A qualitative investigation to identify return to sports criteria after shoulder stabilization surgery used by professional team physicians

Abstract

Purpose: Purpose of this study is to explore currently utilized readiness to return to sports (RTS) criteria after shoulder stabilization surgery used in elite athletes to gain novel insights into the RTS decision making process of professional team physicians.

Methods: 19 qualitative semi-structured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after shoulder stabilization surgery. General inductive analysis and a coding process were used to identify themes and sub-themes arising from the data. A hierarchical approach in coding helped to link themes.

Results: We were able to identify five key themes that participating physicians focused on to determine RTS decision making: external influence, objective and subjective criteria, time elapsed since surgery and type of sport. The most important RTS criteria included: range of motion and muscle strength followed by clinical joint stability, time since surgery, ability of sporting movement, psychological readiness, functional testing, absence of pain and allied team support.

Conclusion: This study identified several main themes and subordinate minor themes as having the most influence on RTS decision after shoulder surgery. We showed that even among specialized professional team physicians, the main criteria to RTS in these categories were inconsistent necessitating the future development of specific RTS guidelines.

Keywords

sports medicine return to sports shoulder surgery qualitative research

Introduction

Shoulder injuries are one of the most common musculoskeletal injuries in professional athletes.^1–3 The incidence of shoulder injuries varies between 0.2/1000 h and 1.8/1000 h of play^4–6 and more than half of collegiate American football players sustain at least one shoulder injury during their career.¹ Especially in overhead sports and contact sports posttraumatic recurrent shoulder instability is a common pathology.^7–9 After failure of nonoperative therapy, surgery is indicated to restore glenohumeral joint function and stability to allow athletes to return to sport as early as possible.¹⁰ Over the years, the traditional open Bankart repair¹¹ was replaced by the arthroscopic technique,¹² which demonstrated high return to sport (RTS) rates of up to 97.5%.¹³ However, some studies reported recurrent instability after arthroscopic Bankart repair in 48% of the patients aged ≤20 years during long-term follow-up.^14–17 In recent years, bony augmentation techniques, especially the open Latarjet method¹⁸ and later arthroscopic Laterjet technique¹⁹ gained interest in the treatment of recurrent shoulder instability. While there are several studies on RTS after the open Latarjet procedure in athletes,^13,20–26 there are only few that investigated in RTS after arthroscopic Latarjet, with reported RTS rates of 89.4% - 95,7%.^10,22 However, RTS rates not only depend on the underlying shoulder pathology and surgical technique, but also sports type, athletic level, and the definition of RTS.^27–29 So far, there is a lack of high-quality evidence to support rehabilitation and RTS decision making following shoulder stabilization surgery in athletes.³⁰ The exact time frame to RTS after surgery is unknown.³¹ Physiological and psychological factors also influence RTS decision making and RTS success.^31–35 The quantitative measures of RTS often include upper extremity strength and functional shoulder tests.³² In addition to physical readiness, the athlete’s psychological state is gaining more and more interest in determining successful RTS.³⁴ Therefore, psychological scores like the Shoulder Instability-Return to Sport after Injury (SIRSI) score have been developed.^33,36 There still exists a wide variability and a lack of consensus, regarding the appropriate criteria to release athletes to unrestricted sports participation after shoulder stabilization surgery.³⁰ So far, studies have been unable to establish clear guidelines and recommendations that can predict successful RTS after shoulder stabilization surgery. Through semi-structured interviews in qualitative research, concepts and themes, which affect the RTS process can be identified.^37,38 As previously shown for RTS after anterior cruciate ligament reconstruction, a qualitative approach can be helpful to further improve the understanding of RTS criteria.³⁹ The purpose of this qualitative study was to explore currently utilized readiness to RTS criteria after shoulder stabilization surgery (Bankart repair and Latarjet procedure) used by professional team physicians in elite athletes. We hypothesized that even among this group of specialized physicians there would be no definitive measures or criteria used to determine RTS.

Material and methods

Design

A qualitative study design was used to interview 19 professional team physicians. The interviews were used to evaluate in-depth insights into the most relevant criteria used by team physicians to determine the readiness of professional and collegiate athletes for their RTS decision after shoulder stabilization surgery (Bankart repair and Latarjet procedure). The ethical approval for our qualitative study was acquired beforehand (REB # 2020-0020-E) and consent for data collection was ensured by every interviewee prior to the start of our study. Experienced experts were consulted to overview the study design and to ensure that the study protocol was created in accordance with the Consolidated Criteria for Reporting Qualitative Studies.⁴⁰

Recruitment

Participants were contacted via email and an additional phone enquiry. The interviews were solely conducted with physicians involved in the treatment of professional athletes competing on an elite or collegiate level. With these criteria we were able to gather medical expertise from an elite group of orthopedic surgeons to ensure discussions on a distinguished level. Every team physician was invited to participate in a semi-structured telephone interview with open-ended questions to ensure rich data and in-depth insights. Recruitment of further participants was stopped when no further themes were identified in two consecutive interviews to provide an adequate number of observations.

