Development and Validation of the Elbow Instability-Return to Sport After Injury (EI-RSI) Scale: Assessing Psychological Readiness for Return to Sport

Abstract

Background:

Psychological readiness is an essential determinant of safe return to sport (RTS) after injury, yet it is often underrepresented in assessments of patients with elbow instability. The Elbow Instability–Return to Sport after Injury (EI-RSI) scale is a questionnaire designed to evaluate psychological readiness in athletes after lateral ulnar collateral ligament (LUCL) reconstruction for posterolateral rotatory instability of the elbow.

Purpose:

To develop and validate the EI-RSI scale.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

The EI-RSI was developed from the anterior cruciate ligament return-to-sport index (ACL-RSI) and the shoulder instability return-to-sport index (SI-RSI) with input from 10 patients with LUCL reconstruction (10 elbow joints), then tested in a retrospective cohort (2015-2021). Validity was assessed by correlating with the Mayo Elbow Performance Score (MEPS) and the Patient-Rated Elbow Evaluation (PREE). Reliability was assessed using test-retest analysis. RTS was measured via a questionnaire assessing participation (yes/no), return to preinjury level, and time to return. Statistical analyses included the Mann-Whitney U test and the Cronbach alpha.

Results:

A total of 47 patients (47 elbow joints; mean age, 40.7 ± 13 years; 22 men) were analyzed, with a median follow-up of 77 months (interquartile range [IQR], 36-110). The EI-RSI demonstrated good construct validity, showing a moderate positive correlation with MEPS (r = 0.472; P < .001) and moderate negative correlations with the PREE total (r = −0.572; P < .001), PREE pain (r = −0.610; P < .001), and PREE function (r = −0.595; P < .001) scores. Test-retest reliability was excellent (Spearman rho = 0.965; P < .001; ICCsingle = 0.965 [95% CI, 0.935-0.981]; ICCaverage = 0.982 [95% CI, 0.966-0.991]). Internal consistency was high (Cronbach α = 0.982). Patients who returned to sport exhibited significantly higher EI-RSI scores (median, 91.3 [IQR, 83.2-94.6]) compared with those who did not (median, 77.5 [IQR, 52.5-91.7]; P = .017). No floor or ceiling effects were observed.

Conclusion:

Our study demonstrated that the EI-RSI is a valid and reliable instrument for evaluating psychological readiness to RTS after LUCL reconstruction for posterolateral rotatory elbow instability. Its clinical implementation may facilitate informed RTS decisions and identify patients who could benefit from psychological support before safely resuming athletic activity.

Keywords

elbow instability reinjury anxiety psychosocial factors sport confidence

With an incidence of 6 to 9 per 100,000 patients, the elbow is the second most frequently dislocated joint, following the shoulder.^1,40 In recent decades, the incidence and treatment of collateral ligament injuries in overhead sports have increased significantly.^19,31 Advances in surgical techniques, increased clinical experience, and improved rehabilitation protocols have significantly improved the rate of successful return to sport (RTS) for these athletes.³¹ Studies^9,16,35,39 on posterolateral rotational elbow instability treated with lateral ulnar collateral ligament (LUCL) reconstruction or repair show favorable results, with return to work, RTS, and return to preinjury activity rates ranging from 83% to 94.1%. However, the literature provides conflicting data on the allowable RTS timeline, with estimates ranging from 3 to 9 months.³⁵

Traditionally, the decision to perform an RTS after such an injury has been based on time after injury/surgery and physical criteria, such as joint stability, range of motion, and pain levels, often overlooking psychological factors.²² However, previous studies have shown that the psychological state of the patient, their processing of the traumatic experience, fear of reinjury, and motivation to return to their preinjury level of activity influence the recovery outcome.^21,32,41 RTS involves multiple phases of a patient's psychological response and coping mechanisms related to the injury, its diagnosis, the rehabilitation process, and the eventual return to competition. Negative emotional and behavioral responses, such as fear of reinjury or concerns about performing at preinjury levels, may contribute to suboptimal outcomes. This highlights the need for comprehensive psychological preparation to support the athlete throughout the recovery process.^6,33,37

To quantify psychological readiness to RTS, Webster et al⁴² developed the Anterior Cruciate Ligament–Return to Sport after Injury (ACL-RSI) questionnaire, which evaluates emotions, confidence, and risk perception—all critical factors influencing RTS outcomes.⁴² The study evaluated 220 patients after ACLR (ACLR) and found that patients who did not RTS had significantly lower ACL-RSI scores than those who did. The authors concluded that psychological factors are crucial for returning to sport after ACL surgery and that the ACL-RSI scale can identify athletes who may have difficulty returning to sport.⁴² Gerometta et al¹⁵ later adapted this questionnaire to assess psychological readiness for RTS in patients with shoulder instability. However, no tool is currently available to assess the psychological readiness to RTS in patients recovering from elbow instability.

