Psychological factors influencing return to sport after shoulder stabilization: assessment tools and intervention strategies—a narrative review

Introduction

Background

Glenohumeral instability is frequently seen in the orthopaedic and sports medicine community. It commonly involves physically active individuals, especially young competitive athletes (1). Traumatic glenohumeral dislocations alone are estimated to affect over 75,000 individuals in the United States per year (2), and competitive athletes sustain glenohumeral instability at a rate of up to 20 times higher than the general population (3,4). Given the significant risk of recurrence when treated non-operatively, there is a trend to address traumatic glenohumeral instability with surgical stabilization (5). The primary goal of any stabilization procedure is to prevent recurrence of instability, and in this domain, shoulder stabilization procedures are generally effective (6). However, athletes may place even higher priority on returning to their preinjury levels of activity (7). Given the inherent risk of traumatic glenohumeral instability in sport participation, these competing goals present a unique challenge for the sports medicine provider. Unfortunately, many athletes are unable to return to their prior sport levels (RTSP) after shoulder stabilization procedures. Evidence currently reports that up to 25% of athletes sustain recurrent instability after return to sport (8,9). Further, shoulder stabilization surgery alone may not be as effective as desired regarding RTSP outcomes. Fewer than 2/3 of athletes are able to RTSP after primary operative management (10), and fewer than half achieve this after revision procedures (11). Such data suggest that improvements are needed throughout the continuum of care to reduce recurrent instability rates and to improve the athlete’s ability to RTSP.

Both modifiable and non-modifiable factors can influence an athlete’s ability to RTSP after shoulder stabilization. Non-modifiable factors such as engaging in shoulder-dominant activity, revision stabilization, increasing number of prior dislocations and levels of bone loss have all been reported to decrease an athlete’s ability to RTSP (12-16). Modifiable risk factors including loss of range of motion, imbalances in shoulder rotational strength, generalized weakness, players’ sport position, and participation level (17-22) can all influence RTSP. Multifactorial, criteria-based return to sport (CBRTS) decision making processes have been endorsed to comprehensively assess an athlete’s readiness to return after shoulder stabilization (23,24). However, despite promising initial results (25,26), standardized criteria have not yet been established nor accepted. Further, while these testing batteries have traditionally focused on an athlete’s physical strength and function, non-physical aspects, such as psychological and psychosocial factors have emerged as potentially significant factors affecting athletes’ ability to RTSP after shoulder stabilization. However, these factors may frequently go unaddressed and unassessed in current practice.

Rationale and objective

While evidence regarding these non-physical factors is in its infancy, a significant portion of athletes have identified psychological factors as primary reasons that they were unable to RTSP after shoulder stabilization (27-29). Fear of reinjury and kinesiophobia are the most cited reasons for an unsuccessful RTSP, while other factors such as decreased confidence, anxiety, and depression (30) have also been associated with negative outcomes. Neuroimaging studies have also identified altered brain activity related to threat perception, motor control, and emotional regulation in individuals with shoulder instability and apprehension (31-33). While these changes may partially explain the presence of these psychological factors, they also highlight the neuromuscular complexities of shoulder instability and the need for consideration of central mechanisms in an athlete’s recovery.

Tools such as the Shoulder Instability-Return to Sport After Injury (SI-RSI) (34) scale, among others, have been developed to assess athletes’ psychological readiness to return and have been reported with promise as being able to discriminate between those who are and are not psychologically ready to return. Despite the recent increase in recognition of these non-physical factors, little has yet emerged regarding specific interventions that sports medicine providers can utilize to support athletes’ successful RTSP after shoulder stabilization. However, work in other musculoskeletal injuries and surgeries sheds light on potential avenues for further study and integration into rehabilitation protocols and decision-making algorithms for athletes recovering from shoulder stabilization. Therefore, the purpose of this narrative review was to describe the psychological and psychosocial factors that influence athletes’ RTSP outcomes after shoulder stabilization, and to discuss currently available tools for assessment and potential interventions to address these factors to improve RTSP outcomes. We present this article in accordance with the Narrative Review reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-67/rc).

