Authors: Christopher J. Lamb, Amir Fathi, Eric H. Lin, Max Yang, Cailan L. Feingold, Frank A. Petrigliano, Joseph N. Liu
Categories: Shoulder, Return to sport, Shoulder instability, Psychological readiness, Shoulder dislocation, Kinesiophobia, Athletic injury
Source: JSES International
Authors: Christopher J. Lamb, Amir Fathi, Eric H. Lin, Max Yang, Cailan L. Feingold, Frank A. Petrigliano, Joseph N. Liu
Shoulder instability is a common athletic injury, which can be treated surgically or nonsurgically. Studies estimating return to sport (RTS) rates following treatment vary widely. While there are many factors affecting RTS rates, recent studies have revealed that psychological factors significantly impact an athlete's ability to RTS. Therefore, multiple validated scales have been created to assess an athlete's psychological readiness to RTS after treatment for shoulder instability. The goal of this study is to review these psychological assessments currently being used for shoulder instability and determine whether athletes who RTS after being treated for shoulder instability have higher psychological readiness scores than those who do not.
A search was conducted in the PubMed, Scopus, and SPORTDiscus databases for all studies using any validated questionnaire to assess psychological outcomes and RTS rates after treatment for shoulder instability. Athlete characteristics, outcome measurements, and readiness scores were collected and compared between two athletes who did RTS and athletes who did not RTS.
Nine studies including a total of 844 athletes were included. Of these, 579 athletes (68.60%) were able to RTS and 265 (31.40%) were not. The Shoulder Instability-Return to Sport after Injury scale was the most commonly used, appearing in eight studies. The Shoulder Instability-Return to Sport after Injury scores for athletes who did RTS ranged from 48.40 to 79.10, while scores for athletes who did not return ranged from 36.40 to 65.34. One study used the Tampa Scale of Kinesiophobia; the score for those who did RTS was 23.4 and 30.1 for those who did not.
Athletes who RTS after treatment for shoulder instability have higher psychological readiness compared with those who do not return. Our results support previous findings that psychological factors are an important consideration when evaluating athletes for RTS after treatment for shoulder instability.
Shoulder instability is a common athletic injury, with 0.12 injuries per 1,000 athletic exposures.^18^ When surgical correction is necessary, both bony and soft tissue stabilization procedures are commonly employed procedures which have been shown to be effective.^1^^,^^4^ Despite this, studies report widely varying rates of athletes being able to return to sport (RTS) after undergoing surgical treatment for shoulder instability with rates ranging from 48% to 97.5%.^1^^,^^6^^,^^9^
Studies have examined the factors influencing an athlete's ability to RTS after treatment for shoulder instability. Athlete's age, sex, direction of instability, quality of surgery and rehabilitation, and type of sport are all factors that have been identified.^11^^,^^20^^,^^26^ Interestingly, a recent systematic review found that the most common reasons athletes gave for not returning were not related to recurrent pain, recurrent instability, or range of motion limitations.^14^ Instead, 70% of athletes gave reasons which were independent of shoulder function, with the most common being a “fear of reinjury.” Another study interviewing 25 athletes after arthroscopic Bankart repair reported that fear of reinjury, in addition to shifts in priority, mood, social support, and self-motivation, greatly influenced their decision to RTS.^23^ While clinical measurements of shoulder function are important in determining RTS, these studies suggest that the athlete's psychological state is also critical and therefore should be considered when assessing athletes.
In response to the importance of psychological factors for RTS, multiple scales have been developed to assess an athlete's psychological readiness to return after injury. The Tampa Scale of Kinesiophobia (TSK) is a 17-item questionnaire used to assess kinesiophobia, the fear of movement of an injured joint.^16^ The TSK can be employed for various injuries; however, the Shoulder Instability-Return to Sport after Injury (SI-RSI) scale is specific to shoulder instability. The SI-RSI scale was adapted from the ACL-RSI scale, by replacing the term “knee” with “shoulder.”^8^ The SI-RSI consists of 12 questions, which pertain to evaluating an individual's emotions, perceived risk, and confidence in performance. Scores are combined and represented on a scale from 0 to 100, where higher scores correspond to higher psychological readiness to RTS after treatment.
The goal of this study is to review the use of the psychological assessments for shoulder instability and determine whether athletes who RTS after being treated for shoulder instability have higher psychological readiness scores than those who do not.
