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Annals of Physical and Rehabilitation Medicine xxx (2020) xxx–xxx

Available online at

ScienceDirect
www.sciencedirect.com

Review

The challenge of the sporting shoulder: From injury prevention

through sport-specific rehabilitation toward return to play
Ann M. Cools a,b,*, Annelies G. Maenhout a, Fran Vanderstukken a, Philippe Declève a,c,
Fredrik R. Johansson d, Dorien Borms a
a
Dept. of Rehabilitation Sciences, Faculty of Health Sciences, Campus UZ Gent, Ghent University, Corneel Heymanslaan 10, B3, entrance 46, 9000 Gent,
Belgium
b
Dept. of Occupational and Physical Therapy and Institute of Sports Medicine, University of Copenhagen, Bispebjerg Hospital, Bispebjerg Bakke 23,
Copenhagen, Denmark
c
Dept. of Physical Therapy, Institut Parnasse-ISEI, Avenue Mounier 84, 1200 Brussels, Belgium
d
Sophiahemmet University, Musculoskeletal & Sports Injury Epidemiology Center, Box 5605, 114 86 Stockholm, Sweden

A R T I C L E I N F O A B S T R A C T

Article history: Shoulder injuries and sports-related shoulder pain are substantial burdens for athletes performing a
Received 10 December 2019 shoulder loading sport. The burden of shoulder problems in the athletic population highlights the need
Accepted 15 March 2020 for prevention strategies, effective rehabilitation programs, and a individually based return-to-play
(RTP) decision. The purpose of this clinical commentary is to discuss each of these 3 challenges in the
Keywords: sporting shoulder, to assist the professional in: (1) preventing injury; (2) providing evidence-based
Shoulder practice rehabilitation and; (3) to guide the athlete toward RTP. The challenges for injury prevention may
Sports
be found in the search for (the interaction between) relevant risk factors, develop valid screening tests,
Injury
Prevention
and implement feasible injury prevention programmes with maximal adherence from the athletes.
Rehabilitation Combined analytical and functional testing seems mandatory screening an athlete’s performance. Many
Return-to-play questions arise when rehabilitating the overhead athlete, from exercise selection, over the value of
stretching, toward kinetic chain implementation and progression to high performance training.
Evidence-based practice should be driven by the available research, clinical expertise and the patient’s
expectations. Deciding when to return to sport after a shoulder injury is complex and multifactorial. The
main concern in the RTP decision is to minimize the risk of re-injury. In the absence of a ‘‘gold standard’’,
clinicians may rely on general guidelines, based on expert opinion, regarding cutoff values for normal
range of motion, strength and function, with attention to risk tolerance and load management.
C 2020 Elsevier Masson SAS. All rights reserved.

1. Introduction
Shoulder injuries and sports-related shoulder pain are exten-
sive burdens for athletes performing a shoulder loading sport, such
as tennis, handball, volleyball, and swimming but also gymnastics,
field hockey, or lacrosse. Shoulder injury rates depend upon many
variables such as type of sports, sex, level of performance, and age
but are reported to be between 18% and 61% in overhead throwing
or smashing sports [1,2] and up to 90% in elite swimmers
[3]. Shoulder problems represent not only injuries leading to the
athlete being unable to fully participate in normal training and
* Corresponding author at: Dept. of Rehabilitation Sciences, Faculty of Health
Sciences, Campus UZ Gent, Ghent University, Corneel Heymanslaan 10, B3, entrance
46, 9000 Gent, Belgium.
E-mail address: ann.cools@ugent.be (A.M. Cools).
competition (time-loss) but also any chronic complaint the athlete
reports, regardless of participation [4].
The overhead throwing motion is a highly complex movement
in which the individual body segments need to work together in a
sequenced and coordinated way for an integrated functional
movement, also referred to as the kinetic chain [5,6]. Throwing is
considered one of the fastest human motions performed, and
maximum humeral internal rotation (IR) velocity reaches about
7000 to 75008/s [7]. Extreme amounts of external rotation (ER) in
the range of 1658 to 1758 are achieved by the throwing extremity
during the late cocking phase [7]. Other sports, such as swimming,
are characterized by an enormous amount of repetitive move-
ments. Competitive athletes may swim 10 to 14 km a day, 6 or
7 days a week. This equates to 16 000 shoulder revolutions per
week (2500 revolutions per day). Many of these revolutions are
performed in sequence, without any rest for the muscles to recover

