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J Shoulder Elbow Surg (2017) ■■, ■■–■■
www.elsevier.com/locate/ymse
ORIGINAL ARTICLE
Return to play after shoulder instability in
National Football League athletes
Kelechi R. Okoroha, MD*, Kevin A. Taylor, MD, Nathan E. Marshall, MD,
Robert A. Keller, MD, Mohsin Fidai, MD, Michael C. Mahan, MD, Vishal Varma, MD,
Vasilios Moutzouros, MD
Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, MI, USA
Hypothesis: We hypothesized that National Football League (NFL) players sustaining a shoulder desta-
bilizing injury could return to play (RTP) successfully at a high rate regardless of treatment type.
Methods: We identified and evaluated 83 NFL players who sustained an in-season shoulder instability
event while playing in the NFL. NFL RTP, incidence of surgery, time to RTP, recurrent instability events,
seasons/games played after the injury, and demographic data were collected. Overall RTP was deter-
mined, and players who did and did not undergo operative repair were compared.
Results: Ninety-two percent of NFL players returned to NFL regular season play at a median of 0.0 weeks
in those sustaining a shoulder subluxation and 3.0 weeks in those sustaining a dislocation who did not
undergo surgical repair (P = .029). Players who underwent operative repair returned to play at a median
of 39.3 weeks. Forty-seven percent of players had a recurrent instability event. For players who were able
to RTP, those who underwent surgical repair (31%) had a lower recurrence rate (26% vs. 55%, P = .021)
and longer interval between a recurrent instability event after RTP (14.7 vs. 2.5 weeks, P = .050).
Conclusion: There is a high rate of RTP after shoulder instability events in NFL players. Players who
sustain shoulder subluxations RTP faster but are more likely to experience recurrent instability than those
with shoulder dislocations. Surgical stabilization of the shoulder after an instability event decreases the
chances of a second instability event and affords a player a greater interval between the initial injury and
a recurrent event.
Level of evidence: Level III; Retrospective Cohort Design; Treatment Study
© 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Shoulder dislocation; shoulder subluxation; NFL; return to play; professional athletes; shoulder
injury
Glenohumeral joint instability is a common orthopedic con- may present as a spectrum of disorders that range from minor
dition for young athletes participating in contact sports, subluxations to frank dislocations. For the competitive athlete,
affecting thousands of collegiate athletes each year.16 The treatment options have significant implications for player per-
unique anatomy of the shoulder provides inherent laxity that formance and longevity.
Current treatments for shoulder instability include
nonoperative therapies emphasizing a combination of im-
Institutional Review Board approval was not required for this retrospective mobilization and physical therapy18 or operative procedures
cohort study that used publicly available Internet-based reports.
*Reprint requests: Kelechi R. Okoroha, MD, Department of Orthopaedic
aimed at restoring the compromised stabilizing elements by
Surgery, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202, USA. direct repair or reconstruction.19 Proposed benefits to surgi-
E-mail address: [email protected] (K.R. Okoroha). cal repair over conservative management include reduced rates
1058-2746/$ - see front matter © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
http://dx.doi.org/10.1016/j.jse.2017.07.027
ARTICLE IN PRESS
2 K.R. Okoroha et al.
of recurrent instability1,8,11,17 and possible prevention of further to identify those who underwent surgical treatment during the season
joint damage. or in the off-season. The percentage of the season lost was calcu-
Previous studies have demonstrated variability with respect lated by dividing the number of regular season games lost because
to return to play (RTP) and athletic performance with each of injury by 16 (number of regular season games in a standard NFL
season).
