Treatment of Posterior Shoulder Instability in National Hockey League Players: A Survey of NHL Team Physicians

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Abstract
Background: Posterior shoulder instability is a common yet underappreciated condition in elite hockey players. It presents unique treatment dilemmas during both the season and the offseason. Purpose: To investigate treatment trends and decision-making factors among National Hockey League (NHL) team physicians when managing posterior shoulder instability. Study Design: Cross-sectional study. Methods: A 35-item questionnaire addressing treatment decisions, surgical thresholds, bone loss management, and return-to-play (RTP) protocols was sent to all 32 NHL team orthopaedic surgeons. Data were collected on both in-season and offseason preferences and analyzed as descriptive statistics. Results: Of the 32 invited team physicians, a total of 31 (97%) completed all (n = 29) or most (n = 2) of the survey. For first-time in-season posterior shoulder instability, 100% of physicians chose nonoperative management. For recurrent posterior instability, 35% favored in-season surgery if there was no bone loss, and 74% favored in-season surgery when bone loss was ≥15%. Timing within the season did not influence the majority of surgeons. In the offseason, 39% would recommend offseason surgery for first-time injuries and 48% for recurrent instability without bone loss. Arthroscopic stabilization was the preferred procedure in all soft tissue cases; in cases of bone loss ≥15%, 53% would perform a soft tissue only procedure, and 30% would perform augmentation with distal tibial allograft. RTP was guided by full strength, range of motion, absence of pain, and absence of subjective instability. Conclusion: NHL team physicians strongly favor nonoperative management in-season for first-time posterior shoulder instability events. Recommendation of in-season surgery becomes more likely in the presence of injury recurrence or bone loss. Heterogeneity exists among surgeons regarding the amount of combined bone loss that would lead to the recommendation of a bony procedure. Injury timing during the season rarely alters treatment decisions, and arthroscopic repair remains the standard approach.

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