Methods

A literature review on the psychological aspects of injury, recovery, and return to sport associated with shoulder instability was conducted from inception until October 17, 2024, by the first two authors (A.J.P. and W.A.F.). Relevant studies were identified initially through a search of PubMed (MEDLINE) for articles that reported on return to sport outcomes and psychological measures after shoulder instability and stabilization. The structured approach for identification of available literature related to shoulder instability is displayed in Table 1. ‘Shoulder Instability’ was favored as a search term over ‘shoulder stabilization’ to ensure a broader search while still capturing postoperative outcomes. Due to the limited available evidence (n=29 articles) directly related to shoulder instability and stabilization, additional evidence, including psychological characteristics associated with other orthopaedic injuries, other appropriate patient-reported outcome measures, and psychologically directed interventions in the presence of orthopaedic injuries was identified via targeted searches. Further evidence was identified via citation mining for relevant topics.

Psychological factors that influence return to sport

A relatively large number of individuals do not return to sport, despite a high level of patient satisfaction and shoulder function after stabilization (35). Historically, physical recovery and testing have received the majority of the attention relative to return to sport and clearance decision-making (36). Comparatively, little attention has been given to the psychological factors that influence return to sport after shoulder instability and stabilization (37). However, emerging evidence suggests greater attention to psychological factors is required to optimize return to sport in athletes after shoulder instability.

Psychological challenges

Athletes with injuries are experience a variety of psychosocial challenges throughout the recovery process, including hurdles such as decreased self-esteem, anger, frustration, and fear of reinjury (38). Injuries are often associated with negative psychological responses, such as increased tension, feelings of depression, anger, reduced self-esteem, frustration and anxiety (35,39). Generally, such responses are a normal aspect of recovery and tend to change throughout the rehabilitation process (35). Unfortunately, when such responses are maladaptive, they may be detrimental to the athlete’s ability to return to their previous level of sport participation (36,40).

Fear of reinjury and returning/not returning to sport

In athletes who do not return to sport after shoulder stabilization, the decision not to return is frequently not attributed to a perceived lack of shoulder function, but rather a collection of extrinsic and intrinsic factors that are non-physiological in nature (35). The factor that has been reported to influence an athlete’s decision to return to sport or not the most is fear of reinjury (35,37). Additionally, even in those patients who do return to sport, high levels of fear and concern for their shoulder are still present (37). Fear of reinjury has been found to correlate with diminished self-reported functional outcomes and, when present, is thought to increase the risk of recurrent instability due to factors such as decreased sport-related attention, decreased efficiency with skill execution, and decreased efficiency of neuromuscular control and joint stiffness regulation (19,37). Therefore, it is possible that high levels of fear and concern are key factors related to the high rates of recurrent instability (37). Knowing that negative psychological responses, especially fear of reinjury, have been linked not only to not returning to sport, but also recurrent instability in those who do return to sport emphasizes the need to understand and know how to assess an athlete’s psychological readiness and fear level during the postoperative rehabilitation period.

Additional psychological factors

In addition to fear of reinjury, additional psychological factors that may be present but are less commonly reported include (I) fear of reduced competence in their sport; (II) self-awareness; (III) and the athlete’s degree of confidence (35). Additionally, preexisting psychological factors may impact an athlete’s ability to return to sport following shoulder injury. Brindisino et al. (30) performed a systematic review that investigated psychological factors’ influence on pain, function, quality of life and time to return to sports in athletes with shoulder instability. The investigators found subjects with preoperative depression demonstrated worse quality of life scores compared to a cohort without depression at 1-year postoperative (30). Additionally, shoulder function was also found to have a negative correlation with the presence of depression (30). Conversely, positive psychological responses, which include increased motivation and confidence, and reduced levels of fear have been associated with a more rapid return to sport and a higher likelihood of returning to pre-injury levels of participation (37,38,40,41). In totality, such findings highlight the need to recognize and address psychological factors throughout the post-injury time period. Such factors have a significant impact on an athlete’s decision to return to sport or not (35). Longitudinal examination of the psychological recovery after shoulder stabilization and how it may change over time is warranted and clinical management of these psychological factors may be a crucial component of the rehabilitation process (37). It must also be noted that while both soft tissue (e.g., Bankart) and bony block (e.g., Latarjet) procedures are frequently used in shoulder stabilization, there is currently no robust evidence to suggest that these psychological factors play distinct roles after different surgery types, and comparative studies are lacking (27,42). This area warrants further investigation, as these procedures are clearly distinct and evidence suggests that bony block procedures decrease recurrent instability.