https://doi.org/10.1016/j.rehab.2020.03.009
1877-0657/ C 2020 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Cools AM, et al. The challenge of the sporting shoulder: From injury prevention through sport-specific
rehabilitation toward return to play. Ann Phys Rehabil Med (2020), https://doi.org/10.1016/j.rehab.2020.03.009
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2 A.M. Cools et al. / Annals of Physical and Rehabilitation Medicine xxx (2020) xxx–xxx
[3]. Alterations in one segment can affect all other segments. As a
result, deficits in any of the kinetic chain segments can cause a
‘‘break’’ that is often compensated in the more distal segments
such as the shoulder joint. This break could lead to increased
shoulder load, with the overhead throwing shoulder highly
susceptible to injury. For this reason, the assessment and
management of overhead athletes should not be limited to the
shoulder joint or function but should also extend to the whole
kinetic chain, including the lower extremities, the trunk and the
more distal joints of the arm.
The burden of shoulder problems in the athletic population
highlights the need for prevention strategies, effective rehabilita-
tion programs, and an individually based return-to-play (RTP)
decision. Therefore, there is a need for a global approach including
injury prevention, rehabilitation and RTP. However, these are not
separate strategies to guide an athlete through the sporting career
but are highly interrelated. During preventive screening, the
clinician uses tools/measurements to identify possible risk factors,
and the same tools are used for assessing the athlete in view of RTP.
Rehabilitation is linked to injury prevention as well as a return to
sports. Indeed, during rehabilitation, emphasis is often placed on
exercises reducing the known injury risk factors, and from day one,
attention is already given to RTP by incorporating the kinetic chain
in the exercise program. Moreover, given the high prevalence of
shoulder disorders in overhead athletes, clinicians are often forced
to focus more on secondary than primary prevention. Therefore,
although this paper focuses on each of the 3 themes separately —
prevention, rehabilitation, and RTP — the interrelationship among
these interventions should not be ignored.
The purpose of this clinical commentary is to discuss
3 challenges in the sporting shoulder to assist the professional in:
 reducing the incidence of injuries;
 providing evidence-based practice rehabilitation an;
 guide the athlete toward RTP. This paper aims to elaborate on
current tendencies, based upon the available scientific evidence,
clinical good practices and expert opinion.
2. Shoulder injury prevention in sports
2.1. The cycle of injury prevention
The cycle of injury prevention [8] consists of 4 steps:
 identify the problem (injury registration);
 examine injury mechanisms and risk factors for the identified
injuries;
 introduce a preventive program, and;
 investigate whether it is effective by repeating step 1.
In step 1, the problem (injury rates in specific populations) is
identified, and a functional profile of the ‘‘normal’’ sporting
shoulder in that population is provided. Several epidemiological
publications provide scientific evidence of the extent of the
problem [1,2], and numerous papers have described ‘‘normal’’
shoulder profiles in a variety of sports [9].
In a second step, the etiology and the mechanisms of sports
injuries are identified. Several studies examined risk factors for
throwing-related shoulder pain in a variety of overhead sports.
Risk factors may be modifiable (e.g., strength and range of
motion [ROM]) or non-modifiable (e.g., age and sex) [1]. Pre-
season reduced glenohumeral IR ROM (GIRD), reduced total
ROM, a strength deficit in the external rotators and inadequate
scapular position during clinical testing were shown to increase
Please cite this article in press as: Cools AM, et al. The challenge of the sporting shoulder: From injury prevention through sport-specific
rehabilitation toward return to play. Ann Phys Rehabil Med (2020), https://doi.org/10.1016/j.rehab.2020.03.009
the risk of overuse chronic shoulder pain in elite handball,
volleyball and baseball players [10–13]. Additionally, training
and competition volume as well as arm fatigue (pitching while
fatigued) have been found to increase the risk of shoulder injury
[14,15]. However, in the systematic review from Asker et al. [1],
most investigated potential risk factors for shoulder injury in
overhead sports have limited evidence and most are non-
modifiable, such as age and sex.
In a third step of the model, a preventive measure is introduced,
such as an exercise or a stretching program, but also changing the
rules of the sports, introducing protective equipment, and adapting
the quality of sports equipment are considered preventive
measures [16].
Finally, in a fourth step, the effectiveness of the preventive
intervention is assessed by repeating step 1, to analyse whether the
introduction of the preventive measure decreased the incidence of
complaints/injuries.
2.2. From a linear model toward a complex system approach
The traditional models for risk factors and injury prevention
have some limitations with respect to their predictive value
