– Written by Matthew Rees and Andrew Cole, Qatar

THE WHY?   

The Athletic Shoulder   

The athletic shoulder complex, an area exposed to a multitude of complex demands, comprises of a shallow ball and socket joint and two additional joints that, interestingly, only articulate with the body at the sterno-clavicular joint. The unique nature of this area makes it inherently unstable and, hence, highly susceptible to both acute and overuse injuries.

The complexity of this area, along with the diverse and demanding nature of sports activities, makes it challenging to manage effectively (Figure 1). Research consistently shows that, contrary to popular belief, everyday simple movements often place significant stress, strain, and load on the shoulder, before even considering the added demands of sports. As a result, the shoulder is frequently underloaded during rehabilitation and sports preparation, which contributes to high rates of injury and re-injury throughout an athlete’s career.  

The complexity of navigating such injuries highlights the need for a systematic mindset aimed at a consistent, team-led, data-driven approach for the best possible outcome in the management of injuries involving the shoulder complex.   

THE WHAT? 

At Aspetar, we see a wide variety of shoulder conditions in athletes from diverse sporting backgrounds, especially those involved in throwing, overhead, and collision sports. Our mission is to deliver an individualised approach to their management, that enables Athletes to achieve their maximum performance and potential. It takes a team of experts to deliver our vision and we are fortunate at Aspetar to have these experts all under one roof. The ‘Aspetar Way’ has previously been described as our approach to developing and delivering an integrated rehabilitation plan:  

• Individualised approach  
• Assessment guided rehabilitation  
• MDT collaboration  
• Address multiple physical qualities concurrently  
• A focus on motor learning and development    

Decision-making during rehabilitation is often complex and influenced by multiple factors. Return to Sport (RTS) decisions present additional challenges for practitioners, especially given the absence of a definitive, gold-standard RTS testing. Recognizing a potential bias toward reductionist thinking in shoulder rehabilitation program design and acknowledging that a one-size-fits-all approach conflicts with our philosophy at Aspetar, we set out to design our Aspetar approach to shoulder rehabilitation.   

The design process has brought our diverse team together to reflect on past performance, identify the challenges specific to our context, and enable creative thinking and innovation in our clinical delivery. Our aim is to equip practitioners with the tools necessary to develop individualized rehabilitation programs. Grounded in the principle of assessment-guided rehabilitation, this approach promotes accountability by aligning actions with defined objectives and offers a clear framework for evaluating the effectiveness of the rehabilitation process.   

THE HOW? 

From the moment an athlete presents with a shoulder complaint, we strive to begin a shared decision-making process. The complexity of this process depends on the nature of the issue, whether it’s a acute injury or an overuse condition, which is especially common among our overhead athletes.  

Our approach is grounded in a clear understanding of each professional’s role within the multidisciplinary team (MDT). The goal of our approach is to ensure that the Athlete is fully informed for what lies ahead in their rehabilitation journey. Key relationships between the Orthopedic Surgeons, Physiotherapists, Coaches and Performance Support Staff underpin the decisions reached.

To use shoulder instability as an example to highlight how we apply this collaborative MDT approach to deliver individualized care at Aspetar. The decision of surgical v conservative management is often the first that needs to be made. This can only be made with careful deliberation and collaboration amongst the key stakeholders already mentioned. The type of surgical intervention, expected timelines of recovery, any performance implications and the likelihood of a successful outcome all need to be understood. The age of the Athlete, where they are in their career and at what point of the season they are in are also factors that need to be considered.

Given the complexity of these decisions, and the variation in return-to-sport timelines across different athletes and sporting contexts, our phased rehabilitation approach is designed to provide both the MDT and the athlete with the clarity and structure required throughout the rehabilitation process. With the evidence available to evaluate effectiveness of our management decisions, we know that restoring the anatomy and the passive structures alone doesn’t guarantee a successful outcome for our Athlete in the short, medium or long term. Therefore, planning and delivering high quality rehabilitation becomes even more important. In the context of the Athletic shoulder, we must remember that our goal is to return the athlete to a performance environment. With this in mind, it is of great importance that the Athlete understands the opportunities that can be afforded during a prolonged period of rehabilitation.

