Shoulder Instability in the Athlete Management and Surgical

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 Editors

Jonathan F. Dickens, MD
Chief, Sports Medicine, Walter Reed National Military Medical Center
Vice Chair (Research), Department of Surgery, Uniformed Services University
Associate Professor of Surgery, Uniformed Services University
Adjunct Faculty, John A. Feagin Jr. Sports Medicine Fellowship, USMA
Bethesda, Maryland

Brett D. Owens, MD
Professor of Orthopaedic Surgery
Brown University Alpert Medical School
Providence, Rhode Island
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Library of Congress Cataloging-in-Publication Data

Names: Dickens, Jonathan F., editor. | Owens, Brett D., 1972- editor.
Title: Shoulder instability in the athlete : management and surgical
techniques for optimized return to play / editors, Jonathan F. Dickens,
Brett D. Owens.
Description: Thorofare, NJ : SLACK Incorporated, [2021] | Includes
bibliographical references and index.
Identifiers: LCCN 2020034481 (print) | LCCN 2020034482 (ebook) | ISBN
9781630916640 (hardcover) | ISBN 9781630916657 (epub) | ISBN
9781630916664
Subjects: MESH: Joint Instability--therapy | Shoulder | Athletes | Shoulder
Injuries--therapy | Athletic Injuries--therapy
Classification: LCC RD557.5 (print) | LCC RD557.5 (ebook) | NLM WE 810 |
DDC 617.5/72044--dc23
LC record available at https://lccn.loc.gov/2020034481
LC ebook record available at https://lccn.loc.gov/2020034482

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 This book is dedicated to my family: to my wife, Amy; my children, Mary Gray and Jonathan; and my loving and sup-
portive parents, who taught me the value of hard work, a positive attitude, and perseverance.
—Jonathan F. Dickens, MD

I would like to dedicate this text to my family: my wife, Julie, and children, Cassidy, Ryan, Jocelyn, and Bennett. I thank
my parents and brother for helping instill a foundation of integrity and service, and my mentors in orthopedics, many of
whom I am proud to have contribute to this text. Finally, I dedicate this text to my patients, whom have taught me more than
can be captured in a text.
—Brett D. Owens, MD

The authors would like to further dedicate this book to Dr. John A. Feagin, Jr. He was the ultimate mentor who made
everyone who knew him better. We are fortunate to have had the opportunity to walk by your side for a part of this journey.
Dedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Contributing Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

Section I Principles for the Team Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1 Team Physician Principles for the Management of Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Jessica L. Brozek, MD and Bradley J. Nelson, MD
Chapter 2 Epidemiology of Shoulder Instability: Incidence, Risk Factors, and Prevention of Instability
in the Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
David J. Tennent, MD; Matthew A. Posner, MD; and Kenneth L. Cameron, PhD, MPH, ATC
Chapter 3 Evaluation of Shoulder Instability on the Field and in the Clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
Francis P. Bustos, MD; Jeremy K. Rush, MD, FAAP; and Stephen F. Brockmeier, MD
Chapter 4 Clinical Anatomy and Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
David Eldringhoff, MD; Barry I. Shafer, PT, DPT, ATC; Gregory J. Adamson, MD;
and Thay Q. Lee, PhD

Section II Anterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Chapter 5 Management of In-Season Anterior Instability and Return-to-Play Outcomes . . . . . . . . . . . . . . . . . . . . . . . .43
Jonathan F. Dickens, MD and Maj. Michael A. Donohue, MD
Chapter 6 Decision Making in Surgical Treatment of Athletes With First-Time vs Recurrent
Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Brian C. Lau, MD; Carolyn A. Hutyra, MMCi; and Dean C. Taylor, MD
Chapter 7 Radiographic and Advanced Imaging to Assess Anterior Glenohumeral Bone Loss . . . . . . . . . . . . . . . . . . .67
Lisa K. O’Brien, DO and Brian R. Waterman, MD
Chapter 8 Arthroscopic Anterior Shoulder Instability in the Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
Lauren A. Szolomayer, MD and Robert Arciero, MD
Chapter 9 Open Treatment of Anterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Michael J. Pagnani, MD and Jason A. Jones, MD
Chapter 10 Latarjet and Coracoid Transfer in Athletes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
Alexander Beletsky, BA; Ian J. Dempsey, MD, MBA; Brandon J. Manderle, MD;
and Nikhil N. Verma, MD
Chapter 11 Glenoid Bone Loss Augmentation Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Matthew L. Vopat, MD; Liam A. Peebles, BA; Maj. Travis J. Dekker, MD, MC, USAF;
and Matthew T. Provencher, MD, MC, USNR
Chapter 12 Arthroscopic Latarjet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
Laurent LaFosse, MD; Christian Moody, MD; and Leonard Achenbach, MD
Chapter 13 Hill-Sachs Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
Morad Chughtai, MD; Andrew Swiergosz, MD; Linsen T. Samuel, MD, MBA;
and Anthony Miniaci, MD
viii Contents