[17]. Recently, a ‘‘complex system approach’’ has been introduced
to describe complicated problems in medicine, biology, economics
and social science [18]. In this conceptual paper, Bittencourt et al.
proposed an alternative model for sports injury risk that might
serve as a new perspective for understanding injury aetiology.
Interacting units of a complex system result in a web of
determinants, in which the units interact with each other in
unpredictable and unplanned ways (frequently unknown). Basi-
cally, translating the hypotheses from the Bittencourt et al. paper
into practice, it is not the individual risk factor that should be
investigated and addressed but rather the complex interaction
between the extrinsic and intrinsic, modifiable and non-modifiable
risk factors. These complex systems, although not yet fully
explored, are probably sports-dependent, meaning that for the
same injury, the risk factor combination depends on the specific
sport the athlete performs. Indeed, the aetiology of sports injuries
is complex with a multifactorial biopsychosocial nature. Current
studies mainly use a more linear and simple approach, but future
research and clinical practice should focus more on the complex
characteristics of sports injuries, considering the injury itself and
also factors related to the injured athlete.
2.3. Which tests should we use in our preventive screening?
Although the critical paper from Bahr debates the pointlessness
of screening tests in preventing injuries [17], others argue that
screening may be important for the individual athlete, and we
should ‘‘not throw the baby out with the bathwater’’[19]. Indeed,
individual screening may be useful as baseline testing, to identify
possible existing problems and to position the individual athlete in
his/her team of peer athletes. Results from continuous monitoring
of athletes and teams may serve as a benchmark for individual
scores.
Many measurement tools and procedures have been developed
to screen the athlete for potential risk factors for shoulder pain
(step 2 in the ‘‘Van Mechelen model’’) [8]. They contain analytical
ROM and strength measurements [20] as well as more functional
performance tests [21]. The analytical ROM and strength tests
allow for identifying possible local deficits in glenohumeral
mobility and rotator cuff strength [22] but do not resemble the
high demands of the shoulder loading sports. Therefore, in
addition, there is a need for more functional testing. These tests
may be divided into laboratory measures such as 3-D kinematic
analysis [9] or stabilometric tests [23,24] and field measures. In
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view of the applicability in the clinical setting, although
stabilometric tests may be useful in detecting proprioceptive
and neuromuscular disorders, here we discuss only the field
measurement tools.
Several upper-extremity functional tests have been described
and evaluated, both in open- and closed-chain position [21,25]. The
most popular tests are the Upper Quadrant Y-Balance Test, the
Seated Medicine Ball Throw, and the Closed Kinetic Chain Upper
Extremity Stability Test. Reliability has been established and
relationships with other tests have been examined [26,27]. As an
example, a moderate to high correlation was found between the
Seated Medicine Ball Throw score and shoulder and elbow strength
[27,28] but low correlation between the Upper Quadrant Y-Balance
Test score and strength values [27]. Also the Closed Kinetic Chain
Upper Extremity Stability Test score is moderately correlated with
strength values of the shoulder [28]. Although the predictive value
of these tests is still unknown, normal values in several reference
populations are available [26,29]. These values allow the clinician
to compare the individual athlete’s performance with a reference
population of the same sport, age and sex. However, none of these
tests place the arm in the overhead position. Recently a new test
was developed, ‘‘the upper limb rotation test’’, in which each
shoulder is tested in an open as well as closed chain, and both
shoulders are moved into the position of abduction ER [30]. Never-
theless, there is a need for development of a standardized, valid
and realistic throwing test, to be performed in a clinical setting,
without the use of high-speed video capture systems.
Despite the uncertainty as to whether one can recognize an
athlete at risk by identifying the risk factors [17], screening tools
for measuring range or motion, strength and shoulder function are
popular in sports medicine. The absolute and relative reliability of
these tools have been established [20], but their predictive value is
unknown. Moreover, these tests are often time-consuming and
require a professional assessor. To comply with these limitations,
Declève et al. recently developed a reliable and valid ‘‘Self-
Assessment Corner’’ for strength, allowing the athletes to perform
regular strength testing themselves [28]. Self-assessment may be
the future for regular screening throughout the sports season. The
practitioner is advised to perform this kind of baseline examina-
tion, if not in the lab, with field-measurement tools, before any
preventive intervention, assuming that the ‘‘normal’’ shoulder
profile of an athlete substantially differs from sport to sport.
