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Journal of Athletic Training 2015;50(7):767–777
doi: 10.4085/1062-6050-50.3.06
Óby the National Athletic Trainers’ Association, Inc
www.natajournals.org systematic review
Return to Preinjury Levels of Participation After
Superior Labral Repair in Overhead Athletes: A
Systematic Review
Aaron Sciascia, MS, ATC, PES*; Natalie Myers, MS, ATC†; W. Ben Kibler, MD,
FACSM*; Timothy L. Uhl, PhD, PT, ATC, FNATA†
*Shoulder Center of Kentucky, Lexington; †Division of Athletic Training, University of Kentucky, Lexington
Context: Athletes often preoperatively weigh the risks and
benefits of electing to undergo an orthopaedic procedure to
repair damaged tissue. A common concern for athletes is being
able to return to their maximum levels of competition after
shoulder surgery, whereas clinicians struggle with the ability to
provide a consistent prognosis of successful return to participa-
tion after surgery. The variation in study details and rates of
return in the existing literature have not supplied clinicians with
enough evidence to give overhead athletes adequate informa-
tion regarding successful return to participation when deciding to
undergo shoulder surgery.
Objective: To investigate the odds of overhead athletes
returning to preinjury levels of participation after arthroscopic
superior labral repair.
Data Sources: The CINAHL, MEDLINE, and SPORTDis-
cus databases from 1972 to 2013.
Study Selection: The criteria for article selection were (1)
The study was written in English. (2) The study reported surgical
repair of an isolated superior labral injury or a superior labral
injury with soft tissue debridement. (3) The study involved
overhead athletes equal to or less than 40 years of age. (4) The
study assessed return to the preinjury level of participation.
Data Extraction: We critically reviewed articles for quality
and bias and calculated and compared odds ratios for return to
full participation for dichotomous populations or surgical
procedures.
Data Synthesis: Of 215 identified articles, 11 were retained:
5 articles about isolated superior labral repair and 6 articles
about labral repair with soft tissue debridement. The quality
range was 11 to 17 (42% to 70%) of a possible 24 points. Odds
ratios could be generated for 8 of 11 studies. Nonbaseball,
nonoverhead, and nonthrowing athletes had a 2.3 to 5.8 times
greater chance of full return to participation than overhead/
throwing athletes after isolated superior labral repair. Similarly,
nonoverhead athletes had 1.5 to 3.5 times greater odds for full
return than overhead athletes after labral repair with soft tissue
debridement. In 1 study, researchers compared surgical
procedures and found that overhead athletes who underwent
isolated superior labral repair were 28 times more likely to return
to full participation than those who underwent concurrent labral
repair and soft tissue debridement (P,.05).
Conclusions: The rate of return to participation after
shoulder surgery within the literature is inconsistent. Odds of
returning to preinjury levels of participation after arthroscopic
superior labral repair with or without soft tissue debridement are
consistently lower in overhead/throwing athletes than in non-
overhead/nonthrowing athletes. The variable rates of return
within each group could be due to multiple confounding
variables not consistently accounted for in the articles.
Key Words: return to play, odds of return, shoulder injuries
Key Points
Odds ratios of full return to participation were greater for nonoverhead athletes after superior labral repair.
Evidence supporting return to participation after superior labral repair was low to moderate.
Shoulder injury, which can affect either the static or
dynamic anatomical structures, can result in poor
upper extremity function and suboptimal athletic
performance. In the overhead athlete, anatomic tissue
derangement frequently manifests as superior labral injury,
which may occur alone or with concurrent rotator cuff
injury (internal impingement).
1
In either condition, symp-
toms can present as pain on external rotation and cocking,
weakness in clinical or functional upper extremity strength,
symptoms of internal derangement (clicking, catching,
sliding), and functional problems with velocity or control
during overhead tasks.
2
In many patients, the symptoms of
tissue derangement can be addressed nonoperatively with
rehabilitation; however, if nonoperative efforts do not
resolve symptoms or restore performance, operative
management may be warranted to restore the compromised
anatomy.
Patients often preoperatively weigh the risks and benefits
of electing to undergo an orthopaedic procedure to repair
damaged tissue. A common concern for patients is being
able to return to their maximum levels of competition after
shoulder surgery, whereas clinicians are concerned with
providing a consistent prognosis of successful return to
participation after surgery. In a systematic review, Gorantla
et al
3
examined postoperative subjective outcomes after the
repair of type II superior labral lesions. The researchers
identified multiple differences among the reviewed studies,
including variations in patient populations (eg, athletes,
Journal of Athletic Training 767
workers, general population), diagnosis, surgical technique,
and size of the patient populations. Of the studies with
populations comprising overhead athletes (5 of 11), return-
to-participation rates varied from 22% to 92%.
3
The
variations in study details and rates of return have not
supplied clinicians with enough evidence to provide
overhead athletes with adequate information about suc-
cessful return to participation when considering shoulder
surgery. Therefore, the purpose of our systemic review was
to investigate the odds of return to preinjury levels of
participation of overhead athletes after arthroscopic supe-
rior labral repair. Two primary objectives were addressed in
this systematic review using the patient, intervention, and
outcome format: (1) In patients undergoing isolated
superior labral repair (intervention), were the odds of
returning to preinjury level of participation (outcome) equal
between overhead and nonoverhead athletes (patient)? (2)
In patients undergoing labral repair with soft tissue
debridement (intervention), were the odds of returning to
preinjury level of participation (outcome) equal between
overhead and nonoverhead athletes (patient)?