Data collection

Initially, two rehearsal interviews were performed to ensure a baseline structure and to guarantee limited guidance through the interview, without leading the interview partner into a predetermined direction. A total of 19 telephone interviews with open questions were conducted by a single trained interviewer in a semi-structured format in order to gather information from the participating team physicians. The conducted interviews were transcribed by an impartial transcriptionist and subsequently pseudonymized with an allocated pseudonym. All participants were asked to provide information about their medical training, number of years in practice and their involvement in the medical treatment of high-performance athletes. Team physicians were asked about differences in the rehabilitation and RTS criteria between Bankhart repair and Latarjet surgery. The interviews were conducted following the principals for qualitative research developed by Yardley to ensure validity.⁴¹

Analysis

The transcribed interviews were reviewed using the analytic strategy of inductive content analysis using open coding to organize the qualitative data. The transcripts were read through and notes were made throughout the reading on general themes.⁴² Thereupon, a commercial computer-assisted qualitative data analysis software (CAQDAS) was used for an efficient coding process (MAXQDA Software, Verbi Software, Berlin, Germany). The coding process which was performed independently by two authors lead to the identification of initial themes. The initial themes were subsequently organized into superordinate themes and subthemes under constant evaluation by both authors to increase validity of the investigation. To increase consistency and to ensure integrity as well as to minimize superabundance, at least two rounds of coding were performed to identify themes and sub-categories as well as newly emerged themes.

Results

The interviewed 19 professional team physicians were on average 52.4 years (standard deviation (SD) ±8.3) old. The predominantly male participants (94,7%) have performed shoulder surgery on average for 17.1 (SD ± 10.2) years with a total of 18.7 (SD ± 9.8) years of clinical experience (Table 1).

Table 1.

Demographic data of participants.

Demographic data	N = 19
Age
Mean (SD)	52.4 (± 8.3)
Sex
Female (%)	1/19 (5.3)
Male (%)	18/19 (94.7)
Years in practice
Mean years (SD)	18.7 (±9.8)
Years performing shoulder surgeries
Mean years (SD)	17.1 (±10.2)

SD: standard deviation.

The interviews were exclusively conducted with formally designated team physicians predominantly (17/19, 89.5%) involved in the treatment of professional athletes competing in in first tier leagues such as the NBA (National Basketball Association), NHL (National Hockey League), MLS (Major League Soccer), MLB (Major League Baseball), the national skiing and snowboarding federation, or Lacrosse. There were also two team physicians interviewed that exclusively treated Division I collegiate level athletes in various sport disciplines. All interviewed participants were fellowship-trained and board-certified orthopedic surgeons.

Development of key themes

We were able to identify five key themes using the method of inductive analysis that the participating physician focused on to determine their RTS decision: external factors, objective and subjective criteria, time elapsed since surgery and type of sport. These key themes were further subdivided into subthemes. The key themes and subordinate themes were identified as shown in the following depiction (Figure 1).

Figure 1.

Schematic representation of the key and subordinate themes derived from the interviews.

External influence

Multi-disciplinary decision-making process

The team physicians in this study emphasized the role of a multi-disciplinary collaboration. They made very clear that the role of other professions in the RTS process is significant, but it was also made clear that the final RTS decision is made by the surgeons themselves.

“Well, it’s a collective effort. It’s the player. It’s the surgeon, if it was myself or someone else. It is obviously the rehabilitation, allied health care personnel. It’s our own strength and conditioning coach, so in and out of house evaluators.” (P #19)

The participants unanimously recalled that the reports of the players´ rehabilitation team such as their athletic trainers and their physical therapists played a significant role in the decision-making process.

“I will go over the physiotherapy report. Particularly the final one.” – (P #11)

Furthermore, the interviewed team physicians reported that the findings of their strength and conditioning coaches are of major interest. These reports provide further information on the athlete’s functional status as well as performance in regards of their ability of their specific sporting movement.

