Return to Sport After Shoulder Stabilization Procedures: A Criteria-Based Testing Continuum to Guide Rehabilitation and Inform Return-to-Play Decision Making

Abstract

The athlete with shoulder instability poses a unique challenge to the sports medicine team. Clinical studies support surgical intervention followed by a phased approach to rehabilitation. In the latter phases, it is important to tailor this program to the individual's specific athletic needs, which requires ongoing qualitative assessment and objective measurement. Passing a return-to-sport testing battery has been shown to decrease the risk of recurrent instability. What is lacking in the literature is a consensus for how to best measure shoulder performance when the required athletic demands are widely varied by hand dominance, sport played, and playing position. Multiple upper-extremity tests have been described in the literature, but there is no consensus on which tests should be used to direct rehabilitation and to safely return the athlete to unrestricted athletic exposure. Using available evidence, we suggest a framework for return-to-play testing that integrates traditional rehabilitation phases with performance testing and graduated sports exposure.

Level of evidence: Level V, expert opinion.

Fig 1

Framework for sequentially testing athletes recovering from shoulder stabilization procedures. This stepwise structure suggests criteria to be administered as the athlete progresses through phased rehabilitation and graduated exposure toward full athletic participation. (CKC, closed kinetic chain; d/s, degrees per second; ER, external rotation; GIRD, glenohumeral internal rotation deficit; HHD, handheld dynamometry; IR, internal rotation; KJOC, Kerlan-Job Orthopedic Clinic Shoulder and Elbow Score; LSI, limb symmetry index [involved/uninvolved × 100]; MMT, manual muscle testing; OKC, open kinetic chain; PSET, Posterior Shoulder Endurance Test; ROM, range of motion; SIRSI, Shoulder Instability Readiness to Return to Sport Index; UQ, Upper Quarter; WOSI, Western Ontario Shoulder Instability Index.)

Fig 2

After shoulder stabilization procedures, athletes should undergo a battery of performance tests determined by the demands of their particular sport. This may include the following open- and closed-chain performance tests for strength, power, speed, endurance, and stability. (A) In the One-Arm Hop Test (OAHT), the athlete begins in a 1-arm plank position (1) and hops on (2) and off (1) a 10.2-cm step 5 times for speed. (B) The athlete assumes the start position (1) of the Seated Single Arm Shot Put (SSASP) and presses (2) the 2-kg ball as far as possible. (C) During the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), the athlete begins in a plank position (1) with the hands 36 inches apart and then alternates touches between tapes for 15 seconds (2). (D) The athlete pushes as hard and as fast as possible on the force plate in the “I” position (1), “Y” position (2), and “T” position (3). (E) For the Y-Balance Test of the Upper Quarter (UQ-YBT), the athlete maintains a plank position and reaches as far as possible in the medial (1), superolateral (2), and inferolateral (3) directions. (F) The athlete maintains a weighted, horizontally abducted arm during the Posterior Shoulder Endurance Test (PSET).