A systematic search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three electronic databases (PubMed, Scopus, and Sport Discus) from inception to September 2023 were queried using the following search
(psych∗ OR “mental disorder∗” OR “mental ill∗” OR “mood disorder∗” OR “mood ill∗” OR “mental health” OR depress∗ OR anxiety OR anxious OR panic∗ OR phobi∗ OR kinesiophobi∗ OR stress∗ OR self-efficac∗) AND (shoulder∗ OR Glenohumeral OR GHJ OR hyperextensib∗ OR hyperlaxity OR laxity OR hypermob∗ OR sublux∗ OR ‘‘joint instability’’ [MeSH] OR “shoulder dislocation” [MeSH] OR “multidirectional instability” OR MDI OR disloc∗ OR redislocat∗ OR unstab∗) AND (“return to sport∗” OR “returning to sport∗” OR RTS OR “return to play∗” OR “returning to play∗” OR RTP OR “return to competit∗” OR “returning to competit∗” OR RTC OR “return to perform∗” OR “returning to perform∗” OR RTP).
Duplicates were removed, and articles were sequentially screened by title, abstract, and then full-text to assess for the inclusion criteria. To be included, studies needed to (1) use a validated questionnaire (SI-RSI, TSK) to assess psychological outcomes after treatment for shoulder instability and (2) report these psychological outcome scores for the group of athletes who returned to sport and the group of athletes who did not RTS. Articles were excluded if they did not include shoulder instability, were unable to delineate shoulder instability from other injuries, included nonathletes, or used only qualitative interviews.
The following data points from each article were extracted onto a shared year of publication, journal, country, psychological outcome measures, clinical outcome measures, sample size, procedure used, level of evidence, study design, dates of injury or procedure, preinjury level of competition (competitive, recreational, or mixed), average follow-up time, number of patients, sex, age, and number of patients who did and did not RTS. We identified failure to RTS either as a complete failure to return or a failure to return to the same level of competition. All clinical outcome scores and psychological outcome scores were recorded for the RTS and no RTS groups. Data collection was performed by two independent researchers (C.L. and M.Y.) and the results were then cross-checked for accuracy.
One study^21^ used median and interquartile range rather than mean and standard deviation. To allow for comparison with other studies, we used the method outlined in Wan et al^27^ to convert median to mean and interquartile range to standard deviation. All statistical analysis was performed using RStudio (version 2022.7.1.554; RStudio).
Study quality was assessed using the methodological index for nonrandomized studies criteria.^22^ In studies that did not report level of evidence, the level of evidence was determined per criteria set by the American Academy of Orthopedic Surgeons.
The initial searches performed on Scopus, PubMed, and Sport Discus yielded 1,027 studies. After removal of duplicates, 601 articles were screened by title, resulting in 127 articles which were screened by abstract. A total of 63 articles were reviewed by full-text, resulting in nine studies which met the predefined inclusion/exclusion criteria (Fig. 1). Of the nine studies, 1 was of level IV evidence, six were of level III evidence, and two were of level II evidence. The methodological index for nonrandomized studies scores ranged from 19 to 22 with an average score of 20.56 plus/minus 0.88, indicating fair study quality.Figure 1PRISMA flowchart summarizing the database search, screening, and review of articles. RTS, return to sport; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
A total of 844 athletes were included in the systematic review. Of these, 733 patients (86.85%) were male, and 111 (13.15%) were female. The mean age of included patients ranged from 22 to 35.5 with an average age of 26.73 years. Five studies took place in Europe, two took place in South America, 1 took place in Turkey, and 1 took place in New Zealand. In studies that included the date ranges that the procedures were performed, these ranged between 2005 and 2020. Two studies exclusively selected patients who had received the Latarjet procedure, while 1 exclusively selected Bankart repair patients, and the remaining six study populations included a combination of both procedures. All studies measured clinical and psychological outcomes at more than 12 months of follow-up, with