THE MISSING PIECE OF THE PUZZLE
– Written by Alexandre Hardy, Carlos Murillo Nieto, Antoine Gerometta, France, and Camille Tooth, Belgium
Glenohumeral instability, which ranges from subtle apprehension and micro instability to frank dislocations, has an incidence of 0.12 injuries per 1,000 athletes in the collegiate population and is a significant contributor to time lost from sport1.
A wide range of treatment options exists, from conservative management such as immobilization and physical therapy to more invasive arthroscopic or open stabilization procedures. However, athletes treated nonoperatively tend to experience higher rates of recurrent instability compared to those undergoing surgery2. As a result, surgical stabilization is often the gold standard for competitive athletes seeking to return to sport (RTS) and return to their pre injury performance levels2. Still, reported RTS rates after surgery vary widely—from 48% to 97.5%—highlighting an inconsistency that demands further exploration2,3.
While successful treatment of shoulder instability has traditionally been defined by the absence of recurrent dislocations, for competitive athletes, true success also involves a full RTS, ideally at their previous level of competition. Despite advances in surgical techniques and rehabilitation protocols, a growing body of research has identified discrepancies between objective clinical outcomes and athletes’ perceptions of their readiness to return4. Many athletes fail to resume sport even after regaining strength, range of motion, and joint stability.
Emerging evidence suggests that psychological readiness may be the missing piece of the recovery puzzle. A recent systemic review reported that 85.1% of athletes who did not RTS, had psychological factors as the primary barrier to return to a preinjury sports level5. This underscores the need to look beyond physical healing and recognize the critical role of mental and emotional recovery5.
Understanding and addressing these psychological barriers is essential not only to improve RTS outcomes but also to redefine what constitutes a successful recovery. By integrating targeted psychosocial strategies into rehabilitation programs, clinicians can better support athletes through the emotional challenges of recovery and facilitate a more confident, sustainable RTS.
WHAT ARE THE PSYCHOLOGICAL BARRIERS TO RETURNING TO SPORT?
After an injury has occurred, an athlete will face a variety of challenges throughout the rehabilitation process. According to a recent study of injured athletes, 74.41% of athletes were affected as a result of their injures, the top 3 responses were stress and anxiety, anger and difficulty adhering to treatment6.
How an athlete responds to these challenges will play a critical role in determining a successful RTS7. To better understand the cognitive, emotional, and behavioral reactions to injury—as well to the multiple factors that shape them—several conceptual models have been proposed.
One of the most well-known approaches for understanding psychological responses to sport injury is the Integrated Model of Psychological Response to Sport Injury and Rehabilitation, proposed by Wiese-Bjornstal, Smith, Shaffer, and Morrey8. This model suggests that multiple factors including personality, past exposure to stress, the ability of each individual to manage with stress, emotions and difficult challenges and how you respond to psychological care can interact, or operate independently to influence an athlete’s stress response and their risk of injury8. Importantly, the same factors that contribute to injury risk also shape the athlete’s psychological response after injury. The central premise of the model is that each individual interprets and reacts to injury differently, based on their appraisal of the injury’s significance, its perceived consequences, and their perceived ability to cope with those consequences.
Kamphoff et al.9 proposed a phase-based approach to rehabilitation that integrates psychosocial elements with the physical aspects of healing. This model outlines three distinct psychological phases:
1. Reaction to Injury
In the initial phase, athletes commonly experience anxiety and other negative emotions. The most frequent behavioral response is seeking social support from family and friends. Cognitive appraisal at this stage is strongly influenced by the athlete’s perception of injury severity.
2. Reaction to Rehabilitation
During rehabilitation, athletes often face doubts and concerns about the recovery process. Frustration is the most commonly reported emotional response. The need for social support remains prominent, with athletes actively seeking and benefiting from emotional encouragement and reassurance during this stage.
3. Reaction to Return to Play
The return-to-play phase introduces new psychological challenges. Fear becomes the predominant negative emotion—whether it involves fear of re-injury, suboptimal performance, or disappointing others. At the same time, positive psychological resources such as motivation, self-confidence, and even a moderate level of fear can facilitate a smoother and more effective transition back to sport.
This phase also aligns closely with Self-Determination Theory, which highlights three fundamental psychological needs: autonomy, competence, and relatedness. Athletes who view their return positively tend to exhibit higher levels of intrinsic motivation—the enjoyment and satisfaction derived from simply participating in sport. This intrinsic motivation is closely associated with greater emotional resilience and long-term engagement in athletic activity9.
HOW DO THESE FACTORS INFLUENCE RETURN TO SPORT AND PERFORMANCE?
Although surgical techniques and rehabilitation protocols have advanced, a subset of patients continues to struggle with achieving a complete and successful RTS after shoulder surgery.
According to the most recent systemic review by Gibbs et al.5, psychological factors are a major contributor to failed RTS in cases of shoulder instability. The review reported that 85.1% of athletes who did not RTS attributed their decision to psychological reasons, with 42.8% specifically identifying fear as the primary barriers5. Another recent systematic review found that the most common reasons athletes gave for not returning were not related to recurrent pain, recurrent instability, or range of motion limitations10. Instead, 70% of athletes gave reasons which were independent of shoulder function, with the most being a “fear of injury”.
In Tjong et al.’s qualitative study11 athletes described a range of personal and social factors shaping their decisions. The fear of reinjury remained the most cited concern, but it coexisted with deeper feelings such as fear of incompetence, apprehension about letting down teammates or family or doubts about self-efficacy. These factors are often stronger than any physical limitation. In this same study, patients also highlighted how external discouragement or lack of social support from coaches or family could decrease their desire to return, even if physically fit.
