RETURN-TO-SPORT TESTING IN CONTACT AND COLLISION ATHLETES
– Written by Edel Fanning, Ireland and Margie Olds, New Zealand
RETURN-TO-SPORT LANDSCAPE
Shoulder injuries are common in contact sports, with clubs losing up to 241 days of training and gaming per season. For young athletes, these injuries can derail promising careers and, in some cases, be career ending. Nonoperative management often results in poor return-to-sport (RTS) outcomes in collision athletes, and even postsurgical RTS rates remain suboptimal, with up to 19% of athletes not returning1.
Although physical effects are well-recognised, psychological and social impacts, such as anxiety, low self-esteem, and reduced quality of life, are increasingly acknowledged. Glenohumeral joint (GHJ) stabilisation procedures and recurrent instability can significantly affect mental well-being and performance, particularly in younger athletes2.
Despite the physical and psychological challenges following shoulder stabilisation, RTS decisions are frequently based on time alone, typically 4–6 months after surgery. This approach oversimplifies the complex recovery process and overlooks key risks, such as re-injury and long-term complications. Similarly, relying solely on clinical examination is inadequate, particularly for athletes in high-risk contact and collision sports. Return-to-sport decisions should be guided by a multifactorial approach that considers the specific physical demands of the sport, objective functional and performance testing, and psychological state of the athlete. This clinical commentary aims to highlight the challenges in selecting appropriate RTS testing protocols, identify key parameters that should be included in an RTS battery for contact and collision athletes, and provide real-life case scenarios to add context.
CHALLENGES FACED BY STAKEHOLDERS
Athletes returning to collision sports after shoulder stabilisation surgery often hold high expectations for their recovery and performance. Meeting these expectations requires a clear understanding of the specific demands that a sport places on the shoulder and a well-defined concept of successful recovery. However, this can be a challenge, as success can mean different things to different stakeholders; for therapists, it may be achieving objective benchmarks; for athletes, a pain-free return to competition; for surgeons, restored joint stability; and for coaches, the return to tackling strength3. Acknowledging these varied expectations underscores the importance of employing a comprehensive battery of tests to aid return-to-sport decision making.
Emerging research has highlighted the value of functional testing, strength benchmarks, and psychological readiness in assessing recovery. These objective measures can be used to guide rehabilitation programs and inform RTS timelines. However, they also have limitations. It is unlikely that any test battery can fully predict the risk of re-injury during high-risk activities such as tackling or falling. Additionally, although studies such as Fanning et al.4 have identified persistent deficits in explosive upper limb strength following stabilisation surgery and assessment tools such as the SARTS test5 offer sport-specific evaluations, the ability of these measures to reliably predict the likelihood of re-injury remains unclear and requires further research. Despite these limitations, ensuring that athletes meet key criteria, including strength parameters, functional capacity, and psychological readiness before returning to sports, offers a structured framework that can support clinical decision-making. More importantly, these benchmarks help build athletes’ confidence that they have regained function comparable to that of their uninjured side. With these challenges in mind, the following section explores the key testing parameters that the authors believe are essential for comprehensive RTS assessment.
KEY TESTING PARAMETERS
There are a number of parameters to consider for the return-to-sport testing of contact and collision athletes. Although advanced technologies offer new testing possibilities, test selection should be driven by a clear understanding of athlete sport-specific demands and recovery goals. Clinicians must understand the constructs being assessed, ensure measurement reliability, and identify meaningful outcomes based on the athlete’s injury, surgical history, and sport.
Range of motion
Unfortunately, there is limited literature investigating range of motion (ROM) as a prognostic factor for injuries in contact and collision sports athletes, particularly following surgery. This makes it challenging for clinicians to synthesise meaningful information on an acceptable ROM that allows for safe RTS in a cohort of contact and collision athletes. Decreased ROM after glenohumeral joint (GHJ) stabilisation (especially following a Latarjet procedure and/or remplissage) is common six months post-surgery and beyond, which often coincides with the timeframe when many athletes resume sports participation9,10.
Clinical guidance:
- The restoration of passive ROM is essential for preserving GHJ kinematics even in non-overhead athletes.
- Emphasis should be placed on symmetry, particularly in external rotation, with the goal of achieving total arc ROM within 10% of the contralateral side.
