Justin Wade Arner

Adductor injuries represent a notable musculoskeletal burden among athletes accounting for half of acute hip injuries in soccer and nearly one quarter in professional basketball. The pyramidalis-anterior pubic ligament-adductor longus complex represents a critical anatomic concept for understanding injury patterns with the adductor longus most injured. Clinical evaluation follows the Doha agreement classification, emphasizing adductor tenderness and pain on resisted adduction testing to differentiate adductor-related groin pain from other etiologies. Magnetic resonance imaging provides comprehensive injury characterization, with validated classification systems predicting return-to-play timelines. Prevention strategies target modifiable risk factors including adductor weakness and reduced hip rotational range of motion, with strengthening programs demonstrating potential to reduce injury incidence. Nonsurgical management remains the cornerstone of treatment for most injuries with return to play averages 2 to 3 weeks for partial tears and 8 to 12 weeks for complete tears managed nonsurgically, although recurrence rates are as high as 19%. Surgical intervention is considered for acute avulsions with greater than 2 cm retraction or chronic injuries refractory to conservative treatment, although comparative evidence versus structured nonsurgical care is limited. Surgical management options include repair, partial tenotomy, or complete tenotomy. All three surgical approaches demonstrate good outcomes in nonrandomized cohort studies with return to play averaging 10 to 14 weeks and repair being favored for traumatic complete avulsion particularly in professional athletes.

Background: Posterior shoulder instability has been associated with abnormal acromial and glenoid morphology. However, the role of coracoid morphology in posterior instability remains unclear. Hypothesis: Patients undergoing surgery for posterior shoulder instability will have more inferiorly oriented and lateralized coracoids compared to patients with anterior instability or a noninstability comparison group. Study Design: Cohort study; Level of evidence, 3. Methods: Magnetic resonance imaging measurements were collected for 3 surgical cohorts: posterior instability (n = 41), anterior instability (n = 39), and a comparison group undergoing arthroscopy for snapping scapula (n = 38). Coracoid morphology metrics included: lateral coracoid offset, sagittal coracoid angle, coronal coracoid angle (CCA), transverse coracoid length, coracoacromial length (CAL), coracohumeral distance, and inferior coracoid coverage (ICC). Glenoid version and bone loss were also measured. One-way analysis of variance with Tukey post hoc testing or Kruskal-Wallis with Dunn testing was used as appropriate to compare groups. The P value was set a priori at <.05 to represent statistical significance. Analyses were performed using SPSS Version 30.0 and R Version 4.5.0. Results: The posterior instability group demonstrated a significantly higher CCA (69.4° ± 23.5°) than the anterior (52.8° ± 23.8°; P = .002) and comparison (56.9° ± 17.7°; P = .015) groups. The CAL and ICC were also significantly different in the posterior group (both P < .001). No significant differences in coracoid morphology were found between the anterior and comparison groups. Patients with posterior instability had significantly increased glenoid retroversion (–8.1° ± 3.7°) versus the anterior (–3.1° ± 5.3°) and comparison (–4.2° ± 4.3°) groups (both P < .001). Conclusion: Coracoid morphology differs significantly in patients undergoing posterior shoulder stabilization when compared to patients undergoing surgery for anterior instability or a comparison cohort. Increased CCA, increased CAL, and greater ICC are associated with patients undergoing posterior stabilization surgery. These findings suggest that a lower coracoid with increased inferior coverage of the humeral head may contribute to the pathogenesis of posterior instability.

Background: The distal tibial allograft (DTA) procedure has been described as an effective treatment option for reconstruction of glenoid bone deficiency in the setting of recurrent anterior shoulder instability; however, no comparative data between an arthroscopic or open DTA approach are available. Purpose: To compare the clinical and radiographic outcomes of patients who underwent open fresh versus arthroscopic frozen DTA stabilization procedures. Study Design: Cohort study; Level of evidence, 4. Methods: A retrospective review was performed of consecutive patients with a minimum of 5% anterior glenoid bone loss (GBL) associated with recurrent anterior shoulder instability who underwent stabilization with either open fresh or arthroscopic frozen DTA glenoid reconstruction and had a minimum 2-year follow-up. Consecutive patients undergoing arthroscopic frozen DTA were matched in a 1-to-1 format to patients undergoing open fresh DTA by age, body mass index, and number of previous shoulder operations. Patients were evaluated postoperatively in terms of the Western Ontario Shoulder Instability Index (WOSI) score, pain relief, and episodes of recurrent instability. All patients also underwent postoperative imaging evaluation with computed tomography (CT) in which graft incorporation and allograft angle were measured. Results: A total of 100 patients (50 open fresh DTA, 50 arthroscopic frozen DTA) with a median ± IQR age of 32.0 ± 6.7 and 27.9 ± 15.9 years, respectively, were analyzed at minimum 2-year follow-up. The open fresh DTA group had significantly more male patients than the arthroscopic frozen DTA group (98% vs 70%, respectively; P < .01), and patients in the open fresh DTA group had significantly greater GBL defects (25% ± 6% vs 21% ± 11%, respectively; P < .01). Both groups demonstrated significantly improved WOSI scores ( P < .05) and had similar clinical outcomes regarding improvement postoperatively ( P = .61), pain relief ( P = .09), and recurrence rates ( P = .31). Only 1 case of recurrent instability was noted, which occurred in the open fresh DTA cohort. Analysis of CT data at a mean of 15 months postoperatively showed no significant difference between open fresh versus arthroscopic frozen DTA groups. Conclusion: Open fresh and arthroscopic frozen DTA for anatomic glenoid reconstruction in patients with recurrent anterior shoulder instability resulted in a clinically stable joint with comparable outcomes and excellent healing rates. Additional long-term studies are needed to determine whether the surgical technique and type of allograft used influence clinical outcomes and whether these results are maintained over time.