a range of 12 to 62.7 months and an average follow-up time of 30.62 months. All nine studies included athletes at varied competition levels ranging from leisure to professional. All studies included athletes from multiple sports except for Gerometta 2018, which surveyed rugby players specifically. Article characteristics and athlete populations are summarized in Table I.Table ISummary of included articles.ArticleJournalTreatment/indicationLevel of evidenceMINORSCountryStudy designTreatment yearsPreinjury level of athletesFollow-up, mo.Eraslan 2022^7^RSMAnterior, posterior, and multidirectional instability treated surgicallyIII20TurkeyRetrospectiveNSMixedMean ± SD; 12.6 ± 10.1Gerometta 2018^8^KSSTAPost-traumatic chronic anterior shoulder instability treated surgically or nonsurgicallyIII20FranceRetrospective2012-2013CompetitiveMean ± SD; 18.5 ± 5.2Hurley 2022^12^SurgeonABRIII20IrelandRetrospective2012-2018MixedMean; 62.7Hurley 2022^13^OJSMOpen LatarjetIII21IrelandRetrospective2012-2019MixedMean; 40Louati 2022^15^JEOLatarjetIII21FranceProspectiveNSMixedMean ± SD; 18.04 ± 7.9Olds 2021^17^AJSMTraumatic anterior shoulder dislocation treated surgically or nonsurgicallyIII19New ZealandCross-sectional2013-2020MixedMean; 9Pasqualini 2023^19^ArthroscopyAnterior shoulder instability treated by ABR, ABR plus remplissage, or open LatarjetII22ArgentinaProspective2017-2019MixedNSRossi 2022^21^AJSMAnterior shoulder instability treated by ABR or open LatarjetII21ArgentinaProspective2019-2020MixedMedian, IQR; 20, 15-25Vascellari 2019^25^JointsAnterior shoulder instability treated by ABR or open LatarjetIV21ItalyRetrospective2005-2015MixedMean ± SD; 61.1 ± 37.5ABR, arthroscopic Bankart repair; AJSM, American Journal of Sports Medicine; JEO, Journal of Experimental Orthopaedics; KSSTA, Knee Surgery, Sports Traumatology, Arthroscopy; NS, not specified; OJSM, Orthopaedic Journal of Sports Medicine; RSM, Research in Sports Medicine; IQR, interquartile range; MINORS, methodological index for nonrandomized studies; SD, standard deviation.
After treatment, 579 athletes (68.60%) were able to RTS, and 265 (31.40%) did not RTS. The RTS rate varied significantly between studies, ranging from 43.48% to 86.13%. Four studies defined RTS as returning to the sport at any level,^7^^,^^8^^,^^15^^,^^17^ while five studies defined RTS as returning to the preinjury level of competition.^12^^,^^13^^,^^19^^,^^21^^,^^25^ In the four studies examining returning to any level of competition, the RTS rates ranged from 43.48% to 70.83%. In the five examining return to preinjury level, the RTS rates ranged from 46.97% to 86.13%. In studies that reported age demographics for the RTS and no RTS groups, the average ages of those who returned ranged from 23 to 35.20, and the ages of those who did not RTS ranged from 25.50 to 35.70 years. A summary of athlete characteristics is given in Table II.Table IISummary of patient characteristics and outcome scores for those who did and did not return to sport after treatment for shoulder instability.ArticleTotal cohortReturn to sportNo return to sportTotal patients, nMale patients, nAge∗Patients, nMale patients, nAge∗Patients, nMale patients, nAge∗Eraslan 2022^7^695523.5 ± 2.9830NSNS39NSNSGerometta 2018^8^625726 ± 5.238NSNS24NSNSHurley 2022^12^20818428.615613828.3 ± 8524629.4 ± 9Hurley 2022^13^10510526.8707026.2 ± 4.9353527.9 ± 8.3Louati 2022^15^483426.81 ± 7.5334NSNS14NSNSOlds 2021^17^45352220NSNS25NSNSPasqualini 2023^19^13712326.9 ± 10.5118NSNS19NSNSRossi 2022^21^10490Median, IQR; 24.5, 20-328269Median, IQR; 23, 20-322221Median, IQR; 25.5, 22-32Vascellari 2019^25^665035.5 ± 9.9312635.2 ± 10.2352435.7 ± 9.8NS, not specified; IQR, interquartile range; SD, standard deviation.∗Age is given in years and written as mean or mean ± SD, unless otherwise specified.
Studies used a variety of clinical outcome measurements (visual analog scale [VAS], subjective shoulder value, Walch-Duplay, Western Ontario Shoulder Instability Index [WOSI], Rowe, and Athletic Shoulder Outcome Scoring System). Most studies had each participant answer multiple scales to compare the results. The most commonly used scale, WOSI, was used in seven studies; however, only two reported the raw WOSI scores for those who did and those who did not RTS. The VAS scores for athletes who did and did not RTS were reported in three studies; however, two of these did not find a statistically significant difference between VAS scores for the two groups.