2.4. Do prevention programs work?
The question arises as to whether preventive programs are
efficient in actually preventing shoulder injuries. Many preventive
programs are described in the literature as expert opinion [9,31],
but only a few have been examined with a strong study design
[32,33], with conflicting results. Andersson et al. [32] found
decreased injury rates after implementing an injury prevention
program, using a randomized controlled trial design, whereas
Sommervold and Osteras [33] did not find any effects of an injury
prevention program. Both studies attributed the possible lack of
strength of their results to the lack of adherence to the exercise
program by players. Attitudes and beliefs toward the program
varied from ‘‘very positive’’ (medical staff) to ‘‘positive’’ (coaches),
and the players even showed ‘‘neutral’’ and ‘‘negative’’ attitudes
toward the program [34,35]. However, adherence to a prevention
or exercise program is the primary condition for success.
Under the premise of ‘‘as the twig is bent, the tree is inclined’’,
the focus leans more toward prevention programs in youth sports.
There is growing evidence of possible risk factors for shoulder pain
in adolescent athletes [1,36,37], and age-specific adaptations have
been examined with clinical measurements [38,39] and imaging
Please cite this article in press as: Cools AM, et al. The challenge of the sporting shoulder: From injury prevention through sport-specific
rehabilitation toward return to play. Ann Phys Rehabil Med (2020), https://doi.org/10.1016/j.rehab.2020.03.009
3
[37]. Recently, an injury prevention program was used in a
randomized controlled trial of 237 baseball players aged 9 to
11 years [36]. The incidence of shoulder and elbow injuries was
significantly lower in the intervention group (1.7/1000 athletic
exposures) than control group (3.1/1000 exposures), with a hazard
ratio of 1.94; thus, the risk of injuries was 48.5% lower in the
intervention group than control group. The authors attributed the
results in part to a high compliance to the program, which
consisted of a 10-min exercise regimen of shoulder, elbow and hip
stretching, dynamic thoracic mobility and lower-extremity bal-
ance training. In summary, the literature shows that perhaps we
are not able to predict injury, but we are able to prevent it.
Compliance to an exercise program may be increased by
involvement of the coach, medical team, and, in youth sports,
parents. Creating positive expectations in view of performance
may also enhance adherence to a program.
2.5. What is the future of screening and injury prevention strategies?
The value of injury prevention strategies has been debated for a
long time [1,17,19]. Despite many efforts from researchers and
clinicians in their attempt to decrease injury rates, there seems to
be a general increase in sports-related injuries in many sports,
probably due to changes in circumstances, rules of play, and a
higher participation rate. Research into risk factors for injury is
advocated for 2 reasons: to help understand why injuries occur and
to ‘‘predict’’ who is at risk of injury. However, for a test to be
predictive for injury, it needs to be validated for that population,
and this is often not performed [17]. We have no screening test to
predict sports injuries with adequate test properties and no
intervention study providing evidence to support screening for
injury risk [17]. In addition, risk factors are temporal and vary over
time [19]. If screening tests are repeatedly performed, one would
notice that the test results would fluctuate over time due to several
factors. ‘‘Static snapshot’’ screening outcomes would fail to identify
risk factors because of their temporality [19]. Therefore, when the
evidence is limited, the screening tool results must be interpreted
with caution. At this time, the main purpose of screening tests in
sports should be to evaluate the actual status of the athlete, put his/
her performance in perspective of colleagues from the same sport,
same level, same sex, etc., and monitor progression in performance
rather than attempt to achieve a risk factor analysis. With respect
to the content of an injury prevention program, most researchers
advise external-rotation strength exercises, core stability training,
thoracic spine mobilization, endurance and plyometric exercises,
and stretching of the posterior shoulder [32,40]. Regarding injury
prevention programs, the 2 main questions for the future are:
 do these programs decrease injury rates and also change the
modifiable risk factors? and:
 how can compliance of the athlete to the program be enhanced?
Who should be in charge? The player, coach, medical staff,
federation? From a clinical perspective, the main message for
professionals seems to be ‘‘keep it simple, keep it short, keep it
fun’’.
3. Rehabilitation of the injured overhead athlete
Many questions arise when rehabilitating the overhead athlete,
from exercise selection, over the value of stretching, toward kinetic
chain implementation and progression to high performance
training. The following section aims to update recent tendencies
with respect to some of these challenges in rehabilitation.
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3.1. Individualization of a treatment program

