Abstract
Background:
With the increasing popularity of shoulder arthroplasty, indications and usage has expanded to younger more physically active patients. Limited knowledge exists on return to outdoorsman sports after shoulder arthroplasty.
Purpose:
To determine return to outdoorsman sports, including fishing, shooting, archery, and rowing, after primary total shoulder arthroplasty at a minimum 2-year follow-up.
Study Design:
Case series; Level of evidence, 4.
Methods:
A retrospective study was performed on patients who underwent primary reverse or anatomic total shoulder arthroplasty between 2012 and 2022 who participated in outdoorsman sports, including fishing, shooting, archery, and rowing, with a minimum 2-year follow-up. Questionnaires were expanded to explore patients’ preoperative and postoperative activity with regard to outdoorsman sports. Patient-reported outcomes (PROs), including visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES), and Subjective Shoulder Value, as well as active range of motion including forward flexion, external rotation, internal rotation, were collected pre- and postoperatively.
Results:
A total of 102 patients met study criteria and responded. Overall, 77% returned to outdoorsman sports, with 80%, 85%, 50%, and 68% returning to fishing, shooting, archery, and rowing, respectively. Of those who returned, 86% reported being mostly or completely satisfied with their performance postoperatively, with 77% reporting a return to at least the same level of activity. Among those who returned, 61% did so within 6 months postoperatively. Patients from all sports showed significant clinical improvement in forward flexion (P≤ .003), external rotation (P≤ .006), and PROs (P≤ .006) at a mean postoperative follow-up of 38 ± 12 months. Between sports, postoperative VAS (P = .04) and ASES (P = .03) values were significantly different, with shooting showing lower ASES (83) and higher VAS (1.5) scores, despite demonstrating the highest return rate (85%). When considering arm dominance, return rates were comparable between patients who had surgery on their dominant arm and those treated on their nondominant arm across each sport.
Conclusion:
Participants had a 77% return to outdoorsman sports, such as fishing, shooting, archery, and rowing, with >50% doing so within 6 months of primary total shoulder arthroplasty. Respondents who participated in rowing and archery returned at lower rates compared with fishing and shooting, despite shooting's showing higher pain postoperatively. Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty.
Keywords
Anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) are common and dependable procedures, consistently showcasing their reliability in delivering symptomatic relief and functional improvement.4,7,9,17 Recently, the United States has witnessed a significant surge in the utilization of both procedures, with RSA gaining prominence. 4 Although traditionally a procedure performed in the elderly, this widespread popularity and success has sparked interest and adoption among the younger, more active demographic. Individuals aged <65 years have exhibited notable functional improvement after shoulder arthroplasty, while often aspiring to reengage in various activities postoperatively.1,3,5
Postoperative return rates, however, vary and are contingent upon the nature of the sport, with lower rates observed in activities with more strenuous physical demands.6,20 Outdoor recreational activities, such as fishing, rowing, shooting, and archery are referred to as outdoorsman, regardless of male or female participation. These outdoorsman sports impose distinct kinematic challenges on the shoulder.6,8,12,13,18 Notably, activities requiring greater abduction and external rotation, such as archery and rowing, pose a greater challenge for patients. 6 While previous studies have reported return rates for these outdoorsman sports, a gap exists in the literature concerning surveys evaluating sport-specific considerations.10,20
The purpose of this study was to determine return to outdoorsman sports, including fishing, shooting, archery, and rowing, after primary TSA or RSA at a minimum 2-year follow-up. As a secondary outcome, we reported sport-specific considerations, including time to return and performance satisfaction after surgery. We hypothesized lower return rates with rowing, shooting, and archery, compared with fishing, particularly among participants who underwent surgery on their dominant arm.
