Disappointing Return to Sport Rates after a SLAP Injury

Freijomil N, Peters S, Millay A, Sinda T, Sunset J, Reiman MP. The success of return to sport after superior labrum anterior to posterior (SLAP) tears: A systematic review and meta-analysis. Int J Sports Phys Ther. 2020;15(5):659-670. doi:10.26603/ijspt20200659

Superior labrum anterior to posterior (SLAP) injuries are prevalent in overhead athletes.  However, management of these athletes is controversial and inconsistent.  The purpose of this systematic review was to investigate return to sport (RTS) and return to sport at previous level (RTSP) proportions after SLAP injury.

Research Methods

This systematic review included randomized control trials, prospective and retrospective intervention or observational studies.  All studies included a population of at least 10 athletes. Athletes were all ages and competitive levels from youth through professional sports.  

Individual studies investigated return to sport for shoulder labral injury.  Both surgical and conservative treatments were reviewed.  Studies that focused primarily on other surgical procedures (e.g. Bankart tear, rotator cuff tear) were excluded.

The primary outcomes were return to sport (RTS) and return to sport at pre-injury level of competition (RTSP).  RTS was defined as any athlete returning to any level of competitive sport.  RTSP was defined as returning to competitive sport, at a level they were playing at pre-injury or higher.

Reviewers independently assessed the risk of bias for each study using the Methodological Index for Non-Randomized Studies (MINORS) scale.  Studies that met >75% of criteria were considered high quality, 50-74% considered moderate, 25-49% considered low, and <25% considered very low.

Key Findings Related to RTS and RTSP

The final review included 22 individual studies with 617 athletes (87.9% males). Most (18/22) were retrospective studies (case series of cohort studies).  Based on the MINORS scale, 4 studies were low quality and 18 were moderate quality.

The most frequently played sports included baseball/softball (227 athletes).  Twenty studies assessed the effects of arthroscopic surgery while one study looked at both non-surgical and surgical intervention.  Another study looked exclusively at non-surgical intervention.

Post-surgical failures resulting in follow up operations were reported in 15 studies with a median rate of 3% (range 0%-13%). 

The overall RTS proportion, regardless of level and type of intervention, was 93% (95% CI: 87% to 98%).  The proportion for RTSP was 72% (95% CI: 60% to 83%) representing both surgical and non-surgical interventions.

Surgical RTS proportion was 92% (95% CI: 86% to 97%), while surgical RTSP proportion was 74% (95% CI: 61 to 85%). Non-surgical RTS and RTSP proportions were 60% (95% CI: 49% to 71%) and 34% (95% CI: 24% to 45%) respectively.

Only 59% of the included studies reported RTS time-frames.  And only nine studies reported some type of return to sport criteria. 

Completion of an interval throwing program was stated as a requirement in 3 of the studies examining baseball athletes. No studies provided specific information on additional requirements before beginning throwing programs.  And no studies reported if all baseball athletes met these timelines or had setbacks.

No study reported post-injury athletic performance or career longevity after SLAP injury.  Post-surgical rehabilitation timelines varied across studies.  Only one study included a citation for specifics about the rehabilitation program.

Returning to Previous Levels of Competition after SLAP Injury is an Uphill Climb

The principle finding of this research is disappointing.  That is less than three in four athletes return to their previous level of sport participation after SLAP injury.  RTS and RTSP appears to be more likely when surgical vs. non-surgical intervention is pursued.

The primary limitation of this review was the inability to discern RTS and RTSP proportions based on sport and competition level.  The demands of the professional baseball pitcher are much different than that of a recreational athlete with minimal overhead demands.  Therefore, it is likely that RTSP proportions in high-level baseball players are lower than the overall rates reported in this review.

Difficulty in diagnosing SLAP injuries and the high prevalence of asymptomatic individuals makes treatment decisions challenging.   The current body of literature provides little guidance for clinicians to assist with these decisions.  However, the current approach of at least 3 to 6 months of non-surgical intervention may be appropriate in most cases.

Rehabilitation time-frames and RTS criteria require further research.  This is an area where further study is badly needed.  When is the ideal time to initiate an interval throwing program?  And more importantly, what criteria should clinicians utilize to determine readiness to begin such a program?

Wilk et al1 outline a criterion-based progression for returning the overhead athlete back to competition.  Progression is based on performance in a comprehensive battery of tests.  This includes patient reported outcome measures, range of motion, strength, and functional performance testing (for both the upper and lower quarter). 

I’d be interested in hearing the experience of others who manage overhead athletes after SLAP injury. Is the RTS and RTSP proportions reported in this systematic review consistent with others experience?

Thanks for reading!

References

  1. Wilk KE, Bagwell MS, Davies GJ, Arrigo CA. Return to sport participation criteria following shoulder injury: A clinical commentary. Int J Sports Phys Ther. 2020;15(4):624-642. doi:10.26603/ijspt20200624

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