Original research
Operative shoulder instability injury management in Australian Football League players: A case series

https://doi.org/10.1016/j.jsams.2017.11.011Get rights and content

Abstract

Objectives

The purpose of this study was to review the surgical management procedures of shoulder instability injuries in Australian Football League (AFL) players, and determine outcomes regarding return to sport and injury recurrence.

Design

Retrospective cohort study.

Methods

Elite AFL players with shoulder instability resulting in surgery were assessed in a retrospective cohort design (72 players/77 shoulders). Type of initial injury, surgical management, return to sport and injury recurrence were obtained. The mean follow-up period post-surgery was 2.9 years. Return to sport outcomes were compared between arthroscopic and open surgery using a Kaplan–Meier survival analysis. Logistic regression modelling was used to determine associations between injury recurrence, type of injury, participant age and method of surgery.

Results

Shoulder instability injuries occurred most frequently during tackling (40%). Arthroscopic surgery was preferred for primary shoulder instability. Nine (16%) recurrences occurred in those who underwent arthroscopic surgery compared to two (9%) following open surgery. Return to the elite level was slightly but significantly (2 weeks, p = 0.049) longer for open compared to arthroscopic surgery. Recurrence was 5 times more likely if the primary injury was a dislocation and more likely in players who were younger at the time of surgery.

Conclusion

Tackling was the predominant mechanism for shoulder instability injuries in AFL players and arthroscopic surgery was more commonly performed for primary injuries. Sustaining a dislocation as the primary injury and younger age increased the likelihood of recurrent instability. Careful consideration should be given to the operative management of these individuals.

Introduction

Shoulder instability (SI) injuries involve excessive translation of the humeral head relative to the glenoid resulting in subluxation or dislocation.1 SI is common in high-contact collision sports such as rugby, American Football and Australian Rules Football (ARF).2, 3, 4 ARF is a fast-paced, highly-physical overhead contact sport that involves regular collisions and tackling.5 The Australian Football League (AFL) is the premier ARF competition in Australia. The AFL maintains a publicly available injury surveillance report and groups SI injuries within a group of injuries collectively as “shoulder sprains and dislocations”.4 These injuries are the most common upper limb injury in AFL players and in 2015 players were unavailable to play matches due to shoulder sprains and dislocations for an average of 11.5 games per season for each AFL club.6

In AFL players, there is little evidence to guide clinical decision making for operative management of SI. In the only study to date, Roberts et al.7 compared the outcomes of an open surgical technique (OT) to an arthroscopic technique (AT) in 56 ARF players, most of whom played at an amateur-league level, and reported recurrent instability in 30% of players who underwent OT versus 78% who had AT suture repair and 38% who had AT using an absorbable polyglyconate tack. For current clinicians there is little to draw from this study due to the vast changes in AT since 19998. Further, this data was merely descriptive and did not investigate factors that may have contributed to recurrence of injury. Given the prevalence and impact of SI injuries in AFL players there is a need to understand current operative management of traumatic SI and subsequent outcomes in this setting to better inform clinical decision-making.

The primary aims of this study were to: (1) determine the mechanism of SI injuries and frequency of OT and AT being used to manage these injuries in professional AFL players; and (2) determine the return to sport time and the rate of post-operative injury recurrence for OT and AT. The secondary purpose of this study was to examine the factors that contribute to post-operative injury recurrence.

Section snippets

Methods

This study used a retrospective cohort design. Participants were elite AFL listed players with SI that underwent primary surgical treatment between 2009 and 2013. SI was defined as gleno-humeral instability that underwent stabilisation surgery, irrespective of the mechanism or extent of instability (i.e. dislocation or subluxation). An AFL listed player is a professional athlete who is registered to play with an AFL club. The study was approved by the Deakin University Human Ethics Advisory

Results

Seventy-seven SI injuries from 72 participants were recorded (5 had bilateral SI). The mean age and height of participants was 21.9 (3.1) years and 1.88 (0.07) m, respectively. Tackling was the predominant injury mechanism for primary traumatic SI injuries (Fig. 1). The primary instability event was more often subluxation (53 injuries; 68.8%) than dislocation (24 injuries; 31.2%). All dislocations were in the anterior or anterior-inferior direction. SI injuries occurred during a match (87.0%),

Discussion

In this cohort of AFL players AT (71.4%) was used more frequently than OT (28.6%). The recurrence rate was 16% and 9% for AT and OT, respectively. 82% of participants with recurrent instability underwent a subsequent OT procedure. A second operation was five times more likely if the primary injury was a dislocation and younger players were at greater risk of recurrent instability.

The predominant mechanism of injury in AFL players was tackling (40%). Within this event, 74% of injuries occurred

Conclusion

Tackling was identified as the primary mechanism for SI injuries within AF players. Arthroscopic surgery was performed for the majority of primary SI injuries whereas an open technique was used for the majority of revision procedures, though the results from this case series do not delineate the best management paradigm for these injuries. A very high proportion of elite AFL players return to their pre-injury sport level. Recurrent injuries post-surgery when the initial injury involved a

Practical implications

  • Tackling is the predominant mechanism of shoulder instability injuries in AFL players.

  • Operative management of shoulder instability in AFL players is most commonly performed arthroscopically.

  • Recurrence of injury post-surgery is more likely in AFL if the primary injury was a dislocation and the athlete is of a younger age. Clinicians should carefully consider the operative management options for these athletes.

Acknowledgements

We thank the Australian Football League for the financial support and opportunity to undertake this project. To the participating clubs, club medical officers and physiotherapists, thank you for committing to the study and allowing access to medical records and on occasions welcoming us into your club facilities. None of this would have been possible without your compliance. The authors declare no conflict of interest.

References (23)

  • A.J. Gray et al.

    Match analysis and the physiological demands of Australian football

    Sports Med

    (2010)
  • Cited by (0)

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