METHODS
Data Acquisition
Search Strategy. We accessed the CINAHL, MEDLINE,
and SPORTDiscus online databases to search the terms
listed in Table 1. Terms were searched individually and
then combined into distinct Boolean phrases. The search
limits were human studies, English-language articles only,
and years 1972 to 2013. In some cases, review of a
retrieved article revealed potential citations not originally
identified in the electronic search. A total of 215 articles
were retrieved from the systematic search (Figure).
Study Selection and Retention. Articles were retained
based on the following inclusion criteria: articles reporting
surgical repair of an isolated superior labral injury or a
labral injury with soft tissue debridement, patient
population comprising overhead athletes with a mean age
equal to or less than 40 years, and record of assessment of
return to preinjury level of participation. We excluded
articles if the type of labral lesion repaired was not
identified (this was done to avoid including studies in which
only debridement of the labrum occurred) or if the surgical
technique or procedure was not described in detail.
Additionally, articles were excluded if concurrent repair
of the superior labrum and rotator cuff was performed. We
excluded literature (nonsystematic) reviews and current
concepts or opinion papers because the level of evidence
was less than level 4 case series (Figure).
4
Data Extraction and Analysis
For this systematic review, we collected and recorded
from each article the percentage of athletes who returned to
Table 1. Systematic Review Search Terms Using Patient or Problem, Intervention, Comparison, Outcome Method
Patient or Problem Intervention Comparison Outcome
Final Patient or Problem, Intervention, Comparison,
Outcome Combination
Athlete
a
NA Athlete
a
and overhead or throwing
AND AND
Overhead
OR
Throwing
Rotator cuff
a
Rotator cuff
a
or SLAP or superior labrum anterior posterior or
superior labrum and shoulder
OR AND
SLAP
OR
Superior labrum
anterior posterior
OR
Superior labrum
AND
Shoulder
Return to Return to and play or competition or activity or sport or preinjury
levels or preinjury levels
AND
Play
OR
Competition
OR
Activity
OR
Sport
OR
Pre-injury Levels
OR
Preinjury Levels
1188 5563 2 220 316 215
Abbreviations: NA, not applicable; SLAP, superior labrum, anterior to posterior.
a
Denotes selection of all variations of the term.
768 Volume 50 Number 7 July 2015
full participation so that we could calculate the primary
measure of interest, odds of return to full participation, for
this systematic review. For studies that provided data
regarding return to participation for dichotomous popula-
tions or surgical procedures, we constructed 2 32
contingency tables in Excel (version 2007; Microsoft
Corporation, Redman, WA) to calculate the odds of return
to full activity for each comparative group. We calculated
the odds of full return to condense the reported rates of
return into a more definable chance of success or failure
after surgery. When return to participation was reported
only as a percentage (without the raw data), we multiplied
the percentage of participants who returned by the total
number of participants in each subgroup to complete the 2
Figure. Flow chart for selecting articles to be included in the systematic review.
Table 2. Assessment of Risk Criteria for Case Series Reports
Type of Bias Criterion
Attrition Attrition includes loss to follow up, exclusion of participants, and dropouts. Were missing data handled appropriately, such as
using intent-to-treat analysis?
Detection Were the assessors of the outcome blinded to the intervention?
Were interventions assessed or defined using valid and reliable measures and implemented across all study participants?
Were outcomes assessed or defined using valid and reliable measures and implemented across all study participants?
Were confounding variables assessed using valid and reliable measures and implemented across all study participants?
Performance Did researchers rule out any impact from a concurrent intervention that might bias the results?
Did the study maintain fidelity to the intervention protocol?
Recall Was information collected prospectively and compared to a similar follow-up measure?
Reporting Were the potential outcomes prespecified by the researchers and were all prespecified outcomes reported?
Selection Does the design or analysis control account for important confounding and modifying variables through matching, stratification,
multivariable analysis, or other approaches?
Adapted from Viswanathan M, Ansari MT, Berkman ND, et al. Assessing the risk of bias of individual studies in systematic reviews of health
care interventions. Agency for Healthcare Research and Quality Web site. http://www.effectivehealthcare.ahrq.gov/search-for-guides-
reviews-and-reports/?pageaction¼displayproduct&productid¼998. 2012.
