Diagnosing the direction of shoulder instability in rugby players.

The muscular characteristics of rugby players may make diagnosing the direction of shoulder instability and labral pathology challenging. This study aimed to assess the accuracy of clinical examination and specifically instability tests, in diagnosing the direction of shoulder instability in rugby players. One-hundred-and-forty rugby players, who had undergone a shoulder stabilization procedure, over a 55-month period, were included in this study. The mean age was 21.5 years with 137 males. Data collected included clinical examination and intraoperative findings. The two were compared to calculate the diagnostic accuracy of special tests for instability. The Anterior Apprehension Test had good sensitivity (82.7%), specificity (100%) and PPV (100%) but poor NPV (55.8%). All posterior instability tests demonstrated a sensitivity of over 85%, but all had a specificity of 25% or less. In 83.6% of cases the direction of instability was correctly identified from history and examination. Anterior instability was correctly diagnosed in 78.9% of cases and posterior in 100.0%. The poor NPV of the anterior apprehension test suggests that clinicians should be suspicious of anterior instability in rugby shoulders even in the light of negative examination findings. Positive posterior instability tests are highly suggestive of posterior instability in rugby players.

Surgical repair and rehabilitation of a ruptured pectoralis major muscle in a professional footballer - A case report.

BACKGROUND: Pectoralis Major ruptures normally occur in activities and sports such as powerlifting and American football or rugby. It is a rarely reported phenomena in professional footballers. Surgery is normally considered the choice of management to enable a safe return to play with conservatively managed ruptures often resulting in significant strength deficits. This case report highlights the management of a pectoralis major rupture in a professional footballer. CASE PRESENTATION: A 27-year-old professional footballer sustained a left pectoralis major rupture after falling to the floor. A subsequent MRI reported a 5cm retraction of the pectoralis major tendon from its attachment at the humerus. Following a consultation with an orthopaedic surgeon the player underwent a pectoralis major surgical repair. Following surgery, the player underwent a rehabilitation programme under the care of the club physiotherapist. Return to play testing included a handheld dynamometer test, closed kinetic chain upper extremity test and progressive falling activities. The player returned to full contact training after 87 days. CONCLUSION: This case study demonstrates a successful return to professional football following a pectoralis major rupture and supports the notion that surgical repair of these injuries produces a favourable outcome in professional athletes when returning to sport.

Imaging Posterior Instability of the Shoulder.

Posterior instability of the shoulder is much less common than anterior instability with a clinical presentation that is often less obvious, making the diagnosis more challenging and more easily missed. We describe the imaging findings of posterior instability so the radiologist can make the diagnosis and provide a detailed description, enabling the surgeon to make more informed decisions regarding management and surgery.

Shoulder hydrodilatation for primary, post-traumatic and post-operative adhesive capsulitis.

BACKGROUND: Adhesive capsulitis (frozen shoulder) is characterised by pain and loss of range of motion of the glenohumeral joint. It can be present as primary (idiopathic) or secondary to surgery, trauma or other conditions that restrict the use of the shoulder joint. Various treatment options have been adopted including physiotherapy, manipulation under anaesthetic, hydrodilatation and arthroscopic or open capsular release but the optimal form of management remains uncertain. OBJECTIVES: The purpose of the study was to assess the clinical outcome of glenohumeral hydrodilatation in three cohorts of patients with different aetiologies with adhesive capsulitis. STUDY DESIGN & METHODS: We carried out a retrospective study of patient who underwent hydrodilatation for adhesive capsulitis between 2013 and 2015. The procedure was performed by a specialist musculoskeletal radiologist under radiological guidance. The injection consisted of steroids, local anaesthetics and NaCl solution with a target volume around 35 mL. Our outcome measures were range of motion, and pre- and post-operative pain. Patients were divided into three groups based on the presumed cause of their stiffness: idiopathic, post-traumatic and post-surgical. RESULTS: Two hundred fifty patients were included, with a mean age of 59 years (range: 20-79). Of these, 180 had idiopathic primary adhesive capsulitis (27 were diabetic), 23 were post-traumatic, and 20 following surgical procedures. Thirty-four required further intervention following initial hydrodilatation with 8 undergoing repeat hydrodilatation, and 26 requiring arthroscopic capsular release. The diabetic group accounted for 16 capsular releases and 4 repeat procedures, while the idiopathic group accounted for 9 and 4, respectively. One patient required capsular release in the surgical group. An improvement was recorded in ROM in all groups with mean abduction improving from 59° to 110°, flexion from 50° to 120° and external rotation from 20° to 50°. With regards to pain, the majority showed an improvement from severe or moderate pain to no or mild pain. CONCLUSIONS: Results show that hydrodilatation resulted in an improvement in all outcome measures, with only a small number of patients, especially those with diabetes, needing further procedures or showing no improvement in range of motion and pain. There was no difference between the post-traumatic and post-surgical groups.