Strength
1. Rotational torque
Internal and external rotator muscles play crucial roles in shoulder stability. Isokinetic dynamometry is considered the gold standard for shoulder strength quantification. It allows for the analysis of interlimb differences in isokinetic rotational torque and external-to-internal rotation strength ratio (ER:IR). A study assessing angle-specific isokinetic rotational torque measured at 0°, 80° external rotation, and 50° internal rotation following glenohumeral joint (GHJ) stabilisation found that deficits at the end range of motion were more pronounced than at peak torque, particularly in external rotation4. Hence we advocate caution when relying solely on maximum peak torque measurements, as they may overestimate rehabilitation progress and fail to detect strength deficits in positions of high risk for shoulder instability.
When isokinetic testing is unavailable, handheld dynamometry offers a practical and reliable method for assessing shoulder rotational strength. Although it does not provide the full force-velocity profile offered by isokinetic systems, it is effective for comparing interlimb differences in isometric rotational strength. Consistent with the isokinetic testing protocol discussed, we recommend the assessment of isometric rotational strength in the plane of 90° of abduction at 0°, end-range external rotation, and end-range internal rotation6. As the tester technique and positioning can influence the results, the use of standardised protocols is essential to ensure consistency and accuracy.
Research has demonstrated that contact athletes who did not undergo criteria-based return-to-sport testing, including both isokinetic and isometric peak torque assessments, were four times more likely to experience recurrent instability within one year following arthroscopic Bankart repair. Notably, the most significant deficits were identified in rotational strength tests rather than functional tests7. Similarly, another study reported that a greater proportion of participants passed functional field tests than isokinetic strength tests six months post-surgery, further emphasising the importance of evaluating rotational strength during rehabilitation8.
Clinical guidance:
- Do not rely solely on conventional isokinetic maximum peak torque analysis; angle-specific analysis of isokinetic shoulder rotational torque provides a more comprehensive profile of rotational strength.
- Standardised protocols should be used when handheld devices are implemented to minimise variability.
2. Long Lever Isometric Strength test
The Athletic Shoulder (ASH) test is a long-lever, isometric strength assessment designed to evaluate the maximal voluntary isometric force and rate of force development (RFD) in three prone long-lever positions using a force platform9. This setup eliminates tester strength as a source of variability and offers a more objective alternative to the free-moving handheld dynamometer. Among its advantages is the use of test positions that closely reproduce sport-specific demands, such as the tackle position in rugby, making it particularly appropriate for assessing the peak isometric force in athletes who engage in contact sports.
The test demonstrated excellent reliability for peak force measurements when performed in elite adult rugby players18. However, while some advocate measuring the rate of force development (RFD), it must be acknowledged that RFD is highly time-dependent, with the early (0–50 ms) and late (100–200 ms) phases reflecting different physiological mechanisms. RFD is also influenced by test familiarity, which makes standardisation challenging. Accurate measurements require high sampling rates (≥1000 Hz) and consistent maximal effort10. Overall, the ASH test serves as a reliable and sport-specific tool for assessing shoulder peak force in contact athletes, although caution is advised when interpreting RFD metrics because of its inherent variability.
Clinical guidance:
- Be cautious with RFD interpretation: Ensure proper familiarisation and high sampling rates (≥1000 Hz) during assessment.
- We recommend integrating ASH test results with other measures to form a comprehensive profile of shoulder function during rehabilitation and RTS decision making.
3. Explosive upper limb strength
In contact and collision sports, athletes require high levels of upper-body explosive strength to perform key actions such as tackling and hand-offs. Assessing upper quadrant performance using explosive strength tests during return-to-sport evaluations can be highly valuable in identifying potential deficits in athletes.
The countermovement Push-Up (CMPU), press-up jump, and box drop tests conducted on dual force plates have demonstrated strong reliability in contact and collision sports athletes11. These tests measure vertical ground reaction force (vGRF) metrics and provide objective and quantifiable data. When interpreted alongside key statistical parameters, such as minimum detectable change (MDC), standard error of measurement (SEM), and absolute asymmetry values, they offer a robust framework for upper quadrant performance in both injured and post-surgical athletes. Parry et al.12 further validated the CMPU in elite boxers, confirming its high reliability and reporting no significant interlimb asymmetry in healthy individuals. This supports the use of CMPU as a benchmark for detecting post-injury deficits. The Clap Test is a practical alternative in situations without access to force plates. This test requires athletes to complete as many repetitions as possible within one minute and has demonstrated high test–retest reliability, making it a valuable measure of upper-body muscular endurance and power13.