Journal of Athletic Training 769
Table 3. Study Descriptive Details and Original Reported Return-to-Participation Rates After Isolated Superior Labrum Anterior-Posterior Repair or Superior Labrum Anterior-Posterior
Repair With Concurrent Procedures, Continued on Next Page
Authors (Year)
Participant
Demographics Sports Included Surgical Procedure Follow-Up Time Return to Participation
a
Return to Participation
Determined
b
Kim et al
5
(2002) N ¼34; 30 males, 4
females; mean age ¼
26 y; 18 overhead
athletes, 12 contact
athletes, 4 no sport
Baseball, tennis, and
volleyball
Isolated SLAP repair 33 mo (range,
24–49 mo)
Overhead sports: 22% full
return and 78% return with
some limitation
Postoperative assessment of
preinjury and postinjury
function via visual analog
scale with a 5-level graded
scale of limitation (return
with no limitation to return
with severe limitation)
Nonoverhead sports: 63% full
return and 38% return with
some limitation
Cohen et al
12
(2006) N ¼39; 37 males, 2
females; mean age ¼
34 y; 8 throwing
athletes (all baseball),
21 nonthrowing
athletes
Baseball, football,
hockey, lacrosse,
skiing, soccer, and
volleyball
Isolated SLAP repair 44 mo (range,
25–97 mo)
Throwers: 37% full return and
63% return with limitation
Postoperative assessment of
preinjury and postinjury
function via oral questionAll athletes: 48% full return,
45% return with limitation,
and 7% no return
Yung et al
13
(2008) N ¼16; 13 males, 3
females; mean age ¼
24 y; 13 overhead
athletes
Badminton, handball,
tennis, and weight
lifting
Isolated SLAP repair 27.6 mo (range,
24–31 mo)
Overhead athletes: 92% full
return
Postoperative assessment of
preinjury and postinjury
function via oral questionNonoverhead athletes: 100%
full return
Maier et al
14
(2013) N ¼24; 20 males, 4
females; mean age ¼
36 y; 18 overhead
athletes
Badminton, basketball,
boxing, climbing,
soccer, swimming,
tennis, volleyball,
and weight lifting
Isolated SLAP repair with
suture anchor or
transglenoid suture
24 mo (range,
24–96 mo)
All athletes: 58% full return Postoperative assessment of
preinjury and postinjury
function via oral question,
Constant Score, and
subjective shoulder value
Overhead athletes: 67% full
return
Nonoverhead athletes: 50%
full return
Park et al
15
(2013) N ¼24; 18 males, 6
females; mean age ¼
23 y; 24 overhead
athletes
Badminton, baseball,
javelin, and volleyball
Isolated SLAP repair 45.8 mo (range,
24–68 mo)
All athletes: 50% full return Postoperative assessment of
preinjury and postinjury
function via oral question
Baseball: 38% full return
Other athletes: 75% full return
Morgan et al
16
(1998) N ¼53; mean age ¼24
y (range, 15–36 y); 53
overhead athletes
Baseball, tennis, and
volleyball
SLAP repair with rotator
cuff repair
12 mo Pitchers: 84% full return and
16% return with limitation
Postoperative assessment of
preinjury and postinjury
function via oral question
Ide et al
17
(2005) N ¼40; 33 males, 7
females; mean age ¼
24 y
Baseball, basketball,
goalkeeping,
handball, racquetball,
softball, swimming,
and volleyball
SLAP repair with rotator
cuff debridement
41 mo (range,
24–58 mo)
Baseball: 63% full return and
37% return with limitation
Postoperative assessment of
preinjury and postinjury
function via oral question
with a 4-level graded scale
of limitation (return with no
limitation to no return due
to severe limitation)
Other sports: 86% full return
and 14% return with
limitation
Brockmeier et al
18
(2009) N ¼47; 39 males, 8
females; mean age ¼
36 y (range, 14–49 y);
34 athletes
Baseball, softball,
squash, swimming,
tennis, and volleyball
SLAP repair with
acromioplasty,
bursectomy, distal
clavicle excision, or
rotator cuff debridement
Minimum 2 y Overhead sports: 71% full
return
Postoperative assessment of
preinjury and postinjury
function via oral questionOther sports: 74% full return
Friel et al
19
(2010) N ¼48; 39 males, 9
females; mean age ¼
33 y (range, 16–59 y);
22 overhead athletes
Baseball, tennis, and
volleyball
SLAP repair with Bankart,
subacromial decompres-
sion, distal clavicle
excision, or debridement
39 mo (range,
24–68 mo)
All overhead athletes: 59%
full return
Postoperative assessment of
preinjury and postinjury
function via questionnaire
770 Volume 50 Number 7 July 2015
32 table. Odds for a distinct group were computed by
dividing 1 return-to-participation variable by another.
For example, in 1 study, 4 overhead athletes returned to
full participation, and 14 overhead athletes returned to
limited activity; however, 10 nonoverhead athletes returned
to full participation, with only 6 returning in a limited
capacity.
5
To calculate the odds for each group of athletes,
we simply divided the occurrences for each group
(overhead athletes: 4 with full return divided by 14 with
limited return ¼0.3; nonoverhead athletes: 10 with full
return divided by 6 with limited return ¼1.7). When the
calculated odds were 1.0 or less, the resultant interpretation
was that the chance of not returning to full activity after
surgery was greater. Conversely, when the odds were
greater than 1.0, the interpretation was that the chance of
returning to full activity after surgery was greater.
6
The odds were needed to calculate the final odds ratios
(ORs) that would compare the odds of the event of interest
(returning to full activity) between the specified groups (eg,
overhead versus nonoverhead athletes, throwing versus
nonthrowing athletes) for each study. Therefore, using the
example given, the OR calculation of 1.7/0.3 ¼5.8 would
be interpreted as nonoverhead athletes being 5.8 times more
likely to return to full activity after surgery than overhead
athletes. An OR greater than 1.0 would indicate a possible
statistical relationship or association between the vari-
ables.
6
To confirm if a statistical association existed, 95%
confidence intervals (CIs) were constructed. If the 95% CI
contained the value 1.0, then no statistical association was
present at an alevel of .05.
Assessment of Quality and Bias for Retained Articles
We used the intervention study appraisal score sheet
described by MacDermid
7
to assess the quality of each
article retained for the systematic review. This instrument
was selected because it aligned well with case series reports
that characterized most of the retained articles’ designs.