treatment type. For example, Dickens et al5 demonstrated that
A control group was then identified to compare our cohort with
73% of collegiate athletes could successfully RTP after
a representative group of NFL players with similar attributes who
nonoperative management of a shoulder dislocation without had not sustained a shoulder instability event. The control group was
any limitations. In contrast, Arciero et al1 prospectively com- assembled via a blinded age-, size-, and position-matched cohort
pared a nonoperative treatment regimen to operative repair of NFL players that had previously not sustained a shoulder insta-
in young military cadets and found significantly fewer re- bility injury. Players were also excluded if there was a report of
currences in the operative group. “undisclosed shoulder injury.” Our methods for selecting a control
Although shoulder instability has been examined in ath- cohort were similar to those reported in previous literature.6,7,10,13-15
letes of varying skill sets in prior studies,3,5,12,18 limited data We then compiled a deidentified database of all remaining players
are available regarding shoulder instability in elite Ameri- who participated in the NFL between 2006 and 2014. Players were
can football athletes such as those in the National Football matched to the respective athletes by the year of the instability event
for the respective player in the original cohort, designated as the
League (NFL).3,9 The purpose of this study was to deter-
index year. The controls were then selected based on age during the
mine the RTP rate of NFL athletes who experience a shoulder
index year, qualified as ±1 year, listed position, NFL experience,
instability event according to the type of instability and mode height, and weight. Beyond demographic data, for each control player
of treatment. A secondary aim was to identify factors at the we evaluated career length, draft round, and number of Pro Bowl
time of the initial injury that predict a player’s career lon- selections before and after injury in the index year.
gevity, ability to RTP, or incidence of recurrent instability. Primary outcome measures included type of instability injury
We hypothesized that NFL players sustaining a shoulder de- (subluxation/dislocation), initial treatment (surgery/no surgery), RTP,
stabilizing injury could RTP successfully at a high rate time to RTP (in weeks), presence of recurrent instability, time to
regardless of treatment type and that those undergoing recurrent instability from RTP date (in weeks), and treatment for
nonoperative treatment would be at greater risk for develop- recurrent instability, if applicable.
ing recurrent shoulder instability after successful RTP. The χ2 test or Fisher exact test were used for categoric vari-
ables and independent t test or Wilcoxon rank sum test for continuous
data. The Kruskal-Wallis test was used to test for differences between
Materials and methods categoric variables with greater than 2 groups and a continuous vari-
able. Pearson correlations were used to test for differences between
We conducted a retrospective cohort study evaluating NFL players 2 continuous variables. A paired t test was used to test for differ-
with a history of a shoulder instability event while playing profes- ences before and after injury among NFL players at different time
sionally between 2006 and 2014. These players were identified by points. All analyses were done using SAS 9.4 software (SAS In-
methods similar to those in previous studies that used publically avail- stitute Inc., Cary, NC, USA). Statistical significance was set at P < .05.
able Internet-based reports.6,7,10,13-15 Sources for injury reports included
team injury reports, team Web sites, press releases, personal Web
sites, and professional and college football statistical Web sites. In- Results
juries were verified using www.NFL.com. A player was included
in the instability cohort if he was drafted to the NFL and partici- We identified 83 NFL players who experienced a shoulder
pated in at least 1 NFL game before sustaining a shoulder instability
instability event from 2006 to 2014, with a dislocation injury
event.
occurring in 72 and subluxation in 11. Demographic char-
For the purposes of this study, subluxation was defined as a tran-
sient instability requiring no true reduction maneuver or positive acteristics of the study cohorts and control players are listed
radiographic/magnetic resonance imaging. A dislocation was defined in Table I. Players were more likely to undergo surgical repair
as complete loss of glenohumeral joint congruency and requiring if they injured their right arm (P = .027) or were injured in
a manual reduction maneuver or documented imaging of the dis- the later part of the season (P = .013). Twenty-six players
location. The direction of the instability could not be identified from (31%) were treated operatively after their index instability
the reports reviewed. episode, and the remaining 57 players (69%) were treated
Demographic data for each player were recorded, including age, nonoperatively. Seventy-seven NFL players (92.8%) success-
NFL experience, height, weight, and position. RTP data, including fully RTP after an in-season shoulder instability event occurred,
date of injury, overall RTP rate, and RTP on the same team were regardless of the initial treatment method. Of the players who
recorded. Also recorded were the number of regular season games,
RTP, 46% (36 of 77) later experienced a recurrent shoulder
playoff games, and seasons played before and after injury, as well
as career length, draft round, and number of Pro Bowl selections
instability event; however, 94% were once again able to RTP.
