, then only 40%. So there's a 60% recurrence rate in inability to compete the next season. So non-operative treatment leads to six times more likely not to complete the following season. And then utilizing data that was publicly reported, so we don't know if there was anterior posterior dislocations. In the NFL, 92% were able to return back to play that season, treated non-operatively, zero weeks for subluxation, three weeks for dislocation. But again, that 60% number comes into play with regard to the recurrent instability. So we'll just go through a few case examples here. These are Tim's cases. This is his running back. You can see him landing on his outstretched arm there. And if you look at the MRI that he shows, you can see there's some pretty significant degenerative changes in there. And here you can see the cystic changes as well, but I believe that we didn't even talk about these sides, but my thought is a pretty large bony bankart, so he's going to be fairly aggressive with this and fix this early. And this is their tight end. He's going for this catch, grabs it there, lands on his outstretched arm. And on this MRI, you can see the loose body. So I think that he was fairly aggressive with that, but he also has this front back lesion. So I'm assuming he had some episodes of instability prior to this, probably a recurrent instability guy. Now with these loose pieces, as you can see on the MRI, so that was also treated surgically. And this is one of our players. I just popped these slides in. And you can see him landing on his elbow there. That dislocates his shoulder backwards. And on his MRI, you can see he's got not just the posterior labral tear, but also real significant capsular injuries. So that was the decision for that. And I really put this in because I had the previous slide that said that most of these dislocations are anterior, but quarterbacks are getting them posteriorly, so just an example of that. And so with his repair, fixing the posterior labrum. And then he had that reverse haggle as well. So we repaired that also. I'm not supposed to really be talking about surgery, so I'm not going to belabor this, but a good result with that. And he still is in the NFL. So with regard to just a summary of this, and these are some of the pearls that Tim put in here. With regard to the HillSacks lesion, the on-track, off-track, just like Dr. Bradley said, consider a remplissage for that. Bone stabilization is still an option. I completely agree with that, too. Putting a 6 o'clock anchor can really help with regard to your surgical outcomes and the repair. And then with regard to the coracoid transfer, I actually changed the slide a little bit because he didn't think that it was, you shouldn't do this in a primary case because of the fact that you have a fairly significant complication rate. But I do think that if you have an athlete that does have, say, 5% bone loss, they're a collision athlete, that they likely will do better with a coracoid transfer. And I might do that in a primary setting because we have ways of doing this, trying to minimize the complications. And I'll touch on that briefly. So this is one of the cases that Tim had. You can see significant bone loss anteriorly there. So likely a recurrent dislocator because he treated this with a Latter-J that went well. But Latter-Js don't always go well. These are some of the complications that Dr. Bradley was alluding to where you have a breaking of these screws. These cancellous screws are dangerous. I think that if you're going to use screws, definitely want to not use cancellous screws. Looks like the coracoid graft there has fractured. And he's developed some significant arthrosis with this, too. So this is what you want to avoid, and this is what he was referring to when you see these at the combine that makes you nervous. But I think that there are new constructs. I like to use a double-button construct that will put a compression across the graft. I also like to do these arthroscopically. This is kind of my plug for that, where you can do a nice guided approach where you get that graft right next to the bone. You can do a great capsule repair over this, and the outcomes are quite good. And I've been using this in collision athletes, good success as well. So in summary, non-op should be offered, except when there's large bone involvement or a throwing shoulder of the quarterback. But consider both these medical and situational reasons for doing in-season surgery versus conservative care, and then some of those supplementary procedures, such as rinposage, coracoid transfers, I think are going to be required in the collision athlete. And this is a saying, you don't have to fix them after the first one, but just fix them before the second one. Thank you.

shoulder instability

football players

managing

surgical treatment

non-operative treatment