The assessment sheet comprised 24 questions divided
among 7 subheadings (study question, study design,
subjects, intervention, outcomes, analysis, and recommen-
dations); each question could receive a score ranging from
0 to 2 for a maximum score of 48 points. This scoring sheet
was modified to a binary (yes ¼1orno ¼0) scoring system,
yielding a possible 24 points to better illustrate common-
alities among retained studies. Two of the authors (A. S.,
N. M.) individually reviewed and appraised each retained
article. Upon completion of all appraisals, the 2 authors met
to compare their results. When the authors agreed on an
individual article’s score, they accepted it. When the
authors disagreed on a score, they revisited the article and
discussed the discrepancy in score until agreement was
reached. If agreement could not be reached, a third author
(T.L.U.) was consulted to serve as the final authority. After
the critical appraisal, the appropriate strength of recom-
mendation was selected using the Strength of Recommen-
dation Taxonomy, which consists of ratings of A, B, or C
(high to low).
8
We determined the risk of bias per the recommendations
from the PRISMA guidelines.
9,10
The retained articles were
assessed for different types of bias, including selection,
performance, attrition, detection, reporting, and recall.
11
Each type of bias was determined by the primary author per
Table 3. Continued From Previous Page
Authors (Year)
Participant
Demographics Sports Included Surgical Procedure Follow-Up Time Return to Participation
a
Return to Participation
Determined
b
Park and Glousman
20
(2011) N ¼12; 10 males, 2
females; mean age ¼
32.6 y (range, 19–67
y)
Baseball, softball, and
volleyball
SLAP, subacromial
decompression, or
debridement
50.5 mo (range,
8–81 mo)
Overhead athletes: 41.3% full
return
Postoperative assessment of
preinjury and postinjury
function via oral questionNo baseball player returned to
preinjury level
Neri et al
21
(2011) N ¼23; mean age ¼25
y (range, 18–45 y)
Baseball, tennis,
volleyball, and water
polo
SLAP repair with rotator
cuff debridement
38 mo (range,
12–70 mo)
All athletes: 57% full return,
26% return with limitation,
and 17% no return
Postoperative assessment of
preinjury and postinjury
function via oral question
Abbreviation: SLAP, superior labrum, anterior to posterior.
a
The return-to-participation rates after superior labrum anterior-posterior repair or superior labrum anterior-posterior repair with concurrent procedure are provided as percentages.
b
Summary of return to participation was determined from each article.
Journal of Athletic Training 771
the definitions provided by the Agency for Healthcare
Research and Quality (Table 2).
RESULTS
The findings from each study are summarized in Table 3.
Five articles that met all inclusion criteria were retained
because they provided information about return to preinjury
level of participation after isolated superior labral re-
pair.
5,12–15
Another 6 articles were retained because they
met all inclusion criteria and focused on superior labral
repair with concurrent shoulder procedures (ie, labral repair
with debridement of the rotator cuff or other surrounding
tissue).
16–21
Surgical details for the labral-repair procedures
are reported in Table 4.
Return to Preinjury Levels of Participation
Isolated Superior Labral Repair. The proportion of
athletes who returned to their preinjury levels of
participation after isolated superior labral repair was
reported to range from 22% to 92% for the 5 studies
reviewed.
5,12–15
In 2 studies,
5,12
the authors subdivided
return to participation into 2 levels (full return, limited
return) based on perceived functional limitation; full return
for overhead or throwing athletes ranged from 22% to 37%,
but 63% to 78% of athletes returned with limitation. These
authors also reported that a higher percentage (48% to 63%)
of nonoverhead or nonthrowing athletes returned in full,
whereas only 38% to 45% returned with limitation.
5,12
In 3
other studies,
13–15
investigators divided return to
participation into full return and no return. When
comparing baseball players with other overhead athletes,
return to full participation was 38% for the former and 75%
for the latter.
15
When comparing the return to full activity
for 2 repair techniques,
14
we observed that suture anchor
repairs were superior to transglenoid suture repairs;
however, little difference existed in the rate of return to
full activity for overhead athletes between the techniques
(56% for suture anchor and 67% for transglenoid suture
repair). When comparing specific sports, Yung et al
13
demonstrated a 92% return to participation for tennis,
handball, and badminton athletes.
Using the originally reported return-to-participation rates,
we generated ORs for full return for 4 of 5 studies (Table
5).
5,12,14,15
Authors of 3 studies found that nonbaseball
players (OR ¼5.0; 95% CI ¼0.8, 33.2),
15
nonthrowers (OR
¼2.3; 95% CI ¼0.4, 12.5),
12
and nonoverhead athletes (OR
¼5.8; 95% CI ¼1.3, 26.2; P,.05)
5
had at least a 2 times
greater chance of returning to full activity after isolated
superior labral repair. Yung et al
13
noted return-to-
participation rates of 92% for 12 of 13 overhead athletes
and 100% for 3 of 3 patients classified as nonoverhead
athletes (n ¼2) or nonathletes (n ¼1). We could not
calculate the odds because the denominator was zero,
nullifying the calculation and limiting the comparison
between overhead and nonoverhead athletes.
Concurrent Shoulder Procedures. Researchers
16–21
examining various types of overhead athletes after
superior labral repair with concurrent procedures reported
Table 4. Surgical Technique Comparison
Study (Year)
Portal
Location
Described?
Hardware
Identified?
No. of
Anchors
Reported? Anchor Location Described?
