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Abstract

Background:

Psychological readiness is increasingly recognized as a return-to-sport (RTS) determinant after shoulder stabilization surgery. The Shoulder Instability–Return to Sport After Injury (SIRSI) score is a tool to assess psychological recovery, yet prognostic value at intermediate postoperative milestones remains unclear.

Purpose/Hypothesis:

The purpose was to evaluate whether 6-month SIRSI scores relate to 1-year patient-reported outcome measures (PROMs) and RTS in adolescents after shoulder stabilization surgery. It was hypothesized that higher 6-month SIRSI scores would be associated with improved 1-year PROMs and RTS rates.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included patients aged 14 to 18 years who underwent surgical shoulder stabilization between August 2022 and August 2023 with follow-up at 6 months and ≥1 year. Psychological readiness was assessed with the SIRSI score, and the following PROMs were collected: American Shoulder and Elbow Surgeons assessment form, Tegner Activity Scale, Quick Disabilities of the Arm, Shoulder, and Hand questionnaire, and Pediatric/Adolescent Shoulder Survey. Associations between 6-month SIRSI scores and 1-year PROMs and RTS were analyzed.

Results:

Twenty-three athletes were included (mean ± SD age, 16.7 ± 1.1 years; 65.2% male; 69.6% dominant-arm surgery), including 5 (21.7%) anterior labral repairs, 1 (4.3%) posterior labral repair, and 17 (74.0%) combined anterior-posterior labral repairs. At 1 year, 17 athletes (73.9%) returned to their primary sport. Six-month SIRSI scores demonstrated moderate positive correlations with 1-year American Shoulder and Elbow Surgeons score (ρ = 0.42) and Tegner score (ρ = 0.51). Athletes who returned to their primary sport had higher median 6-month SIRSI scores (78.3) as compared with those who did not (46.7; P = .006). Improvements were observed across all PROMs from 6 months to 1 year.

Conclusions:

Six-month SIRSI scores are associated with 1-year functional outcomes and RTS success in adolescent athletes after shoulder stabilization surgery. Incorporating SIRSI into routine 6-month postoperative assessment may help identify athletes whose recovery-related confidence and readiness to RTS lag postoperative milestones, particularly in the context of limitations such as weakness, stiffness, or pain. Future research should stratify by surgical technique, sex, and other variables to better understand individualized recovery patterns and explore interventions that target psychological as well as physical readiness.

Keywords

shoulder instability return to sport Shoulder Instability–Return to Sport After Injury (SIRSI) scale psychological readiness patient-reported outcome measures

Glenohumeral instability is a common injury among young athletes and often leads to recurrent episodes that impair performance and participation. In a national survey, the incidence of instability was reported at 0.12 per 1000 athletic exposures in a young active population.⁸ Although surgical stabilization reduces recurrence, successful return to sport (RTS) remains variable.^1,13 Traditional RTS criteria often rely on time-based thresholds, particularly the 6-month postoperative mark. However, recent data suggest that many athletes do not achieve key physical benchmarks by this point, such as range of motion or strength symmetry.^2,9,15 The Multicenter Orthopaedic Outcomes Network Shoulder Group found that 55% of athletes failed to meet RTS criteria at 6 months after shoulder stabilization surgery,² suggesting that time alone may be insufficient to guide RTS decisions.

Psychological readiness has gained increasing recognition as a key determinant of postoperative recovery. The Shoulder Instability–Return to Sport After Injury (SIRSI) score is a validated tool that assesses confidence, emotional response, and perceived risk in athletes recovering from shoulder instability.³ Higher SIRSI scores have been associated with improved clinical outcomes, higher RTS rates, and reduced recurrence.^10,14 Yet the prognostic value of SIRSI scores for 1-year patient-reported outcome measures (PROMs) has not been well defined.

To our knowledge, the application of SIRSI to examine its relationship with postoperative recovery beyond the 6-month point has not been well explored. The primary objective was to evaluate whether 6-month SIRSI scores are associated with 1-year PROMs and RTS among young athletes after shoulder stabilization surgery. We hypothesized that higher 6-month SIRSI scores would be associated with improved 1-year PROMs and RTS rates. The secondary objective was to evaluate the change in PROMs over time, particularly the SIRSI.

Methods

Study Design

This retrospective cohort study evaluated patients who experienced a shoulder instability event, underwent surgical repair at a single institution between August 2022 and August 2023, and completed follow-up visits at 6 months and 1 year (median [IQR], 6.04 [5.30-6.14] and 12.19 [11.97-12.44] months). The study was approved by the local ethics committee, and informed consent was obtained. The study inclusion criteria were (1) an age of 12 to 18 years with a history of shoulder instability necessitating surgical intervention, (2) readily available preoperative clinical data, and (3) complete follow-up visits at 6 months and 1 year. Patients were excluded if they had incomplete follow-up data or if they experienced reinjury and had to undergo revision surgery before the 1-year mark, which would automatically result in an absence of follow-up data.