“Yeah, so, the higher the level of the athlete, the more people we get involved. So, at the Division 1 college level, and at the professional level, it’s a combination of their athletic trainer, probably a physical therapist, their strength and conditioning coach.” (P #1)

External input

The interviewed team physicians reported that even though the multi-professional input is crucial for their RTS decision, there are additional interests/concerns expressed by team principals, managers, sponsors or even parents.

“I obviously am naïve if I don’t think that is not influenced by coaches, teammates, family, financial pressures, stage of their career, stage of the season, etc., etc. There’s a whole host of factors that can affect that, but I try to leave it—I try to reduce those extraneous forces as much as I can.” (P #13)

Objective criteria

Pain-free range of motion

All interviewed team physicians checked on pain-free and comfortable full range of motion after shoulder surgery. It was made clear that athletes need to regain their range of motion post-surgery with less than 10 degrees of motion deficit compared to the contralateral side to be able to RTS.

“Full range of motion except for external rotation I do accept within ten degrees of the opposite side.” (P #10)

Joint stability

In addition to adequate range of motion, all surgeons made clear that joint stability is a key criterion for their RTS decision after shoulder stabilization surgery. The reduction of excessive anterior translation is tested with provocative tests such as the apprehension test as well as the load and shift test.

“Elimination of any sort of excessive anterior translation and/or or a negative apprehension and relocation sign.” (P #19)

“They can’t have any kind of apprehension” (P #5)

“Negative shift, load shift of their glenohumeral joint, negative apprehension.” (P #9)

Inspection

The surgeons also mentioned that they would visually inspect muscle bulk of the rotator cuff and absence of recurrent swelling.

“In terms of their general assessment of their own readiness to play by way of their expression of symptoms of instability, pain or recurrent swelling.“(P #3)

“Make sure their muscle bulk is, you know, and strength is good.“ (P #2)

Functional tests

Regarding specific functional testing after shoulder surgery there was a wide variety of answers and no standardized set of functional tests were regularly used in the RTS decision.

“We just don’t have great functional tests for the shoulder. It’s probably going to be a combination of strength and ability to do sport-specific activity.” (P #1)

“For the shoulder, we don’t really have any functional testing that we utilize in our guys. It’s more on-ice testing.” (P #18)

Muscle strength testing

Furthermore, the interviewed team physicians highlighted the importance in terms of muscle strength of the rotator cuff and shoulder muscles prior to RTS.

“I look at their strength, not only, you know, biceps, triceps, deltoid, but also assess supraspinatus, infraspinatus, subscap, just for their global strength in the shoulder” – (P #2)

“Full and symmetrical strength with no strength deficits.” – (P# 7)

While most of the participants evaluated strength without isokinetic systems, some surgeons use objective strength testing devices such as the Biodex® (Biodex Medical Systems, Shirley, New York, USA) or Cybex® systems (Cybex, division of Lumex, Inc., Ronkonkoma, New York, USA).

“I don’t routinely use objective strength measurements like Cybex testing or anything.” (P #16)

“For the shoulder we use Biodex or assessment of the strength of the rotator cuff and compare it to the other side.” (P #18)

Radiographic imaging

The interviewed orthopaedic surgeons routinely use postoperative x-rays after bony procedures, such as a Latarjet procedure. However, the participants made clear though, that they do not routinely order additional imaging for their RTS decision.

“I just do a simple x-ray but it’s not really determining for return to sport, I do a follow up x-ray in six months for all of my reconstructions, no matter what they are.” (P #6)

Subjective criteria

Patient-reported outcome measures (PROMs)

There are only a few team physicians that use PROMs on a regular basis, mostly for scientific purposes and not as a tangible gadget for their RTS decision.

“I do not currently employ any clinical scores to determine return to sports.” (P #3)

Interviewer: “Do you use any clinical scores to determine return to sports after surgery in your athletes?” Participant: “No, for academic purposes but for return to sport, no.” (P #7)

Psychological questionnaires

The majority of the interview surgeons do not use specific psychological scores on a regular basis in order to verify their RTS decision. The Tampa Kinesophobia Scale was mentioned, but not routinely used by the interviewed physicians. However, some surgeons highlighted the importance of psychological evaluation and readiness during the RTS process.

“I do not currently employ any psychological testing.” (P #3)

Interviewer: “Do you use any psychological questionnaires to determine readiness to return to sports after Bankart repair? Participant: “I do not currently.” – (P #17)

Furthermore, the participants mentioned the relevance of sports psychologists in order to determine an athlete’s ability to return to professional competition. The role of sports psychologists in the RTS decision was seen ambivalent.