Brindisino et al.12 found that symptoms of depression and anxiety correlated with pain and functional limitations post-surgery, suggesting that psychological distress can hinder progression through rehab milestones.
Finally, in the 2022 Bern Consensus13 frames RTS after a shoulder injury as a continuum rather than a binary outcome, advocating for psychological integration throughout the recovery process. It supports the concept that RTS readiness must include confidence, motivation and emotional readiness, not just physical benchmarks.
FACILITATING RETURN TO SPORT: THE ROLE OF THE INTERDISCIPLINARY SUPPORT TEAM
Across all phases of recovery, one constant remains: the athlete’s need for emotional and social support. Coaches, teammates, healthcare professionals, and family members all play a critical role in maintaining the athlete’s confidence and reinforcing their identity as a competitor.
Among these, physiotherapists are particularly central within the biopsychosocial model of care. Owing to their close and sustained contact with the athlete, they are uniquely positioned to recognize signs of psychological distress and respond appropriately.
Recovery from shoulder injury involves not only physical rehabilitation but also emotional and psychological adjustment. While numerous clinical tools exist to evaluate physical function, recent research highlights the importance of incorporating psychological assessment instruments into the rehabilitation process. In response, several scales have been developed to assess an athlete’s psychological readiness to return after injury.
The Shoulder Instability–Return to Sport after Injury (SI-RSI) scale, was specifically adapted from the ACL-RSI scale to assess psychological readiness in athletes with shoulder instability. It consists of 12 items designed to evaluate emotional response, perceived risk, and confidence in performance. It could also be used as a tool to authorize patients to return to sport. The total score ranges from 0 to 100, with higher scores indicating greater psychological readiness to RTS14. It has been translated, culturally adapted, and validated in three other languages: French, Italian and Turkish15,16,17.
More recently, Pasqualini et al.18 proposed a shortened version of the SI-RSI, consisting of 5 items which demonstrate excellent predictive ability for return to sports at final follow-up. As a short version scale, it could help physicians in a busy clinical environment to reduce the time required for completion and minimizes the burden on patients, helping identify more easily patients in need of psychologic care during the rehabilitation process.
In a study involving 104 patients who underwent surgical stabilization for shoulder instability, Rossi et al.19 identified an SI-RSI cutoff score of >55 as indicative of psychological readiness. Notably, they found that for every 10-point increase in the SI-RSI score, the odds of returning to sport and returning to preinjury performance levels increased by 2.9 and 11.7 times, respectively. Knowing these cutoff values thought-out the recovery process is clinical valuable, as they provide the treating team a measurable way to identify athletes who might be experiencing psychological challenges during the recovery process.
Similarly, Hurley et al.20 demonstrated that athletes with lower SI-RSI scores were significantly less likely to RTS—even when their physical recovery was objectively satisfactory. In these cases, psychological readiness appeared to be a stronger predictor of RTS than physical parameters such as strength or range of motion. Fear of pain recurrence or performance decline were commonly reported psychological barriers.
Addressing these psychological obstacles requires a proactive and structured approach. Recommendations include the application of cognitive-behavioral therapy (CBT) principles to help athletes identify and reframe maladaptive thoughts while developing more adaptive coping mechanisms12. Structured educational interventions have also been shown to normalize emotional responses, reduce uncertainty, and enhance athletes’ sense of control during recovery. Additionally, gradual, sport-specific exposure protocols can progressively restore confidence and reduce avoidance behaviors21. However, these approaches are most effective when implemented within an interdisciplinary model of care one that encourages collaboration among physiotherapists, sports psychologists, surgeons, and coaches. Such a model promotes consistency and comprehensiveness in managing both the physical and psychological aspects of rehabilitation20.
Besides, psychological readiness is a critical yet often overlooked determinant of successful RTS following shoulder instability surgery. While traditional rehabilitation protocols have focused predominantly on physical recovery, a growing body of evidence highlights the influence of fear, anxiety, and self-confidence on post-operative outcomes. Tools such as the SI-RSI scale and broader psychological screening instruments can help clinicians identify athletes who may be at risk of delayed or incomplete return due to psychological barriers.
Early preoperative identification of these at-risk individuals is essential. When psychological factors are detected and addressed from the outset, clinicians can implement targeted strategies—such as cognitive-behavioral techniques, sport-specific exposure, and structured education—to support emotional recovery alongside physical rehabilitation. Importantly, these efforts are most effective when delivered within a collaborative, interdisciplinary framework, where physiotherapists, surgeons, sports psychologists, and coaches share the responsibility of guiding the athlete through a holistic recovery process.
By integrating psychological care into standard rehabilitation practice, clinicians not only reduce the risk of return-to-sport failure but also foster a more resilient, confident, and timely return to high-level athletic performance.
Alexandre Hardy MD, PhD
Orthopaedic Surgeon
Clinique du sport
Paris, France
Carlos Murillo Nieto MD
Orthopaedic Surgeon
Clinique du sport
Paris, France
Dr Antoine Gerometta MD
Orthopaedic Surgeon
Clinique du sport
Paris, France
Dr Camille Tooth
LAM – Motion Lab
Department of Physical Activity and Rehabilitation Sciences
University of Liège
Liège, Belgium.
Contact: dr.hardy@chirurgiedusport.com
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Header Image by filip bossuyt (Cropped)