The primary objective of the present study was to develop and validate an Elbow Instability – Return to Sport after Injury questionnaire. It was hypothesized that this tool would be reliable and valid for assessing patients’ psychological readiness to RTS after LUCL reconstruction for posterolateral rotatory elbow instability.

Methods

The study received institutional review board approval (2022-223-S-NP) and was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants before their clinical evaluation.

Proposed EI-RSI Scale

The Elbow Instability-Return to Sport after Injury (EI-RSI) scale was adapted from the SI-RSI scale,¹⁵ which, in turn, was derived from the ACL-RSI scale.⁴² The primary modification involved replacing the term "shoulder" with "elbow" to suit the focus on elbow instability. Similar to the ACL-RSI and SI-RSI scales, the EI-RSI consists of 12 questions, each rated on an 11-point Likert scale ranging from 0 to 10. The total score is calculated by summing the 12 responses and converting the total to a percentage out of 100. Higher scores indicate a more positive psychological response to returning to sport.

Following international guidelines for self-administered questionnaires,⁵ a pretest of the initial version was conducted among randomly selected patients who had experienced an episode of elbow instability. The questionnaire was subsequently revised based on the participants’ feedback, particularly regarding their overall impression and the clarity of specific terms.

Validity and reproducibility of EI-RSI

The final version of the EI-RSI (Appendix 1) was validated in accordance with the Consensus-based Standards for the selection of health status Measurement Instruments²⁷ guidelines. A retrospective review identified patients who underwent LUCL reconstruction with an autologous triceps tendon graft for posterolateral rotatory instability (PLRI) between 2015 and 2021. The inclusion criteria were as follows: (1) age ≥16 years at the time of injury; (2) regular sports participation defined as training ≥2 sessions/week in the year before injury; and (3) minimum follow-up of 12 months. Patients with acute LUCL repair without reconstruction, previous elbow surgery, or concomitant fractures requiring fixation were excluded. All patients in the cohort initially underwent a course of nonoperative management, including activity modification, physiotherapy, and bracing, before surgical intervention was considered because of persistent symptoms or ongoing functional impairment.

Descriptive data were collected for each patient. The EI-RSI was benchmarked against the validated versions of the Mayo Elbow Performance Score (MEPS)²⁸ and the Patient-Rated Elbow Evaluation (PREE).²⁴ RTS was assessed via a patient-reported questionnaire that asked whether the individual had resumed sport participation after surgery (yes/no) and, if yes, whether the preinjury level of sport was regained. The time (in months) from surgery to RTS was also recorded. The rate and timing of RTS were also assessed. Any complications or revision procedures were documented. Each patient completed the EI-RSI twice, with a minimum interval of 14 days between administrations to assess test-retest reliability.

Statistical Analyses

All calculations were performed with SPSS Statistics (Version 28; IBM Corp). Data normality was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Normally distributed data are presented as mean ± standard deviation, while nonnormally distributed data are presented as median with interquartile range (IQR). Receiver operating characteristic (ROC) curve analysis was performed to assess the ability of the EI-RSI to discriminate between patients who returned to sport and those who did not. The area under the curve (AUC) with 95% CI was calculated, and the optimal cutoff value was determined using the Youden index. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratios, and overall accuracy were reported for the optimal cut-off. The reliability of the EI-RSI was evaluated using test-retest reliability, where Spearman's Rho was calculated to assess the correlation between the first and second tests. Intraclass correlation coefficients (ICCs) were computed to assess reproducibility, including single- and average-measure ICCs, along with their 95% CIs. Internal consistency was assessed using Cronbach α. The strength of correlations was interpreted according to Hinkle et al¹⁸ as follows: negligible (0.00-0.30), low (0.30-0.50), moderate (0.50-0.70), high (0.70-0.90), and very high (0.90-1). A Mann-Whitney U test was conducted to compare EI-RSI scores between patients who returned to sports and those who did not. P < .05 was considered statistically significant.