“We have a psychologist that works with the players right from the moment that they sign to our farm team.” (P #15)

“We don’t typically use a sports psychologist unless an athlete is struggling with return to play issues.” – (P #18)

Time since surgery

Time-based return-to-sport

One major factor for the RTS decision was the time since surgery. Timeframes ranged from 3 months up to 9 months after surgery for athletes in non-contact sports, whereas athletes in contact-sports would return to competitive sports after 5 to 12 months.

“We would wait a minimum of four months for return to sport.” (P #14)

“I’m usually getting people back between four-and-a-half and five months.” (P #1)

Type of sport

The interviewed surgeons put major emphasis on the type of sport a professional athlete was competing in to make their RTS decision after shoulder surgery.

“Shoulder surgery, contact sports hold them out slightly longer than non-contact.” – (P #12)

“We’ll let them go back at five months, but most of the athletes I do Bankarts on are contact athletes so it’s six months then.” – (P #11)

Most important RTS criteria

During the interviews the surgeons were asked to name their top three criteria that they use for their RTS decision. The most common answers for RTS criteria given by the interviewed team physicians were: range of motion and muscle strength in comparison to the contralateral side (13/19 each), clinical joint stability with a negative anterior apprehension sign as well as time since the surgery (5/19) (Tables 2 and 3). Even though short-term postoperative follow-up treatment could vary between Bankhart repair and Latarjet surgery, the criteria mentioned regarding their RTS decision would not differ significantly.

Table 2.

Main criteria for RTS after arthroscopic shoulder treatment.

Main criteria	Number of participants
1. Satisfactory range of motion	13/19
2. Satisfactory muscle strength	13/19
3. Clinical joint stability	10/19
4. Time elapsed since surgery	5/19
5. Ability of sporting movement	4/19
6. Athletes’ psychological readiness	4/19
7. Functional testing	3/19
8. Absence of pain	3/19
9. Objective testing	1/19
10. Allied team support (physiotherapists, athletic trainers)	1/19

Table 3.

Main criteria for RTS after shoulder surgery according to their priority.

	First priority		Second priority		Third priority
1	Clinical joint stability	7/19	Satisfactory range of motion	6/19	Satisfactory range of motion	5/19
2	Satisfactory muscle strength	3/19	Satisfactory muscle strength	5/19	Satisfactory muscle strength	5/19
3	Time elapsed since surgery	3/19	Absence of pain	2/19	Ability of sporting movement	2/19
4	Satisfactory range of motion	2/18	Functional testing	2/19	Athletes’ psychological readiness	2/19
5	Athletes’ psychological readiness	2/19	Ability of sporting movement	2/19	Clinical joint stability	2/19
6	Absence of pain	1/19	Clinical joint stability	1/19	Allied team support (physiotherapists, etc.)	1/19
7	Functional testing	1/19	Time elapsed since surgery	1/19	Objective testing	1/19
8					Time elapsed since surgery	1/19

Discussion

Five major key themes were identified from the interviews that seem to influence the RTS decision of professional team physicians after shoulder stabilization surgery. The authors hypothesized that even among this group of professional team physicians there still exists no consensus regarding RTS criteria after shoulder surgery. The hypotheses of our study were confirmed; the results of our study show that professional team physicians use a variety of criteria for their RTS decision.

There exists little evidence regarding RTS criteria or RTS timing after shoulder surgery and predictors for successful RTS are relatively unknown.⁴³ Qualitative research techniques can help to get insights into themes that influence an athlete’s return to sport pathway, which subsequently contribute to a better understanding of the RTS decision making process.^44–46 Previous qualitative studies have tried to identify and define RTS criteria after shoulder surgery.^45,46 However, there is no study yet investigating criteria used by professional team physicians and their RTS decision process in elite athletes.