In the management of the overhead athlete with shoulder pain,

several variables determine the individual exercise choice and
progression. Although a clear diagnosis with respect to structural
damage may assist the clinician in the process of staged rehabilita-
tion, the clinician will rely more on the functional impairments of
the patient, tissue irritability and his/her goals and expectations
[41]. When high irritability is apparent (high pain levels at rest, night
pain, high disability), the focus of the treatment is on pain
management and minimizing the physical stress on the tissues
[42]. In early rehabilitation phases, the clinician may use shoulder
symptom reduction tests to guide exercise and treatment choice.
The rationale is to reduce the existing symptoms by performing an
active or passive correcting intervention, such as a posterior glide of
the humeral head, an upward rotation of the scapula during active
elevation, and to repeat this as a treatment strategy [43,44]. In case
of low irritability (low pain levels, pain only during activity, no night
pain), the purpose of the therapy is to increase tissue capacity by
providing increasing physical stress on the tissue. Although not fully
explored in an overhead sports population, one should also consider
the possibility of central sensitization components in the complaint
of the athlete [45]. Throughout the rehabilitation period, the athlete
should also perform exercises to maintain global trunk and lower-
extremity condition and strength [46]. Furthermore, the treatment
program must be individualized for each athlete, taking into account
the specific sport, the level of performance, the history of injuries in
general and the shoulder in particular, and environmental factors
etc.

3.2. How do we select the appropriate exercises?

Regardless of the specific pathology, all shoulder rehabilitation Figure 1. Elevation with external rotation.
programs consist of a regimen of active exercises. The choice of an
exercise program may be based on several criteria. The main
criterion is without any doubt the goal of the exercise. Overall,
evidence for exercise interventions in overhead athletes with
shoulder pain is dominated by expert opinion [47]. Clinical experts
mainly support an advanced, global treatment approach consistent
with the complex, multidimensional nature of sport.
A criterion for exercise selection may be the assumed activity
level of the targeted muscles during the exercise. Numerous
studies have investigated graded rotator cuff (RC) activity [48],
scapular muscle balance [49,50], plyometric exercises [51], or
kinetic chain integration [52]. It is beyond the scope of this article
to discuss these studies in detail; however, in general, the
following guidelines may be extracted from research data:

 lower and middle trapezius are mainly activated by adding an ER

component to the exercise [49,50] (Fig. 1);
 pectoralis minor may be inhibited by performing ER, with
preference in an open kinetic chain [49];
 serratus anterior is more activated during elevation exercises
than isolated protraction exercises [53];
 rotator cuff activity is low during low-load closed-chain
exercises such as bench or wall slides [48] (Figs. 2 and 3);
 infra- and supraspinatus activity is high during ER exercises
[48];
 subscapularis activity may be increased by performing flexion-
extension exercises in low elevation angles [54];
 biceps activity is high during plyometric elevation exercises in
supination [55];
 exercises with an open hand favor middle trapezius and lower
trapezius activity, whereas making a fist possibly increases
rotator cuff activity [52,56];
Figure 2. Bench slide against resistance.
 the clinician may combine the above-mentioned guidelines in
the individualized exercise program, based on several treatment
goals, thereby resulting in a variety of specific exercises.
3.3. GIRD: Should we stretch or not?
GIRD or posterior shoulder stiffness is one of the most common
adaptations seen at the dominant side of overhead athletes of
multiple sports disciplines. GIRD manifests clinically as decreased
glenohumeral cross-body adduction and IR mobility and is
believed to result from both capsular tightness and muscular
contracture [57]. The cumulative loads on the posterior shoulder