Superior capsular reconstruction for irreparable rotator cuff tears: A literature review and specialist practice report.

BACKGROUND: Recent evidence continues to confirm the effectiveness of arthroscopic superior capsular reconstruction (SCR) in relieving pain and improving function in an irreparable cuff deficient shoulder. This paper presents an up-to-date literature review on SCRand a tertiary referral unit experience in the United Kingdom. METHODS: Data was prospectively collected on patients undergoing SCR for irreparable rotator cuff tears using a dermal allograft. Patients with already established arthritis were excluded. The first 49 consecutive cases performed by 3 surgeons over 3 years (including their learning curve) with average follow-up of 19 months (range 3-37 months) were analysed. The outcomes assessed were re-operation rates, patient satisfaction and complications. The study group was analysed to identify the factors predicting outcomes. RESULTS: The average age of the cohort was 56 years. The re-operation rate in this group was 12.2% with each of these 6 patients subsequently undergoing a reverse total shoulder arthroplasty. Forty (82%) patients were satisfied with the outcome of the procedure with 35 (72%) of them showing complete pain relief, 5 (10%) having dull aches and clicks and the remaining 9 (18%) unsatisfied due to pain. There was no difference in satisfaction rates between different age groups (p > 0.05). The pre-operative factors associated with poor outcomes included patients with multiple previous surgeries on the same shoulder (p = 0.02) and teres minor atrophy or tear (p = 0.03). The other factors that showed a trend towards inferior outcomes (but not statistically significant) included patients with degenerative tears, symptoms of longer duration (>24 months) and subscapularis tear/atrophy. No serious adverse effects such as graft rejection, infection or neuro-vascular injury were observed. CONCLUSION: Early results of superior capsular reconstruction are promising and may offer an answer to a challenging group of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery.

Rehabilitation following rotator cuff repair: A multi-centre pilot & feasibility randomised controlled trial (RaCeR).

OBJECTIVE: To evaluate the feasibility of a multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of early patient-directed rehabilitation versus standard rehabilitation following surgical repair of the rotator cuff of the shoulder. DESIGN: Two-arm, multi-centre pilot and feasibility randomised controlled trial. SETTING: Five National Health Service hospitals in England. PARTICIPANTS: Adults (n = 73) with non-traumatic rotator cuff tears scheduled for repair were recruited and randomly allocated remotely prior to surgery. INTERVENTIONS: Early patient-directed rehabilitation (n = 37); advised to remove their sling as soon as able and move as symptoms allow. Standard rehabilitation (n = 36); sling immobilisation for four weeks. MEASURES: (1) Randomisation of 20% or more eligible patients. (2) Difference in time out of sling of 40% or more between groups. (3) Follow-up greater than 70%. RESULTS: 73/185 (39%) potentially eligible patients were randomised. Twenty participants were withdrawn, 11 due to not receiving rotator cuff repair. The between-group difference in proportions of participants who exceeded the cut-off of 222.6 hours out of the sling was 50% (80% CI = 29%, 72%), with the early patient-directed rehabilitation group reporting greater time out of sling. 52/73 (71%) and 52/53 (98%) participants were followed-up at 12 weeks when withdrawals were included and excluded respectively. Eighteen full-thickness re-tears were reported (early patient-directed rehabilitation = 7, standard rehabilitation = 11). Five serious adverse events were reported. CONCLUSION: A main randomised controlled trial is feasible but would require allocation of participants following surgery to counter the issue of withdrawal due to not receiving surgery.

An OrthoRadiological review of superior capsularreconstruction in the shoulder.