Fanning et al.4 reported that athletes recovering from upper limb surgery continued to exhibit deficits in explosive strength and significant interlimb asymmetries even six months postoperatively. Notably, their findings showed no significant correlation between performance on dynamic assessments, such as the CMPU, Box Drop, and Press-Up Jump, and traditional isokinetic strength tests. This highlights the importance of employing a combination of testing modalities to comprehensively evaluate the recovery status.
Clinical guidance:
- Explosive strength tests identify deficits not evident in isometric/isokinetic assessments.
- Aim to achieve interlimb asymmetry variables below 10–15% in the CMPU, Press jump, and box drop tests.
- If force plates are not available, practical field tests, such as the Clap Test, offer a reliable alternative for assessing upper-body power and endurance.
4. Endurance
Following the assessment of explosive strength, endurance tests provide an additional layer of insight by measuring the athletes’ ability to sustain high performance. Given that fatigue increases the risk of injury, it is important to measure the endurance strength of athletes before they return to sports activities. Endurance strength can be assessed using force plates or handheld devices by calculating the percentage decline in output over ten repetitions, comparing the final repetition to the first. Although limited research has examined the predictive validity of this percentage drop, clinicians may use a guideline of 15–20% depending on the importance of endurance strength in a specific sport. In addition, this change in the output should exceed the minimal detectable change in the measurement tools.
The Rugby Shoulder Arm Return to Sport Test (SARTS) offers another method to assess endurance strength by measuring the number of repetitions completed within one minute5. Normative data for several SARTS tests in elite and schoolboy rugby players have been previously published. We recommend using the 75th percentile of these normative data as the cut-off point for endurance capacity in return-to-sport assessments. For example, the cutoff points for schoolboys and elite rugby players were as follows: Ball Abduction External Rotation (BABER) (21 and 27 repetitions), side-hold rotations (26 and 31 repetitions), and Line Hops (38 and 39 repetitions). The number of push-up claps completed in one minute varied by body weight, with cut-off points of 44 repetitions for players weighing < 95 kg and 30 repetitions for those weighing ≥ 95 kg.
Clinical guidance:
- Aim for a <15–20% drop in force output over ten repetitions.
- Use the 75th percentile normative data for SARTS tests to benchmark endurance capacity (e.g. 27 reps in the BABER test for elite rugby).
Psychological Assessments
Many athletes have reported decreased confidence and increased kinesiophobia post injury. Notably, kinesiophobia tends to remain high over time, and is a strong predictor of recurrent shoulder instability. Beyond physical healing, an athlete’s decision to return to sports is heavily influenced by psychological factors such as personal priorities, mood, self-motivation, and fear of re-injury1,14.
Implementing Psychological Assessments: The Role of the SIRSI
A crucial component of psychological assessment is the Shoulder Instability–Return to Sport after Injury (SIRSI) questionnaire, a tool designed to gauge psychological readiness by evaluating confidence, fear of reinjury and other emotional aspects. The SIRSI questionnaire is a validated tool specifically developed for contact and collision sports athletes to assess their psychological readiness following shoulder instability. It evaluates critical psychological constructs, including confidence in performance, fear of re-injury, emotional responses, perceptions of rehabilitation, and surgical outcomes15.
Recent prospective trials have established clinically meaningful cut-off scores for interpreting the SIRSI results. A threshold score of ≥5516 and 60.517 has both been shown to predict an athlete’s psychological readiness to return to play. Furthermore, a condensed 5-item version of the SIRSI has demonstrated predictive utility in one country, although it did not reach statistical significance in forecasting actual return to sport outcomes in another country.
Clinical guidance:
Integrate SIRSI questionnaire with physical testing batteries
Suggestive threshold score of ≥55
Proprioception
Research has demonstrated that proprioception is altered following traumatic shoulder dislocation and subsequent surgical stabilisation18. Additionally, participation in contact and collision sports has been shown to negatively affect shoulder joint position sense (JPS)19. Consequently, proprioception may serve as a valuable outcome measure when evaluating an athlete’s readiness to return to sports following glenohumeral joint (GHJ) stabilisation.
Proprioception is most commonly assessed using the JPS, which measures an individual’s ability to perceive and replicate specific joint angles after limb movement. Various tools and techniques have been used to evaluate the JPS, including isokinetic dynamometry, custom laboratory devices, motion analysis systems, inclinometers, and photographic methods. However, a systematic review highlighted the inherent challenges in accurately quantifying proprioceptive deficits in the shoulder, and underscored the need for assessment protocols with strong psychometric properties20. Furthermore, there is a lack of normative data and standard error of measurement (SEM) values for uninjured contact and collision athletes, limiting the establishment of robust baseline comparisons.