before and after injury. Return to same team was based on the team Time required to RTP is listed in Table II. Players treated
for which the athlete appeared in his first regular season game after nonoperatively who sustained a shoulder subluxation RTP
injury. Athletes with a report of “undisclosed shoulder injury” or faster than those sustaining a shoulder dislocation (median,
who were on the injured list at the time of data gathering were ex- 0.0 vs. 3.0 weeks; P = .029). Irrespective of a player’s in-
cluded. A thorough search was conducted of all included players stability type, RTP was significantly quicker for players who
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RTP after shoulder instability in NFL 3
Table I Demographic data Table III Playing time of athletes who return to play com-
Variable* Surgery No surgery P value † pared with matched controls
Age, y 25.6 ± 2.3 26.1 ± 3.3 .482 Variable* RTP group Controls P value
Body mass index, kg/m2 29.7 ± 4.2 28.8 ± 3.0 .900 Games
Position Preinjury 44.7 ± 31.4 46.6 ± 30.4 .642
Quarterback 5 (19.2) 5 (8.8) Post-RTP 40.9 ± 35.5 42.2 ± 32.4 .402
Wide receiver 4 (15.3) 5 (8.8) Seasons
Guard 1 (3.8) 2 (3.5) Preinjury 3.3 ± 2.2 3.5 ± 2.1 .368
Safety 4 (15.3) 13 (22.8) Post-RTP 3.4 ± 2.3 3.3 ± 2.2 .891
Linebacker 4 (15.3) 7 (12.3) Games played per season
Offensive tackle 2 (7.7) 0 Preinjury 12.2 ± 3.6 12.4 ± 3.7 .543
Cornerback 4 (15.3) 12 (21.1) Post-RTP 10.9 ± 3.8 11.6 ± 4.4 .182
Tight end 0 3 (5.3) Career 7.4 ± 3.5 7.5 ± 2.8 .506
Running back 1 (3.8) 8 (14.0) Pro Bowl
Defensive end 0 2 (3.5) Preinjury 0.7 ± 1.8 0.3 ± 1.0 .100
Defensive tackle 1 (3.8) 0 Post-RTP 0.5 ± 1.6 0.4 ± 0.9 .842
Date of injury‡ .013 RTP, return to play.
Spring/preseason/week 4 10 (38.5) 28 (49.1) * Data are provided as the mean ± standard deviation.
Week 5 to end of season 16 (61.5) 29 (50.9)
Laterality .027
Left 11 (44) 31 (59.6)
Right 14 (56) 21 (40.4)
Draft round (mean) .318 instability events between players sustaining a dislocation vs.
≤Third round 18 (69.2) 35 (62.5) subluxation. However, players in both groups who under-
>Third round 8 (30.8) 21 (37.5) went surgical treatment were less likely to have a recurrent
* Data are presented as the mean ± standard deviation or number (%). instability event (26.1%) than those treated nonoperatively
†
Bold values are statistically significant. (54.6%; P = .022). Of the players with recurrent instability
‡
Date of injury: Spring/preseason/week 4 vs. week 5 to end of season. episodes, those with shoulder subluxations experienced a re-
current instability event sooner than patients with shoulder
dislocations (median, 1.5 vs. 5.0 weeks; P = .044). Patients
Table II Return to play who were treated operatively enjoyed a significantly longer
recurrence-free interval than the nonoperative group (median,
Variable Players Return to play P value*
(No.) (median weeks)
14.7 vs. 2.5 weeks; P = .050).
Patients who were able to RTP exhibited a significant de-
Date of injury† .004 crease in the average number of games played per season.