Results

Pretest

The pretest was completed by 10 patients (mean age, 42.2 ± 3.2 years). The mean follow-up period after dislocation was 1 ± 0.2 years. The participants provided no additional comments on the questionnaire and answered all questions in full.

Patient Characteristics and RTS

A total of 47 patients with a median follow-up of 77 months (IQR, 36-110) met the inclusion criteria. Their demographic characteristics are summarized in Table 1.

Table 1

Patient Characteristics ^a

Variable	Value
Number of patients, n	47
Sex	Male: 22 (46.8)
Sex	Female: 25 (53.2)
Affected side	Right: 20 (42.6)
Affected side	Left: 27 (57.4)
Age at surgery, years	40.7 ± 13 ^b
Follow-up, months	77 [36-110] ^c
Concomitant pathologies	Lateral epicondylitis: 13 (27.7)
	Elbow stiffness: 1 (2.1)
	Ulnar nerve entrapment: 4 (8.5)
Concomitant surgical procedures	Nirschl procedure³⁰: 6 (12.8)
	Nirschl procedure with epicondyle osteotomy: 1 (2.1)
	Extensor tendon refixation: 1 (2.1)
	Extensor tendon refixation with epicondyle osteotomy and ulnar nerve neurolysis: 1 (2.1)
	Epicondyle osteotomy: 2 (4.3)
	Extensor tendon debridement: 2 (4.3)
	Ulnar nerve neurolysis: 3 (6.4)
	Arthrolysis: 1 (2.1)

Data are presented as n (%), unless otherwise indicated. IQR, interquartile range.

Normally distributed data are reported as mean ± SD.

Nonnormally distributed data are reported as median (IQR).

Patients reported excellent outcomes, with a median MEPS score of 100 (IQR, 9.8-100 [range, 60-100]) and a median PREE score of 3.5 (IQR, 0-7.4 [range, 0-91.5]). The median PREE pain score was 2 (IQR, 0-5 [range, 0-43]), and the median PREE function score was 0.5 (IQR, 0-1.6 [range, 0-48.5]). Two patients (4.3%) developed recurrent instability and underwent revision surgery.

A total of 40 patients (85.1%) returned to their sport, and 30 patients (63.8%) resumed participation at the same or a higher level. It took patients 6 (IQR, 5.5-6.5 [range 2-12]) months to RTS. A breakdown by specific sports is provided in Table 2.

Table 2

RTS by Type of Sport ^a

	Total	RTS	Returned to Same or Higher Level of Sport
Fitness	12	11 (91.7)	10 (83.3)
Strength training	10	9 (90)	8 (80)
Hiking	6	6 (100)	5 (83.3)
Cycling	6	6 (100)	5 (83.3)
Skiing	3	3 (100)	3 (100)
Horse riding	2	2 (100)	2 (100)
Jogging	2	2 (100)	2 (100)
Snowboarding	2	2 (100)	2 (100)
Climbing	2	2 (100)	2 (100)
Football	2	2 (100)	2 (100)
Mountain biking	2	1 (50)	1 (50)
Floorball	1	1 (100)	1 (100)
Pilates	1	1 (100)	1 (100)
Ice hockey	1	0 (0)	0 (0)
EMS training	1	1 (100)	0 (0)
Badminton	1	1 (100)	1 (100)
Swimming	1	1 (100)	1 (100)
Squash	1	1 (100)	1 (100)
Bowling	1	0 (0)	0 (0)
Gymnastics	1	11 (91.7)	10 (83.3)

Data are presented as n (%). Some patients participated in multiple sports. EMS, electric muscle stimulation; RTS, return to sport.

EI-RSI Scale

The median EI-RSI score was 88.3 (IQR, 69.2-93.8 [range, 34.2-100]). ROC analysis of the EI-RSI for predicting RTS yielded an AUC of 0.650 (95% CI, 0.387-0.913; P = .264). The optimal cutoff, determined by the Youden index, was 70 points, resulting in a sensitivity of 80% and a specificity of 57.1% (Figure 1). At this cutoff, the PPV was 91.43%, and the NPV was 33.33%, with an overall accuracy of 76.6%.

