Article Reviewed by: Evan Peterson PT, DPT
“Return to sport” (RTS) has been a topic of discussion throughout the physical therapy community and has been researched for a variety of sports related injuries. One of the most common injuries looked at is ACL reconstruction or other lower extremity injuries. Not as widely discussed in return to sport is for athletes with shoulder injuries. In response to minimal high-quality evidence or guidelines to direct the return to sport decision making process, The Athlete Shoulder Consensus Group convened. Their goal was to create guidelines for clinicians, athletes, and coaches in order to provide the best quality care following shoulder injury. This particular statement was ascertained through the use of several rounds of questionnaires to obtain a consensus for rehabilitation in athletes. Following these surveys, the group had an in person discussion to solidify the results of the questionnaires. The consensus that was established is categorized into 4 main points. 1) Managing injury risk 2) Managing and progressing load 3) Shoulder injury rehabilitation and 4) evidence to support RTS decisions.
Managing Injury Risk
One of the first ideas brought up in managing risk is to understand the risk factors and predispositions athletes my have for each sport, as each sport involves different types of shoulder mechanics. Some risk factors have been pulled out that encompass many shoulder related sports include: loss of ROM, strength imbalances in rotational planes, change in load, player positions, level of sport (i.e. amateur or professional), previous history of shoulder injury, and psychosocial aspects. Attempting to screen athletes to prevent injury has not shown good evidence; however, it may be important for the RTS decision making process.
The consensus agreed that injury risk can be managed with both primary and secondary prevention programs. Primary programs should be initiated at young ages, particularly in overhead athletes, to allow decreased injury rates and increase the likelihood of adhering to healthy shoulder programs. It is recommended that secondary programs begin soon after injury. The article discusses general principles for training, including sport specific exercise, multiple joint exercises, emphasis on team training, and programs that take no more than 15 minutes at a time. They suggest these programs should be done at a minimum of twice per week to encourage adherence and self-efficacy.
Managing Shoulder Specific Loads in Athletes
Two types of load exist in the shoulder athlete. There is the external load such as a swimming pool’s resistance or the number of pitches in a game. Then there is the internal load, which is the physiological forces placed on the shoulder. It has been difficult to determine which of these factors is most important when managing load and currently there is no measure in order to determine the internal load. External load is much easier to measure (for example, number of pitches thrown); however, in games such as handball it is hard to have a “pitch count” due to the more chaotic nature of the game. At the consensus meeting, it was proposed to utilize a rating of perceived exertion scale to measure the internal load the shoulder. A combination of perceived exertion of the shoulder and overall fatigue of the body are good indicators to help assess a patient’s overall load. One study supported the idea that decreased external shoulder rotation strength or scapular dyskinesis is an indicator of decreased tolerance for load during sport.
Key Principles for Quality Rehab After Shoulder Injury in Athletes
Experts at the consensus meeting agreed that rehabilitation programs should emphasis on:
- Improving sport specific mechanics
- Challenging the patient in rehab at the limit of their capacity
- Building resilience in patients’ ability to load at the physiological and physiological level
- Multi-disciplinary decision making
The Key principles proposed are as follows:
- Let Irritability Guide Rehab Process
- Address Glenohumeral Range of Motion Deficits Using Active Therapy
- Address the Scapula but Do Not Screen for Dyskinesis
- Injury Tolerated Exercises
- Introduce Plyometric Activities Early
- Retrain the Brain/ Expose Shoulder to Fearful Positions Safely
- Sport Specific Tasks
- The consensus suggested objective repeated measures on a weekly basis to assess response to rehab
Return to Sport
The authors suggest that “Return to Sport” is a continuum consisting of three aspects: Return to participation, Return to sport, and Return to performance.
- Return to Participation: the athlete is continuing rehabilitation, but participating in modified training in their sport at a level lower than their usual; they are not physically or psychologically ready for regular sport activities.
- Return to Sport: the athlete can return to their sport but is not performing at an optimal level or their desired level
- Return to Performance: the athlete is performing at their usual level without any restrictions
6 Domains to Consider when Returning to Sport
- Pain: pain may be present when returning to participation but should not be present in return to performance
- Active Shoulder Joint ROM: this is a sport specific criterion and should be evaluated as such. For example, pitchers require much more rotational ROM as compared to a collision athlete (i.e. football)
- Strength, Power, Endurance: the importance of each is sport specific; however, the importance of overall strength in internal and external rotation as well as shoulder stability is crucial for return to sport
- Kinetic Chain: be able to identify issues outside of the shoulder including the elbow, wrist, and thoracic spine
- Psychological Readiness: athletes must be able to demonstrate confidence in muscle testing or activities that cause collisions before returning to participation and sport
- Sport Specific: if possible compare to norms of other athletes in sport to determine readiness for play
Summary
One of the major takeaways from this consensus is that there is room for improvement in how we measure athlete performance in rehab and how to prevent injuries from happening/reoccurring. This consensus did however highlight the importance of multidisciplinary and all-encompassing approach for an athlete to return to their sport following injury.
Here at Physical Therapy First, therapists are trained to assess for shoulder abnormalities and detect faulty mechanics in those who have shoulder pain or sport injury. We also look to work with the patient and all involved with their care to prevent future injuries while returning to a high level of performance.
Reference:
Schwank A, Blazey P, Asker M, Møller M, Hägglund M, Gard S, Skazalski C, Haugsbø Andersson S, Horsley I, Whiteley R, Cools AM, Bizzini M, Ardern CL. 2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels. J Orthop Sports Phys Ther. 2022 Jan;52(1):11-28. doi: 10.2519/jospt.2022.10952. PMID: 34972489