Of the nine studies, all found a statistically significant difference in the psychological outcome scores between athletes who did and did not RTS except for 1. Eight studies reported psychological outcome scores using the SI-RSI, and 1 study reported scores using the TSK. In the eight studies using SI-RSI, the scores for athletes who returned ranged from 48.40 to 79.10, and scores for athletes who did not return ranged from 36.40 to 65.34. Vascellari 2019 evaluated readiness using the TSK; the score for those who did RTS was 23.4 and 30.1 for those who did not (P value .006). The clinical and psychological outcome measurements for all included studies are displayed in Table III.Table IIIPsychological and clinical outcome scores for those who did and did not return to sport after treatment for shoulder instability.ArticlePsychological outcome scoresClinical outcome scoresScale usedRTSNo RTSStatistically significant?Scale usedRTSNo RTSStatistically significant?Eraslan 2022^7^SI-RSI79.1 ± 13.544.6 ± 13.6YesWalch-DuplayNSNSNSWOSINSNSNSGerometta 2018^8^SI-RSI60.9 ± 26.638.1 ± 25.6YesWOSINSNSNSWalch-DuplayNSNSNSHurley 2022^12^SI-RSI68.9 ± 2239.8 ± 24.6YesSSV88.5 ± 11.672.4 ± 26.2YesVAS2 ± 2.12.4 ± 2NoHurley 2022^13^SI-RSI74.5 ± 19.841.5 ± 21.9YesSSV88 ± 11.175.7 ± 16.9YesVAS1.7 ± 1.72.9 ± 2.5YesLouati 2022^15^SI-RSI78.69 ± 11.6965.34 ± 18.59YesWOSINSNSNSWalch-DuplayNSNSNSOlds 2021^17^SI-RSI48.4 ± 1944.1 ± 15NoWOSINSNSNSPasqualini 2023^19^SI-RSI66.6 ± 2336.4 ± 18.7YesWOSINSNSNSRossi 2022^21^∗SI-RSI67.33 ± 17.3638.17 ± 4.75YesVAS0.33 ± 0.75460.67 ± 1.58NoRowe96.67 ± 7.5587.5 ± 11.89YesASOSS96.67 ± 7.5588.33 ± 11.89YesWOSI96.66 ± 7.5586.67 ± 11.89YesVascellari 2019^25^TSK23.4 ± 7.430.1 ± 9.6YesWOSI1.9 ± 1.84.5 ± 2.7YesASOSS, Athletic Shoulder Outcome Scoring System; NS, not specified; RTS, return to sport; SSV, subjective shoulder value; VAS, visual analog scale; WOSI, Western Ontario Shoulder Instability Index; IQR, interquartile range; SD, standard deviation; TSK, Tampa Scale of Kinesiophobia.∗Data were converted from median/IQR, to mean/SD, using the method described in Wan et al.
The principal findings of this review demonstrated that the majority (68.60%) of athletes were able to RTS, and those that were able to RTSs typically had higher psychological readiness scores compared to athletes who did not return. The most common psychological readiness score used was the SI-RSI, with eight of the nine studies finding a statistically significant difference in the psychological readiness scores between athletes who did and did not RTS. The results of this systematic review indicate that athletes who RTS after treatment for shoulder instability have higher psychological readiness compared to those who do not RTS.
The results of this review are consistent with the growing body of evidence demonstrating the importance of psychological factors in an athlete's ability to RTS. In a 2015 study conducting interviews with volleyball players recovering from shoulder injuries, Bele et al identified that motivation to succeed and a strong community support network were common themes affecting these athletes' rehabilitation.^3^ A 2023 systematic review examined specific psychological factors affecting failure to RTS after surgical shoulder stabilization and identified fear of reinjury as the most reported reason.^10^ Clement et al used interviews to characterize three stages of emotional growth that athletes progress through over the course of their recovery.^5^ The initial post-traumatic period is characterized primarily by negativity toward the severity of their injury and the inability to play. During physical rehabilitation, frustration is the main emotion. When returning to play, athletes experience doubts about their capability and a fear of reinjury. Clearly, the recovery process following shoulder injury is both physical and emotional. While there are many clinical shoulder function scales focusing on physical ability, results of current research indicate a need for psychological assessments as well.
