Diagnosing Instability in Rugby Players
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Making the clinical diagnosis of direction of instability in contact athletes can be difficult and this research confirms this.
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Diagnosing Instability in Rugby Players
- 1. Diagnosing the Direction of Shoulder Instability in Rugby Players Dr Ciaran Clarke Dr Emma Torrance Prof Lennard Funk The Wilmslow Hospital
- 2. Background Shoulder injuries responsible for 9-11% of all injuries in elite rugby 1 A dislocations/instability injury leads to an average of 81 days absence from sport 2 High rates of recurrence reported (62-79%) with greater morbidity Literature suggests that well-muscled athletes offer a unique challenge for identifying the direction of instability 5
- 3. Aim Review the accuracy of clinical examination in diagnosing the direction of shoulder instability in rugby players
- 4. Materials and Method Data analysed retrospectively for 300 patients over a 55 month period. Must participate in regular, competitive rugby and have received a shoulder stabilisation procedure. Excluded if participated in any other sport. All participants consented for their data to be used for research purposes. Data collected Demographics Results of Special Tests Clinical Direction of Instability Surgical Direction of Instability* Analysis 2x2 tables
- 5. Results Overall - Direction of instability correctly identified from physical examination in 42% of cases (n=300) Anterior n = 150 Anterior n = 114 75.4% (n = 86) None n = 30 Posterior n = 23 Combined n = 11
- 6. Results – Special Tests Sensitivity Specificity PPV NPV Anterior Apprehension (n= 220) 53.8% 100% 100% 18.6% Wrightington Posterior Instability Test (n = 125) 87.9% 30.6% 76.2% 55% Kim test (n = 83) 87.9% 44.4% 85.3% 53.3% Thrower’s (n = 34) 96.0% 11.1% 75.0% 50.0%
- 7. Results – Posterior Posterior n = 36 Posterior n = 119 26.0% n=31 None n = 2 Anterior n = 0 Combined n = 3
- 8. Conclusion Direction of instability is challenging to diagnose in rugby players Anterior apprehension test less sensitive and poorer NPV than in normal subjects High sensitivity of WPIT, Kim test and Thrower’s in posterior instability
- 9. References • 1. Headey J, Brooks JHM, Kemp SPT. The epidemiology of shoulder injuries in English professional rugby union. Am J Sports Med. 2007;35(9):1537– 43. • 2. Brooks JHM. Epidemiology of injuries in English professional rugby union: part 1 match injuries. Br J Sports Med. 2005;39(10):757–66. • 3. Larrain MV, Montenegro HJ, Mauas DM, Collazo CC, Pavón F. Arthroscopic management of traumatic anterior shoulder instability in collision athletes: analysis of 204 cases with a 4- to 9-year follow-up and results with the suture anchor technique. Arthroscopy. 2006 Dec;22(12):1283-9. • 4. Bohu Y, Klouche S, Lefevre N, Peyrin J-C, Dusfour B, Hager J-P, et al. The epidemiology of 1345 shoulder dislocations and subluxations in French Rugby Union players: a five-season prospective study from 2008 to 2013. Br J Sports Med. 2015;49:1535–40. • 5. Funk L. Treatment of glenohumeral instability in rugby players. Knee Surgery, Sport Traumatol Arthrosc. Springer Berlin Heidelberg; 2016;24(2):430–9.
Notes de l'éditeur
- Good morning, my name is Ciaran Clarke and I am Foundation Year 1 Doctor at Royal Bolton Hospital My presentation today regards the diagnosis of shoulder instability in rugby players and was undertaken at The Wilmslow Hospital under the supervision of Dr Emma Torrance and Prof Lennard Funk
- As well all know, rugby is a high impact, collision sport. Epidemiological studies of elite rugby injuries have demonstrated that shoulder injuries overall are responsible for 9-11% of all injuries. Shoulder dislocations and instability carry a particularly high morbidity, with an average of 81 days absence from the sport following injury. Shoulder instability injuries also carry a high rate of recurrence following initial injury. Furthermore, these recurrences carry an even greater level morbidity with a 2007 study by Headley et al. demonstrating that recurrences carry a mean 115 days lost from participation. it has recently been suggested that the well-muscled anatomy of rugby players and their characteristically high tolerance for pain results in a unique challenge for the clinician in identifying the direction of shoulder instability on clinical examination.
- Therefore, the aim of this study was to review the accuracy of clinical examination for diagnosing the direction of shoulder instability in rugby players.
- To achieve our aim, we retrospectively analysed data for 300 patients over a 55 month period in a single specialist upper limb unit. To be included in the study the patients had to participate in regular, competitive rugby league or union and must have received a shoulder stabilisation procedure as part of their care. We excluded any patient who reported participating in more than one sport. In particular, we collected demographic data, the results of clinical examination and orthopaedic special tests. The direction of instability recorded from the clinical examination findings was recorded as the clinical direction of instability. The direction of shouder instability recorded in the operation note was recorded as the surgical direction of instability. This final measure was taken as the gold standard for the direction of shoulder instability. Utilising the gold standard, we were able to construct 2x2 tables with statstics on the sensitivity, specificity, negative and positive predictive values of individual special tests. All of our participants consented for their data to be used for research purposes.
- The sample consisted of 300 patients, 296 of whom were male. The mean age was 22.6 years. Overall, the results suggest that it is diagnosing the direction of shoulder instability in rugby players is challenging. Overall, the direction of shoulder instability was correctly diagnosed in just 42% of cases. Anterior shoulder instability was diagnosed in 114 patients from clinical examination and 75% of these went on to have isolated anterior instability at surgery, which sounds relatively reasonable. However, 64 patients who were clinically diagnosed with other forms of instability went on to have isolated anterior instability at surgery. This included 30 patients who were not diagnosed with any form on instability
- The hypothesised challenge posed by rugby players in the literature is that they are characteristically well-muscled, which enables them to compensate for instability as well as having a high pain tolerance. 20% of the patients with surgical anterior instability were diagnosed as having no instability from clinical examination This may be somewhat explained by the lower than previously reported sensitivity and negative predictive value of the anterior apprehension test in our sample. In studies of thousands of patients, Hegedus et al. and Jia both reported sensitivities of over 65%. But in our study, the sensitivity was just 53% which In terms of diagnosing posterior instability, all three of the special tests analysed in our study had high sensitivity. Therefore a positive result had a high probability of isolated posterior instability. However, none of the tests had a specificity above 50%, so ruling out posterior instability remains challenging.
- This is illustrated further as we follow through the 119 patients diagnosed with posterior instability from clinical examination. Whilst only 30.2% went on have posterior instability, only 5 patients went on to have posterior instability who were not originally diagnosed with it from clinical examination
- Overall, this study demonstrates the challenge which rugby players offer us as clinicians trying to determine the direction of shoulder instability. The study highlights the lower sensitivity and negative predictive value of the anterior apprehension test in rugby players compared to the normal population. Finally, this study suggests that the WPIT, Kim test and Throwers test are all useful tools for diagnosing posterior instability of the shoulder as a positive test is highly suggestive of posterior instability.