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Lennard Funk
Wrightington Upper Limb Unit
Salford University
lenfunk@shoulderdoc.co.uk
CONTACT ATHLETES
DECISION MAKING
Sport Popularity in UK
SPORT TV Viewing Participation Interest
Football 46% 10% 45%
Rugby Union 21% 6% 27%
Tennis 18% 3% 23%
Cricket 18% 2% 19%
Athletics 18% 2% 21%
Snooker 17% 5% 24%
Motorsport 16% NA 20%
Rugby
League
12% 2% 15%
Boxing 11% NA 14%
Golf 11% 6% 16%
My Elite Athletes (2010-2013) = 663
SPORT Percent Commonest
Path.Rugby Union 37% (247) Anterior Labral
Rugby
League
28% (182) Posterior Labral
Football/
Soccer
8% (54) Anterior Labral
Motorsport 3% (22) Mixed Labral
TearsClimbers 3% (20) SLAP
Swimming 3% (18) Int Imping/
SLAPCricket 2% (14) Anterior Labral
Paralympics 2% (13) Mixed Labral
TearsOthers 14% (93)
Three P’s
Patient
Pathology Participation
1. Age
2. Gender
3. Laxity
4. Fatigue
5. Sport
6. Position
1. Major
1. Bony
2. ALPSA
3. HAGL
4. FTCT
2. Minor
1. Labral
2. PTCT
1. Season
2. Events
3. Pressure
4. Age
Recurrent Instability Rates
(after arthroscopic stabilisation)
[Cho et al. Arthroscopy 2006]
CONTACT / COLLISION
OVERHEADFLEXIBILITY
29%
7%
Recurrent Instability
Rates in Contact Sports
• Non-operative = 80% [Arciero, 1994]
• Open Bankart repair = 12%
• Arthroscopic Stabilisation = 14% [Larrain,
2006]
– First dislocation = 4%
– Recurrent dislocations = 24%
– Under 18yrs age = 30% [Nixon & Funk, 2013]
• RCT of Latarjet vs. Arthroscopic Bankart
• Recurrence rate at 5 years:
– Latarjet = 12%
– Arth. Bankart = 24%
• Return to sport the same!
• Complication Rates higher (20%)
Latarjet Procedure 

[Bessier et al. JOST. 2013]
Recurrence Summary
• Higher in contact/collision sport
• Higher in young
• Higher after surgery for recurrent
dislocations
• Arthroscopic = Open Bankart
• Lower after Latarjet procedure
WHY?
PATIENT
Predisposing Factors
• Player:
1.Laxity

Cheng et al. JBJSB 2007; 

Akhtar & Robinson. BJSM 2010
2.Proprioception

Herrington, 2011
3.Isokinetics

Jones & Funk, 2010
4.Mass
5.Running Speed
6.Aerobic ability
7.Previous Injury
• Sport:
1. Speed of play
2. Timing
3. Fatigue
1. Physical
2. Mental
Injury Reduction
Predispostion Model Meeuwisse
PATHOLOGY
Pathology
Mechanisms of Injury
video analysis study
Direct Impact
Complex
Labral
Bony Bankart
PTCT
Flexed Fall
Posterior
Labral
RHAGL
Try Scorer
Bankart
SLAP
Rotator Cuff
Tackler
Bankart
SLAP
HAGL
Crichton, Jones & Funk - BJSM 2012
Player Position
• 25 Professional Footballers
– 15 Field players
– 10 Goalkeepers
Funk & Sargent, 2010
Injury Patterns
Clinical Examination:
Instability in Athletes
• True Instability
– Dislocation
– Subluxation
– Apprehension
– Large lesions
• Subclinical
Instability
– Dead Arm in ABER
– Pain in ABER
– Clunking
– No Apprehension
– Smaller lesions
Investigations
• No previous Surgery = MR Arthrogram
• Previous Surgery = CT Arthrogram
MR Arthrogram v. Scope
Sensitivity Specificity Accuracy
SLAP 0.42 0.92 77%
Rotator Cuff
Tear
0.50 0.86 83%
Hill Sachs 0.91 0.78 90%
Bankart 0.85 0.83 86%
N Karlson, J Geoghan, L Funk; 2008
• An experienced Shoulder Surgeon
better
• Can correlate with clinical context
• Experience of reviewing Scopes & Scans
Pathology
Major ‘Minor’
• Bony Bankart
• ALPSA
• Rotator Cuff Tear
• HAGL
• Undisplaced Labral
Tear
• Partial Cuff Tear
Timing of Surgery
(Participation)
• Early Surgery:
– Large structural lesions
– Late in Season
– Unable to Return
• Rehab & Return:
– Minor lesions
– Early season
Types of Surgery
• Mostly Arthroscopic Direct Repairs
• Latarjet for High-Risk/Revision
• Anterior Instability
– Revision surgery (even without bone loss)
– Chronic Bony Bankart (> 3months)
– Any Bony Glenoid Loss
– True dislocation in Front Row forward 

(Rugby Union)
– Higher level of sports
Latarjet in Athletes
Three P’s
Patient
Pathology Participation
1. Age
2. Gender
3. Laxity
4. Fatigue
5. Sport
6. Position
1. Major
1. Bony
2. ALPSA
3. HAGL
4. FTCT
2. Minor
1. Labral
2. PTCT
1. Season
2. Events
3. Pressure
4. Age
lenfunk@shoulderdoc.co.uk
THANK
YOU