Figure 1.

ROC curve for the EI-RSI scale in predicting RTS. The AUC was 0.650 (95% CI 0.387-0.913; P = .264). The optimal cutoff value determined by the Youden index was ≥70 points, yielding a sensitivity of 80% and a specificity of 57.1%. AUC, area under the curve; EL-RSI, Elbow Instability–Return to Sport after Injury; ROC, receiver operating characteristic.

A total of 35 patients (74.5%) surpassed the EI-RSI threshold of 70. The floor and ceiling effects for the EI-RSI were minimal, each at 2.1%, with the lowest recorded score being 34.2 and the highest 100. The median EI-RSI scores for the first and second tests were 90 (IQR, 68.5-94.1[range, 34.2-100]) and 91.3 (IQR, 71.6-97.5 [range, 35-100]), respectively. The correlation between the 2 tests was very high, with a Spearman rho of 0.965 (P < .001). Reproducibility was also “very high,” demonstrated by a single measure ICC of 0.965 (95% CI, 0.935-0.981; P < .001) and a mean measures ICC of 0.982 (95% CI, 0.966-0.991; P < .001). Additionally, internal consistency was assessed using Cronbach α, yielding a coefficient of 0.982, indicating excellent internal consistency. A Bland-Altman plot is provided in Figure 2.

Figure 2.

Bland-Altman plot assessing the test-retest reliability of the EI-RSI measured at 2 different time points. The mean difference is close to zero, indicating no significant systematic bias between the measurements. Most data points are clustered around the mean, demonstrating good reliability, with a few outliers observed at lower mean values. EL-RSI, Elbow Instability–Return to Sport after Injury.

The construct validity ranged from low to moderate, demonstrated by a low positive correlation between the EI-RSI and the MEPS (r = 0.472; P < .001), along with moderate negative correlations with the overall PREE score (r = −0.572; P < .001), the PREE pain subscale (r = −0.610; P < .001), and the PREE function subscale (r = −0.595; P < .001).

A statistically significant difference in EI-RSI scores was observed between the subgroup of patients who returned to sports and those who did not: 91.3 (IQR, 83.2-94.6 [range, 40.8-100]) versus 77.5 (IQR, 52.5-91.7 [range, 34.2-98.3]; P = .017), indicating good discriminant validity.

The internal consistency of the scale measuring the strength of the correlation among the 12 items was excellent, with a Cronbach α coefficient of .936.

Discussion

The most significant finding of this study is that the EI-RSI is a valid and reliable tool for assessing psychological readiness to RTS after LUCL reconstruction for posterolateral rotatory instability of the elbow.

Recent studies have further highlighted the significant impact of psychological factors on recovery outcomes.^4,7,20,29 Negative factors, such as fear, anxiety, difficulty regaining skills, and pressure to meet specific return dates, have been shown to increase the risk of reinjury. Conversely, positive factors, including high levels of motivation, self-confidence, and moderate anxiety, are associated with successful recovery and RTS outcomes.^4,7,29 Ford et al¹⁴ investigated the role of psychosocial variables in moderating the relationship between life stress and injury-related time loss in elite athletes. Their study, which included 121 athletes at state, national, and international levels in a variety of sports, concluded that higher levels of optimism, resilience, and self-esteem enable athletes to cope more effectively with life stress. This, in turn, reduces susceptibility to injury and improves recovery outcomes.¹⁴ These findings, supported by more recent research, underscore the importance of implementing preventive strategies in sport and rehabilitation protocols.^20,29 Injuries often trigger significant negative psychological responses, including depression, anxiety, and other mental health problems. Such reactions may be exacerbated by the pressures of responsibilities (social, athletic, academic, job-related, etc), making recovery even more challenging. To address these challenges, comprehensive screening for mental health issues in athletes is critical. This includes a holistic approach to the patient, early identification and effective treatment, and the promotion of healthy coping mechanisms, all of which are essential for optimizing recovery and RTS outcomes.^13,34,36 Recognizing the impact of psychological responses on patient rehabilitation has made the concept of psychological readiness an essential criterion for optimal RTS.^6,3,11,26

