Return to Sports (RTS) Criteria for Overhead Athletes Following Shoulder Injury.

(5-10 minute read)

Shoulder injuries are a significant concern for athletes in overhead sports like tennis, handball, and volleyball. The incidence of these injuries range from 18% to 61%, depending on factors such as sports type, gender, and age⁹. For physiotherapists and sports clinicians, determining an athlete’s readiness to RTS while minimising the risk of re-injury is crucial.

How can a clinician be confident at getting athletes safely back to sports following shoulder injury?

In this blog I will cover the 5 outcome measures clinicians should assess when determining an athlete’s readiness to return to overhead sports:

1. Shoulder Strength
2. Range of Motion
3. Pain
4. Functional Patient-Reported Outcome Measure
5. Psychological Patient-Reported Outcome Measure

Below is an infographic with a summary of this blog:

RTS Criteria for Overhead Athletes After A Shoulder Injury

Current research on RTS criteria for shoulder injuries is somewhat limited^{3, 9}, emphasising the need for evidence-based practice supported by clinical expertise and guidelines⁸. The 2022 Bern Consensus outlines five key outcome measures for RTS criteria⁹:

1) Shoulder Strength

Considerations: Strength assessment should focus on:

• External Rotation/Internal Rotation (ER/IR) Ratio

• Absolute Strength of IR and ER

• Strength Relative to Body Weight

The literature provides normative data for the ER/IR ratio and absolute strength for handball, tennis, and volleyball⁴. Clinicians are encouraged to search for normative data specific to their athletes’ sports.

When comparing athletes’ strength within a team, the clinician should normalise their body weight for accurate comparison^{4, 9}.

Implications:

Absolute strength values are more important than the ER/IR strength ratio⁹. Clinicians must consider the absolute values when testing for strength. An athlete might score well on the ER/IR strength ratio but still have low overall muscle strength, increasing their risk of injury ³.

2) Range of Motion (ROM)

Clinical tips: Overhead sports athletes tends to develop an increased in glenohumeral ER and decrease in glenohumeral IR in the dominant arm. This changes appears to be an adaptive response to the demands of their sports. The exact causes of this change are uncertain, but they may be caused by bony adaptation, posterior capsule tightness, muscular weakness and tightness, or a combination of all these factors^13,14.

So be mindul of this adaptation when measuring your athletes ROM.

Controversy: Evidence on Glenohumeral Internal Rotation Deficit (GIRD) as a predictor of injury is mixed⁶. A systematic review of 2,195 athletes found no significant link between ROM deficits and injury risk, though this study had limitations such as poor methodological quality and limited generalisability to baseball players⁶.

In another study comparing the shoulder mobility of 47 professional World Tour tennis players with and without a history of pain found no significant side-to-side asymmetries in ROM. However, the pain history group exhibited significantly less internal rotation in both shoulders and a reduced total arc of motion compared to the non-pain history group. In summary, athletes with a history of shoulder pain tend to have decreased internal rotation and total rotational ROM. Therefore, it is crucial to compare these athletes against a healthy population, especially when addressing bilateral shoulder pain¹².

Although there are conflicting results on whether GIRD or reduced total rotational ROM do increase the risk of injuries, experts recommend the following when comparing between sides³:

• GIRD: < 20^o
• External Rotation Difference: < 5-10^o
• Total ER/IR ROM Difference: < 10^o

Implications:

ROM criteria should be tailored to individual sports and specific injury types⁹. Restoring pre-injury ROM may not always be feasible, particularly after surgeries like shoulder stabilisation. Comparing results with normative data when it is available is useful especially if the athlete has bilateral shoulder pain history.

3) Pain

Expert Recommendations:

• Athletes may return to training with some pain, but they should be pain-free when performing at their pre-injury level⁹.
• Clinicians should assess tissue irritability and severity by analysing pain during activity, after activity, and at night to guide the RTS process³.
• The Strategic Assessment of Risk and Risk Tolerance (StARRT) framework can be helpful in this decision-making process, involving athletes, coaches, and medical staff collaboratively^{3, 9, 10}.

4) Functional Patient-Reported Outcome Measures (PROMs)

Kerlan-Jobe Orthopaedic Clinic (KJOC) Questionnaire: This tool is recommended over the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for assessing functional outcomes in overhead shoulder athletes. The KJOC is more valid, reliable, and responsive for this population¹.

Clinical tips: Check out the KJOC questionnaire and compare that with other PROMs you use. Which content do you think are more specific for the overhead sporting population?

5) Psychological PROMs

It is important to assess the psychological readiness and kinesiophobia when making RTS decisions^{5,7, 11}. Fear of movement can lead to poor movement patterns, worsening shoulder pain, impaired physical function, and a lower quality of life^{7, 11}. Neglecting the psychological aspects may put athletes at risk of re-injury^{5, 9}.

• Injury Psychological Readiness to Return-to-Sport Scale (IPRRS): This is a valid tool in assessing psychological readiness in RTS for non-professional athletes suffering from various musculoskeletal injuries⁵.
• Tampa Scale of Kinesiophobia for Anterior Shoulder Instability (TSK-SI): This is a modified tool from the original TSK to assist clinicians in assessing and evaluating the severity of fear of movement, specifically in patients experiencing anterior shoulder instability¹¹. It has been tested for content validity to determine kinesiophobia in the shoulder population and can be useful for overhead shoulder athletes. Further research is needed to assess its external validity on larger groups and overhead athletes.

Implications: Psychological readiness is crucial for athletes returning to sports. Athletes should feel comfortable and have low fear of reinjury before advancing to the next phase of their RTS process⁹.

Limitations of Current Research

Current research often lacks methodological rigor and is not always applicable across different sports. There is a need for studies that examine the interplay between extrinsic and intrinsic factors, including sport-specific risks. Future research should adopt a biopsychosocial approach, integrating injury-specific and individual factors to better inform RTS decisions².

Conclusion

A comprehensive approach to RTS criteria involves evaluating strength, ROM, pain, functional and psychological aspects. Despite the current limitations in research, using a combination of these measures and tools like the StARRT framework can guide clinicians in making informed RTS decisions. Future research should focus on filling gaps in knowledge and improving methodological approaches to enhance our understanding of effective RTS strategies.

References:

1. Alberta, F. G., ElAttrache, N. S., Bissell, S., Mohr, K., Browdy, J., Yocum, L., & Jobe, F. (2010). The development and validation of a functional assessment tool for the upper extremity in the overhead athlete. The American Journal of Sports Medicine, 38(5), 903–911. https://doi.org/10.1177/0363546509355642
2. Bittencourt, N. F. N., Meeuwisse, W. H., Mendonça, L. D., Nettel-Aguirre, A., Ocarino, J. M., & Fonseca, S. T. (2016). Complex systems approach for sports injuries: Moving from risk factor identification to injury pattern recognition—narrative review and new concept. British Journal of Sports Medicine, 50(21), 1309–1314. https://doi.org/10.1136/bjsports-2015-095850
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6. Keller, R. A., De Giacomo, A. F., Neumann, J. A., Limpisvasti, O., & Tibone, J. E. (2018). Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: A meta-analysis and systematic review. Sports Health, 10(2), 125–132. https://doi.org/10.1177/1941738118756577
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8. Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn’t: It’s about integrating individual clinical expertise and the best external evidence. BMJ (Online), 312(7023), 71–72. https://doi.org/10.1136/bmj.312.7023.71
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10. Shrier, I. (2015). Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play decision-making. British Journal of Sports Medicine, 49(20), 1311–1315. https://doi.org/10.1136/bjsports-2014-094569
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