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Decision making in the Contact athlete

  • 1. Lennard Funk Wrightington Upper Limb Unit Salford University lenfunk@shoulderdoc.co.uk CONTACT ATHLETES DECISION MAKING
  • 2. Sport Popularity in UK SPORT TV Viewing Participation Interest Football 46% 10% 45% Rugby Union 21% 6% 27% Tennis 18% 3% 23% Cricket 18% 2% 19% Athletics 18% 2% 21% Snooker 17% 5% 24% Motorsport 16% NA 20% Rugby League 12% 2% 15% Boxing 11% NA 14% Golf 11% 6% 16%
  • 3. My Elite Athletes (2010-2013) = 663 SPORT Percent Commonest Path.Rugby Union 37% (247) Anterior Labral Rugby League 28% (182) Posterior Labral Football/ Soccer 8% (54) Anterior Labral Motorsport 3% (22) Mixed Labral TearsClimbers 3% (20) SLAP Swimming 3% (18) Int Imping/ SLAPCricket 2% (14) Anterior Labral Paralympics 2% (13) Mixed Labral TearsOthers 14% (93)
  • 4. Three P’s Patient Pathology Participation 1. Age 2. Gender 3. Laxity 4. Fatigue 5. Sport 6. Position 1. Major 1. Bony 2. ALPSA 3. HAGL 4. FTCT 2. Minor 1. Labral 2. PTCT 1. Season 2. Events 3. Pressure 4. Age
  • 5. Recurrent Instability Rates (after arthroscopic stabilisation) [Cho et al. Arthroscopy 2006] CONTACT / COLLISION OVERHEADFLEXIBILITY 29% 7%
  • 6. Recurrent Instability Rates in Contact Sports • Non-operative = 80% [Arciero, 1994] • Open Bankart repair = 12% • Arthroscopic Stabilisation = 14% [Larrain, 2006] – First dislocation = 4% – Recurrent dislocations = 24% – Under 18yrs age = 30% [Nixon & Funk, 2013]
  • 7. • RCT of Latarjet vs. Arthroscopic Bankart • Recurrence rate at 5 years: – Latarjet = 12% – Arth. Bankart = 24% • Return to sport the same! • Complication Rates higher (20%) Latarjet Procedure 
 [Bessier et al. JOST. 2013]
  • 8. Recurrence Summary • Higher in contact/collision sport • Higher in young • Higher after surgery for recurrent dislocations • Arthroscopic = Open Bankart • Lower after Latarjet procedure
  • 11. Predisposing Factors • Player: 1.Laxity
 Cheng et al. JBJSB 2007; 
 Akhtar & Robinson. BJSM 2010 2.Proprioception
 Herrington, 2011 3.Isokinetics
 Jones & Funk, 2010 4.Mass 5.Running Speed 6.Aerobic ability 7.Previous Injury • Sport: 1. Speed of play 2. Timing 3. Fatigue 1. Physical 2. Mental
  • 15. Mechanisms of Injury video analysis study Direct Impact Complex Labral Bony Bankart PTCT Flexed Fall Posterior Labral RHAGL Try Scorer Bankart SLAP Rotator Cuff Tackler Bankart SLAP HAGL Crichton, Jones & Funk - BJSM 2012
  • 16. Player Position • 25 Professional Footballers – 15 Field players – 10 Goalkeepers Funk & Sargent, 2010
  • 18. Clinical Examination: Instability in Athletes • True Instability – Dislocation – Subluxation – Apprehension – Large lesions • Subclinical Instability – Dead Arm in ABER – Pain in ABER – Clunking – No Apprehension – Smaller lesions
  • 19. Investigations • No previous Surgery = MR Arthrogram • Previous Surgery = CT Arthrogram
  • 20. MR Arthrogram v. Scope Sensitivity Specificity Accuracy SLAP 0.42 0.92 77% Rotator Cuff Tear 0.50 0.86 83% Hill Sachs 0.91 0.78 90% Bankart 0.85 0.83 86% N Karlson, J Geoghan, L Funk; 2008
  • 21. • An experienced Shoulder Surgeon better • Can correlate with clinical context • Experience of reviewing Scopes & Scans
  • 22. Pathology Major ‘Minor’ • Bony Bankart • ALPSA • Rotator Cuff Tear • HAGL • Undisplaced Labral Tear • Partial Cuff Tear
  • 23. Timing of Surgery (Participation) • Early Surgery: – Large structural lesions – Late in Season – Unable to Return • Rehab & Return: – Minor lesions – Early season
  • 24. Types of Surgery • Mostly Arthroscopic Direct Repairs • Latarjet for High-Risk/Revision
  • 25. • Anterior Instability – Revision surgery (even without bone loss) – Chronic Bony Bankart (> 3months) – Any Bony Glenoid Loss – True dislocation in Front Row forward 
 (Rugby Union) – Higher level of sports Latarjet in Athletes
  • 26. Three P’s Patient Pathology Participation 1. Age 2. Gender 3. Laxity 4. Fatigue 5. Sport 6. Position 1. Major 1. Bony 2. ALPSA 3. HAGL 4. FTCT 2. Minor 1. Labral 2. PTCT 1. Season 2. Events 3. Pressure 4. Age