Preoperative Evaluation and Surgical Technique

During the preoperative evaluation, clinical history was obtained, and physical examination was performed. Information regarding mechanism of injury, number of instability episodes, primary sport, and level of sports participation was also collected during this time. Surgical intervention was indicated for patients with recurrent symptomatic shoulder instability or imaging evidence of labral injury that failed nonoperative management. Surgical interventions varied according to extent and severity of glenohumeral instability as deemed by the operating surgeon and included anterior labral repair, posterior labral repair, and combined anterior-posterior labral repair (Table 1). No patients with severe bone loss requiring bony augmentation procedures such as Latarjet or distal tibial allograft were included. All patients were without bone loss or demonstrated subcritical bone loss (<10%) on imaging and intraoperative evaluation. Of note, 1 participant required a SLAP (superior labrum anterior-posterior) repair in addition to an anterior labral repair. Although these procedures represent a spectrum of surgical complexity, all were performed arthroscopically and shared comparable rehabilitation goals. The patient who underwent concomitant SLAP repair was included given the similar underlying mechanism of instability and adherence to the same standardized postoperative rehabilitation protocol. Clinical shoulder examinations were performed at postoperative visits as part of standard care. However, recurrence and redislocation rates were not analyzed given the small sample size and the study's primary focus on psychological and functional outcomes. Two patients who sustained recurrent instability requiring revision surgery were excluded from the analysis.

Table 1

Demographic Information

Characteristic	Median [IQR], Mean ± SD, or No. (%)
Follow-up
6 mo	6.04 [5.30-6.14]
12 mo	12.19 [11.97-12.44]
Age at date of surgery, y	16.7 ± 1.1
Body mass index, kg/m²	23.1 [21.8-25.8]
Sex
Male	15 (65.2)
Female	8 (34.8)
Hand dominance
Right	18 (78.3)
Left	5 (21.7)
Involved arm in injury
Right	15 (65.2)
Left	8 (34.8)
Surgery on dominant arm	16 (69.6)
Surgical procedure
Anterior labral (Bankart) repair	5 (21.7)
Anterior and posterior labral repair	17 (74.0)
Posterior labral repair	1 (4.3)
Sport
Football	6 (26.1)
Soccer	3 (13.0)
Basketball	2 (8.7)
Baseball	2 (8.7)
Swimming	2 (8.7)
Skiing/snowboarding	1 (4.3)
Lacrosse	1 (4.3)
Hockey	1 (4.3)
Softball	1 (4.3)
Tennis	1 (4.3)
Other	3 (13.0)

Postoperative Follow-up

After surgery, all patients participated in a rehabilitation program directed by licensed physical therapists at various outpatient facilities. Rehabilitation emphasized progressive recovery phases, beginning with restoring range of motion, followed by strengthening, functional mobility training, and sport-specific exercises. Minor variations in timing and specific exercises were permitted according to the surgical procedure performed and individual patient progress. RTS clearance was determined by (1) the operating surgeon, who incorporated the patient's clinical recovery, (2) results of an RTS assessment performed by the physical therapist, and (3) shared decision-making discussions with the patient and family. RTS clearance was determined after the 6-month postoperative evaluation, and SIRSI scores were collected before and independent of formal clearance decisions, minimizing potential bias related to clearance status. The RTS assessments included evaluation of shoulder range of motion, strength, functional stability, and quality of movement, with comparison against the contralateral side and consideration of sport-specific demands.

Postoperative follow-up assessments were performed at 6 months and 1 year after surgery to evaluate for overall recovery, psychological readiness, functional status, and PROMs. The psychological readiness was assessed with SIRSI. Other validated tools that were administered at both visits were the American Shoulder and Elbow Surgeons (ASES) assessment form, the Tegner Activity Scale, the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, and the Pediatric/Adolescent Shoulder Survey (PASS). The ASES score and the PASS measured pain and shoulder function, while the Tegner evaluated physical activity levels. The QuickDASH assessed upper extremity disability. These measures provided a comprehensive view of recovery at key intervals. Additionally, patients were asked if they attempted to return to their primary sport. If they had not, they were asked to indicate a reason. If they attempted to return, they were asked if they successfully returned. If they returned to their primary sport, they were asked if they returned to a lower, same, or higher level of play. Participants categorized as engaging in recreational sport or physical activity (nonorganized) and grouped within the “other” category were assessed by return to their self-reported baseline level of physical activity rather than to organized competitive sport. Time to RTS was not analyzed as a continuous outcome. Instead, RTS status was assessed categorically at follow-up visits based on patient-reported return to primary sport or baseline physical activity level.