Kim et al
5
(2002) Yes Yes 1 Base of biceps
Cohen et al
12
(2006) Yes Yes 1–4 Where indicated
Yung et al
13
(2008) Yes Yes 2–4 2:00 to 10:00
Maier et al
14
(2013) Yes Yes 1–2 Where indicated based on lesion type
Park et al
15
(2013) Yes Yes 1 12:00 for double-loaded suture anchor or 11:00 and 1:00 for single-
loaded suture anchor
Morgan et al
16
(1998) Yes Yes No Articular margin
Ide et al
17
(2005) Yes Yes 2 11:00 to 1:00
Brockmeier et al
18
(2009) Yes Yes 1 Articular margin not beyond 10:00
Friel et al
19
(2010) Yes Yes 1 Base of biceps to 11:00
Park and Glousman
20
(2011) Yes Yes No No
Neri et al
21
(2011) Yes Yes Mean ¼2.3 On either side of biceps
Table 5. Return-to-Participation Odds and Interpretations for Athletes With Isolated Superior Labral Repair
Study (Year) Comparison
Full
Return
Limited or
No Return Total Odds
a
Odds
Ratio
b
95% Confidence
Interval
Greater Chance
of Full Return?
Kim et al
5
(2002) Overhead 4 14 Limited return 18 0.3
Nonoverhead 10 6 Limited return 16 1.7 5.8
c
1.3, 26.2 Yes
Cohen et al
12
(2006) Thrower 3 5 Limited return 8 0.6
Nonthrower 11 8 Limited return 19 1.4 2.3 0.4, 12.5 Yes
Maier et al
14
(2013) Overhead (suture anchor) 5 4 No return 9 1.3
Overhead (transglenoid suture) 6 3 No return 9 2.0 1.6 0.2, 10.8 Yes
Park et al
15
(2013) Baseball 6 10 No return 16 0.2
Other overhead 6 2 No return 8 3.0 5.0 0.8, 33.2 Yes
a
Calculation of odds ¼full return divided by limited or no return.
b
Calculation of odds ratio ¼group with greater chance of success for full return divided by group with lesser chance for full return.
c
Indicates difference (P,.05).
772 Volume 50 Number 7 July 2015
return to preinjury levels of participation ranging from 41%
to 86%. Concurrent procedures consisted of debridement of
partial-thickness rotator cuff tear or the labrum,
subacromial decompression, bursectomy, or distal clavicle
excision. Follow-up time ranged from 12 to 120 months,
with the populations from all articles including baseball
players. Researchers who categorized return to participation
with limitation reported that 14% to 37% of athletes
returned with limitation,
16,17,21
whereas those who focused
on no return reported that 17% to 100% of athletes did not
return to sport after surgery.
18–21
Using the originally reported return-to-participation rates,
we generated ORs for 4 of the 6 studies that focused on
labral repair with concurrent soft tissue debridement (Table
6).
17–19,21
The subgroupings for each study varied: authors
comparing baseball and ‘‘other’’ sports,
17
overhead and
nonoverhead athletes,
18,19
and only overhead athletes who
underwent surgery for superior labral tears and superior
labral tears with concomitant rotator cuff injury.
21
Ide et
al
17
reported that both baseball and ‘‘other’’ athletes had
positive chances of returning to full participation (all odds
.1.0); however, the other group had a greater chance of
successful return to full activity (OR ¼3.5; 95% CI ¼0.8,
16.3) than did baseball athletes. The 2 investigations also
showed that overhead athletes (odds ¼1.3–2.5) and
nonoverhead/other athletes (odds ¼2.0–5.0) both had
positive odds for returning to full activity after superior
labral repair with soft tissue debridement, but again the ORs
favored the nonoverhead (OR ¼1.5; 95% CI ¼0.4, 6.0)
19
and other (OR ¼2.0; 95% CI ¼0.2, 19.9) groups.
18
These
observations were not different, as each 95% CI contained
the value 1.0. When comparing surgical procedures among
only overhead athletes, most of whom were baseball players
(20 of 23 patients), Neri et al
21
observed an association for
athletes who underwent isolated superior labral repair. The
patients with isolated repairs had a much greater chance of
returning to full participation (OR ¼28; 95% CI ¼2.4,
323.7; P,.05) than those who underwent concurrent labral
repair and soft tissue debridement.
21
Critical Appraisal Results
The results of the critical appraisal outcomes are
presented in Table 7. Of 24 possible points available as
part of the binary assessment, the scores of the 5 studies
specific to isolated superior labral repair ranged from 10 to
15 total points (42% to 63% of available points). The 6
articles that described superior labral repair with concurrent
soft tissue debridement scored from 11 to 17 points (42% to
70%) of the 24 possible points. The wide variation of
return-to-participation findings among the 11 studies
suggests that the Strength of Recommendation Taxonomy
recommendation would be C due to the quality of the
studies with level 3 (case series) evidence.
8
Risk of Bias Results
The risk-of-bias assessment revealed that recall bias was
the most prevalent across all studies (100%) because return
to participation was assessed 1 to 2 years after patients were
discharged from formal care. Both detection bias and
selection bias were evident in 73% of the studies reviewed
(Table 8).