Spring/preseason/week 4 27 3.1
RTP players played an average of 1.5 fewer games per season
Week 5 to end of season 28 0.5
Side .625
than in their preinjury state (P = .014). However, when com-
Left 29 2.0 paring our injured cohort to matched NFL controls, we found
Right 21 3.0 no differences in games, seasons, or Pro Bowl selections after
Injury type .029 RTP (Table III).
(nonoperative treatment)
Dislocation 47 3.0
Subluxation 10 0.0 Discussion
Treatment type <.001
Operative 26 39.3 Although glenohumeral instability commonly occurs in the
Nonoperative 57 2.3 NFL, there is no single consensus regarding RTP criteria or
* Bold values are statistically significant (P < .05). initial treatment modalities. The factors effecting RTP and treat-
†
Date of injury: Spring/preseason/week 4 vs. week 5–end of season. ment implications have not been clearly defined. Our study
found that 92.8% of players who experience a shoulder in-
stability event in the NFL will RTP. For players treated
were injured in the late season than for those who were injured nonoperatively, those having subluxations and who were
in the early season (median, 0.5 vs. 3.1 weeks; P = .004). Op- injured in the later part of the season were likely to RTP faster
erative management required significantly longer recovery time than those who were not. Players treated surgically were less
than nonoperative treatment (median, 39.3 vs. 2.3 weeks; likely to sustain a recurrent instability event and played for
P < .001). a longer period before reinjury, if reinjury occurred. Players
Factors effecting recurrent instability are presented in Figs. 1 who RTP showed no difference compared with matched con-
and 2. There was no difference in the incidence of recurrent trols for overall career longevity; however, they did display
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4 K.R. Okoroha et al.
Figure 1 Incidence of recurrent instability. Percentage of athletes who sustained recurrent instability events compared by injury type and
by treatment type. National Football League players treated nonoperatively experienced a higher incidence of recurrent instability than the
surgical cohort. There was no difference in recurrent instability events between the dislocation and subluxation cohorts. Bold values are
statistically significant.
16
14 P = .050
12
Time (Weeks)
10
8 P = .044
6 V.S.
4
V.S.
2
0
Operative Non- Subluxation Dislocation
Operative
Time (Weeks) 14.7 2.5 1.5 5.0
Figure 2 Time to recurrent instability event. Time after return to play from a primary instability event to recurrent instability event com-
pared by treatment type and injury type. Data are reported by median weeks. National Football League players treated operatively had a
significantly longer time to recurrent instability. Players with dislocation also had a significantly longer time to recurrent instability com-
pared to subluxation. Bold values are statistically significant.
a significant decrease in the number of games played per collegiate athletes, and limited information is available on NFL-
season when returning to competition. level athletes. Our cohort of NFL athletes demonstrated a 93%
Several studies have evaluated RTP after shoulder instability RTP after a shoulder instability event, irrespective of treatment
at the high school or collegiate level. Dickens et al5 demonstrated type. These results are similar to those reported for the non-
that 73% of athletes within the United States Military Acad- professional athlete and suggest that shoulder instability events
emies RTP with nonoperative management after an in-season do not preclude athletes from continuing their playing career,
shoulder instability event. Buss et al4 revealed an in-season RTP regardless of skill level. The higher RTP rate in NFL players
success rate of 90% in 30 high school and collegiate athletes. suggests a combination of factors, including player motiva-
However, these studies were limited to high school and tion, access to medical resources, and rehabilitation services.
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RTP after shoulder instability in NFL 5
Although nonoperative management leads to successful The effect of season timing of injury on RTP has not been
recoveries in some injuries, surgical management has been previously evaluated. We found that individuals who sus-
shown to decrease recurrence rates in the literature. LeClere tained a shoulder destabilizing injury early within the season
et al12 evaluated the medical records of a single NFL team were slower to RTP than if the injury occurred later in the
and found that nonoperative treatment of shoulder instabil- season. The basis for this phenomenon is unclear; however,
ity led to significantly higher rates of repeat dislocation (41.7% one could speculate that the rate of RTP after an instability
vs. 10.5%; P = .04) and earlier time to recurrence (4.4 vs. 26 injury might be influenced by team needs at a particular time.