A quantitative questionnaire can provide a standardized, measurable, and reproducible method for assessing psychological readiness to RTS, enabling clinicians to track progress and compare results over time. Recent research on ACLR found that higher psychological readiness, as measured by the ACL-RSI, is associated with superior performance on functional tests.²⁵ Similarly, a prospective study by Rossi et al³⁷ involving patients who had undergone glenohumeral stabilization surgery showed that patients who successfully returned to sport or to their preinjury level of participation had significantly higher psychological readiness, as measured by the SI-RSI, than those who did not RTS. The present study echoes these findings, revealing a significant difference in psychological readiness, as measured by the EI-RSI, with significantly lower EI-RSI scores among patients who did not RTS after an episode of instability.

RTS is a critical indicator of success in the management of elbow instability. Modern surgical approaches demonstrate good RTS rates in both cases of bilateral and isolated (medial or posterolateral) instability.^{8,10,12,16,17,22,38,39} In cases of PLRI, clinical outcomes do not differ significantly regarding the cause of instability.¹⁶ Geyer et al¹⁷ compared surgical and conservative treatment of simple elbow dislocations and found excellent results in 95.5% of cases with no significant difference in joint gapping between the 2 groups. However, 10% of conservatively treated patients reported dissatisfaction with elbow stability, whereas RTS rates and recovery speed were higher in patients who underwent surgery, suggesting that surgery may be more appropriate for highly active individuals who wish to return to preinjury activity levels. Further, athletes were more likely to opt for surgery, driven by their desire for the best possible outcomes. These findings highlight the importance of addressing psychological and personality factors that may influence rehabilitation and RTS. Although modern surgeons have access to advanced techniques and tools to achieve optimal joint stability and achieve excellent outcomes in terms of general RTS rates, a subset of patients exhibit no objective signs of instability, meet all criteria for returning to play, yet ultimately reduce or entirely discontinue their sporting activities after treatment.²²

The classic criteria for RTS after elbow stabilization is time after surgery, and it differs significantly in the literature ranging between 10 and 18 months after reconstruction surgery and from 3 to 9 months for repair and repair with bracing ^8,17,22,35 Secondary criteria for determining RTS timeline in the context of elbow instability rely primarily on such measures as range of motion, strength, pain, and clinical and radiographic indicators of stability.^{8,10,12,16,17,22,38,39} To optimize the RTS process, individualization of postoperative treatment, particularly of elite and professional athletes, is widely discussed in the literature, with greater emphasis on the importance of psychological and personality factors.^{3,6,11,21,23,25,32,37,42}

This study has several limitations. As a retrospective analysis, it is subject to potential biases and confounding factors. While the present study established the validity and reliability of the EI-RSI, it did not examine long-term trends in psychological readiness or the sustainability of RTS over time. Moreover, variations in rehabilitation protocols and psychological support among patients were not accounted for. Follow-up durations varied among participants but consistently exceeded 12 months posttreatment, reflecting the retrospective nature of the data collection. Additionally, the relatively small sample size limited the ability to analyze outcomes across different sports, making it difficult to determine whether certain sports are associated with lower RTS rates. The study did not account for sport-specific factors, such as differences in physical and psychological demands, which may influence RTS outcomes. One limitation of this study is the relatively small sample size. However, given the rarity of the condition and the single-center study design, the cohort size is comparable to those reported in the existing literature.^2,12

Furthermore, the EI-RSI, like the ACL-RSI and SI-RSI, serves not only as a tool to identify patients who may be facing psychological challenges in returning to sport and play but also underscores the need for developing targeted psychological support strategies. These could help patients overcome mental barriers and enhance their overall rehabilitation outcomes.

Conclusion

Footnotes

Appendix

Final revision submitted February 17, 2026; accepted March 14, 2026.

One or more of the authors has declared the following potential conflict of interest or source of funding: S.S. serves as a consultant for Arthrex GmbH, medi GmbH & Co. KG, and KLS Martin Group. S.G. serves as a consultant for Medacta GmbH.

Ethical approval for this study was obtained from the Ethics Committee of the Technical University of Munich (2022-223-S-NP).

ORCID iDs

Pavel Kadantsev

Ahmed Ellafi

Sebastian Siebenlist

Lukas N. Muench

Armin Runer

Maximilian Hinz

Stephanie Geyer

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