Assessing the Effectiveness of Arthroscopic Capsular Repair in Elite Baseball Players: Response

Authors’ Response:

We thank the authors of the letter to the editor for their initiative in providing a carefully constructed critical review of our article. As they correctly state in their commentary, distinguishing acute from chronic injury, standardizing a nonoperative treatment protocol, and controlling for cumulative exposure to repetitive throwing injury and concomitant pathology would most certainly have improved the reproducibility and validity of the study’s findings and improved the readers’ understanding on how best to treat capsular injury in throwers.

We could not agree more with the letter writers’ insights regarding the chronic nature of this injury. The senior author (N.S.E.) believes that capsular injuries and latissimus dorsi and teres major tears in throwers represent a catastrophic later-stage pathologic feature of the chronic internal impingement continuum. The senior author has observed a constellation of findings that are felt to be pathologic and, in his opinion, that begin with glenoid dysplasia. He hypothesizes that progressive posterior glenoid dysplasia leads to anterior capsule strain brought about by a pathologically forward and down position of the humeral head as a result of posterior abutment and disruption of dynamic shoulder stabilization secondary to posterior rotator cuff injury. All patients in the study cohort had these findings of internal impingement (ie, posterior glenoid dysplasia; posterior chondrocapsulolabral hypertrophy and ossification [Bennett-like lesion]; posterior labral pathology; articular-sided partial thickness tearing of the infraspinatus and posterior cable; posterior greater tuberosity notching, cystic change, and edema; and subacromial bursitis) and had been previously treated for 1 or more of these pathologies. Many had also been treated for previous latissimus and teres major tears. Thus, while we acknowledge the importance of distinguishing acute versus chronic presentation in many injuries, we believe this is an entirely different entity than a humeral avulsion of the glenohumeral ligament lesion seen in an acute dislocation. In fact, the senior author has not encountered this injury in isolation, and throwers universally report a long history of previous shoulder injuries and pain when presenting with capsular tear.

We acknowledge that the study methods would have benefited from a more rigorous definition of nonoperative treatment. All patients presenting for surgical consideration had invariably undergone unsuccessful nonoperative care under the supervision of their respective team medical staff before presentation for surgical consultation, the nonoperative treatment encompassed many, if not most, of the modalities mentioned in the letter. Retrospective review of patient charts revealed documentation of a period of rest, an attempt at an interval throwing program, and a corticosteroid injection in 5 of the 11 study players. The remaining 6 players had a documented period of rest, with 1 of these patients undergoing previous shoulder arthroscopy and platelet-rich plasma injection. The senior author has been hesitant to advise further nonoperative care once a capsular injury has been diagnosed, as he is aware of 4 professional and 1 collegiate baseball player who subsequently dislocated while attempting to return to throwing with a known capsular tear. Two of these players were study patients. These players had axillary pain with throwing in addition to imaging findings of capsular injury. The acute dislocations led to new pathology, including full-thickness cuff tears, enlargement of capsular tears, and bipolar chondral damage. With few exceptions, valuable months of season play had already been lost, thus deeming further nonoperative care unpalatable.

Finally, we agree that it is reasonable to presume that the severity of comorbid shoulder disease and varying amounts of chronic throwing exposure may negatively affect surgical outcomes and return-to-play statistics. We recognize the utility measures such as career length may provide as a method of control. The primary purpose of our study was describing the patient-reported outcomes and rates of return to sport after arthroscopic capsular repair in the largest cohort of elite throwers to date. Future studies with larger sample sizes will likely foster additional statistical comparisons and multivariate analyses to better elucidate these complex interactions.

William J. Uffmann III, MD Duluth, Minnesota, USA Neal S. ElAttrache, MD Los Angeles, California, USA