Psychological recovery

Psychological recovery after injury has been divided into 3 distinct stages of recovery with various responses at each stage (37,38,41). The three phases, described by Kamphoff et al. (41), include (I) reaction to the injury, (II) reaction to rehabilitation, and finally, (III) reaction to return to sport. During the reaction to injury phase, athletes’ initial cognitive appraisals are mostly negative (38), with the athletes often exhibiting frustration and depression due to the injury and subsequent lack of sport involvement and anxiety and negative cognitive appraisals (38,41). The extent of the initial cognitive appraisals is greatly influenced by the perceived severity of the injury (38), with increasingly serious injuries eliciting more negative emotional responses. Common behavioral responses to such negative cognitive appraisal include seeking social support from family, teammates, coaches, and significant others (38).

Throughout the reaction to rehabilitation phase, athletes may experience frustration, apathy and poor adherence to treatment recommendations, resulting in decreased motivation to follow through with the rehabilitation process or an inappropriate impatience with rehabilitation and excessive eagerness to return to sport (38,41). Additionally, athletes may be cautious and have significant questions regarding the rehabilitation process, including but not limited to its value (38). For such reasons, athletes identify an increasing role of the rehabilitation professional as a source of social support (38).

Lastly, in the return to sport phase, both negative and positive emotional responses are often present. Negative concerns related to self-confidence regarding performance, anxiety and fear about reinjury are present (38,41), while positive excitement regarding the ability to return to sport emerges. Such conflicting emotional responses often cause the athlete to take a cautious approach to returning to sport (38). As suggested by Kamphoff et al. (41), it appears that the athlete’s physical and psychological recovery after injury and during the postoperative rehabilitation time period is dynamic and ever evolving and requires various levels of support and attention throughout from multiple members of the medical team, family, teammates, and coaches.

Impact of psychological challenges and recovery

The impact of these psychological responses throughout the recovery process on the athlete’s ability to ultimately return to sport participation at their pre-injury level appears to be significant. In particular, anxiety and depression are frequently present throughout the rehabilitation period after orthopaedic injuries (43-45). Though not specific to shoulder instability, the prevalence of anxiety symptoms is highest immediately after orthopaedic injury (46). However, nearly 56% of individuals continue to have anxiety 2 weeks post-injury with a modest reduction in prevalence noted at 6 weeks (31%) and 12 weeks (35%) post-injury (43,46). Likewise, prevalence rates of depression after shoulder instability can range from 21% (44) to 50% (45). Even though surgical intervention is associated with improved function and depressive symptoms over time, patients with depression tend to have worse patient-reported outcomes scores and greater lifetime recurrent instability rates (44). When examined in a prospective manner, clinical depressive symptoms appear to be the most prevalent around 6 weeks post-injury/surgery (~66%) with an improvement to approximately 25% at 3 months to 1 year post-injury/surgery (45). Therefore, while the evidence is limited, it appears that psychological distress is most prevalent approximately 4 to 6 weeks after surgery, corresponding to a rehabilitation time-period after shoulder stabilization where strict protection and immobilization are ending and range of motion is slowly being progressed. However, as the usual duration of rehabilitation after shoulder stabilization can extend up to 6 months, it is likely that additional psychological challenges of various constructs become present. This is an area that requires further prospective examination to elucidate additional challenges and barriers encountered throughout the recovery process.