Clinical guidance:
Proprioceptive results can be used, along with strength and functional tests, to inform rehabilitation progression and RTS decisions.
Clinicians should be aware of the current limitations of standardised testing protocols and the lack of normative data.
Visuomotor reaction time
The neuromuscular responsiveness to dynamic sports environments plays a crucial role in injury prevention. Visuomotor reaction time, which is the speed at which an individual responds to a visual stimulus, is a key component of this responsiveness. While research on visuomotor reaction time in the upper limb is still developing, emerging evidence suggests that it may be impaired following anterior cruciate ligament (ACL) injury. Furthermore, slower visuomotor reaction times are correlated with heightened injury-related fear in individuals with a history of ACL.
Preliminary studies have indicated that tools such as reaction lights (e.g. BlazePods, FitLight, and Dynavision) are reliable tools for assessing upper-limb visuomotor reactivity following a familiarisation period21. Therefore, these tools may serve as valuable instruments to measure neuromuscular readiness during rehabilitation.
Clinical guidance:
- While visuomotor reaction time shows promise as a useful metric, there is insufficient evidence to provide formal clinical recommendations for its use in return-to-sport testing following shoulder stabilisation.
PRACTICAL INSIGHTS FOR DESCISION-MAKING
Integrating testing into rehabilitation sessions can provide both the athlete and clinician with valuable insights into potential deficits. For example, following surgery, assessments are typically carried out around the 14-week mark and again at six months, aligning with common return-to-sport timelines. However, if the patient demonstrates sufficient strength and range of motion, it may be appropriate to conduct testing earlier.
Case Example 1 (See Table 1)
Integrating Return-to-Sport Testing After Arthoscopic Posterior Bankart Repair
Athlete Profile
- Collision sport athlete
- Underwent arthroscopic posterior bankart repair
- Decision to return-to-train supported by testing results
Case Example 2 (See Table 2 on next page)
Integrating Testing in Nonoperative Management of Anterior Shoulder Instability
Athlete Profile
- National-level netball player
- Managed anterior shoulder instability non-operatively
- Despite acceptable limb symmetry indices, strength, control, and visuomotor delays remained
- Objective data supported a delayed return to full sport, with continued targeted rehabilitation
TIPS WHEN TESTING
Standardisation and Normative Data
Standardising testing procedures is crucial to ensure consistent and reliable results. For example, a professional football club may use a set of tests, such as the rotational torque, ASH test, and countermovement push-up, administered by the same clinician in the same order during the pre-season, post-injury, and return phases to reduce variability. Individual baseline data from pre-season screenings allows for more accurate post-injury comparisons. When pre-injury data is not available, clinicians should use published normative datasets, but adjust for sports, position, age, and sex.
Caution with limb symmetry indices
Limb symmetry indices (LSIs) are frequently used in return-to-sport decision making; however, they should be interpreted with caution. For instance, athletes recovering from shoulder injuries may demonstrate LSIs above 90%, yet still present with bilateral neuromuscular deficits. Therefore, LSIs should be evaluated alongside absolute strength measurements and movement assessments to provide a more complete clinical picture. For example, the rehabilitation team at the Sports Surgery Clinic in Dublin (Figure 2) utilise three-dimensional motion analysis to identify compensatory movement patterns on a CMPU that LSIs alone might miss, thus enabling further understanding of the vertical ground reaction forces.
CONCLUSION AND FUTURE DIRECTIONS
Return-to-sport decisions following shoulder injury in contact and collision athletes must extend beyond simple time-based criteria and adopt a comprehensive, multifaceted assessment approach. Incorporating objective measures such as range of motion, strength, psychological readiness, proprioception, and visuomotor reactivity can greatly enhance clinical decision-making. Equally important is understanding how these testing protocols relate to long-term outcomes, including athlete performance, career longevity, and re-injury rates. As return-to-sport assessments continue to evolve, the current lack of longitudinal studies tracking these long-term results represents a significant gap in the research. Addressing this gap through future studies is essential to validate the prognostic value of these assessments and optimise return-to-sport strategies.
Edel Fanning PhD
Sports Shoulder Performance Rehab Ltd.
Dublin, Ireland
Margie Olds PhD
Auckland, New Zealand
Contact: edel@sportshoulderrehab.com
margie@flawlessmotion.com
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Header Image by Singapore 2010 Youth Olympic Games (Cropped)