Superior capsular reconstruction (SCR) is an emerging surgical technique used to treat patients with irreparable rotator cuff tears. In this procedure, a graft is attached between the superior glenoid and the greater tuberosity, with the aim of optimising glenohumeral joint function and stability. Pre-operative radiological evaluation of patients having such cuff tears is crucial for appropriate patient selection. Such imaging is particularly useful for the assessment of the cuff tear size and location, muscle wasting, fatty infiltration and the presence of any glenohumeral joint arthritis. In addition, post-operative imaging is useful in assessing graft integrity, with specific patterns of graft failure now being recognised on imaging. This article will discuss the indications and contraindications for this procedure, and review the biomechanical concepts of SCR in improving glenohumeral joint stability and restoring the force couples around the joint. The radiological appearances of the intact graft and the various patterns of graft failure will be illustrated, along with various radiological examples.

In Vivo Randomized Controlled Study of the Bone Response of All-Suture Anchors and Biocomposite Anchors.

BACKGROUND: Suture anchors are widely used for labral reconstruction surgery. However, there has been some concern over the development of osteolysis around the anchor. This has been reported for both biocomposite and all-suture anchors, but they have not been compared directly in vivo. PURPOSE: To compare the bone response to 2 common suture anchors: a traditional biocomposite push-fit anchor and an all-suture anchor. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Included in this study were 17 patients with a total of 37 unique suture anchors. Magnetic resonance imaging scans were performed at 3 weeks and 6 months postoperatively. A total of 38 senior radiologists and shoulder surgeons evaluated the images using a previously validated system for grading the bone response around suture anchors. The mean difference in grading at 3 weeks and 6 months was calculated using unpaired t tests, and the interrater reliability was evaluated with an intraclass correlation coefficient (ICC). RESULTS: At 3 weeks, there was no statistically significant difference in the degree of osteolysis surrounding each suture anchor type (P = .258), with little bone response. However, on the 6-month scans, there was a significantly lower level of osteolysis seen in the all-suture anchors compared with the biocomposite anchors (P = .040). Interrater reliability was excellent, with an ICC value of 0.975 (95% CI, 0.962-0.985). CONCLUSION: All-suture anchors cause significantly less osteolysis in glenoid bone at 6 months compared with biocomposite anchors.

Failed Latarjet surgery: why, how, and what next?

BACKGROUND: The Latarjet procedure is an established and popular procedure for recurrent anterior shoulder instability; however, to our knowledge, few studies have reported on the outcomes of revision for failed Latarjet surgery. We reviewed the causes and management of recurrent instability after previous Latarjet stabilization surgery. The outcomes of revision surgery were also evaluated. METHODS: A retrospective analysis of prospective data in patients undergoing revision surgery after failed Latarjet stabilization was conducted. Data were collected over a 5-year period and included patient demographics, clinical presentation, cause of recurrent instability, indications for revision surgery, intraoperative analysis, outcomes of revision surgery, and return to sport. RESULTS: We identified 16 patients (12 male and 4 female patients) who underwent revision surgery for recurrent instability after Latarjet stabilization. Of these patients, 11 were athletes: 9 professional and 2 amateur athletes. The mean age at revision was 29.9 ± 8.9 years (range, 17-50 years). The indications for revision were anterior instability in 11 patients, posterior instability in 4, and both anterior and posterior instability in 1. Of the anterior instability cases, 54.5% were due to coracoid nonunion and 36.4% were due to capsular failure (retear). All posterior instability cases had posterior capsulolabral injuries, and the mean Beighton score in this group was 6 or higher. One patient had a failed Latarjet procedure with coracoid nonunion and a posterior labral tear. CONCLUSION: Coracoid nonunion was the most common cause of recurrence after Latarjet stabilization, requiring an Eden-Hybinette procedure. The patients who returned with posterior instability had a high incidence of hypermobility and could be treated successfully by arthroscopic techniques.

Scapula Fractures in Elite Soccer and Rugby Players.