DISCUSSION
Injuries to the glenoid labrum or rotator cuff are common
in overhead athletes. When nonoperative management of
these injuries is unsuccessful, surgical interventions are
used. In this systematic review, we identified that return to
preinjury levels of participation is variable, and full return
is not always attainable after isolated superior labral repair
or superior labral repair combined with debridement of
other soft tissue. The use of ORs helped to reduce the
‘‘noise’’ within the literature, showing that nonoverhead and
nonbaseball athletes had greater chances of returning to full
activity after superior labral repair. The authors of the
reviewed articles reported return to participation as
percentages, which showed inconsistent rates of return
(ie, more noise), possibly due to inconsistencies in methods
among studies. The defined variables that differed among
studies included population demographics (age, sport, years
of experience, and level of participation [ie, recreational
versus elite athletes]), details related to surgical technique,
and postoperative rehabilitation guidelines.
Population Demographics
The mean age of the participants across all studies ranged
from 24 to 36 years. This range of ages indicated that the
reported return-to-participation rates cannot be extrapolated
Table 6. Return-to-Participation Odds and Interpretations for Athletes With Concurrent Superior Labral Repair and Soft Tissue
Debridement
Study (Year) Comparison
Full
Return
Limited or
No Return Total Odds
a
Odds
Ratio
b
95% Confidence
Interval
Greater Chance
of Full Return?
Ide et al
17
(2005) Baseball 12 7 Limited return 19 1.7
Other 18 3 Limited return 21 6.0 3.5 0.8, 16.3 Yes
Brockmeier et al
18
(2009) Overhead 20 8 No return 28 2.5
Other 5 1 No return 6 5.0 2.0 0.2, 19.9 Yes
Friel et al
19
(2010) Overhead 13 10 No return 23 1.3
Nonoverhead 10 5 No return 15 2.0 1.5 0.4, 6.0 Yes
Neri et al
21
(2011)
c
Superior labral repair 12 3 No return 15 4.0
Superior labral repair with con-
current rotator cuff debridement
1 7 No return 8 0.1 28.0
d
2.4, 323.7 Yes
a
Calculation of odds ¼full return divided by limited or no return.
b
Calculation of odds ratio ¼group with greater chance of success for full return divided by group with lesser chance for full return.
c
Indicates that all patients in this case series were classified as overhead athletes (baseball, tennis, volleyball, water polo).
d
Indicates difference (P,.05).
Journal of Athletic Training 773
Table 7. Critical Appraisal Results for Studies Retained for Systematic Review
Criteria
Isolated Superior Labral Repair Superior Labral Repair With Soft Tissue Debridement
Kim
et al
5
(2002)
Cohen
et al
12
(2006)
Yung
et al
13
(2008)
Maier
et al
14
(2013)
Park
et al
15
(2013)
Morgan
et al
16
(1998)
a
Ide et al
17
(2005)
a
Brockmeier
et al
18
(2009)
a
Friel et al
19
(2010)
a
Park and
Glousman
20
(2011)
b
Neri et al
21
(2011)
a
Total
of All
Articles, %
Study question
Relevant background for research question? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100
Study design
Comparison group? Yes No No Yes No No Yes No No No Yes 36
Patient status at .1 time point? No No Yes Yes No Yes Yes Yes Yes Yes No 64
Prospective collection? No No Yes No No Yes Yes Yes Yes No No 45
Randomized groups? No No No No No No No No No No No 0
Patients blinded? No No No No No No No No No No No 0
Providers blinded? No No No No No No No No No No No 0
Independent evaluator? No No No Yes No No Yes No No No No 18
Participants
Sample and selection bias minimized? No Yes No No No No Yes Yes Yes No No 36
Inclusion and exclusion criteria defined? Yes Yes Yes No Yes No Yes Yes Yes Yes Yes 82
Appropriate enrollment obtained? Yes No No No No No No Yes No No Yes 27
Appropriate retention and follow up obtained? Yes Yes Yes Yes Yes Yes Yes Yes Yes No No 82
Intervention
Intervention applied via established principles? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100
Provider biases minimized? No No No Yes No Yes No Yes Yes No Yes 45
Intervention compared with appropriate
comparator? No No No Yes No No No No No No No 9
Outcomes
Primary outcome defined? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100
Secondary outcomes considered? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100
Appropriate follow-up period? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100
Analysis
Appropriate statistical test or tests performed? Yes No Yes Yes Yes No Yes Yes Yes No Yes 73
Power to identify treatment effects? No No No Yes No No No No No No No 9
Size of effects and differences reported? No No No No No No No No No No No 0
Missing data accounted for and considered? No No No No No No No No No Yes No 9
Clinical and practical importance considered in
interpreting results? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100
Recommendations
Conclusion and clinical recommendations
supported by the study objectives, analysis,
and results? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 100
Total per each article, No. (%) 12 (50) 10 (42) 12 (50) 15 (62) 10 (42) 11 (46) 17 (70) 15 (62) 14 (58) 10 (42) 12 (50)
a
Includes superior labral repair with debridement of rotator cuff, repair of rotator cuff, subacromial decompression, bursectomy, capsular release, distal clavicle excision, or acromioplasty.
b
Revision superior labral repair with labral debridement or subacromial decompression.
774 Volume 50 Number 7 July 2015
to younger age groups, which is a concern because younger
athletes (age ,18 years) have a greater chance of
advancing to additional stages of participation (collegiate
or professional levels) than athletes already performing at
those upper levels of competition. If operative intervention
is recommended for a younger athlete, supplying preoper-
ative return-to-participation prognoses may be helpful in
determining if undergoing the corrective procedure will
allow return to the current level of activity and advance-
ment to higher stages of participation. However, it is
possible that factors beyond patient age, such as variations
in healing rates, skill levels, financial considerations, and
internal or external motivators, can influence the decision to
have surgery.