Further, these psychological responses along with other non-physical factors have been identified by athletes as greatly influencing their decision to return to sport or not. A qualitative study involving athletes who had sustained shoulder instability investigated specific factors that influenced their decision to return to sport after stabilization surgery (35). The investigators identified five themes, which were divided into two primary domains, extrinsic factors and intrinsic factors (35). Three key extrinsic factors were identified to be influential in the athlete’s decision to return to sport including (I) competing interests and limited time; (II) positive and negative support from their social support; and (III) increasing age, with those athletes in their third decade being less likely to return (35). Two key intrinsic factors related to their decision to return to sport were identified: (I) kinesiophobia and (II) other psychological drivers (35). In terms of kinesiophobia, the most prevalent theme to emerge from all athletes was the fear of redislocation, with many who did not return to sport indicating they had not overcome that specific fear (35). Other psychological drivers were also reported to have influenced their decision to return to sport including their confidence and overall state of mind, in particular during the postoperative rehabilitation and the first game back to competition (35). In summary, the authors concluded the following factors greatly influenced an athlete’s decision to return to sport: (I) fear of reinjury; (II) shifts in their priorities; (III) their mood; (IV) their social support; and (V) their self-motivation level (35).

Patient-reported tools for assessing psychological factors

The availability of tools with sufficient validity for assessing important psychological factors is imperative during the care of patients with shoulder instability, and the selection of appropriate outcome measures is a critical step in the return to sports decision-making process (47). Ideally, such patient-reported outcome measures are implemented at the beginning, throughout, and at the end of an episode of care. The following paragraphs will provide a brief review of the most commonly used patient-reported outcome measures to assess one’s psychological status after a shoulder stabilization procedure. While certainly not exhaustive, these measures provide the clinician with general and shoulder instability-specific assessment tools covering various psychological constructs that may affect an athlete returning to sport after shoulder stabilization. A summary of the available psychometric properties of the measures is presented in Table 2.

SI-RSI scale

The SI-RSI is a validated and reliable self-report scale that plays a role in identifying psychological preparedness to return to sport in individuals who have experienced shoulder instability (34). More specifically, the SI-RSI evaluates confidence in the domains of sports performance, risk perception, fear of reinjury, and emotional factors (34,36). The specific questions within each domain are detailed in the study by Olds et al. (37). In total, the SI-RSI consists of 12 items across the 4 domains to assess emotions, confidence in performance, and risk evaluation. Each question is rated on an 11-point Likert scale with scores ranging from 0 to 10. The total score is calculated by taking the sum of the 12 responses and dividing the total by 1.2 to obtain a percentage of the maximum possible score, with higher scores indicating a more positive psychological response (34,36). The SI-RSI has been reported to have excellent test-retest reliability (intraclass correlation coefficient >0.90), without the presence of ceiling or floor effects (34,36), and it is moderately correlated with the Western Ontario Shoulder Instability Index (WOSI) score and its subscales (37). Originally developed in English, the SI-RSI has proven translations, cross-cultural adaptation, and validation in Italian (36), Turkish (72), and French (73).

Scores on the SI-RSI greater than or equal to 55 have been reported to indicate that an individual is psychologically prepared for return to play, regardless of chosen stabilization procedure (i.e., soft tissue vs. bony block) (34). Hurley et al. (74) investigated outcomes in collision athletes 20 years of age and younger after they had received an open Latarjet procedure. At the final follow-up, the mean SI-RSI in the sample was 69.9±20.6, with 75.2% of athletes passing the SI-RSI benchmark of 56 (74). Hurley et al. (75) also investigated outcomes after both open and arthroscopic Latarjet procedures. In this study of 110 patients (75), they reported an SI-RSI of 66.7±25.6 (arthroscopic Latarjet) and 67±24.1 (open Latarjet) at the final follow-up, which occurred at a mean of 51.3 months. Recently, a multicenter retrospective cross-sectional study examined the SI-RSI at the time of testing to inform return to sport decisions, in 52 pediatric patients after arthroscopic Bankart repair (76). The authors found the median SI-RSI was 75.4 (interquartile range, 62.5–88.3) and that sex differences existed, with females reporting scores that were significantly lower than males (76). Additional investigations have found that individuals who had undergone surgery score significantly lower on the reinjury and risk subscales in the SI-RSI than those who had not undergone surgery, indicating poorer psychological responses (37). However, they found no difference in the total SI-RSI score in those who had and had not returned to sports, nor did they find a difference in those who had and had not undergone surgery (37). Currently, there is no evidence directly comparing scores on the SI-RSI between soft tissue and bony block procedures for shoulder stabilization.