BACKGROUND: Scapula fractures are uncommon in sports and are poorly understood in this patient group. PURPOSE: To report on scapula fractures in contact and collision athletes and assess the injury patterns of different mechanisms of injury. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective case series was performed of all sports-related scapula fractures treated at a single institution between 2007 and 2015. The mechanisms of injury were divided into direct lateral impact, fall onto an outstretched arm, or abduction/external rotation. RESULTS: A total of 11 patients were identified: 9 professional rugby players, 1 professional soccer player, and 1 amateur soccer player. The mean age was 28 years (range, 18-35 years). The mean return to play was 127 days in those treated nonoperatively and 163 days in those treated operatively. A direct impact mechanism occurred in 7 patients, all of whom sustained glenoid neck and body fractures and were treated nonoperatively. Two rugby players had a concomitant suprascapular nerve injury. An outstretched arm mechanism occurred in 2 cases, leading to posterior and inferior glenoid fractures. Both patients were treated operatively. An abduction/external rotation mechanism occurred in 2 cases, resulting in an anteroinferior and an anterior glenoid rim fracture. One case was treated operatively and the other was treated nonoperatively. Of those with glenoid fractures, 75% were not visible on plain radiographs and required further imaging. CONCLUSION: Scapula fractures acquired in sports are a serious injury with a prolonged recovery period. The mechanism of injury can help predict the injury pattern and highlight the need for further imaging. There is a high association with suprascapular nerve injuries.

The Incidence of Traumatic Posterior and Combined Labral Tears in Patients Undergoing Arthroscopic Shoulder Stabilization.

BACKGROUND: Posterior and combined shoulder instabilities have been reported as accounting for only 2% to 5% of cases. More recently, an increased incidence of posterior capsulolabral tear has been reported. PURPOSE: To assess the incidence of posterior and combined labral tears in a large cohort of patients with surgically treated shoulder labral tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This was a retrospective study that evaluated 442 patients who underwent an arthroscopic capsulolabral repair over a 3-year period. Patients were categorized according to the location of their labral tear and whether their injury was sustained during sporting or nonsporting activity. Proportions of labral tears between sporting and nonsporting populations were compared using the chi-square test. RESULTS: Patients had a mean age of 25.9 years and 89.6% were male. Isolated anterior labral tears occurred in 52.9%, with posterior and combined anteroposterior labral tears accounting for 16.3% and 30.8%, respectively. The frequency of posterior and combined lesions was greater in the sporting population compared with the nonsporting population (P = .013). CONCLUSION: Posterior and combined labral tears are more prevalent than previously reported, particularly in the sporting population.

Protocol for a multi-centre pilot and feasibility randomised controlled trial with a nested qualitative study: rehabilitation following rotator cuff repair (the RaCeR study).

BACKGROUND: Shoulder pain is a highly prevalent complaint and disorders of the rotator cuff, including tears, are thought to be the most common cause. The number of operations repair the torn rotator cuff has risen significantly in recent years. While surgical techniques have progressed, becoming less invasive and more secure, rehabilitation programmes have remained largely like those initially developed when surgical techniques were less advanced and more invasive. Uncertainty remains in relation to the length of post-surgical immobilisation and the amount of early load permitted at the repair site. In the context of this uncertainty, current practice is to follow a generally cautious approach, including long periods of immobilisation in a sling and avoidance of early active rehabilitation. Systematic review evidence suggests early mobilisation might be beneficial but further high-quality studies are required to evaluate this. METHODS/DESIGN: RaCeR is a two-arm, multi-centre pilot and feasibility randomised controlled trial with nested qualitative interviews. A total of 76 patients with non-traumatic rotator cuff tears who are scheduled to have a surgical repair will be recruited from up to five UK NHS hospitals and randomly allocated to either early patient-directed rehabilitation or standard rehabilitation that incorporates sling immobilisation. RaCeR will assess the feasibility of a future, substantive, multi-centre randomised controlled trial to test the hypothesis that, compared to standard rehabilitation incorporating sling immobilisation, early patient-directed rehabilitation is both more clinically effective and more cost-effective. In addition, a sample of patients and clinicians will be interviewed to understand the acceptability of the interventions and the barriers and enablers to adherence to the interventions. DISCUSSION: Research to date suggests that there is the possibility of reducing the patient burden associated with post-operative immobilisation following surgery to repair the torn rotator cuff and improve clinical outcomes. There is a clear need for a high-quality, adequately powered, randomised trial to better inform clinical practice. Prior to a large-scale trial, we first need to undertake a pilot and feasibility trial to address current uncertainties about recruitment, retention and barriers to adherence to the interventions, particularly in relation to whether patients will be willing to begin moving their arm early after their operation. TRIAL REGISTRATION: ISRCTN Registry, 18357968 . Registered on 10 August 2018.

The combined shoulder assessment: a convenient method for obtaining equivalent outcome scores.