22–24
Eisner et al
25
reported a return-to-
participation rate of 70% after partial-thickness rotator cuff
repair in patients less than age 19 years; however, the
article could not be included in this review because it did
not meet all inclusion criteria.
The populations across all studies reviewed were
heterogeneous, as they comprised multiple types of athletes
from various sports with subgroups defined as overhead/
nonoverhead,overhead/other,orthrowing/nonthrowing
athletes. Grouping throwing/overhead sports, such as
baseball, softball, swimming, tennis, and volleyball, and
nonthrowing/nonoverhead sports, such as football, karate,
and weightlifting did not provide a clear estimate of return
to participation because individual sports have different
biomechanical requirements and demands. Combining
athletes from multiple sports into 1 distinct group limits a
clinician’s ability to delineate return-to-participation prog-
noses for individual athletes, creating a gap in the
knowledge. As such, the calculated ORs need to be
interpreted in context for each study.
Another concern that we identified was an overwhelming
lack of prospective data collection related to athletic
performance and playing status and a lack of reporting of
these same factors in the postoperative data. Detection, recall,
and selection bias were the most common types of bias
present within the studies, likely due to the retrospective case
series design. Outcome measures were rarely selected
prospectively, and the assessors who performed follow-up
examinations were not blinded to the intervention, creating
the possibility of detection bias. All individuals were asked
orally at postoperative follow-up if they had returned to their
preinjury levels of participation, which subjected the
responses to recall bias and individual patient perception
given that postoperative follow-up occurred between 1 and 10
years. Selection bias was also evident due to a lack of
matching or stratification. The identified biases weaken the
strength of the information derived from each article because
the level of return to participation was not consistently known
(full return, limited return, no return, or return with or without
pain), thus lessen the usefulness of the reported return-to-
participation rates.
Surgical Considerations
Orthopaedic surgeons are charged with determining if
apparent shoulder pathologic conditions are clinically
important. The decision to recommend or not recommend
surgical intervention depends on the information derived
from subjective history and objective testing, as well as
patient goals and expectations. However, we observed that
the likelihood of returning to preinjured levels of participation
was inconsistent across studies, indicating that preoperative
discussions focused on the rate of return to activity would be
difficult for clinicians to have with their patients.
The ORs for returning to full, preinjured levels of
participation after isolated superior labral repair favored
nonoverhead athletes; however, some overhead athletes did
return to full preinjured levels. This observation suggested
that some type of return is possible, either in a full or
limited capacity, for some overhead athletes after repair,
although the exact technique of repair was not standardized.
However, only 1 study
5
demonstrated an association, with
researchers finding that nonoverhead athletes were 5.8
times more likely to return to full activity after superior
labral repair. However, clinicians should interpret this
result with caution, as the 95% CI was rather wide (1.3,
26.2). Furthermore, surgically debriding the surrounding
soft tissue appeared to confound the return-to-participation
rates for overhead athletes, as the odds for returning to full
participation after these procedures were all greater than 1,
meaning more likely to return to full participation. This
observation is in contrast to the isolated repair studies, for
which all odds were less than 1 for the overhead-athlete
groups. To further examine why greater odds of return to
participation occurred with more surgery, 3 possible
explanations were identified: unequal group sizes, surgical
details, and clinical experience. First, unequal group sizes
were identified within and between the studies of isolated
Table 8. Possible Risk of Bias Results
Study (Year)
Attrition
Bias
Detection
Bias
Performance
Bias
Recall
Bias
Reporting
Bias
Selection
Bias
Isolated superior labral repair
Kim et al
5
(2002) No Yes No Yes No Yes
Cohen et al
12
(2006) No Yes No Yes No Yes
Yung et al
13
(2008) No Yes Yes Yes No Yes
Maier et al
14
(2013) No Yes No Yes No No
Park et al
15
(2013) No Yes No Yes No Yes
Superior labral repair with soft tissue debridement
Morgan et al
16
(1998) No Yes Yes Yes No No
Ide et al
17
(2005) No No No Yes No Yes
Brockmeier et al
18
(2009) No No No Yes No Yes
Friel et al
19
(2010) No No No Yes No Yes
Park and Glousman
20
(2011) Yes Yes No Yes No No
Neri et al
21
(2011) Yes Yes No Yes No Yes
Journal of Athletic Training 775
repair and the studies that included concurrent debridement
(from which odds could be calculated). The concurrent-
debridement studies had an average of 8.5 more patients in
the overhead-athlete groups than the same patient groups in
the isolated-repair studies.
16–21
The increased number of
patients undergoing labral repair with concurrent debride-
ment inflated the odds of successful return, which could
explain why the chance of full return was greater after a
procedure that involved treatment to more tissue. Con-
versely, the data from Neri et al
21
suggested a 28 times
greater chance of returning to full activity after isolated
superior labral repair than after concurrent procedures.
However, in that study, twice as many patients were in the
isolated superior labral repair group and relatively few
patients did not return to full activity, which could account
for the difference in observations between the procedures.