Given its specificity to shoulder instability and association with return to sport outcomes, these authors recommend the SI-RSI be the primary assessment for an athlete’s psychological profile throughout the rehabilitation process after shoulder stabilization. Although respondent burden is relatively low in the 12-item version, a shorter, 5-item version has demonstrated concurrent validity with the original and is also available (77,78).

Tampa Scale for Kinesiophobia (TSK)

The TSK, originally developed by Miller et al. (79), aims to assess for fear of reinjury and movement (i.e., the construct of kinesiophobia) through reflections on beliefs and underlying serious conditions with activity avoidance (80). Therefore, the TSK is able to quantify fear of reinjury due to movement and physical activity. The original version of the TSK was developed for patients with musculoskeletal pain and consisted of 17 statements related to an individual’s perception of their experience of injury and physical activity (79,81). Higher TSK scores indicate more fear. This scale has been reported to have acceptable internal consistency (Cronbach’s alpha 0.77–0.81) and validity in patients with acute and chronic musculoskeletal conditions (81,82). However, since its publication, modified versions of the TSK have been proposed and studied (80). The 11-item TSK (TSK-11) was first proposed by Woby et al. (49). The TSK-11 has also been reported to have good internal consistency, with some evidence of concurrent validity (50). The TSK-11 has been deemed appropriate for use in patients with shoulder pain, especially as shoulder-specific scoring resulted in good test-retest reliability (83). The TSK-11 has also been used to assess the degree of kinesiophobia for sports-related injuries, with the majority of the literature focusing on athletes after anterior cruciate ligament reconstruction (ACL-R) (84). Recently, a modified version has been proposed specifically for anterior shoulder instability (85) and may provide a disease-specific measure of kinesiophobia in the future as its clinical utility is established.

Acceptance and Action Questionnaire-II (AAQ-II)

The AAQ-II (51) is a measure of experiential avoidance and psychological inflexibility and was originally described by Hayes et al. in 2004 (86). The AAQ has been reported to be broadly useful with the ability to predict a wide range of quality-of-life outcomes such as depression, anxiety, and general mental health (51). The AAQ-II was developed to address insufficient levels of reliability in various populations of the original version (AAQ-I) (86), with psychometric testing proving stronger and more stable properties across different groups (51). The AAQ-II has sound factor structure, good reliability, and association with the variables to which it is theoretically tied. For example, higher levels of psychological inflexibility, as measured by the AAQ-II has been reported to be related to greater levels of depression, anxiety, stress, and overall psychological distress (51). Lastly, higher scores on the AAQ-II have been reported to be predictive of greater psychological distress 1-year later and are able to predict workplace absence over a 1-year period (51).

Brief Resilience Scale (BRS)

The BRS measures an individual’s ability to recover from ongoing health-related stresses (54). The short, six-item scale has three positively worded items and three negatively worded items that the respondent indicates their level of agreement with (54). The BRS has been reported to have good internal consistency and test-retest reliability (54). The BRS has been reported to be positively correlated with optimism, purpose in life, social support, active coping, and positive reframing, while being negatively correlated with pessimism, negative social interactions, behavioral disengagement, denial, self-blame, stress, anxiety, and depression (54).

Grit Scale (Grit-S)

The Grit Scale is a measure of perseverance and passion for long-term goals, which the authors of the scale defined as grit (87). The Grit scale is a stand-alone measure of grit with evidence of psychometric soundness, face validity for both adolescents and adults who are pursuing goals, low likelihood of ceiling effects, and good fit with the construct of grit (87). The original, 12-item version of the Grit Scale (87) was reduced to an 8-item version (Grit-S) (88). The Grit-S comprises two 4-item subscales that measure perseverance of effort (POE) and consistency of interest (COI) (88). Regardless of the version, the Grit Scales demonstrate adequate internal consistency, test-retest reliability, and criterion-related validity (89). However, recent studies of children and adolescents have revealed potential concerns with some psychometric qualities of the Grit-S in this population (89-92). However, overall, the Grit Scales provide a mechanism to assess concepts such as resilience, perseverance, passion, and tenacity. Scores on the Grit-S items vary from low grit (1 point) to high grit (5 points), with a total score derived by summing the 8 items and dividing by 8 (88). Adult population averages have been reported as 3.4 (Grit-S) (88).

