By Dev K. Mishra, M.D.
President, Sideline Sports Doc
Clinical Assistant Professor of Orthopedic Surgery, Stanford University
- There is controversy about the management of shoulder instability in the high school aged athlete, with many orthopedic specialists recommending surgery for first-time instability
- However, a recently published study indicates a high rate of successful nonsurgical treatment for first time shoulder instability in collision based sports
Shoulder instability is a common occurrence with collision-based sports such as tackle football and rugby. Extensive available data suggests that repeat instability events for high school age athletes is exceptionally common, and for that reason orthopedic surgeons have become more likely to recommend surgery for first time shoulder instability.
However, recently published data shows that shoulder instability events can often be managed non-surgically with high rates of successful return in the same season. Furthermore one study indicates a very high rate of continued sport participation in the following season. This study shows that first time shoulder instability for athletes participating in collision-based sports can be managed without surgery in a much higher percentage of patients than we have previously believed.
When we speak of shoulder instability we are referring to the ball and socket portion of the joint, anatomically this is the “glenohumeral joint”. There are varying degrees of shoulder instability. When the ball portion (the humeral head) is completely removed from the socket (the glenoid) this is called a “dislocation”. A partial shifting of this joint is called a “subluxation”.
The study was published in the American Journal of Sports Medicine and has an excellent study design. The athletes were closely monitored in a prospective manner. All athletes were properly evaluated by experienced sports medicine physicians, and properly monitored by certified athletic trainers. 129 athletes had an initial instability event. About one fourth of those were managed surgically and three fourths were managed without surgery.
We will typically consider nonsurgical management of first time shoulder instability in young athletes who are in the earliest portion of their competitive season. Once the athlete has progressed properly through all phases of their rehabilitation they are assessed for possible return to play in the same season.
85% of the non-surgically treated athletes were able to return to their same sport for at least one full season without any further injury. If an athlete did have recurring instability and then elected to have surgery to stabilize the shoulder, about 80% of them were able to successfully play another season. This means that overall those athletes treated without surgery had very good outcomes regardless of the ultimate pathway taken.
In my opinion this is a very interesting study because it challenges the conventional thinking that has been prevalent amongst orthopedic surgeons for about the past decade. In the high school athlete playing a collision based sport it’s very reasonable to consider nonsurgical care for a first time shoulder instability event.