To build on the scenario for an Athlete with shoulder instability where the decision has been made for surgical intervention. Our philosophy of assessment guided rehabilitation begins in the pre-operative phase. The opportunity to gather a mix of pre-intervention objective measures offers a number of benefits. Perhaps no more important than the therapeutic relationship with the Athlete that can begin in pre-intervention setting. Expectations can be understood and goals for the rehabilitation period can be discussed. The needs analysis of the Athlete and their sport allows the rehabilitation team to focus on what is going to be important to determine the success of the rehabilitation period.   

THE ASPETAR WAY  

Aspetar’s individualized shoulder rehabilitation combines philosophy, theory, and research into a structured, phased approach designed to simplify and guide the rehabilitation process.

Each rehabilitation phase is distinct and helps highlight the focus of each rehabilitation block. The purpose of this differentiation is three-fold, helps the physiotherapist and athlete clearly understand the purpose of that phase, sets accountability to what was set out to achieve and allows the team to objectively measure entry and exit points for each stage, to ensure rehabilitation consistency.  

“Do what you say you’ll do”

 – James M Kouzes

Aspetar’s six core phases identified are:   

Foundation: Many times, our rehabilitation mindset is fixed on re-loading our athletes, often at the mercy of overlooking subtle motor/neurological changes that may occur post-injury/surgery. Re-loading our athletes without addressing any individualized deficits may result in unwarranted issues later down the line. The Foundation phase aims to address this by dialing in and setting groundwork for the athlete to ensure optimal motor control, muscle patterning and quality purposeful movement that, we believe, will ensure effective and efficient rehabilitation across our rehabilitation pathway.   

Reload: This phase encompasses progressive strength work, graded exposure to load whilst re-developing daily and sporting movement. This phase prepares our athletes for load accumulation and sport specific demands.   

Accumulation: The accumulation phase mainly encompasses demand specific loading preparation together with sporting specific exposure. This may include shoulder volume specific to the sport in question, i.e. early throwing, impact/collision or overhead exposure.   

Transition: This phase is characterized by the progression from clinical-based rehabilitation to a more ‘field-based’ rehabilitation block. The transition phase progresses away from ‘training in the presence of injury’ and now focuses on setting the groundwork for sports simulation and performance.     

Simulation: This stage is characterized by sport specificity. In this stage we are testing the scene, not only exposing the athlete to their particular sport, but now exposing them to the specific sporting demands needed in real-life sporting situations. Exposure characteristics such as throwing velocity, throwing loads, collision volume and peak loads are now being discussed and considered.   

Resilience: The resilience phase is the final piece of the puzzle. This stage is not solely characterized by returning to sport but by returning the athlete to performance at a previous, if not, better pre-injury level. Recognizing that injury, apart from causing a disruption in sports participation, may also offer an opportunity to address any issues that could not have been addressed or identified during non-injured circumstances, allows us to truly understand this phase. The final phase of rehabilitation is building resilience, confidence and character!

Component Based Rehabilitation 

Each of the above phases of rehabilitation comprise of specific component-based rehabilitation strategies aimed at addressing the primary focus of each individual phase. Within our rehabilitation framework, the main identified components include:   

• Motor Control - laying the foundations for normal shoulder movement and it’s ability to handle progressive loads.
• Strength – A structured, progressive approach to loading the shoulder, tailored to the athletes specific positions and demands. It must include targeted loading of muscles in their inner, mid and outer ranges of length. 
• Explosiveness – The ability to generate maximum force rapidly, starting from zero with full intent. It is a key quality for restoring the dynamic power and speed required in athletic shoulder performance. 
• Reactive Strength – working on the body’s ability to transition from absorbing to producing force by utilizing the stretch shortening cycle. 
• Sport Specificity - Exposing the athlete to their sport specific demands and incorporating exposures that closely mimic loads often experienced in the sporting context.  
• Conditioning - Truly ensuring that the team is thinking beyond the shoulder. This component focuses on key aspects of physical preparation to ensure that the athlete is ready to cope with the rigors of their sport.

Each component is integral to the Aspetar approach, guiding our data-driven approach with clearly defined entry and exit points. This structure supports both multidisciplinary team (MDT) and athlete accountability, ensuring the delivery of a consistent and effective rehabilitation pathway. While each component serves a distinct function, they frequently overlap and integrate across phases, promoting continuity throughout the athlete’s personalized rehabilitation journey.