BACKGROUND: Outcome scores are useful tools with respect to quantifying how pain and limitations in strength and movement affect the patient's functionality and lifestyle. Three shoulder outcome methods [Oxford, Constant and QuickDASH (Disability of the Arm, Shoulder and Hand)] are commonly used in practice but collectively consist of 34 questions, taking approximately 7 min to complete. We have developed a concise shoulder assessment to derive three equivalent outcome scores in a 12-item patient-reporting questionnaire. METHODS: Outcome scores from 1285 outpatients of an upper limb clinic were collected. The patient cohort consisted of 462 females and 823 males with a mean (SD) age of 47.2 (16.79) years (range 13 years to 90 years). Using a correlation matrix, a 12-item questionnaire was drafted. The combined shoulder assessment was validated by 227 patients; consisting of 101 females and 126 males with a mean (SD) age of 47.91 (16.63) years (range 13 years to 88 years). RESULTS: Agreement was achieved between the two methods, with an equivalent Oxford Shoulder Score intraclass correlation (ICC) of 0.930, equivalent Constant Shoulder Score ICC of 0.942 and equivalent QuickDASH ICC of 0.869. Bland-Altman analyses showed no systematic differences. Large effect sizes highlighted the responsiveness to change. CONCLUSIONS: The new combined shoulder assessment is a more convenient and patient-friendly method to obtain equivalent Oxford, Constant and QuickDASH shoulder outcome scores.

Surgical reconstruction of unrepairable pectoralis major rupture using tendo-achilles allograft.

Rupture of the pectoralis major remains an infrequent injury, although, recently, it has been reported more commonly as a result of the expansion and increasing popularity of competitive sports, as well as developments in sports medicine. A number of surgical repair techniques have been described for direct repair in the acute setting. However, on occasion, the pectoralis major muscle is so retracted that a tension-free direct repair is not possible. We describe a technique for allograft reconstruction of the pectoralis major, with our preliminary outcomes, where it is found or anticipated that a direct repair is not possible.

Recurrence After Arthroscopic Labral Repair for Traumatic Anterior Instability in Adolescent Rugby and Contact Athletes.

BACKGROUND: Traumatic glenohumeral dislocation of the shoulder is one of the most common shoulder injuries, especially among adolescent athletes. The treatment of instability for young athletes continues to be controversial owing to high recurrence rates. PURPOSE: To investigate the recurrence rate of shoulder instability after arthroscopic capsulolabral repair for adolescent contact and collision athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Sixty-seven patients aged <18 years underwent an arthroscopic labral repair over a 5-year period. The mean ± SD age of the cohort was 16.3 ± 0.9 years (range, 14-17 years) and consisted of 1 female and 66 males. All patients were contact athletes, with 62 of 67 playing rugby. Demographic, clinical, and intraoperative data for all patients with shoulder instability were recorded in our database. Recurrence rates were recorded and relative risks calculated. RESULTS: At a follow-up of 33 ± 20 months, 34 of 67 patients had recurrent instability for an overall recurrence rate of 51% among adolescent contact athletes after arthroscopic labral repair surgery. The mean time to recurrence was 68.1 ± 45.3 weeks. All recurrences occurred as a result of a further sporting injury. Relative risk analysis demonstrated that athletes aged <16 years had 2.2 (95% CI, 1.2-2.1) times the risk of developing a further instability episode as compared with athletes aged ≥16 years at the time of index surgery ( P = .0002). The recurrence rate among adolescent athletes after bony Bankart repairs was 57.9% versus 47.9% for soft tissue labral repairs ( P = .4698). The incidence of Hill-Sachs lesions ( P = .0002) and bony Bankart lesions ( P = .009) among adolescent athletes was significantly higher than among adult controls ( P = .002). The presence of bone loss did not lead to a significant increase in recurrence rate over and above the effect of age. CONCLUSION: Adolescent contact athletes undergoing arthroscopic labral repair have an overall recurrence rate of 51%. Rugby players who undergo primary arthroscopic shoulder stabilization aged <16 years have 2.2 times the risk of developing a further instability episode when compared with athletes aged ≥16 years at the time of index surgery, with a recurrence rate of 93%.

Functional outcome of open acromioclavicular joint stabilization for instability following distal clavicle resection.