Chapter 14 Rehabilitation of the In-Season and Postoperative Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149

Kevin E. Wilk, PT, DPT and Lenny Macrina, MSPT, SCS, CSCS
Chapter 15 Return-to-Play Evaluation in the Postoperative Athlete for Anterior Shoulder Instability . . . . . . . . . . . . . 175
Brian Busconi, MD; Jonathon A. Hinz, DO; Benjamin J. Brill, DO;
and Vickie Dills, PT, DPT, OCS, ITPT, CSAC

Section III Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Chapter 16 History and Examination of Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .187
Trey Colantonio, MD, CPT and CDR Lance LeClere, MD
Chapter 17 Imaging of Posterior Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197
Josef K. Eichinger, MD, FAOA and Joseph W. Galvin, DO, FAAOS
Chapter 18 Management of In-Season Athletes With Posterior Glenohumeral Instability . . . . . . . . . . . . . . . . . . . . . . .205
Mark Slabaugh, MD, FAAOS and Christopher Gaunder, MD
Chapter 19 Arthroscopic Management of Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Fotios Paul Tjoumakaris, MD and James P. Bradley, MD
Chapter 20 Bone Augmentation for Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .221
Jaymeson R. Arthur, MD and John M. Tokish, MD
Chapter 21 Postsurgical Rehabilitation of Posterior Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .233
Evan W. James, MD; Kenneth M. Lin, MD; Lawrence V. Gulotta, MD; and Samuel A. Taylor, MD
Chapter 22 Return to Play Following Posterior Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241
Tracey Didinger, MD; Jennifer Reed, NP; and Eric McCarty, MD

Section IV Special Topics in Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .249

Chapter 23 Revision Arthroscopic Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .251
Craig R. Bottoni, MD and Zackary Johnson, MD
Chapter 24 Instability in the Throwing Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265
Ashley J. Bassett, MD and Steven B. Cohen, MD
Chapter 25 Instability in the Pediatric and Adolescent Athlete . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .281
Joseph W. Galvin, DO, FAAOS and Xinning Li, MD
Chapter 26 Special Considerations for Multidirectional Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .291
Mark E. Cinque, MD and Geoffrey D. Abrams, MD
Chapter 27 Special Considerations for Return to Play in Collision Athletes (Hockey, Football, and Rugby) . . . . . . . .299
Bruce S. Miller, MD, MS; Asheesh Bedi, MD; and Jack W. Weick, MD
Chapter 28 Management of the Aging Athlete With the Sequelae of Shoulder Instability . . . . . . . . . . . . . . . . . . . . . . . .307
Lucca Lacheta, MD; Maj. Travis J. Dekker, MD, MC, USAF; and Peter J. Millett, MD, MSc