PROMIS self-efficacy

Self-efficacy can be described as the belief that one can behave in a manner necessary to achieve a desired goal (e.g., returning to sport after shoulder stabilization), even when presented with obstacles (57,93). Further, self-efficacy can be a major determinant of behavior and behavior change, with an individual’s perception of their capabilities possibly being more predictive of function than their actual level of impairment (57). Additionally, self-efficacy can be an important mediator between self-management skills and other outcomes including physical activity (57,94). The Patient-Reported Outcomes Measurement Information System (PROMIS) Self-Efficacy includes five domains of self-efficacy, calibrated across diverse conditions (57). The measure has been reported with good internal consistency and cross-sectional validity (57). The item banks for the computer adaptive test version and the associated short forms are freely available to clinicians and researchers who want to assess patient confidence in performing important tasks (57).

Pain Catastrophizing Scale (PCS)

Individuals with a tendency to experience catastrophizing are generally described as having a tendency to magnify or exaggerate the threat value or seriousness of painful sensations or are unable to divert attention away from pain (95). Sullivan et al. (96) described catastrophizing as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience”. The PCS investigates the impacts of such catastrophizing on the pain experience (95). The PCS is a 13-item instrument that can be administered and scored in less than 5 min. The PCS asks respondents to reflect on past painful experiences, and to indicate the degree to which they experienced each of the 13 thoughts or feelings when experiencing pain (95). From the responses, the PCS yields a total score and scores for three subscales (rumination, magnification, and helplessness) (95). The PCS has been reported to have adequate to excellent internal consistency for all scores (95). Past research indicates a total PCS score of at least 30 corresponds to the 75^th percentile and is deemed a clinically relevant level of catastrophizing (95). As it is believed that catastrophic thinking related to pain may be a risk factor for chronicity, assessing for the presence may allow the clinician to address such thoughts before the condition possibly persists over an extended period of time (95).

Single Assessment Numerical Evaluation (SANE)

The SANE is a simple, one-question patient-reported measure in which they rate their involved body region on a 0–100% scale, with 100% being completely normal. Thigpen et al. (97) reported a minimal clinically important difference of 15% and good correlation with the American Shoulder and Elbow Surgeons score in patients with non-instability related shoulder diagnoses. Regarding instability specifically, a recent small case series (98) of athletes who had undergone arthroscopic shoulder stabilization (n=22, 10 females, mean age 19.8 years (range, 11–44 years) found that the SANE of the athletes’ subjective return to baseline at the time of return to sport was more highly correlated with the corresponding SI-RSI score (Pearson’s r=0.92) than the WOSI (Pearson’s r=0.67). These results suggest that, while the SANE correlates moderately with a broader assessment of overall function (WOSI), it may be more closely tied an athlete’s psychological readiness (SI-RSI) and provide more useful insight in this realm.

WOSI (66)

The WOSI is a shoulder-specific patient-reported outcome that was designed for use as a primary outcome measure in clinical trials evaluating treatments for patients with shoulder instability (99). The WOSI questionnaire consists of 21 items across 4 domains: physical symptoms (10 items), sports, recreation, and work (4 items), lifestyle (4 items), and emotions (3 items) with scores ranging from 0 (best) to 2,100 (worst) (99). The emotions domain specifically assesses questions regarding frustration, confidence, and emotional well-being related to a patient’s shoulder instability. However, robust confirmation of this factor structure remains unclear, as a one-factor structure has been shown to demonstrate worse fit than a four-factor model (100). The WOSI demonstrates construct validity with the Disabilities of the Shoulder Arm and Hand (DASH) questionnaire and excellent test-retest reliability. The WOSI was also found to be responsive and sensitive to detect change over time, demonstrating its ability to monitor patients’ progress over time. They also noted that the questions ‘often lack face validity for the suggested subscales’, suggesting the WOSI may not be as effective as other measures in comprehensively assessing psychological readiness to return to sport (100).