months). Zaremski et al19 found in a large meta-analysis of That is, a player is more likely to be held out from playing
young and adolescent athletes that nonoperative treatment had activities early in the season to allow a more complete re-
a greater than 10-fold chance of developing recurrent shoul- covery vs. quicker return in order to be available for the last
der instability (odds ratio, 13.41) than if an operative and critical games of the season (games to qualify for play-
stabilization was first performed. offs or playoffs themselves). Regardless, additional studies
Our study found that 46% of our RTP cohort experi- are needed to clarify how injury management is influenced
enced a secondary instability. However, upon stratifying for by season timing.
treatment type, patients who underwent surgical repair had Several limitations should be noted regarding this study.
a significantly reduced rate of recurrent shoulder instability First, the data cohort used for the analysis were collected and
than those who did not undergo surgical repair. Players who pooled from an independent third-party source (NFL website),
had surgical repair also played for a longer period before sus- which lends itself to possible inaccuracies. This also allows
taining a recurrent instability event, if one occurred. These for variations within the reported data resulting from indi-
results demonstrate the protective benefit of undergoing sur- vidual orthopedic providers’ management of each injury.
gical repair on recurrence rates and time to reinjury for the Another weakness of this study is the limited application
professional athlete. it provides when translating the results to the general popu-
For nonoperative patients, subluxation had a minimal effect, lation. Although this was implicit to the study objective, the
with players missing no playing time, whereas shoulder dis- overall consistency of our data with previous studies on
location required a median of 3 weeks of recovery before RTP. amateur athletes demonstrates that the general principles from
Although players with shoulder subluxations are able to come our study data remain largely applicable. In addition, our cohort
back faster, there appears to be unintended drawbacks to their most likely does not include every player that experienced a
earlier return; that is, players with subluxations who RTP shoulder instability episode during the study interval, which
quicker appear to experience recurrent instability sooner. Likely could lead to a selection bias. Also, prior medical history of
an inadvertent consequence of an expedited RTP, the exact shoulder instability is not always reported.
cause of this difference is unknown. One possible mecha- Finally, the direction of instability and the type of surgi-
nism could involve inadequate periods of immobilization and cal repair were not collected. Direction of instability and the
periscapular physical therapy, which might limit the degree surgical procedure performed can influence the time to RTP
of total healing. These data show that balancing the short- and likelihood of a recurrent episode.
term and long-term repercussions of shoulder instability are
vital to appropriate counseling of patients after the develop-
ment of an unstable shoulder. Conclusion
Although the rate of successful RTP may be similar
between operative and nonoperative approaches, duration There is a high rate of RTP after shoulder instability events
until the RTP date is markedly different, an expected outcome in NFL players. Players sustaining subluxations RTP faster
given the requisite time needed for adequate recovery and but are more likely to have recurrent instability events than
postoperative rehabilitation after surgical stabilization. those who have dislocations. Surgical stabilization of the
What is more intriguing about our results were the subtle shoulder after an instability event decreases the chances
effects a history of shoulder instability had on NFL career of a second instability event and affords a player a greater
trends. In particular, injured players experienced a signifi- interval between a recurrent event. Players sustaining a
cant decrease in the average numbers of games played per shoulder instability event may play in fewer games per
season when their preinjury and postinjury states were season compared with before injury.
compared. However there were no differences in athlete
career longevity compared with the control population.
This is contrasted by prior data collected from a single NFL
team that demonstrated a significantly shorter career span
Disclaimer
for players with histories of shoulder instability3 or those
The authors, their immediate families, and any research
requiring shoulder stabilization surgery.2 Additional epide-
foundations with which they are affiliated have not re-
miologic studies on expected career length are needed and
ceived any financial payments or other benefits from any
could further help clarify the unknown economic effect of
commercial entity related to the subject of this article.
the injury.
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6 K.R. Okoroha et al.
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