Introduction

Young athletes in overhead sports risk developing shoulder instability due to repetitive microtrauma and extreme movements. Here the open Latarjet surgery has proven promise in the treatment of young athletes with recurrent instability. However, rehabilitation protocols have not yet been established, and this results in different ways of determining successful outcomes and consequently also in when the time is right to return to sports (RTS). Most often, the decision to clear an athlete to RTS is made upon respecting particular timeframes. But Rogowski et al. in 2023 demonstrated that at the mean RTS time – which is mainly set at 4–5 months postoperatively-, a majority of Latarjet patients have some residual strength or functional deficits. Therefore, there is a need for further examination of the right time to reintroduce sports. The current study examines criteria-based testing and evaluates its clinical outcomes in a subset of athletes. The primary objective of this study was thus to examine criteria-based shoulder instability RTS testing after open Latarjet surgery and to assess the ability of the athletes to return to play.

Methods

This was a retrospective case series study, that included 10 young competitive athletes after they underwent primary open Latarjet surgery for recurrent anterior instability. At least one of the following indications had to be present:

1. They either failed arthroscopic Bankart repair with or without remplissage or
2. There was a critical glenoid bone loss greater than 20%

Multidirectional instability, concomitant rotator cuff pathology, connective tissue disorders, and poorly controlled epilepsy were exclusion criteria.

Following surgery, the athletes participated in a standardized post-operative rehabilitation protocol, consisting of three main phases

1. Phase 1 during weeks 0–8 involved sling immobilization for 4 weeks with the initiation of pendulums and formal physical therapy with passive range of motion (PROM) at 2 weeks postoperatively. During the first 6 weeks, external rotation was limited to 30◦ at the side.
2. Phase 2 from week 8 to week 12 consisted of the initiation of active range of motion (AROM), with a focus on dynamic stabilization and neuromuscular control.
3. Phase 3 lasted from week 12 to week 24) and focused on the normalization of strength and neuromuscular control through progressive strengthening via submaximal tissue loading.

When they completed these rehabilitation phases, the surgeon decided when they could participate in the shoulder instability RTS testing.

The RTS testing after open Latarjet surgery involved isometric strength testing, isokinetic strength testing, endurance testing, and functional testing.

The isometric strength testing was performed for external rotation and internal rotation using a hand-held dynamometer at 0° and 90° of shoulder abduction. Isokinetic strength testing of ER and IR was evaluated using a Biodex isokinetic dynamometer.

Posterior rotator cuff endurance was evaluated using a repetition-to-failure technique with 5% body weight at 0◦ and 90◦ of abduction with the goal of 90% of nonoperative extremity (measured in repetitions)

The functional testing consisted of the Closed Kinetic Chain Upper Extremity Stability test (CKCUEST) and the Unilateral Seated Shot Put (USS) test. The first test lets the patient touch the contralateral hand from a plank position with 3 rounds of 15 active seconds with 45-s breaks. This test measures the number of repetitions. Touches per 15 seconds were averaged over three trials. The patient passes the CKCUEST by performing on average ≥22 repetitions over 3 trials of the test.

The USS test had the patient seated with his back against a wall or a box. From this position, this test required throwing a 2.72 kg medicine ball as far as possible. The purpose was to achieve 90% (if the injury was on the dominant side) or 80% (if the injury was on the non-dominant side) of the contralateral side’s toss (measured in cm). The distance was averaged over three trials with a 30-second rest period between trials.

Hereafter, the decision to clear the athlete to RTS was made by the surgeon:

• Patients who passed all sections of the test were given full clearance to return to full participation with the coaching staff and athletic trainers.
• Patients who failed only one section were given 4–6 weeks delayed clearance to return to sport after deficit-guided rehabilitation with the physical therapist.
• Patients who failed multiple sections of the test underwent formal deficit-guided rehabilitation for 4–6 weeks and repeated the test before final clearance.

Results

10 patients met all inclusion criteria and underwent shoulder instability RTS testing after open Latarjet surgery with a minimum of 2 years follow-up. Seven of the recruited participants were operated because they had glenoid bone loss ≥20%, while the others had failed prior arthroscopic stabilization.

At a mean of 5.3 ± 0.33 months post-operatively they underwent the RTS testing. Three of the ten participants passed the test without failing any sections, while one participant passed the testing but failed one section. The other 6 participants failed two or more sections of the RTS testing after open Latarjet surgery and as a consequence, they were reinvited to deficit-based physiotherapy rehabilitation for at least 4-6 weeks. These 6 participants were also required to repeat the RTS testing before full clearance. After a mean of 2.5 ± 1.9 months after their initial test, four out of these six participants were retested and passed the RTS testing after open Latarjet surgery, while 2 patients did not return for repeat testing.