Potential interventions to address specific psychological factors

As the influence of psychological factors on athletes recovering from shoulder stabilization has become better known, it is of interest to discuss interventions that may be utilized to support athletes’ psychological well-being after shoulder stabilization. Limited evidence exists specifically in this population; however, work in other areas highlights the possible utility of certain interventions and provides potential avenues for further research in athletes after shoulder instability. Further, many of these interventions have been delivered successfully alongside physical rehabilitation showing positive effects on both physical and psychological outcomes.

Cognitive behavioral therapy (CBT)

CBT is a structured therapeutic approach that aims to change the content of specific thoughts and thus modify dysfunctional emotions and behaviors to improve psychological and physical well-being. CBT has been increasingly applied in the athletic setting. In a small sample of mostly female athletes (n=8, 6 females) who underwent ACL-R, a telephone delivered CBT-based physical therapy intervention improved scores on the TSK-11 and the PCS at 6 months postoperatively, demonstrating CBTs potential to limit the negative effects of psychological dysfunction after injury and subsequent surgical management (101). Another study tested the effects of a CBT intervention on 16 severely injured NCAA Division I athletes and found that affect was improved during rehabilitation and at the time of return to play clearance (102). These interventions have also been shown to decrease reinjury anxiety (102) and hasten return to play (102) in injured athletes. Evidence for CBT interventions is limited in shoulder instability specifically, but its potential usefulness has been demonstrated in other types of musculoskeletal shoulder pain to decrease pain and negative emotional responses in patients (103).

Acceptance and commitment therapy (ACT)

ACT is also a structured therapeutic approach, part of the cognitive-behavioral tradition (104), that aims to increase psychological flexibility to adjust emotions and behaviors depending on present situations and chosen values (105). ACT interventions focus on switching an athlete’s attention to the relevant task (committed action), instead of internal states such as anxiety or frustration (106), in order to behave like the person we want to be (105). Six core processes underpin the key feature of ACT, psychological flexibility: (I) cognitive defusion, (II) acceptance, (III) flexible attention to the present moment, (IV) self-context, (V) values, and (VI) committed action (107). Each of these six processes is linked with each other allowing for psychological flexibility via maintaining an open, centered, and engaged state where individuals can accept and make room for unpleasant thoughts, emotions, and sensations, by paying conscious attention to their present moment and staying connected to their chosen values (107).

In contrast to CBT, ACT seeks to change the relationship that one has with their thoughts, rather than changing the thoughts themselves. ACT focuses as much on overall wellness, as it does on amelioration of distress (108). From an ACT perspective, the emphasis of promoting psychological flexibility is similar to the more commonly referenced construct of resilience (assessed with BRS). The focused shifting of the relationship an individual has with their thoughts, the clarifying an individual’s values, the enhancing present-moment attention, and the boosting of engagement in values-consistent activities (105) underpin much of ACT’s usefulness. ACT has been successfully applied in the sport setting (106,107,109-112) with evidence suggesting potential efficacy in enhancing an athlete’s psychological readiness ability to return to sports participation. However, this approach needs further study in larger samples, though it has proven effective in individual case studies (106,113) with athletes to decrease fear of reinjury, performance anxiety, and rehabilitation and exercise adherence.

Mindfulness practice

Mindfulness is a less structured approach than CBT or ACT interventions and is often a component of those therapies. Training in mindfulness practices emphasizes non-judgmental attention on the present moment and allowing thoughts or emotions to pass without labeling them as good or bad. Mindfulness training has been associated with decreases in sport-related anxiety and burnout (114). They have also been linked with a lower incidence of injury (60% in control subjects vs. 33% in intervention subjects) in junior elite soccer players (115).