Statistical Analysis

Continuous variables were described by means and standard deviations or medians and interquartile ranges, whereas categorical variables were presented as frequencies and percentages. Given the nonnormal distribution of the data, a Wilcoxon signed rank test was used to compare continuous outcomes at 6 months and 1 year. Spearman rank correlation assessed the association between 6-month SIRSI and continuous PROMs at 1 year. P values <.05 were considered statistically significant. Associations between 6-month SIRSI and 1-year RTS or level-of-play outcomes were analyzed by the Mann-Whitney U or Kruskal-Wallis test. All statistical analyses were conducted in R Statistical Software (Version 4.4.1; R Foundation for Statistical Computing).

Results

The study included 23 participants who had a mean ± SD age of 16.7 ± 1.1 years at the time of surgery. Demographic data including hand dominance, sport participation, and surgical procedures performed (Table 1). The majority of the participants were male (65.2%), and most had surgery on the dominant arm (69.6%). All were seen at 6 months and at the 1-year mark or beyond. SIRSI scores, RTS data, and PROMs were collected from all 23 participants.

Primary Outcomes

The primary aim of the study was to examine the relationship between 6-month SIRSI scores and 1-year PROMs. A moderate positive correlation was seen between 6-month SIRSI scores and 1-year ASES scores with a Spearman rank correlation coefficient of 0.42 (95% CI, 0.01-0.71). A moderate positive correlation was seen between 6-month SIRSI scores and 1-year Tegner scores with a Spearman rank correlation coefficient of 0.51 (95% CI, 0.12-0.76). The Spearman rank correlation coefficient was −0.24 (95% CI, –0.59 to 0.19) when 6-month SIRSI scores and 1-year QuickDASH scores were compared, noting no associated correlation.

Review of RTS outcomes showed differences in 6-month SIRSI scores among the 17 patients who successfully returned to their primary sport and the 6 who did not (P = .006) (Figure 1). Patients who returned to their primary sport had a median 6-month SIRSI score of 78.3 (IQR, 68.3-85.8). The 6 participants who did not return to primary sport had a median score of 46.7 (IQR, 30.8-56.3).

Figure 1.

Median 6-month SIRSI scores in relation to primary RTS outcome (P = .006). RTS, return to sport; SIRSI, Shoulder Instability–Return to Sport After Injury.

In terms of the level of play to which participants were able to return within their primary sport, 4 (23.5%) reported playing at a higher level 1 year postoperatively, 2 (11.8%) played at a lower level, and 10 (58.8%) maintained the same level of play. One participant's level of play was not reported. The median 6-month SIRSI scores for these groups were 72.9 (IQR, 46.5-94.4) for those who played at a higher level, 55.4 (IQR, 43.1-67.7) for those who played at a lower level, and 79.2 (IQR, 73.9-85.1) for those who maintained the same level of play. The participant with the unknown level of play had a median score of 78.3. Statistical analysis revealed no significant differences in 6-month SIRSI scores across these groups (P = .84). When the analysis was limited to participants with known levels of play, the results remained consistent, with no significant association between 6-month SIRSI scores and changes in the level of play within the primary sport (P = .62) (Figure 2).

Figure 2.

Median 6-month SIRSI scores in relation to return to primary sport level of play (P = .62). Only data for patients with known level of play are shown. SIRSI, Shoulder Instability–Return to Sport After Injury.

Secondary Outcomes

The comparison of 6-month and 1-year PROMs revealed significant improvements across all evaluated measures, including SIRSI, ASES, Tegner, QuickDASH, and PASS scores (Table 2). The median SIRSI score improved from 73.3 at 6 months to 89.2 at 1 year (P < .004). When stratified by RTS status, athletes who returned to their primary sport demonstrated significantly higher 1-year SIRSI scores as compared with those who did not return (median, 92.5 vs 66.3; P = .003). ASES scores also improved, with a median increase from 91.7 at 6 months to 96.7 at 1 year (P = .009). Tegner scores rose from a median 6.0 at 6 months to 9.0 at 1 year (P = .007). QuickDASH scores demonstrated a significant decrease, with the median score reducing from 2.3 at 6 months to 0.00 at 1 year (P = .004). The PASS score increased from 90.0% at 6 months to 95.0% at 1 year (P = .006).