At the final follow-up at a mean of 3.6 years, nine out of the ten participants returned to play while one had recurrent subluxations. The authors indicated that the patient with recurrent instability was a non-throwing American football player who failed three sections of the initial RTS test (isometric strength, isokinetic strength, endurance) but did not return for repeat testing. The patient who did not return to play was an American football quarterback who also failed multiple sections (isokinetic strength, isometric strength) of the initial RTS test but eventually passed on repeat testing.

Questions and thoughts

Based on the current study’s results, you can conclude that a time-based decision for athlete clearance to RTS is outdated. If the authors had stuck to the time-based criteria, the athletes would have returned at 4-5 months despite only 4 passing all testing criteria at 5.3 months.

The table below shows that for most individuals, the isokinetic strength testing at 60° and 180° per second proved most challenging for the cohort, with only 40% meeting goals for external rotation and internal rotation at both angular velocities.

Further, the isometric strength testing showed that 70% reached the required internal rotation strength, but only 50% reached their external rotation strength goals. The functional testing revealed that 9 out of 10 participants passed both tests. Among the 8 patients that eventually passed their initial or repeat RTS test (as 2 did not return for repeat testing), the mean time to full clearance for return to sport was 6.4 ± 1.8 months.

These results indicate that we cannot rely solely on functional testing to base our clearance to RTS decision, as almost all participants passed this section, despite having important remaining deficits. This indicates that an athlete may appear ready, but probably can compensate for his deficits. The current study made it clear that shoulder instability RTS testing should consist of many more than just measuring the function of the athlete.

Talk nerdy to me

Hurley et al. in 2019 found a wide range of return-to-play criteria. Time-based clearance was used the most to determine readiness for RTS in two-thirds of the research, followed by CT imaging (25% of studies) and physical examination (11.1%).

• The time point most often chosen for clearing to RTS (35.4% of studies) among the time-based clearance studies for return to play was three months, while the average return to play occurred 5.8 months after surgery.
• The outcomes of this current study, however, show that time-based clearance ranging from 3 to 6 months postoperatively may not be optimal, as most patients continue to demonstrate some level of strength, endurance, or functional shortages over this period.

With this in mind, this study provides an interesting insight into the requirements for athletes’ return to sport, however, the primary goal of the study was not to determine the right time to RTS. Rather, it looked retrospectively at the influence of passing the RTS criteria.

They found that those who passed the RTS testing after open Latarjet surgery were successful at returning to sports. They did not report recurrent shoulder instability episodes at the follow-up of 3.6 years. Thereby we can use this testing protocol to examine athletes undergoing such shoulder surgery and rely on the objective outcomes to determine when to clear him for RTS. However, we should bear in mind that the scope of this study was not to prospectively define who was ready for sports participation, and the small number of participants keeps us from making definite conclusions. Nevertheless, the results from this study can guide you to make individualized RTS recommendations and refrain from making time-based decisions. Especially, because of the lack of literature guiding this topic, this study forms a starting point for this subset of patients.

Two athletes did not return to the second RTS testing after failing the first testing. We do not know the reasons why the athletes did not return for the second RTS testing. Was it because of their shoulder or had it nothing to do with it? That wasn’t specified by the authors.

Ideally, the results of this study should be compared to RTS outcomes after time-based clearance to RTS. Brzoska et al. in 2023 noted that when readiness to RTS was determined based on the radiographic union of the Latarjet procedure, 8.7% of participants showed recurrent instability. In this study, only 1% of recurrent instability was reported, making the criteria-based athlete clearance to RTS seem favorable.

Take home messages

Using a testing protocol as used in this study leads to excellent results regarding safe RTS after open Latarjet surgery. It showed that of those passing the initial testing, RTS was possible and safe since these athletes did not report repeat shoulder instability at a mean follow-up of 3.6 years. Those who failed the initial testing, underwent deficit-guided physiotherapy for an additional 4 to 6 weeks. After repeat testing, they were cleared to RTS. Only 1 participant had recurrent shoulder instability, but this athlete never returned for repeat testing after failing his initial test. The insights that this study gives us, can guide you to prescribe physical treatment and tailor clearance to RTS based on examination findings.

Reference

Reddy RP, Como M, Charles S, Herman ZJ, Nazzal EM, Como CJ, Singh-Varma A, Fails A, Popchak A, Lin A. Criteria-based return to sport testing after open Latarjet reveals residual deficits and can be utilized for sports clearance with excellent outcomes at mean 3.6 year follow-up: A small case series of competitive athletes. Phys Ther Sport. 2024 Jan;65:23-29. doi: 10.1016/j.ptsp.2023.11.002. Epub 2023 Nov 19. PMID: 37995416.