Methods
Study Design
A retrospective study was performed on a prospectively maintained database that was queried for all patients who underwent TSA or RSA between January 2012 and January 2022 by a single fellowship-trained shoulder surgeon (P.J.D.). Outdoorsman sports was used as a general term to describe outdoor recreational activities such as fishing, shooting, archery, and rowing, regardless of patient sex. The inclusion criteria were male or female patients who participated in outdoorsman sports and underwent primary TSA with a ≥2-year follow-up. Those with revision surgeries, history of fracture or nerve injuries, incomplete intraoperative information, or without postoperative results were excluded. Institutional review exemption was granted before the study's inception.
Surgical Technique and Postoperative Rehabilitation
All surgeries were performed by the senior author (P.J.D.). A deltopectoral approach was used in all cases. In the TSA group, a lesser tuberosity osteotomy was used to access the joint, followed by placement of an all-polyethylene pegged glenoid and a short stem (Univers Apex; Arthrex Inc) or stemless (Eclipse; Arthrex, Inc) humeral component. In the RSA group, a subscapularis peel was used to access the joint, a 135° inlay component was placed with a lateralized glenoid (Univers Revers; Arthrex, Inc), and the subscapularis was repaired in all cases. Postoperatively, patients wore a shoulder immobilizer for 4 weeks, after which slow progression of activities with minimal weight-bearing was encouraged. Strengthening was allowed at 8 weeks.
Outdoorsman Sports Questionnaire
Questionnaires were designed to explore pre- and postoperative athletic activity and ability of outdoorsman sports (ie, fishing, firearm use, archery, and rowing) (see Supplemental Material). Questions were closed-ended multiple-choice questions that required each patient to respond before proceeding to the next item. Incorporated into the survey were 4 sports options, allowing patients to specify (1) their participation status both pre- and postoperatively; (2) their capacity to resume activities with the same level of intensity, frequency, and duration postoperatively; and (3) the timeline of their postoperative return to each sport. In addition, there were questions on sport-specific considerations, such as equipment and technique. These questionnaires have not been validated. Patients were contacted via email. If a patient did not fill out the survey after 3 contact attempts, these were considered lost to follow-up. A total of 1204 patients met study criteria.
Study Variables
Preoperative diagnoses, implant type, age, sex, arm dominance, body mass index (BMI), type 2 diabetes mellitus, tobacco use, and length of follow-up were collected. Active range of motion (ROM) and patient-reported outcomes (PROs) were documented at baseline and postoperatively. ROM measurements including forward flexion, external rotation at the side, and internal rotation were recorded by the treating surgeon or a physician assistant at the initial and most recent in-person appointment. Internal rotation was numerically scaled based on the nearest spinal level achieved with the thumb (i.e., T10 = 10; T12 = 12; L2 = 14; L4 = 16; S1 = 18; hip = 20). Pre- and postoperative PROs, including the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale for pain (VAS), and Subjective Shoulder Value, and satisfaction level were collected from electronic medical records and the emailed questionnaire, respectively.
Statistical Analysis
Categorical and continuous variables were identified for analysis. Categorical variables were reported as fractions and percentages, whereas continuous variables were reported as means and standard deviations. Questionnaire responses were displayed descriptively for all patients and per sport. Chi-square tests were employed to analyze return rates overall and for each sport based on arm dominance. Analysis of variance was performed to compare preoperative and postoperative scores between sports. Paired t test was used to assess for clinical improvement within the same sport. A P value threshold of <.05 was used to denote statistical significance.
Results
A total of 1204 patients were contacted, of which 124 responded. Of these, 7 declined to participate and 15 did not participate in outdoorsman sports. Thus, a total of 102 patients met the inclusion criteria and were included for analysis. Of these 102 patients, 30 (29%) participated in fishing, 41 (40%) in firearm use, 6 (6%) in archery, and 25 (25%) in rowing (Table 1). When considering all patients, the mean age, follow-up, and BMI were 68 ± 7 years, 38 ± 12 months, and 30 ± 6 kg/m2, respectively. Of total patients, 78 (76%) were male, with the highest male predominance seen with fishing (25/30; 83%). Nearly half of patients (53/102; 52%) underwent RSA, with the majority of patients (74/102; 73%) treated for primary glenohumeral arthritis. Pre- and postoperative PROs and ROM are displayed for all patients and per sport in Table 2. PROs improved significantly in all patients and when separated by sport.