Financial Disclosures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

 The authors would like to acknowledge the indefatigable Julia Dolinger, Kayla Whittle, Dani Malady, and Allegra Tiver.
Thank you to everyone with the SLACK Incorporated team for their dedication and commitment to this project. This journey
began as a concept, and with the support and guidance from SLACK has been made into a reality. We are also deeply indebted
to all of the world-renowned authors who have graciously contributed their time and expertise to make this into a cogent
resource of extraordinary quality. Lastly, we want to acknowledge all those whose footsteps we have followed in service to
our country. There has been no better source of comradery and friendship, no finer arena in which to practice, and most of
all, no better patient for which to care.
 Jonathan F. Dickens, MD is Chief of the Orthopaedic Sports Medicine and Shoulder Service at Walter Reed National
Military Medical Center (WRNMMC) in Bethesda, Maryland; Vice-Chair of Research for the Uniformed Services University
Department of Surgery; and Adjunct Faculty at the John A. Feagin Jr. Sports Medicine Fellowship at the US Military Academy
in West Point, New York. He is an Associate Professor of Surgery at the Uniformed Services University of the Health Sciences.
Dr. Dickens earned his Bachelor of Science from Davidson College in North Carolina before entering the Army. He sub-
sequently completed medical school at Indiana University in Bloomington, followed by Orthopaedic Surgery Residency at
WRNMMC. He completed his Fellowship in Sports Medicine and Arthroscopy at the John A. Feagin Jr. Sports Medicine
Fellowship at West Point. Dr. Dickens is a Lieutenant Colonel in the US Army and has served as a Consultant Physician for
Special Operations Task Force–Afghanistan in 2015 and Commander of the Hamid Karzi International Airport NATO Role
II Hospital in Kabul, Afghanistan in 2019.
xii About the Editors

Brett D. Owens, MD is a Board-certified orthopedic sports medicine surgeon. Dr. Owens is currently a Professor in the
Department of Orthopaedic Surgery at the Brown University Alpert Medical School and practices in Providence, Rhode
Island. He is a retired Colonel in the US Army and previously served as Chief of Orthopaedics and Sports Medicine at Keller
Army Hospital, West Point, New York. He is currently Team Physician for Brown University Athletics and the Providence
Bruins (AHL).
He attended the US Military Academy and Georgetown University School of Medicine. He completed his residency at the
University of Massachusetts and the John A. Feagin Jr. Sports Medicine Fellowship at West Point. He was an AOA North
American Traveling Fellow as well as an AOSSM-ESSKA Traveling Fellow.
Dr. Owens has published more than 250 articles in orthopedics and sports medicine. This is his fourth textbook. His
research has garnered the O’Donoghue Research Award, Aircast Award, and NCAA Research Awards from the American
Orthopaedic Society for Sports Medicine and the AAOS Kappa Delta Award. Dr. Owens is proud to serve as Associate Editor
of the American Journal of Sports Medicine since 2012.
Geoffrey D. Abrams, MD (Chapter 26) James P. Bradley, MD (Chapter 19)
Stanford University School of Medicine Clinical Professor, Orthopaedic Surgery
Department of Orthopedic Surgery University of Pittsburgh Medical Center
Veterans Administration–Palo Alto Health Care System Head Team Physician, Pittsburgh Steelers
Palo Alto, California Pittsburgh, Pennsylvania

Leonard Achenbach, MD (Chapter 12) Benjamin J. Brill, DO (Chapter 15)

Department of Trauma, Hand, Plastic and Orthopaedic Surgeon
Reconstructive Surgery Longview Orthopaedic Center, LLC
University Hospital Wuerzburg Leominster, Massachusetts
Wuerzburg, Germany
Stephen F. Brockmeier, MD (Chapter 3)
Gregory J. Adamson, MD (Chapter 4) Sports Medicine and Shoulder Surgery
Congress Medical Foundation Professor of Orthopaedic Surgery
Pasadena, California University of Virginia
Director, UVA Sports Medicine Fellowship Program
Robert Arciero, MD (Chapter 8) Team Physician, UVA Athletics
Professor, Orthopaedics Charlottesville, Virginia
University of Connecticut
UCONN Health Jessica L. Brozek, MD (Chapter 1)
Farmington, Connecticut Orthopedic Surgeon
Newton Medical Center
Jaymeson R. Arthur, MD (Chapter 20) Newton, Kansas
Department of Orthopedics
Mayo Clinic, Scottsdale Brian Busconi, MD (Chapter 15)
Phoenix, Arizona Chief of Sports Medicine and Arthroscopy
University of Massachusetts
Ashley J. Bassett, MD (Chapter 24) UMass Memorial Health Care
The Orthopedic Institute of New Jersey Division of Sports Medicine
Sparta, New Jersey Worcester, Massachusetts

Asheesh Bedi, MD (Chapter 27) Francis P. Bustos, MD (Chapter 3)

