Decision making in the Contact athlete

Lennard FunkWrightington Upper Limb UnitSalford University

[email protected]

CONTACT ATHLETESDECISION MAKING

Sport Popularity in UKSPORT TV Viewing Participation InterestFootball 46% 10% 45%Rugby Union 21% 6% 27%Tennis 18% 3% 23%Cricket 18% 2% 19%Athletics 18% 2% 21%Snooker 17% 5% 24%Motorsport 16% NA 20%Rugby League

12% 2% 15%Boxing 11% NA 14%Golf 11% 6% 16%

My Elite Athletes (2010-2013) = 663

SPORT Percent Commonest Path.Rugby Union 37% (247) Anterior Labral

Rugby League

28% (182) Posterior LabralFootball/Soccer

8% (54) Anterior LabralMotorsport 3% (22) Mixed Labral

TearsClimbers 3% (20) SLAPSwimming 3% (18) Int Imping/

SLAPCricket 2% (14) Anterior LabralParalympics 2% (13) Mixed Labral

TearsOthers 14% (93)

Three P’s

Patient

Pathology Participation

1. Age 2. Gender 3. Laxity 4. Fatigue 5. Sport 6. Position

1. Major 1. Bony 2. ALPSA 3. HAGL 4. FTCT

2. Minor 1. Labral 2. PTCT

1. Season 2. Events 3. Pressure 4. Age

Recurrent Instability Rates (after arthroscopic stabilisation)

[Cho et al. Arthroscopy 2006]

CONTACT / COLLISION

OVERHEADFLEXIBILITY

29%

7%

Recurrent Instability Rates in Contact Sports

• Non-operative = 80% [Arciero, 1994]

• Open Bankart repair = 12%• Arthroscopic Stabilisation = 14% [Larrain,

2006]

– First dislocation = 4%– Recurrent dislocations = 24%– Under 18yrs age = 30% [Nixon & Funk, 2013]

• RCT of Latarjet vs. Arthroscopic Bankart• Recurrence rate at 5 years:

– Latarjet = 12%– Arth. Bankart = 24%

• Return to sport the same!• Complication Rates higher (20%)

Latarjet Procedure [Bessier et al. JOST. 2013]

Recurrence Summary• Higher in contact/collision sport• Higher in young• Higher after surgery for recurrent

dislocations

• Arthroscopic = Open Bankart• Lower after Latarjet procedure

WHY?

PATIENT

Predisposing Factors• Player:

1.LaxityCheng et al. JBJSB 2007; Akhtar & Robinson. BJSM 2010

2.Proprioception Herrington, 2011

3.Isokinetics Jones & Funk, 2010

4.Mass5.Running Speed6.Aerobic ability7.Previous Injury

• Sport:

1. Speed of play

2. Timing

3. Fatigue

1. Physical

2. Mental

Injury Reduction Predispostion Model Meeuwisse

PATHOLOGY

Pathology

Mechanisms of Injury video analysis study

Direct Impact

Complex Labral

Bony Bankart PTCT

Flexed Fall

Posterior Labral

RHAGL

Try Scorer

Bankart SLAP

Rotator Cuff

Tackler

Bankart SLAP HAGL

Crichton, Jones & Funk - BJSM 2012

Player Position

• 25 Professional Footballers– 15 Field players– 10 Goalkeepers

Funk & Sargent, 2010

Injury Patterns

Clinical Examination: Instability in Athletes

• True Instability– Dislocation– Subluxation– Apprehension– Large lesions

• Subclinical Instability– Dead Arm in ABER– Pain in ABER– Clunking– No Apprehension– Smaller lesions

Investigations• No previous Surgery = MR Arthrogram

• Previous Surgery = CT Arthrogram

MR Arthrogram v. Scope

Sensitivity Specificity Accuracy

SLAP 0.42 0.92 77%

Rotator Cuff Tear

0.50 0.86 83%

Hill Sachs 0.91 0.78 90%

Bankart 0.85 0.83 86%

N Karlson, J Geoghan, L Funk; 2008

• An experienced Shoulder Surgeon better

• Can correlate with clinical context• Experience of reviewing Scopes & Scans

Pathology

Major ‘Minor’

• Bony Bankart• ALPSA• Rotator Cuff Tear• HAGL

• Undisplaced Labral Tear• Partial Cuff Tear

Timing of Surgery (Participation)

• Early Surgery:

– Large structural lesions

– Late in Season

– Unable to Return

• Rehab & Return:

– Minor lesions

– Early season

Types of Surgery• Mostly Arthroscopic Direct Repairs• Latarjet for High-Risk/Revision

• Anterior Instability– Revision surgery (even without bone loss)– Chronic Bony Bankart (> 3months)– Any Bony Glenoid Loss– True dislocation in Front Row forward

(Rugby Union)

– Higher level of sports

Latarjet in Athletes

Three P’s

Patient

Pathology Participation

1. Age 2. Gender 3. Laxity 4. Fatigue 5. Sport 6. Position

1. Major 1. Bony 2. ALPSA 3. HAGL 4. FTCT

2. Minor 1. Labral 2. PTCT

1. Season 2. Events 3. Pressure 4. Age

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THANK YOU