Baseline Demographics a
BMI, body mass index; DM 2, diabetes mellitus type 2; GHOA, glenohumeral arthritis; RCA, rotator cuff arthropathy; RSA, reverse shoulder arthroplasty; TSA, total shoulder arthroplasty.
Clinical Outcomes a
ASES, American Shoulder and Elbow Surgeons; SSV, Subjective Shoulder Value; VAS, visual analog scale for pain.
Sports Outcomes
In total, 77% of patients (79/102) returned to outdoorsman sports after shoulder arthroplasty, with 61% (48/79) returning within 6 months and 86% (68/79) reporting being mostly to completely satisfied with their performance postoperatively; additionally, 59% of patients (47/79) reported participating in sports ≥4 days per week. Furthermore, 77% (61/79) reported returning to at least the same level of play compared with before surgery. When considering arm dominance, the return rate was similar between patients who underwent surgery on their dominant arm (40/54; 74%) and those treated on their nondominant arm (39/48; 81%) (P = .39).
Fishing
A total of 30 patients reported being consistently interested in fishing. Most patients (18/30; 60%) reported overhead casting as their principal method of fishing before surgery. Postoperatively, 24 of 30 patients (80%) reported returning to fishing. Of these, 14 of 24 patients (58%) reported using the overhead cast method, which represents 78% (14/18) of those that had been using this method before surgery. Of the total who returned to fishing, 18 patients (75%) were able to do so ≤6 months from surgery; 23 of the 24 patients (96%) reported that their performance had at least remained the same after surgery, and 13 patients (54%) felt more comfortable fishing compared with before surgery (Supplemental Material, available separately; Appendix Table A1). Additionally, 21 of the 24 patients (88%) reported being mostly to completely satisfied with their postoperative performance. When considering arm dominance, the return rate was similar between patients who underwent surgery on their dominant arm (11/14; 79%) and those treated on their nondominant arm (13/16; 81%) (P = .86).
Shooting
A total of 41 patients reported shooting for recreational purposes. Patients reported using handguns (17/41; 41%) and rifles (20/41; 49%) as their most frequent firearm of choice preoperatively. Postoperatively, 35 of 41 patients (85%) returned to shooting, with 18 of these 35 patients (51%) returning to shooting ≤6 months from surgery, 13 (37%) using handguns, and 19 (54%) using rifles as their firearm of choice (Supplementary Material; Appendix Table A2). Furthermore, 32 of the patients who returned (91%) reported being mostly to completely satisfied with their postoperative performance. When considering arm dominance, the return rate was similar between patients who underwent surgery on their dominant arm (18/22; 82%) and those treated on their nondominant arm (17/19; 89%) (P = .49).
Archery
Six patients participated in drawback archery for hunting or target practice. No patients used crossbows. Three patients of the 6 (50%) reported shooting <10 arrows per session. Four of the patients (67%) were uncomfortable with archery before surgery. Postoperatively, 3 patients (50%) returned to archery, with 2 of the 3 patients (67%) shooting again ≤6 months from surgery. Of those who returned to archery, 2 patients (67%) reported shooting at least the same number of arrows compared with before surgery and all 3 patients (100%) reported being mostly to completely satisfied with their postoperative performance (Supplementary Material; Appendix Table A3). When considering arm dominance, the return rate was similar between patients who underwent surgery on their dominant arm (2/4; 50%) and those treated on their nondominant arm (1/2; 50%) (P ≥ .99).