Table 2

Comparison Between 6-Month and 1-Year Postoperative PROMs ^a

	Postoperative Period, Median (IQR)
PROM	6 mo	1 y	P Value
ASES	91.7 (83.3-98.3)	96.7 (91.7-100.0)	.009
PASS	90.0 (83.0-97.5)	95.0 (92.0-98.5)	.006
SIRSI	73.3 (50.0-82.5)	89.2 (73.8-95.0)	.004
Tegner	6.0 (4.0-7.0)	9.0 (7.0-9.0)	.007
QuickDASH	2.3 (0.0-10.2)	0.0 (0.0-2.3)	.004

ASES, American Shoulder and Elbow Surgeons; PASS, Pediatric/Adolescent Shoulder Survey; PROM, patient-reported outcome measure; QuickDASH, Quick Disability of the Arm, Shoulder, and Hand; SIRSI, Shoulder Instability–Return to Sport After Injury; Tegner, Tegner Activity Scale.

Discussion

Our study investigated the role of the SIRSI, a validated tool developed to evaluate the psychological factors important for RTS,³ and its association with functional outcomes after shoulder stabilization surgery in adolescent athletes. We found that 6-month SIRSI scores correlate significantly with 1-year PROMs, including the ASES and Tegner scores. Higher 6-month SIRSI scores were associated with improved functional outcomes and a greater likelihood of successful RTS, supporting the importance of psychological readiness during postoperative recovery.

Shoulder stabilization surgery aims to not only improve the structural and mechanical aspects of the shoulder but also restore the functional and psychological aspects to optimize return to previous activity.³ Prior literature has proposed an SIRSI cutoff score of 55 to help identify athletes who may be psychologically ready to RTS and those who may benefit from additional intervention or support.¹⁴ Our findings extend this work by demonstrating that SIRSI scores obtained at the commonly used 6-month postoperative benchmark are associated with PROMs measured at 1 year, suggesting that intermediate psychological readiness may provide early insight into longer-term recovery trajectories. This relationship was most evident in associations with 1-year ASES and Tegner scores, measures that reflect shoulder function and activity level, respectively.^7,16 Although Gerometta et al³ and Rossi et al¹⁴ validated the use of SIRSI scores in RTS, our findings support the use of the SIRSI tool beyond the 6-month postoperative evaluation in examining the psychological readiness of young athletes, providing new longitudinal and age-specific data.

Consistent with prior studies,^3,19 athletes who successfully returned to their primary sport demonstrated significantly higher 6-month SIRSI scores than those who did not. While this finding highlights the importance of psychological readiness, RTS is likely influenced by multiple factors, including physical recovery, sport-specific demands, and external considerations such as season timing and athlete expectations.

As compared with existing literature, our primary RTS rate was 73.9%, which is lower than the rates reported by Shanmugaraj et al (95%)¹⁵ and Ozturk et al (87%).⁹ Several factors may explain this difference, including our smaller sample size, a higher proportion of contact sport athletes, and a more balanced male-to-female ratio. It has been demonstrated that contact sports are associated with greater physical demands and injuries of greater severity,¹² which may influence recovery timelines. Additionally, female athletes may face distinct psychological and physical challenges during rehabilitation, including higher rates of anxiety and stress,¹⁸ and prior multicenter work has demonstrated lower SIRSI scores among females at the time of RTS testing.²⁰

Our cohort also included a broader range of surgical procedures, which contrasts with the uniform approach of arthroscopic Bankart repairs in prior referenced studies. This procedural heterogeneity may contribute to variability in recovery trajectories. A final difference is that our 1-year follow-up period was shorter than that of the 12 to 49 months in the Shanmugaraj et al study¹⁵ and 20 to 32 months in the Ozturk et al study⁹ and may not fully capture continued improvement in function and RTS observed beyond 12 months.

Notably, the relationship between psychological readiness and functional recovery is likely bidirectional. Residual physical limitations such as weakness, stiffness, or pain may negatively influence an athlete's confidence and psychological readiness to RTS. Conversely, lower psychological readiness may reduce engagement in rehabilitation and sport-specific training, potentially limiting functional recovery.^{3,10,14,19,20} This interaction highlights the importance of addressing physical and psychological factors throughout rehabilitation rather than treating them as independent domains.

SIRSI and Level-of-Play and RTS Outcomes

In our study, athletes who ended up returning to their primary sport did so at varying competitive levels: 23.5% returned at a higher level, 11.8% at a lower level, and 58.8% at the same preinjury level. These findings are consistent with prior literature, which reports that approximately 50% to 80% return to their preinjury level of play, with a smaller proportion improving beyond baseline.^11,15 Popchak et al¹¹ found that 11% to 22% of athletes returned to lower levels of competition, which aligns with our observed rate. These findings reinforce the importance of addressing psychological factors, including fear of reinjury and confidence during the later phases of recovery.

