Thank you for the opportunity to present and then also thank you to the Moon Shoulder Group for letting me represent them today. The co-authors on this particular presentation are listed here. I know there are no relevant financial disclosures at Ohio State. So as we know, Ladder J is becoming increasingly popular for the treatment of our young athletes with recurrent anterior shoulder instability. Return to play has traditionally been accepted at six months with a recent study showing that 90% of studies on anterior shoulder instability since 1994 have cited time as the primary determinant on when these athletes return. Of those, only 19% also included strength and only 14% range of motion and it's largely been considered the art of medicine on when to successfully allow these athletes to return. Some more modern consensus may suggest that athletes should have near normal strength and range of motion with little to no pain before returning. An earlier return to play protocols have been trialed with that being as aggressive as eight weeks post-operatively. However, the impact of post-op range of motion and strength needs to be considered and it is currently unknown what percentage of these athletes achieve full strength and range of motion at the six-month mark. So the purpose of this study was to evaluate this at six months after Ladder J and determine whether these results vary by any pre-operative or interoperative factors such as percent bone loss, subscapularis management, or athlete status. So 10 participating sites in this multi-center prospective cohort study with 26 fellowship trained either sports or shoulder and elbow surgeons. I'm sure many of you are familiar but the individual institutions and corresponding surgeons are listed here as well as our research staff that helps make it possible at each location. So we enrolled those undergoing Ladder J, collected baseline demographic data, patient metrics, physical exam data, as well as detailed surgical data. Inclusion criteria included those basically over the age of 12 with anterior shoulder instability again undergoing Ladder J either in a primary or having failed previous shoulder stabilization surgery. Included anyone where the cuff was addressed as well as anyone carrying a diagnosis of posterior or multidirectional instability or associated with workers compensation. So strength and range of motion both pre-op and at six months and return to play criteria were defined as return of full strength and then less than a 20 degree deficit in any range of motion playing. So 65 athletes met inclusion criteria with a mean age of 24 and a half, 59 were male, 88% of instability occurred after injury, 55% specifically after a contact injury, and 74% had greater than one year duration of symptoms with 3.2 dislocations on average in the past year alone. So descriptive statistics here of the group, 71% were performed after having failed a previous procedure, tenotomy was performed 64% of the time, the most common amount of anterior glenoid bone loss was 11 to 20% and that was demonstrated to be the most common size for the Hill Sachs lesion as well. At six months there were no episodes of recurrent instability yet reported, however 55% failed to meet return to play criteria as we defined it, 6% for weakness and 51% experienced that 20 degree loss or persistent stiffness. When we look at overall return to play failure rate, we can see that 37% of overhead athletes failed to meet those criteria and 57% of contact athletes failed to meet that as well. Again we can break that down based upon interoperative factors seen here. Unfortunately the sample size was not powered well enough at this level to draw any statistical conclusions that you may see from those differences in percentages. We did do a multivariate regression analysis on some risk factors for meeting return to play for either strength or range of motion and found that preoperative functional scores as well as a true preoperative side-to-side range of motion deficit in any plane but particularly in external rotation was predictive of failing to meet those return to play criteria. When we looked at range of motion alone again we saw that preoperative stiffness was statistically significant as well as symptom durations for greater than one year correlated with a failure to meet those criteria. There were no significant findings when you looked at strength alone. So in summary a large percentage of athletes in this particular cohort 55% failed to return to full baseline strength and range of motion at the six-month mark. Greater preoperative stiffness, preoperative subjective disability on functional scores, and greater than one year duration of symptoms appeared to be risk factors for failure to meeting those return to play criteria. We do know that in this study as well as consistently across the athletes that we treat that many of these did indeed return to sport prior to six months. So I think we need to be critical of our return to play criteria and perhaps consider transitioning away from strict chronological measures into more sport and position specific functional metrics to determine when these athletes should return to play. Any further updates or information can be found on the Moon Shoulder website. Thank you.

Moon Shoulder Group

young athletes

recurrent anterior shoulder instability

Ladder J

return to play criteria