The shoulder is the joint of the body with the greatest range of motion, thanks to its anatomical design. This particularity confers, however, a greater predisposition to instability, since at any time during the range of motion only a small amount of instability can occur. 25% of the humeral head articular surface contacts the glenoid surface, depending largely on the complex interaction between the static (capsuloligamentous, bony, and labral structures) and dynamic (neuromuscular component) stabilizers.
The prevalence in the population is about 23.9/100,00, with an annual incidence rate of 1.7% in the general population, more frequent in males. The epidemiological risk factors identified are male gender, age under 30 years old and the practice of contact sports, being soccer, field hockey and wrestling the most affected modalities.
The therapeutic orientation must be individualized to the individual and his context. Thus, there are questions that must be answered before a decision is made, such as: Gender? Age? First episode? Amateur or professional athlete? Associated injuries?
After the elementary questions of a careful clinical history have been answered, there is evidence to keep in mind:
- Recurrence of shoulder instability is directly proportional to activity level and inversely proportional to age at first episode;
- The recurrence rate is about 72% when the first episode occurs before the age of 23 and of about 27% after the age of 30;
- Degenerative changes of the shoulder joint 25 years after the first episode should be expected to a moderate degree in about 27% of cases, and to a moderate to severe degree in about 34% of the cases.
THERAPEUTIC ALGORITHM IN ATHLETES
In the first step of the therapeutic decision for an athlete with anterior shoulder instability, ligament hyperlaxity and scapulothoracic dyskinesis should be excluded, which should alter the therapeutic approach.
For conservative treatment, the ideal athlete-type is defined as an athlete with a lesion in-season, non-contact sport practitioner or overhead and who respond favorably to conservative treatment without obvious apprehension or instability. This treatment should aim at progressive gain of mobility, strength, proprioception and, above all, self-confidence.
On the other hand, surgical treatment will be the gold-standard in an athlete with an injury off-season, under 20 years of age and practicing contact sport or overhead, and the most commonly performed procedures are the Bankart and Bristow-Latarget, both with different clinical indications, to be decided on a case by case basis.
The scarcity of publications in the literature on this topic makes it difficult to manage athletes' expectations. return-to-play will be conditioned by intrinsic (age, sex, anatomy, associated injuries) and extrinsic (type of sport, conservative or surgical treatment) factors to the athlete, being variable from case to case.