In the literature, RTS rates after shoulder dislocation differ and several influencing factors are reported. The highest RTS rates are reported for isolated Bankart repair,^27,47–51 Latarjet^{10,13,20–26} and treatment of SLAP lesions.^29,52–54 Satisfactory shoulder ROM and muscle strength were the two most frequently mentioned RTS criteria in our study. A restricted ROM may be correlated with RTS failure or incomplete RTS.⁵⁵ A recent study by Harada et al. reported a greater postoperative external rotation deficit in overhead athletes that failed RTS after arthroscopic Bankart repair compared to athletes with RTS success.⁵⁵ For muscle strength, most participants opted for a clinical muscle strength measurement and few preferred isokinetic and isometric objective testing devices. However, there is no evidence regarding the relationship between tests of muscle strength and functional performance⁵⁶ and some authors consider that isokinetic strength does not correlate with functional shoulder assessment.⁵⁷ Functional performance tests for the shoulder are gaining more and more interest. However, these tests are not yet fully explored in clinical practice^58–61 and there is a lack of normative data and cut-off values for preventing re-injury and successful RTS. Most participants in our study emphasized that there is no standardized set of functional tests regularly utilized in RTS decision making. Functional testing was more often described as sport-specific activity tasks. Besides objective functional tests, there are patient reported outcome measures (PROMs), to quantify and compare patients’ state of health during or after treatment. These scores are mostly used for scientific reasons and do not yet influence their RTS decision. Another objective finding frequently mentioned as a key criterion for RTS decision was joint stability. The stability of the glenohumeral joint is closely connected to muscle strength and shoulder function.⁶² The team physicians mainly focused on provocative tests such as the Apprehension test⁶³ and Load and Shift Test,⁶⁴ which showed a high reliability for clinical shoulder instability in the literature.⁶⁵ However, most studies do not primarily include clinical joint stability as a RTS criterion after shoulder surgery.⁶⁶ Team physicians only use radiographic imaging on a regular basis after certain shoulder surgeries (e.g. Latarjet procedure). However, the performed x-rays do not determine the final RTS decision. In a study from Hurley et al., less than half of the physicians (47%) used radiographic studies after a Latarjet procedure to assess return to play.³⁵

Besides the physical demands of sports, successful RTS requires mental preparedness and RTS decision making should therefore include psychological factors.^46,67 A recent study by van Iersel et al. showed that the majority of athletes who failed RTS following surgical treatment for anterior shoulder instability did so due to shoulder function independent reasons, such as fear of reinjury.⁶⁸ However, most of the professional team physicians do not use a psychological score in their RTS decision making. The Tampa Kinesophobia Scale was mentioned by the interviewed surgeons, but not routinely used. Fear of reinjury, lack of social support, and unrealistic expectations are all barriers to RTS.⁴⁶ Therefore, psychological aspects should be included in the RTS process to maximize RTS progress. However, in our study only few of the participants would engage a sport psychiatrist or supervising sports psychologist in the RTS decision making process. In a systematic review of RTS criteria after anterior shoulder stabilization surgery, Ciccotti et al. reported that the only explicitly used RTS item was time since surgery.⁶⁶ The most commonly used time for RTS was 6 months.⁶⁶ In our study, participants frequently mentioned the time elapsed after shoulder treatment as an important criterion in the RTS decision making process. In the literature, the minimum amount of time before RTS is unknown.³¹ Reported timeframes in our own study ranged from 3 months up to 9 months in non-contact sports, whereas athletes in contact-sports would return to competitive sports after 5 to 12 months. A survey by Hurley et al, reported that the most commonly used RTS criteria after arthroscopic Bankart repair was time (98.7%), strength (74.8%), and range of motion (70%). However, a recent systematic review by Kim et al. showed that subjective and objective criteria for RTS were still lacking in the majority of studies.⁶⁹ In our own study, the main criteria for RTS after SA were satisfactory range of motion and muscle strength, followed by clinical joint stability and time after SA.

Strengths and limitations

To our knowledge, this is the first qualitative study to evaluate RTS criteria after shoulder stabilization surgery in professional team physicians. One of the main strengths of this study is its qualitative design and the used semi-structured interviews. This sheds light on new aspects in the RTS decision making. On the other hand, because of the nature of the interview setting, some participants may have been hesitant in sharing their opinions. Another limitation was the fact that a comparison of the findings of the current study with similar studies in the literature was not always possible since data on RTS involving professional team physicians and professional athletes is scarce. Due to the qualitative design of the study, recruitment of further participants was stopped when no further themes were identified in two consecutive interviews to provide an adequate number of observations. This approach leads to a smaller number of participants making it not feasible to perform a subgroup analysis for each sport.

Conclusion

This study identified five main themes including: external factors; objective findings; subjective findings; type of sport and time after surgery as having the most influence on the return to sport (RTS) decision after shoulder stabilization surgery used by professional team physicians. However, the interviews showed that even among professional team physicians, the main criteria to RTS in these categories were inconsistent.

Footnotes

Acknowledgments

The present work was performed in fulfillment of the requirements for obtaining the degree „Dr. med.“. The contribution of the first author Mike Szlufcik fulfils the requirements for the achievement of the degree of “Dr. med.” at Friedrich Alexander University of Erlangen-Nuremberg.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

IRB statement

Women’s College Hospital Research Ethics Office 76 Grenville Street 6341 Toronto, ON M5S 1B2, REB # 2020-0020-E

ORCID iD

Mario Pasurka

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