BACKGROUND: Acromioclavicular joint instability following distal clavicle resection can result in considerable pain and dysfunction. METHOD: We present a review of 13 patients who underwent ACJ stabilization following one or more distal clavicle resection procedures. RESULTS: The mean Quick DASH and CM scores were 26(0-57) and 73(46-100) respectively. All but one patient reported an improvement in the pain component of their CM score and in the work component of the Quick DASH score. DISCUSSION: Open ACJ stabilization to treat instability following distal clavicle resection resulted in improved functional scores, pain scores and facilitated return to work in most patients.Level of evidence IV.

Arthroscopic repair of bony Bankart lesions in collision athletes.

BACKGROUND: The present study aimed to report the outcomes of acute and subacute arthroscopic bony Bankart repairs in collision athletes. METHODS: We reviewed 22 consecutive rugby players with traumatic anterior glenohumeral instability who underwent arthroscopic bony Bankart repair within 4 months of injury over a 2-year period. All lesions were less than 25% of the glenoid bony area. RESULTS: A significant improvement was noted at three months and was maintained at 28 months postoperatively. The mean Constant score improved from 61.5 to 84.1, the mean Oxford shoulder score decreased from 26.3 to 13.6 and the mean Oxford instability score decreased from 42.9 to 13.5. The mean satisfaction score was 8.3 out of 10 at final follow-up. All patients returned to their pre-injury sporting level. Twenty patients (91%) remained stable and asymptomatic, although two (9%) had recurrent instability after further traumatic sports injuries. One required a modified Latarjet procedure, whereas the other patient sustained a soft tissue Bankart lesion and had a revision arthroscopic repair. CONCLUSIONS: Acute and sub-acute bony Bankart lesions in collision athletes can be addressed through arthroscopic repair with a satisfactory outcome and return to pre-injury level of sport.

Surgery for the fractured clavicle: factors predicting nonunion.

BACKGROUND: This study identifies the reasons for failure after plate osteosynthesis of midshaft clavicle fractures, complication rates, and time to radiographic union. METHODS: A retrospective review of 84 consecutive patients who had undergone surgical fixation for a midshaft clavicle fracture was performed. RESULTS: There were 82 patients who were included for analysis and operated on by 11 different surgeons using a mixture of locking (63%) and nonlocking (37%) plates. The rate of osteosynthesis failure was 12.2%. A logistical regression analysis found that failure of osteosynthesis had no relationship to type of plate used (P = .82), gender (P = .42), number of proximal (P = .96) or distal (P = .63) screws to the fracture, or length of plate (P = .42). Smoking was found to be the only risk factor (P = .02) that increased failure rates after midshaft clavicle osteosynthesis. CONCLUSION: Smoking was the only identifiable risk factor to increase failure rates in clavicle osteosynthesis. Preoperative counseling can identify those at increased risk of implant failure and can help improve clinical results by implementing a smoking cessation plan.

Shoulder Injuries in Canoeing and Kayaking.

OBJECTIVE: We report the largest case series of shoulder injuries among paddlers so far to establish common mechanisms and patterns of injury. We also discuss how these injuries were managed and report the proportion of paddlers that return to paddlesport. DESIGN: Case series. SETTING: Upper Limb Unit, Wrightington Hospital, United Kingdom. Manchester Arm Clinic, United Kingdom. PATIENTS: Fifty-seven shoulder injuries to professional and recreational paddlers were reviewed at a mean follow-up time of 55 months from the first consultation. The patient cohort had a mean age of 36 years and consisted of 56% males. ASSESSMENT OF RISK FACTORS: Sex, mechanism of injury, acute/nonacute injury, and level of sport participation. MAIN OUTCOME MEASURES: Patient data were analyzed with regards to Constant score, QuickDASH score, and VAS satisfaction score before and after treatment. RESULTS: The most common mechanism of injury was a capsize which accounted for 15 (26%) injuries. Ten injuries caused by a capsize were labral tears all of which needed surgery. A significant improvement in patient outcome scores was noted. Patients were able to return to a high level of paddling such as 3 slalom paddlers who returned to international competition; one of whom had bilateral surgery. CONCLUSIONS: Paddlers most commonly injure their shoulder when preventing a capsize, during a capsize or while rolling. The paddles strokes performed at these times often require paddlers to place their shoulder in a dangerous abducted and externally rotated position. We believe this is one of the commonest causes of serious shoulder injuries to paddlers.