Care of the Contact Athlete’s Shoulder

Background: Posterior shoulder instability has recently been linked to a higher and flatter acromion. However, the effect of acromial morphology on surgical outcomes has not been evaluated. Purpose: To evaluate differences in acromial morphology between patients undergoing primary and revision arthroscopic stabilization for posterior shoulder instability. Study Design: Case-control study; Level of evidence, 3. Methods: A series of patients who underwent either primary or revision arthroscopic stabilization for posterior shoulder instability between 2001 and 2022 were identified. Revision patients were matched to nonrevision patients based on age, sex, and sport. Comparisons of patient characteristics and acromial and glenoid morphology were done between groups using previously described magnetic resonance imaging parameters, including posterior acromial tilt (PAT), anterior acromial coverage (AAC), posterior acromial coverage (PAC), and posterior acromial height (PAH). Glenoid bone loss and glenoid version were also evaluated. Continuous variables were compared between groups using a 2-tailed Student t test. Results: A total of 37 patients who underwent revision posterior shoulder stabilization during the study period were identified and matched to 37 patients who underwent primary posterior shoulder stabilization. The mean ages of the primary and revision patients at the time of initial surgery were 21.5 ± 4.8 years (range, 13-35 years) and 19.6 ± 6.1 years (range, 12-45 years), respectively ( P = .95). Men comprised 54% of each group. The mean PAT in the primary and revision groups was 51.6° and 53.7° ( P = .32), while the mean PAH was 10 mm and 13.5 mm ( P = .04), respectively. The mean AAC in the primary and revision groups was 4.44° and 7.10° ( P = .20), while the mean PAC was 72.1° and 63.3°± 8.11° ( P = .08), respectively. No difference was found in the glenoid version (6.22° in the primary group vs 8.08° in the revision group; P = .06). The mean glenoid bone loss was 0.57% (range, 0%-8.9%) in the primary group and 1.4% (range, 0%-5.8%) in the revision group ( P = .02). Conclusion: A higher acromion was associated with requiring revision of previous arthroscopic posterior capsulolabral repair. PAT and coverage were not significantly different between patients undergoing primary versus revision repair. There was no significant difference in glenoid version between groups. Although the amount was small, glenoid bone loss was statistically higher in the revision group.

Background: The modified Jobe and docking techniques are the most utilized ulnar collateral ligament (UCL) reconstruction techniques, with previous research demonstrating successful and equivalent outcomes at midterm follow-up. However, these techniques have not been compared with UCL repair with suture augmentation (SA), nor has longer-term follow-up been reported. Purpose: To directly compare clinical outcomes at midterm follow-up of these 3 surgical techniques: the modified Jobe, docking, and repair with SA. Study Design: Cohort study; Level of evidence, 3. Methods: Twenty-four surgical procedures for UCL repair with SA were performed by a single surgeon, each with a minimum 2-year follow-up. Patients were matched by age, gender, and handedness to patients from previously published modified Jobe and docking cohorts. The following were compared among groups: Conway Scale, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score, years played, gender, handedness, sport, position, graft type (for reconstructive techniques), future upper extremity injury, need for additional surgery, rates of ulnar nerve symptoms, and return-to-play time. Results: Patients were similar with respect to age ( P = .54), gender ( P = .66), handedness ( P = .29), sport ( P = .23), years played ( P = .72), level of competition ( P = .08), type of pathology ( P = .23), future shoulder surgery ( P = .71), and future elbow surgery ( P = .61). The mean ± SD follow-up was 6.2 ± 3.9, 7.3 ± 4.6, and 5.2 ± 1.1 years in the modified Jobe, docking, and repair + SA groups, respectively ( P = .66). The reconstruction groups had a greater proportion of pitchers than the repair + SA group ( P = .02). Tear locations in the SA cohort were proximal in 18 (75%) and distal in 6 (25%). In the SA cohort, 13 (54%) were partial tears, 10 (42%) were complete tears, and 1 (4%) was attenuated. The repair + SA cohort had a significantly greater proportion of proximal tears than the docking cohort ( P = .03). No difference was identified among techniques in results on the Kerlan-Jobe Orthopaedic Clinic score ( P = .70) or Conway Scale ( P = .06). The UCL repair + SA cohort returned to sports 4 months earlier than the reconstruction cohorts ( P = .0001). Conclusion: No differences in outcomes scores or return-to-play rates were found when the modified Jobe and docking UCL reconstruction techniques were compared with the UCL repair + SA technique at >5-year mean follow-up; however, the SA group returned to sport 4 months earlier on average. Given the similar outcomes among groups, all 3 techniques are viable treatment options for UCL injuries.