Other interventions

A systematic review by Gennarelli et al. (116) aimed to examine the effectiveness of interventions for addressing psychosocial factors after sports injuries. The authors found nearly all studies to be related to anterior cruciate ligament (ACL) injuries and ACL-R. The variety of interventions included: relaxation and guided imagery, positive self-talk, goal setting, counseling, written emotional disclosure, and modeling. Relaxation techniques, such as progressive muscle relaxation or breathing exercises, combined with imagery and standard rehabilitation after ACL-R were reported to elevate athletes’ mood during and after rehabilitation (117), decrease pain and reinjury anxiety (118), and potentially lead to increased strength (118). One study found that the addition of relaxation and imagery interventions led to decreased levels of stress markers and knee laxity after ACL-R (119). Positive self-talk (120) (i.e., self-encouragement), goal setting (120), and counseling were associated with maintaining motivation and rehabilitation adherence, though this was associated with only home exercises in the case of positive self-talk.

Written emotional disclosure encourages patients to write down their feelings related to their injury and has been reported to decrease athletes’ grief responses and increase motivation and injury acceptance after surgery (121). One study (122) utilized coping modeling videos pre-surgery and during the first two weeks post ACL-R in which models performed exercises and discussed difficulties and strategies to overcome them, along with another video reviewing exercises at different rehabilitation stages. Compared to a control group, the intervention group demonstrated lower expected pain perception, improved self-efficacy, improved function, and required crutches for less time after surgery.

Psychological intervention’s relationship with return to play at the previous level

While these various interventions have been associated with positive psychological and rehabilitation outcomes, most are not associated directly with RTSP outcomes or even evaluated in athletes after shoulder stabilization. The intervention parameters and sport types comprising the evidence vary widely and there remains a need to standardize and prospectively assess the utility of these interventions in the context of the athlete after shoulder stabilization. Many of these interventions also incorporate social support at some level, whether with a trained psychological practitioner, or incorporated with rehabilitation professionals, or via recordings of peers. In a qualitative study with athletes going through injury recovery, one factor that remained consistent was the athletes’ need for social support at each phase (38). This is also supported by evidence showing a positive association between a group-based training intervention and ACL-RSI scores in soccer players (123).

Clinical implications and future needs

For the orthopaedic surgeon, physical/physiotherapist, and athletic trainer, venturing into the realm of psychological recovery may seem daunting. However, it is becoming quite apparent that clinical team members of the orthopaedic care continuum may benefit from familiarizing themselves with these important psychological features their patients and athletes must confront.

Given the availability of various assessment measures, the clinician must first choose the appropriate tool to assess their patient/athlete. As it relates specifically to shoulder instability and post-operative rehabilitation after stabilization surgery, the authors recommend utilization of a disease specific functional measure (WOSI) and a disease-specific measure to assess psychological readiness/status (SI-RSI) at a minimum. Further, as many of the scales presented in this review are relatively brief with low respondent burden, clinicians may also benefit from the information gained regarding their patients’ kinesiophobia (TSK-11), grit (Grit-S), and self-efficacy (PROMIS self-efficacy scale). Administration and evaluation of the patient-reported measures at the initiation of care, at important clinical milestones (i.e., start of resistance training, start of functional training, at time of return to sport testing), and at time of discharge to return to sports competition is recommended. At each of these important clinical milestones, use of such measures allows for identification of existing barriers present and patients who may benefit from additional intervention, in addition to identifying those patients who may not be ready for a return to sports competition. From the perspective of the clinician-scientist, further research is warranted to identify both the psychological factors associated with outcomes and the impact of targeted intervention to address identified barriers.

Conclusions

The prevalence of psychological factors that significantly affect athletes’ ability to return to pre-injury levels of sport after shoulder stabilization has become well known. General and disease-specific assessment tools are available to identify those who may benefit from psychological interventions alongside physical rehabilitation to support athletes’ overall readiness and ability to return successfully. Structured psychological interventions in addition to traditional, physical interventions have been reported to have positive effects on known emotional and behavioral impairments displayed by athletes after shoulder stabilization surgery, though this is based upon a small amount of low-level evidence and thus more research is needed to describe specific interventions and their effects directly on return to sport outcomes in appropriately matched athletes. It is important for the clinician to recognize these barriers and work with their patients to address them to maximize patient outcomes, especially a reduction of fear of reinjury and a return to sports at their prior level of performance.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-67/rc

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