Rowing
A total of 25 patients participated in rowing. Sixteen patients (16/25; 64%) reported at least monthly involvement. Only 5 of the 25 patients (20%) reported feeling comfortable rowing for ≥1 hour. Postoperatively, 17 patients (68%) returned to rowing. Of those who returned to rowing, 8 patients (47%) reported being able to row for ≥1 hour. In addition, 10 of the 17 patients (59%) returned to rowing ≤6 months from surgery. Among those who returned, 16 patients (94%) reported rowing at least the same frequency as before and 14 patients (82%) were using the same paddling technique as before. Furthermore, 16 patients (94%) reported being mostly to completely satisfied with their postoperative performance (Supplementary Material; Appendix Table A4). When considering arm dominance, the return rate was similar between patients who underwent surgery on their dominant arm (9/14; 64%) and those treated on their nondominant arm (8/11; 73%) (P = .65).
Discussion
This retrospective study analyzed and described return to outdoorsman sports, including fishing, firearm use, archery, and rowing, in patients who underwent total shoulder arthroplasty. Overall, 77% patients returned to outdoorsman sports, with 61% returning within 6 months and 86% reporting being mostly to completely satisfied with their performance postoperatively. Although all patients achieved significant clinical improvement, postoperative VAS and ASES were significantly different between sports, with higher VAS and lower ASES scores with shooting. Despite having greater pain, firearm users showed a higher return-to-sport rate compared with other outdoorsman sports.
Shoulder arthroplasty has consistently shown positive clinical outcomes and high levels of return to sports.7,17 In our study, all outdoorsman groups experienced significant improvement from baseline and 77% reported returning to sport. Although not specific to outdoorsman sports, Küffer et al 10 reported in their systematic review of 23 studies a return-to-sport rate of 76% with a mean return time of 7 months after shoulder arthroplasty. Similarly, Liu et al 15 reported a return rate of 85% after shoulder arthroplasty in their systematic review of 13 studies. The difference in rates could possibly be due to patients returning to sports with varying shoulder demands. A retrospective study by Tangtiphaiboontana et al 20 of 109 RSA patients demonstrated a significantly higher return rate with low- and medium-demand sports compared with high-demand sports (77% vs 63%; P = .005). Studies have also shown that those with reportedly higher preoperative activity levels were most likely to return to play.1,10,15,20 This latter statement could shed light on future research to investigate a possible link between patient resilience and pre- and postoperative sport activity.
Sports with low to medium demand exhibit higher rates of return to activity after shoulder arthroplasty.9,10,20 Patients engaged in such activities, including fishing, cycling, and skiing, often experience a quicker return, frequently within 6 months postoperatively. 9 Notably, our study revealed that 75% of those resuming fishing did so within the initial 6 months. A retrospective study by Lachance et al 12 involving 19 RSA patients reported a 79% return rate to fishing, with 67% maintaining postoperative casting distance. Our study showed an 80% return rate among respondents, and among them, 78% were comfortably implementing the overhead casting technique. The ability to cast is intricately linked to such factors as range of motion, grip, and technique.11,16 The sequential movement, transitioning from peak shoulder internal rotation to elbow extension and concluding with wrist ulnar deviation, determines peak angular velocity. 2 Moreover, a grip characterized by substantial hand pronation during the cast may contribute to heightened upper extremity discomfort compared with a more neutral grip.11,16 Optimizing grip and casting techniques may enhance a patient’s postarthroplasty return to fishing by mitigating stress on the glenohumeral joint and prosthesis.
