Football Sports Medicine 2016: On-field
Triage of Long Bone Fractures and
Dislocations
Guidelines for Return to Play
Following Anterior Shoulder
Stabilization
Eric McCarty, MD
Associate Professor
Chief Sports Medicine & Shoulder Surgery
Department of Orthopaedics
Univ. of Colorado School of Medicine
5/6/2016
Disclosures
• Stryker, Smith Nephew, Biomet, Depuy
Mitek, (institutional support)
• Elsevier (book royalties)
• Biomet (consultant)
Big Thanks to Kevin Wilk for his
thoughts and slides
Athlete Dislocates Shoulder
MRI
Discuss Options:
[email protected]
1
Football Sports Medicine 2016: On-field
Triage of Long Bone Fractures and
Dislocations
5/6/2016
Surgery
Recover………and Watch
Lots of Rehab
Shoulder Instability
Post-op Rehab Critical
•Sling x 6 weeks
working on progressive motion
strengthening
•6 – 10 weeks
inc. motion and strength
start neuromuscular activities
•10 – 16 + weeks
advanced activites, functional
return
[email protected]
2
Football Sports Medicine 2016: On-field
Triage of Long Bone Fractures and
Dislocations
Rehab then….
When Return?
• Athlete: “When can I play?”
Rehab then….
When Return?
5/6/2016
Rehab then….
When Return?
• Coach: “When can he play?”
”I Feel Good”
• Athlete: “I Feel Good”
Is that enough to Return
to Play?
Rehab then….
When Return?
”He Looks Good”
• Coach: “He Looks Good!”
Is that enough to Return
to Play?
[email protected]
3
Football Sports Medicine 2016: On-field
Triage of Long Bone Fractures and
Dislocations
5/6/2016
Rehab then….
When Return?
“I don’t have a crystal ball”
• “How much longer?”
Return to Play
Dr. James Andrews
Return to Play after Stabilization
(open bankart) Systematic Review
OJSM 2014
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What is “return to play”?
What does that mean?
Is “play” – practice or competition?
Need to be clearly defined
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Often open to interpretation
Coaches
Athletic trainers
Player & parents
RETURN TO PLAY
CONSIDERATIONS
• Is Athlete Healed?
• Has it been Enough Time
Since Surgery?
• Good Strength?
• Safe Return Possible?
• Any Risk of Further Injury?
• Can the Athlete Protect
Themselves?
• 29 papers
• Avg. return to play 23
weeks
• Very few had
strength or other
parameters for return
to play
RETURN TO PLAY
CONSIDERATIONS
• Is Athlete Healed?
Tissues should be healed at 8
– 12 weeks
• Do they Meet Ideal Criteria?
[email protected]
4
Football Sports Medicine 2016: On-field
Triage of Long Bone Fractures and
Dislocations
RETURN TO PLAY
CONSIDERATIONS
5/6/2016
No Association of “Time” and
Return to Play in ACL patients
• Has it been Enough Time Since
Surgery?
Use of time as the sole
determination of when an athlete
may resume practice or play
following a shoulder instability
surgery is a critical error
AJSM ‘12
Time from the surgery itself is not
the primary element that will
determine readiness
RETURN TO PLAY
CONSIDERATIONS
• Good Strength?
How is this measured?
Which strength tests?
RETURN TO PLAY
CONSIDERATIONS
• Safe Return Possible?
• Any Risk of Further Injury?
• Can the Athlete Protect
Themselves?
Really depends on many
factors including strength,
endurance, neuromuscular
function, stability,
player confidence
RETURN TO PLAY
CONSIDERATIONS
• Safe Return Possible?
• Any Risk of Further Injury?
• Can the Athlete Protect
Themselves?
Really depends on many
factors including strength,
endurance, neuromuscular
function, stability,
RETURN TO PLAY
CONSIDERATIONS
player confidence
Essential that athlete
demonstrates sufficient
confidence in the affected
extremity to successfully return
to sport without any fears or
limitations
player confidence
[email protected]
5
Football Sports Medicine 2016: On-field
Triage of Long Bone Fractures and
Dislocations
5/6/2016
RETURN TO PLAY
CONSIDERATIONS
Ideal Criteria for Return to Play
• Do they Meet Ideal Criteria?
• Numerous Factors for “Ideal Criteria”
“IDEAL” Criteria For
Return to Play
Return to Play involves “Ideal”
Criteria and more…..
• Little / No Pain
– Patient Subjectivity
• Near normal ROM
• Near normal Strength
• Good Stability
• Normal Functional
Ability
• Normal Sports Specific
Skills
• Other Factors
Shoulder Instability Surgery
Return to Play Criteria
3 P Program:
Performance
Practice
Play
[email protected]
Wilk
Shoulder Instability Surgery
Return to Play Criteria
Wilk
3 P Program:
Performance Training:
performance training – sport specific drills
plyometrics
agility drills
speed drills
sport specific drills (throwing, catching, hitting)
(contact sports: hitting a bag, wall pushes, shadow)
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Football Sports Medicine 2016: On-field
Triage of Long Bone Fractures and
Dislocations
5/6/2016
Shoulder Instability Surgery
Return to Play Criteria
Shoulder Instability Surgery
Return to Play Criteria
Wilk
3 P Program:
Practice situations:
Wilk
3 P Program:
Play:
controlled practice
gradual increase time, intensity, reps
lower intensity to begin gradually increase intensity
50-60%
75%
80-90%
100%
return to practice game (game simulation)
return to competition
game situation
100% effort
Shoulder Instability Performance
Progression Testing
Wilk
Return to Play Criteria
Ball Drop Test
• Dynamic stabilization tests
– Prone ball drops
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Return to Play Criteria
Closed Kinetic Chain Upper Extremity Test
(CKCUET)
• Dynamic stabilization tests
– measure of upper quarter
stability, agility and power.
– pushup position with the hands
placed 36 inches apart
– touch the piece of tape under
the opposing hand
– # of cross-body touches
performed in 15 seconds
[email protected]
30 sec test
prone on plinth
number of releases/catches
2 pound plyoball
compare Dom to Non Dom
score: %
Goal: 90%>
Expectation; 110%>
Clearance Criteria for Return to Sport
WILK
• ASES Shoulder Score of ≥ 95
• Full, non-painful PROM
• Satisfactory clinical examination without positive findings or
apprehension
• Ball Drop Test: 100% involved to uninvolved
• Push-up Test: Ability to perform more repetitions in second
testing bout
• CKCUEST ≥ 25 repetitions
• Bench Press ≥ 95% of pre-injury 1RM without substitution
• Unilateral Pulling Assessment
• Unilateral Pushing Assessment
• Isokinetic test that fulfills criteria
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Football Sports Medicine 2016: On-field
Triage of Long Bone Fractures and
Dislocations
SUMMARY - Return to Play
• Many facets in deciding Return to Play for
athlete after anterior shoulder stabilization
• Consider Each Individual - No “Cookbook”
• Ensure Player Confidence
• Refer back to Basic Criteria
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No Pain
Full ROM
Full Strength
Functional Ability
Sport Specific Skills
Thank You
5/6/2016
SUMMARY - Return to Play
• Progress from Rehab phase to the 3 P
program
– Performance Training
– Practice Situations
– Play Game
• Wilk Shoulder Instability Performance
Progression Testing
Case Presentation
• MRI obtained on this player
[email protected]
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