Background: Operative repair of partial proximal hamstring avulsions has been shown to improve pain and function at short- and midterm follow-up. Long-term outcomes have not yet been reported. Furthermore, it is unknown whether greater tendon involvement (ie, tendon number) in partial tears affects clinical outcomes. Hypothesis: Hamstring function and patient satisfaction would remain stable over time at minimum 5-year and mean 10-year follow-up, with no differences in outcomes when comparing isolated and combined tendon involvement. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent surgical repair of partial proximal hamstring avulsions refractory to nonoperative measures were included. Patient-reported outcome measures were completed and included the Lower Extremity Functional Score (LEFS), Marx Activity Rating Scale, custom LEFS, custom Marx, and total proximal hamstring score. Patient satisfaction, return to play, current sport participation, subjective strength, and postoperative complications were also recorded. Long-term outcomes were compared with midterm outcomes. Outcomes of isolated (semimembranosus or conjoint tendon) versus combined (semimembranosus and conjoint tendon) tendon injuries were also compared. Results: A total of 53 patients (57 hamstrings) met the inclusion criteria at a mean follow-up of 10.1 years (range, 5.1-16.2 years). The mean Marx score was 8.0 (range, 0-16), the custom Marx score was 95% (range, 15%-100%), the LEFS and custom LEFS were 90% (range, 22%-100%) and 83% (range, 19%-100%), respectively, and total proximal hamstring score was 89% (range, 19%-100%). In total, 91% of patients were satisfied with surgery and 95% of patients returned to sport at a mean of 11 months after surgery. Current participation in sport was endorsed by 86% of patients. Hamstring strength >75% compared with the contralateral leg was reported in 88% of patients, with 58% of patients reporting equal strength (100%). No differences were found in comparing long-term (mean 10.7 years) to midterm (mean 6.2 years) follow-up with the exception of decreases in the Marx score from 12.0 to 8.5 and custom Marx score from 100% to 95%. One case (1.7%) required revision due to acute reinjury at 4 months postoperatively, with other complications including sitting pain, occasional posterior thigh cramping, and posterior thigh or foot paresthesia. Conclusion: Surgical repair of partial proximal hamstring avulsions refractory to nonoperative measures led to successful outcomes and high rates of return to activities with low complications at mean 10.1-year follow-up, with no differences in outcomes comparing isolated versus combined tendon involvement.

Hamstring injuries are common in athletes and result in missed time from sport and activities. Recurrent injury is a persistent issue. Injury location and severity dictate treatment. Complete acute proximal hamstring avulsions are typically treated successfully with open or endoscopic surgery, while partial avulsions commonly are initially treated nonsurgically. If required, surgical repair results in high patient-reported outcomes, satisfaction, and return to activities. Chronic complete proximal avulsions have less predictable outcomes. Myotendinous injuries are typically treated nonsurgically; however, lost time and reinjury are common. Distal myotendinous injuries can lead to greater delay in return to sport and higher reinjury rate than their proximal or midsubstance counterparts. Owing to this, there has been a recent interest in surgical repair, but historically nonsurgical treatment has been the standard. Distal hamstring avulsions require a thorough knee evaluation for isolated hamstring and/or concomitant injuries, with surgical treatment being determined based on injury pattern, including location and severity. Return to sport and activities require a graduated physical therapy program focused on restoring tissue length without excessive strain. Hamstring injury prevention programs are efficacious, but implementation and compliance are variable. The purpose of this study was to describe the current understanding of the anatomy, pathology, and treatment of hamstring injuries in athletes.