An additional goal of our study was to review the use of the psychological assessments for shoulder instability. The SI-RSI was the most commonly used scale in our included studies. Created in 2016, this scale has been demonstrated to be effective in evaluating RTS.^17^^,^^19^ Despite this, there is still no universally agreed upon cutoff score indicating whether an athlete is psychologically ready to return. In a study of 104 patients who underwent surgical stabilization of shoulder instability, Rossi et al suggested a SI-RSI cutoff score of >55 as indicative of psychological readiness,^21^ which is consistent with studies performed on the ACL-RSI,^2^ the assessment from which the SI-RSI was adapted. If the SI-RSI begins to see use in the clinical evaluation of injured athletes, establishing a cutoff value could help interpret individual scores and readiness to RTS.
Notably, we found widely varying RTS rates (ranging from 43.48% to 86.13%) reported by our included studies, consistent reported ranges in the literature between 48% and 97.5%.^1^^,^^6^ This variation could be explained by the influence of multiple factors affecting RTS rates. Studies have identified that surgical technique, age, sex, mechanism of injury, and type of sport (contact vs noncontact, overhead movements) influence RTS.^20^^,^^24^^,^^28^ Furthermore, the definition of RTS varied between studies. Some studies defined RTS as being able to return to the preinjury level of competition, while others simply required returning at any level. The lack of consistency in the definition of RTS likely contributes to the variation in reported RTS rates and is a limitation of the current systematic review. Of the nine included studies, four defined RTS as returning to play at any level, while the remining five only considered athletes who returned to their preinjury level. To address this, we performed separate analyses when examining the RTS rates of studies based on which of these two definitions were used by the study. While ultimately it would be useful to have a uniform definition of “return,” accepting a universal definition may be difficult given the differing levels of competition, sports, and individual goals in the athletic population.
An important limitation in our analysis was the lack of long-term follow-up and heterogeneity in follow-up times. The average follow-up time of the included studies was relatively short, at 30.62 months. Follow-up time is an important factor in influencing RTS, as shorter follow-up times may fail to include patients who may take longer to fully recover from their injury. Short-term follow-up also excludes athletes who initially appear to return without complication but may ultimately experience recurrent shoulder instability. In addition to lacking long-term follow-up, our included studies also had widely heterogeneous follow-up times which limited our ability to compare outcome measures. Follow-up times between studies ranged from 12 to 62.7 months and varied within individual studies. Many studies were retrospective in design and surveyed athletes at different points in their recovery. For example, Vascellari et al surveyed athletes at multiple different points ranging from 12 to 156 months after surgery.^25^ Having a consistent follow-up time is important, as an individual's outcome scores may change as time passes from the date of the intervention.
Clearly, there is a need for more prospective studies with long term follow-up. In addition to the benefits of longer follow-up periods, having a prospective design would allow researchers to set consistent time points for surveying athletes, ensuring uniform follow-up intervals. Until such studies are more available, it remains challenging to interpret patterns in psychological recovery after shoulder instability treatment.
Our review has several other limitations. The quality of our analysis is limited by the quality of the included studies. This review included validation studies and studies testing translated questionnaires. Furthermore, there were a low number of included studies due to our inclusion and exclusion criteria. Because of these limitations, meta-analysis was not performed on psychological outcome scores. Comparison of clinical outcome scores was also difficult due to the use of multiple different scoring methods between studies. There is also a lack of geographical diversity in the included studies, evidenced by a lack of representation from the US population. The influence of psychological factors in RTS is an evolving field; it would benefit from further investigations with high level of evidence primary studies.
This study provides a review of the use of psychological assessments to determine RTS in athletes recovering from shoulder instability. The SI-RSI is the most commonly used assessment, followed by the TSK. The majority of athletes did RTS after treatment, and athletes who return have higher SI-RSI scores (and therefore higher psychological readiness) than those who do not. Our results support previous findings that psychological factors are an important consideration when evaluating athletes for RTS after treatment for shoulder instability.
Funding: No funding was disclosed by the authors.
Conflicts of Frank A. Petrigliano reports a relationship with Exactech Inc. that consulting or advisory and a relationship with Stryker Orthopaedics that consulting or advisory. Joseph N. Liu reports a relationship with Stryker Orthopaedics that speaking and lecture fees; a relationship with Innocoll Biotherapeutics NA Inc. that travel reimbursement; reports a relationship with Arthroscopy Association of North America as a board or committee member; and a relationship with American Shoulder and Elbow Surgeons as a board or committee member. The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.