Second, clinical details, including anatomical consider-
ations (eg, severity of injury, tissue integrity), surgical
considerations (placement and amount of hardware, amount
of tissue debrided), individual patient differences, and
postoperative rehabilitation details, were either not reported
or were limited in description. The lack of consistent details
among studies possibly limited the ability to draw accurate
conclusions regarding return to activity after superior labral
repair. Third, differences in clinician experiences and skills
are neither standardized nor measurable. Clinicians do not
universally agree about how to optimally repair superior
labral injuries, suggesting that the optimum method for
treating labral pathologic conditions in the symptomatic
overhead athlete is not fully understood.
26
To properly compare results across various studies, we
must know the surgical details that were employed to
address the superior labral lesions in each cohort of
patients. In this review, all researchers reported the
techniques used in the surgical procedures; however, gaps
among the studies included failure to report the number of
anchors used and their placement on the glenoid.
12,14,16,20
Anchor quantity typically is determined during surgery
based on the size of the lesion. Of the 9 studies in which
authors reported anchor quantity, the total number of anchors
used per patient ranged from 1
5,15,17–19
to 4,
12–14
with a mean
of 2.3.
21
The variation in the number of anchors used within
and between studies confounded the return-to-participation
rates because not all superior labral lesions were the same size
and, therefore, were not fixated similarly.
Of similar importance is anchor placement as it relates to
both anatomical fixation and restoration of biomechanical
capabilities.
27
Inappropriately placed anchors can poten-
tially ‘‘strangle the biceps tendon’’
19
and not eliminate the
dysfunction caused by the lesion.
27
Similar to the
discrepancy noted about the quantity of anchors used,
variations were present among the 8 studies
5,12,13,16–19,21
in
which researchers reported the location of anchor place-
ment. With return-to-participation rates ranging from 22%
to 92%, functional restoration for overhead athletes was
possibly affected by the location of anchor placement.
Additionally, surgical portal placement has been shown
to affect the outcomes for superior labral repairs.
Researchers
28
recently reported that poor portal placement
during primary superior labral repair can result in full-
thickness rotator cuff tears of the supraspinatus. Anchor
quantity and placement and portal placement are thought to
contribute to restoration of labral function
29
and are
necessary information for critically analyzing outcomes,
such as patient satisfaction and return to participation.
Rehabilitation
When exploring the reasons why return-to-participation
rates for overhead athletes were not more consistent or
successful, we should also examine the rehabilitation
components. The postoperative rehabilitation guidelines used
for each case series were consistent in design, with
progressive strengthening and range-of-motion exercises
used throughout the rehabilitation process. However, no
researchers reported the critical details of the rehabilitation
program, including the specific exercises used, patient
compliance with the protocol, the duration (total number of
visits) or frequency of rehabilitation, exercise dosage, or use
of a home program. A detailed outline describing each of
these rehabilitation components would allow for better
dissemination of these confounding factors, as 1 or more of
the components could potentially have affected the postop-
erative outcome.
Limitations
Our study had limitations, so clinicians need to exercise
caution in interpreting these results. The data were derived
from retrospective studies with only moderate quality and
evident biases. Whereas retrospective studies permit
reviewers to establish relatively clear inclusion and
exclusion criteria, adequate follow-up time, and definitions
of primary and secondary outcomes, each case series was
limited by (1) not having a prospective assessment of
playing status or functional performance before or imme-
diately after injury diagnosis, (2) no determination of
adequate sample size, (3) lack of a thorough statistical
analysis, and (4) merging groups of athletes from a variety
of sports with a large range of ages. Researchers reported
the postoperative rehabilitation as general guidelines and
did not provide the specific exercises that were implement-
ed, duration and intensity of the exercises, or number of
treatment visits. Given these shortcomings, the best
available evidence is not strong enough to concretely
supply clinicians with global ORs for return to participation
at preinjured levels for either overhead or nonoverhead
athletes after operative repair of the superior labrum with or
without concurrent soft tissue debridement. Instead, we
calculated a range of approximate ORs, showing an
apparent trend for nonoverhead athletes to have more
success returning to full competition after arthroscopic
labral repair. Despite the results favoring nonoverhead
athletes, operative treatment for labral pathologic condi-
tions should not be abandoned as a viable option for
overhead athletes because operative restoration of the
disrupted anatomy may be appropriate based on the
functional deficits and demands of each patient. The
identified gaps in reporting methods suggested that in
future clinical outcomes reports, researchers should control
particular areas, such as specific activity, age, surgical
details and technique, and rehabilitation. Additionally,
future researchers should use prospective data-collection
methods related to preoperative and postoperative subjec-
tive and objective clinical measures in addition to a
preinjury assessment of sport-specific performance. Using
these measures would help control for potential biases and
776 Volume 50 Number 7 July 2015
add an integrated, measurable component of function,
merging the patient-specific subjective considerations with
the objective performance of each athlete.
CONCLUSIONS
Health care providers need to communicate all practical
treatment options to patients who have sustained shoulder
injuries. We purposely limited the odds of return to
participation to overhead athletes, excluding reports in
which overhead athletes were not comparatively examined
and, thus, were able to generate odds for return to
participation after shoulder surgery, which have not been
previously reported. Whereas success can be achieved for
both overhead and nonoverhead athletes, the odds for full
return to activity appear to favor nonoverhead athlete
groups. The ORs should allow clinicians to discuss more
directly with their patients the likelihood of return to
participation after arthroscopic superior labral repair for
overhead and nonoverhead athletes.
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Journal of Athletic Training 777