SIRSI and QuickDASH

In contrast to sport-specific measures, no association was observed between 6-month SIRSI scores and 1-year QuickDASH scores, although a multicenter study in adolescents reported a moderate negative correlation between SIRSI and QuickDASH at 6 months postoperatively.²⁰ The QuickDASH was designed to assess general upper extremity disability and is not sport specific.^4,6 Our finding suggests that psychological readiness to RTS may diverge from perceived disability in daily activities during later phases of recovery, when athletes increasingly shift their focus from restoring basic range of motion and strength to sport-specific training goals such as dynamic stability, proprioception, and confidence in performance rather than basic function.

Secondary Outcomes

Positive changes were seen across all outcome measures (SIRSI, ASES, Tegner, QuickDASH, and PASS scores) between 6 months and 1 year, thus showing continuous improvement after primary shoulder stabilization. Therefore, these assessments may be applied periodically to assess recovery progress, to individualize the rehabilitation plan, and to determine areas requiring more attention. In agreement with others, we were also able to show high functional scores after repair in an adolescent population.⁵ Similarly, Utami et al¹⁷ reported that athletes commonly RTS around 6 months after shoulder surgery, with continued functional improvement at 1 year, and they identified factors such as type of sport, strength, range of motion, pain, and proprioception as contributors to recovery timelines. Although our study did not explicitly evaluate recurrent instability, 2 participants were excluded owing to reinjury requiring revision surgery, highlighting that a subset of adolescents may experience unique challenges in successful recovery. Further study is warranted to better characterize this population.

Overall, these findings align with the growing body of evidence demonstrating progressive functional improvements after shoulder stabilization surgery in the adolescent population. The observed improvements in PROMs suggest that surgical treatment and rehabilitation are effective in restoring function and facilitating return to activity, although further work is needed to better understand factors associated with reinjury and delayed recovery.

Limitations

There are several limitations to our study that need to be considered. First, the relatively small population size limits the generalizability of our results to a broader cohort of young athletes recovering from shoulder stabilization surgery. This sample size also precluded meaningful subanalyses to evaluate potential risk factors for RTS, PROMs, or SIRSI scores, including sex, sport type, age, or underlying pathology. However, this cohort represents all eligible patients within the defined period at our expanding institutional database. We continue to prospectively track these patient populations, which will enable future analyses with larger cohorts to improve external validity, enhance statistical power, and extend these preliminary findings. Another limitation is the variability of surgical techniques, which complicates the outcome interpretation. Although these procedures shared similar rehabilitation protocols and RTS goals, procedural heterogeneity may have influenced functional and psychological outcomes.

Additionally, the 1-year follow-up period of our study may not have fully captured the long-term recovery, as prior studies have demonstrated continued improvement beyond the 1-year mark.^9,15 Longer-term follow-up at 18 or 24 months may provide additional insight into psychological readiness, functional outcomes, and recurrence risk in young athletes. Finally, although our cohort had a more balanced male-to-female ratio than prior studies with overwhelmingly male participants, sex-specific recovery differences may have influenced outcomes, and future studies with larger samples are needed to further evaluate these effects.

Conclusion

Footnotes

Acknowledgements

Research reported in this publication was supported by the Seattle Children's ASPIRE program.

Final revision submitted January 5, 2026; accepted January 12, 2026.

One or more of the authors has declared the following potential conflict of interest or source of funding: Research reported in this publication was supported by Seattle Children's ASPIRE program. M.G.S. has received support for education from Arthrex, Summit Surgical, and Smith + Nephew; compensation for services other than consulting from Arthrex; and grant and hospitality payments from DJO. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was obtained from the Seattle Children's Research Institute Review Board (STUDY00004152).

ORCID iDs

Carolina Pavlenco

Bilal Khilfeh

Xing Wang

References

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Six-Month SIRSI Scores and Return to Sport After Shoulder Stabilization in Adolescent Athletes

Abstract

Background:

Purpose/Hypothesis:

Study Design:

Methods:

Results:

Conclusions:

Keywords

Methods

Study Design

Preoperative Evaluation and Surgical Technique

Postoperative Follow-up

Statistical Analysis

Results

Primary Outcomes

Secondary Outcomes

Discussion

SIRSI and Level-of-Play and RTS Outcomes

SIRSI and QuickDASH

Secondary Outcomes

Limitations

Conclusion

Footnotes

Acknowledgements

ORCID iDs

References