Engaging in high-demand sports such as rowing, archery, and shooting places varied kinetic demands on the shoulder.6,20 In their retrospective study involving 109 RSA patients, Fink Barnes et al 6 concluded that returning to activities requiring greater abduction and external rotation, such as archery and rowing, posed more challenges for patients. Achieving a successful drawback in archery involves peak muscle activity at the biceps in the draw arm and at the triceps and lateral deltoid in the bow arm.14,18 The release phase places greater stress on the teres minor, and prolonged abduction during the draw phase may lead to subscapularis damage. Studies indicate heightened stress on the supraspinatus, infraspinatus, teres minor, and long head biceps tendon in the draw arm, explaining the elevated incidence of tendonitis among elite archers.14,22 Lachance et al’s 13 retrospective review of 13 RSA patients found that 54% returned to archery, with 4 patients switching to a crossbow. Alternatively, Tangtiphaiboontana et al 20 reported a 40% (2/5) return to archery. In our study, 50% (3/6) of patients returned to archery. Like archery dynamics, the kayak stroke offers different but unique shoulder kinematics. The kayak stroke involves the recruitment of multiple muscles during the pull-through, exit, and recovery stroke phases, demonstrating consistent activity in the supraspinatus, latissimus dorsi, and upper trapezius muscles. 21 Electromyographic evidence indicates that supraspinatus activity peaks at 80% of its maximum capacity during the pull-through phase, making return challenging for patients. Küffer et al’s 10 systematic review reported a 67% return rate to kayaking or rowing after shoulder arthroplasty, similar to our observed rate of 68%. Shooting introduces additional complexities, primarily due to recoil—the force directed backward toward the shoulder upon triggering. 19 Approximately 70% of the rifle’s recoil is transmitted through the shoulder, with the remainder distributed through the grip, cheek, and forestock. 8 Rider et al 19 reported a 25% return rate in their retrospective review of 245 shoulder arthroplasty patients, while Tangtiphaiboontana et al 20 noted an 82% return to shooting after RSA. Our findings align more closely with the latter study, revealing an 85% return rate to shooting. Acknowledging the various factors influencing a patient’s ability to return to these high-demand sports is essential for establishing realistic preoperative expectations.
Limitations
This study has several limitations. First, there was a large loss to follow-up despite 3 contact attempts, potentially introducing attrition bias. Second, its retrospective design increases the risk of selection bias. Third, the small sample size increases the risk of a type II error when analyzing clinical outcomes per sport. Fourth, the questionnaire's nature limited the capacity for inferential statistics, leading to the presentation of results in a descriptive manner, akin to previous studies. Fifth, there exists potential for recall bias, as the implementation of the questionnaire relies on patients’ recollections of their preoperative sport involvement. Sixth, the lack of standardization of questionnaires across studies complicates the comparison of results. Seventh, due to the small sample size, there was no comparison between TSA and RSA. Last, we did not perform a multivariate analysis for the effect of age, sex, laterality, hand dominance, or preoperative diagnosis on a patient's ability to return to sports. This analysis could be valuable in future research.
Conclusion
Participants had a 77% return to outdoorsman sports, such as fishing, shooting, archery, and rowing, with >50% doing so ≤6 months from primary total shoulder arthroplasty. Respondents who participated in rowing and archery returned at lower rates compared with fishing and shooting, despite shooting's showing higher pain postoperatively. Activities entailing greater shoulder demands may hinder a patient's ability to return after arthroplasty.
Supplemental Material
sj-pdf-1-ojs-10.1177_23259671251326076 – Supplemental material for Return to Outdoorsman Sports After Primary Total Shoulder Arthroplasty
Supplemental material, sj-pdf-1-ojs-10.1177_23259671251326076 for Return to Outdoorsman Sports After Primary Total Shoulder Arthroplasty by Javier Ardebol, Tammy Hoffman, Colin T. Donnelly, Matthew B. Noble, Lisa A. Galasso, Dan Guttmann and Patrick J. Denard in Orthopaedic Journal of Sports Medicine
Footnotes
Final revision submitted October 2, 2024; accepted November 14, 2024.
One or more of the authors has declared the following potential conflict of interest or source of funding: M.B.N. has received a grant from Arthrex and support for education from Rock Medical Orthopedics. L.A.G. has received a grant from Arthrex, education payments from Arthrex and Pinnacle Inc, and hospitality payments from Stryker and Arthrex. D.G. has received grant funding from Medacta, Stryker, Smith & Nephew, DonJoy, and Breg and consulting fees from Arthrex. P.J.D. has received consulting fees from Arthrex, Interger Holdings, and Pacira Pharmaceuticals; royalties from Arthrex; and support for education from Steelhead Surgical. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was obtained from Salus Institutional Review Board (SORF-05-2022-1).
References
Supplementary Material
Please find the following supplemental material available below.
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