THE RETURN TO SPORT CONUNDRUM  

Aside from the challenges of aligning broad rehabilitation principles and recognizing the high variability in data-driven rehabilitation and athlete presentations, the single most challenging aspect of shoulder rehabilitation must be the “golden” transition between simulation and resilience. This particularly stands out as it encompasses a major milestone, Return to Sport or, in some instances, Clinical Discharge.   

This phase is characterized by a fine balance between a theoretical and philosophical mindset making it a battlefield of anecdotal and research-led decisions. In order to best address this, Aspetar has identified key factors aimed to enhance consistency and ensure effective and efficient rehabilitation.  

These key factors include:  

Athlete-specific goal setting – “Start with the end in mind” is the main crux of this component. We must always remember that each athlete that walks into Aspetar is individual. Recognizing this is vital and has led us to create a rehabilitation strategy the utilizes a reverse-engineering strategy to break down the individual demands needed for the athlete in question. This approach ensures that we are not only addressing a diagnosis but also a human, sport and coaching team environment!  

Assess, Analyze and Action. Central to Aspetar’s ethos is assessing what matters. The ability to assess our athletes throughout the rehabilitation process is the pinnacle of our ambition to provide the best possible care for our athletes. Be it daily monitoring, transitioning to next rehab phase or return to sport decision making, the presence of our dedicated RAMAL biomechanics lab ensures we are ticking all the right boxes and ensures that all the complexities of the athletic shoulder demands are being addressed and ultimately, restored to pre-injury or better levels than ever!

Longevity. Once all data-specific requirements have been ticked off, we feel that the final piece of the puzzle lies within longevity. Longevity, to Aspetar, is equipping our athletes with the physical and mental tools needed to overcome such an impactful event. Ensuring that these, often overlooked, elements are addressed gives us peace of mind that all aspects of the rehabilitation journey have been seen to and our athlete is truly ready to take on the final phase of Resilience.    

The rehabilitation team must recognize that the job isn’t complete once return-to-sport decisions are made. This stage marks the point where we believe the athlete is ready to safely stress their shoulder within their sporting environment. Time must be allocated for the athlete and coach to review, re-learn, and refine technical skills, with this process carefully planned and monitored. 

It is essential to assess both the physical response of the local tissues and the athlete’s psychological response to increasing demands. Psychological readiness is a key factor in guiding return-to-sport decisions and is closely linked to long-term outcomes. Collaboration between the athlete, coach, and multidisciplinary team (MDT) is crucial in building confidence during this phase. 

Drawing on concepts from Nassim Taleb’s Antifragile, we can see this period as an opportunity. Reintroducing throwing, contact, or swimming loads can be viewed not just as a test of readiness, but as evidence of improved shoulder function and performance. The idea of “expectation violation”, demonstrating that the athlete has exceeded what was thought possible validates the effectiveness of their structured rehabilitation and confirms they are not only ready to return, but capable of thriving under the demands of their sport. 

CONCLUSION 

The effectiveness of any rehabilitation plan depends on how well it meets the needs of the athlete, coach, and the specific demands of their sport. Successful shoulder rehabilitation requires the team to draw on the expertise they have developed throughout their careers. It is this blend of knowledge, experience, and clinical judgment that positions us to provide the best possible care for our athletes. 

By understanding common pitfalls in both practice and decision-making, we aim to maximize opportunities within a multi-sport and multi-athlete rehabilitation environment. Our approach seeks to bring structure to the complex challenge of individualized rehabilitation for the athletic shoulder. It also aims to equip practitioners with the tools to remain adaptable, while still being accountable for delivering effective, evidence-informed programs. 

Despite the valuable contributions of world-renowned experts and decades of research, there remains a lack of high-quality evidence specifically for the athletic shoulder. Through a structured process and by continuously measuring outcomes, we hope to contribute meaningfully to the ongoing effort to address these complex challenges. 

Matthew Rees

Senior Physiotherapist

Andrew Cole

Lead Clinical Physiotherapist

Aspetar Orthopaedic and Sports Medicine Hospital

Doha, Qatar

Contact: matthew.rees@aspetar.com

Header Image by Doha Stadium Plus Qatar (Cropped)