Chief, Sports Medicine Department of Orthopaedic Surgery
Gehring Professor of Orthopedic Surgery University of Virginia
Michigan Medicine Charlottesville, Virginia
Ann Arbor, Michigan
Kenneth L. Cameron, PhD, MPH, ATC (Chapter 2)
Alexander Beletsky, BA (Chapter 10) John A. Feagin Jr. Sports Medicine Fellowship
Division of Sports Medicine Keller Army Hospital
Midwest Orthopaedics at Rush US Military Academy
Rush University Medical Center West Point, New York
Chicago, Illinois
Morad Chughtai, MD (Chapter 13)
Craig R. Bottoni, MD (Chapter 23) Department of Orthopaedic Surgery
Professor of Surgery Cleveland Clinic
Uniformed Services University of the Health Sciences Cleveland, Ohio
Chief, Sports Medicine
Orthopaedic Surgery Department Mark E. Cinque, MD (Chapter 26)
Tripler Army Medical Center Stanford University School of Medicine
Honolulu, Hawaii Department of Orthopedic Surgery
Palo Alto, California
xiv Contributing Authors

Steven B. Cohen, MD (Chapter 24) Christopher Gaunder, MD (Chapter 18)

Rothman Orthopaedic Institute Maj, USAF, MC
Department of Orthopaedic Surgery Orthopaedic Surgeon
Thomas Jefferson University Dayton, Ohio
Philadelphia, Pennsylvania
Lawrence V. Gulotta, MD (Chapter 21)
Trey Colantonio, MD, CPT (Chapter 16) Hospital for Special Surgery
PGY-4, Research Resident New York, New York
Department of Orthopaedic Surgery
Walter Reed National Military Medical Center Jonathon A. Hinz, DO (Chapter 15)
Bethesda, Maryland Orthopaedic Surgeon
Associated Orthopedists of Detroit
Maj. Travis J. Dekker, MD, MC, USAF (Chapters 11 and 28) St. Clair Shores, Michigan
US Air Force
Eglin Air Force Base, Florida Carolyn A. Hutyra, MMCi (Chapter 6)
Assistant Professor Orthopaedic Surgery
Uniformed Services University of the Health Sciences Duke University
Bethesda, Maryland Durham, North Carolina

Ian J. Dempsey, MD, MBA (Chapter 10) Evan W. James, MD (Chapter 21)
Division of Sports Medicine Hospital for Special Surgery
Midwest Orthopaedics at Rush New York, New York
Rush University Medical Center
Chicago, Illinois Zackary Johnson, MD (Chapter 23)
Honolulu, Hawaii
Tracey Didinger, MD (Chapter 22)
LA Bone and Joint Institute Jason A. Jones, MD (Chapter 9)
Encino, California Nashville Knee and Shoulder Center
Music City Orthopaedics and Sports Medicine
Vickie Dills, PT, DPT, OCS, ITPT, CSAC (Chapter 15) Nashville, Tennessee
Department of Orthopedics
University of Massachusetts Medical School Lucca Lacheta, MD (Chapter 28)
Worcester, Massachusetts Steadman Philippon Research Institute
Vail, Colorado
Maj. Michael A. Donohue, MD (Chapter 5) Assistant Professor
Assistant Professor of Surgery Center for Musculoskeletal Surgery
Uniformed Services University of the Health Sciences Charitè—Universitaetsmedizin Berlin
John A Feagin Jr. Sports Medicine Fellowship Berlin, Germany
West Point, New York
Laurent LaFosse, MD (Chapter 12)
Josef K. Eichinger, MD, FAOA (Chapter 17) ALPS Surgery Institute
Sports Medicine, Shoulder and Elbow Surgery Annecy, France
Professor of Orthopaedic Surgery
Medical University of South Carolina Brian C. Lau, MD (Chapter 6)
Charleston, South Carolina Duke Sport Science Institute
Orthopaedic Surgery
David Eldringhoff, MD (Chapter 4) Duke University
Congress Medical Foundation Durham, North Carolina
Pasadena, California
CDR Lance LeClere, MD (Chapter 16)
Joseph W. Galvin, DO, FAAOS (Chapters 17 and 25) Sports Medicine and Shoulder Surgery
Assistant Professor of Surgery Naval Health Clinic Annapolis
Uniformed Services University of the Health Sciences Head Team Physician
Department of Orthopaedic Surgery US Naval Academy
Shoulder and Elbow Surgery Annapolis, Maryland
Madigan Army Medical Center
Tacoma, Washington