return to play after shoulder subluxation cover

RETurn to play after shoulder subluxation in nba players

introduction

Sports physicians and fans are likely aware of recent news with an injury to an NBA star athlete Steph Curry of the Golden State Warriors.  The injury occurred on December 14, 2022 when he was playing defense and had his arm forcefully abducted.  There was immediate pain and he exited the game. 

Initial reports were unclear on what exactly happened and reports and prognosis were dependent on an MRI.  Recent news came that he suffered a “shoulder subluxation” and would be out a few weeks.  The goal of the post is to evaluate recent evidence and return to play with athletes suffering a similar injury. 

Steph curry shoulder subluxation

Image 1: Mechanism of injury.

Many providers and studies refer to this as “shoulder instability” or “glenohumeral instability.”  This is a more general term that encompasses both subluxation and dislocation events. This can be very problematic for competitive basketball players due to the demanding overhead activity.  Instability can result in apprehension with major basketball activities such as shooting and rebounding and can significantly affect performance.

It has been reported that injuries are twice as likely to occur in the National Basketball Association (NBA) than in collegiate basketball [1,2].  Among NBA players, injuries of the upper extremity account for roughly 15% of total injuries, and injuries to the glenohumeral joint account for 3% to 4% of all observed injuries [3,4].

For return to play decisions, there are likely many factors that influence the decision.  The two options are nonoperative and operative management.  Depending on the level of athlete, the level of imaging will likely depend on the injury.  Many times plain radiographs are ordered and an MRI with contrast may be performed to thoroughly evaluate the labrum.  There may be a bony lesion evident on the plain radiographs such as a bony Bankart lesion.

When selecting a management option, the clinician must consider the natural history of shoulder instability, pathologic changes noted on examination and imaging, sport- and position-specific demands, duration of treatment, and the athlete’s motivation.  The athlete and medical team may elect for nonoperative management because shoulder stabilization surgery may be season-ending and carry a lengthy return.

Nonoperative management usually includes physical therapy and soft tissue modalities.  Hovelius et al. found that there was no difference in redislocation rates between patients treated with early mobilization and those treated with 3 to 4 weeks of immobilization in a sling [5].  There is debate among utilization of a sling but most professional athletes will have limited use of any type of sling device after a subluxation event.  Dynamic compression, dynamic ligament tension, reactive neuromuscular control are important factors in the rehabilitation process.

There have been recent studies evaluating NBA players, their return to play and performance after a shoulder instability event.  Li et al. evaluated sixty players from 1987 to 2018 and compared operative and nonoperative management.  Subluxation events happened less frequently (13) than dislocation events (47) over this span.  After the initial index instability event, 28 players (47%) underwent surgery and 32 (53%) underwent nonoperative management. Of the 32 players managed nonoperatively after their instability event, 13 players (41 %) experienced recurrent dislocations. From these 13 players with recurrent dislocations, 9 (69%) underwent surgery. Ultimately, players who underwent surgery did not report any further instability events. In total, 37 players (62%) underwent surgery and 23 players (38 %) did not [6].

Study design Lu et al shoulder instability

Image 3: Study results from Li et al.  Adopted from [6].

It was shown in this same group that individuals undergoing nonoperative treatment played on average 4 less games the season following the event (58 vs 61 games).  There was also a slight decrease in PER, or performance efficiency rating (11.9 vs 12.4) [6].  PER is used as an objective measure of performance calculated by summing positive performance statistics such as points, rebounds, steals, and assists and subtracting negative variables, including turnovers and fouls. The score is adjusted by team and playing style and standardized to a league mean of 15.0 [7].

PER shoulder instability

Image 4.  Nonoperative versus operative games played and performance. Adopted from [6].

Lu et al. performed a somewhat similar study comparing return to play in NBA athletes suffering an instability event. Fifty NBA athletes were evaluated for injuries sustained from 1999 to 2018.  In those treated nonoperatively, athletes who sustained shoulder subluxations returned after an average of 3.6 weeks, compared with 7.6 weeks in those who sustained a shoulder dislocation [8]. Players who underwent operative management returned after an average of 19 weeks. Athletes treated operatively were found to have a longer time interval between a recurrent instability event (70 weeks vs. 28.5 weeks) [8].

Additional studies in NFL athletes and adolescent athletes have shown similar results.  The athletes undergoing arthroscopic stabilization have been shown to be less likely to have recurrent instability but do miss more time from sport immediately.  Many athletes will choose to have a shoulder arthroscopy in the offseason [6].

It is worth noting that in a study with 83 NFL players, ninety-one percent returned to NFL regular season play at an average of 1.6 weeks in those sustaining a shoulder subluxation and 3.7 weeks in those sustaining a dislocation. In players who were able to return to play without surgery, those having a left shoulder instability event were able to return faster (1 week) than those having a right shoulder event (4 weeks) [9].

Summary

In summary, shoulder instability events and return to play data has been recently evaluated and it has been shown that there is a very high return to play rate.  Return to sport has been faster with subluxation events in both the NBA and NFL and the recent and historical studies are likely why Steph Curry was given a time frame of “weeks” before he returns.  The in season and offseason treatment will vary depending on multiple factors that are yet to be determined.

– Read More @ Wiki Sports Medicine: https://wikism.org/Shoulder_Instability

– Read More Shoulder Pain: https://www.sportsmedreview.com/by-joint/shoulder/

References

  1. Robins RJ, Daruwalla JH, Gamradt SC, et al. Return to play after shoulder instability surgery in National Collegiate Athletic Association Division I intercollegiate football athletes. Am J Sports Med. 2017;45(10):2329–2335
  2. Podlog L, Buhler CF, Pollack H, Hopkins PN, Burgess PR. Time trends for injuries and illness, and their relation to performance in the National Basketball Association. J Sci Med Sport. 2015;18(3):278–282.
  3. Deitch JR, Starkey C, Walters SL, Moseley JB. Injury risk in professional basketball players: a comparison of Women’s National Basketball Association and National Basketball Association athletes. Am J Sports Med. 2006;34(7):1077–1083
  4. Drakos MC, Domb B, Starkey C, Callahan L, Allen AA. Injury in the National Basketball Association: a 17-year overview. Sports Health. 2010;2(4):284–290.
  5. Hovelius L, Eriksson K, Fredin H, et al: Recurrences after initial dislocation of the shoulder. Results of a prospective study of treatment. J Bone Joint Surg 65A: 343–349, 1983
  6. Li NY, Lemme NJ, Defroda SF, Nunez E, Hartnett DA, Owens BD. Performance After Operative Versus Nonoperative Management of Shoulder Instability in the National Basketball Association. Orthopaedic Journal of Sports Medicine. 2019;7(12)
  7. About Basketball-Reference.com. https://www.basketball-reference.com/about/. Accessed May 13, 2018.
  8. Lu Y, Okoroha KR, Patel BH, Nwachukwu BU, Baker JD, Idarraga AJ, Forsythe B. Return to play and performance after shoulder instability in National Basketball Association athletes. J Shoulder Elbow Surg. 2020 Jan;29(1):50-57

Okoroha KR, Taylor K, Keller RA, Marshall NE, Varma V, Moutzouros V. Return to Play After Shoulder Instability in National Football League Athletes. Orthopaedic Journal of Sports Medicine. 2017;5(7_suppl6).