Please cite this article in press as: Cools AM, et al. The challenge of the sporting shoulder: From injury prevention through sport-specific
rehabilitation toward return to play. Ann Phys Rehabil Med (2020), https://doi.org/10.1016/j.rehab.2020.03.009
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Figure 3. Wall slide against resistance.
during the deceleration phase of the throwing motion is suggested
to cause microtrauma and scarring of these soft tissues [58]. Thus,
posterior shoulder stiffness has been suggested as a causative or
perpetuating factor in shoulder impingement and labral pathology.
As a result of these findings, stretching of the posterior shoulder is
commonly advocated in overhead athletes with GIRD. Some
studies attribute the changes in rotational ROM to increased
humeral retrotorsion of the throwing arm [59]. Because increased
retrotorsion is a fixed bony adaptation after skeletal maturation, if
the physical examination reveals no deficit in total rotation motion
of the glenohumeral joint but rather a shift in the rotational range,
then no treatment should be applied [57].
In general, stretching programs have been found effective in
increasing glenohumeral internal-rotation ROM [60] and decreas-
ing symptoms [61]. However, the question arises as to whether the
clinician should focus on stretching the posterior shoulder
(supposed to be stiff as a result of frequent throwing) or training
the muscular deceleration mechanism, the external rotators,
which are supposed to decelerate the arm during throwing
[37]. Perhaps when the decelerator strength increases, the capsule
is less likely to stiffen. However, this clinical assumption is not
confirmed by research. Nevertheless, because the external rotators
play an important role as decelerators of the throwing arm in
overhead sports, special attention should be paid to enhancing the
Please cite this article in press as: Cools AM, et al. The challenge of the sporting shoulder: From injury prevention through sport-specific
rehabilitation toward return to play. Ann Phys Rehabil Med (2020), https://doi.org/10.1016/j.rehab.2020.03.009
5
eccentric strength of this muscle group. In particular, we should
focus on the infraspinatus because this muscle has been shown to
be prone to dysfunction in the presence of pain [49]. Moreover,
early signs of tendinosis were found on MRI in a healthy population
of elite adolescent tennis players [37], which highlights the
vulnerability of the external rotators.
3.4. Should we exercise the chain?
Research as well as expert opinion generally encourage the
clinician to integrate kinetic chain exercises as early as possible in
the training program [46,62]. The question arises as to whether
kinetic chain implementation during shoulder rehabilitation has a
beneficial effect in terms of clinical outcome, patient satisfaction,
functional recovery and RTP. Barret at al. [63] showed no
differences in outcome for pain and disability after an exercise
program with or without thoracic extension exercises. Similarly,
for the trunk and lower extremities, a pilot study was conducted
comparing:
 a more ‘‘traditional’’ shoulder rehabilitation program with;
 the same program but with additional training of the lower
extremities and the trunk and;
 a program in which the kinetic chain was incorporated in the
shoulder rehabilitation exercises.
The results showed that the functional outcome was not
influenced by the type of program, and functional outcome and
patient satisfaction were similar for all 3 groups (Borms et al., 2020,
under review).
In conclusion, although many researchers and clinicians seem
to encourage the use of the kinetic chain during shoulder
rehabilitation exercises, evidence to support this as a strategy
superior to the more local approach is still scarce. In the meantime,
the patient may be inspired to do more ‘‘functional’’ kinetic chain
exercises because they are more fun, activate the whole body, and
allow for addressing possible kinetic chain deficits while training
the shoulder.
3.5. What are the challenges in rehabilitation?
Traditionally, shoulder rehabilitation programs are designed to
increase flexibility, strength, endurance, functional stability and
motor control [64]. Rehabilitation often emphasizes motor skill
learning processes rather than strength and performance, in
particular during the early stages of learning a sport-specific task.
Many factors influence these processes, such as the patient’s focus
of attention and feedback on the performance of a task. Studies
examining the role of the patient’s focus of attention have
consistently demonstrated that instructions inducing an external
focus (directed at the movement effect) are more effective than
those promoting an internal focus (directed at the performer’s
body movements). An external focus facilitates automaticity in
motor control and promotes movement efficiency [65]. This
principle can easily be incorporated in a rehabilitation protocol,
even in the early stages. Feedback should be specific and
constructive but not redundant. Feedback has an informational
function and also has motivational properties that have an
important influence on learning. For example, feedback after
successful trials indicating better than average performance have a
beneficial effect on learning [65]. Less is more: better give feedback
occasionally on positive performance than give constant feedback
on every attempt to perform the task.
During the advanced phase of rehabilitation, the practitioner
must balance 2 conflicting components: on one hand, the
knowledge that premature RTP increases the risk of re-injury
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and on the other, that the player as well as the team desire a return
to participation as quickly as possible. Combining evidence with
clinical expertise, the clinician plans the RTP accordingly.
Quantifying and monitoring the progressive training load is key
in guiding this process. Recently, the ‘‘control-chaos-continuum’’
was introduced for lower-limb injuries, offering a framework
moving from high control to high chaos during sport-specific
rehabilitation [66]. The continuum was described for lower-limb
injuries but can easily be transferred to upper-extremity injuries.
The authors suggest starting with ‘‘high control’’ exercises,
controlling ROM, speed, training volume, and circumstances, with
low unexpected environmental forces. During the ‘‘moderate
control’’ phase, changes in direction may be introduced but under
controlled circumstances, such as target throwing or smashing
from a still starting position. In the ‘‘moderate chaos’’ phase,
unpredicted movements are introduced with minimal limitations,
with the additions of pass and move and specific patterns of play
drill. Finally, in the ‘‘high chaos’’ phase, the player returns to
weekly training demands and includes drills designed to test
‘‘worst-case scenarios’’ (high speed, unexpected circumstances,
one-on-one drills etc.).
In summary, the following guidelines should be taken into
account when treating an overhead athlete with sports-related
shoulder pain:
 Let tissue irritability guide the treatment for today; use
symptom reduction tests to determine the specific
approach.
 Let the patient’s goals and expectations determine the
long-term treatment strategy.
 Maintain strength and mobility in the kinetic chain
throughout the rehabilitation process.
 Select the appropriate exercises for activating weak
muscles and inhibiting hyperactive muscles.
 Treat the athlete, not the shoulder.
 Train the chain for fun and functional relevance, rather
than because it makes the shoulder better.
 Prepare the athlete for the ‘‘worst-case scenario’’.
4. Return to play after shoulder injury
4.1. The decision-based return to play model
Deciding when to return to sport after a shoulder injury is
complex and multifactorial. Previous injury is considered one of
the most relevant risk factors for re-injury. Therefore, the
treatment of all injuries must include advice on when it is safe
to resume sport participation. The decision-based RTP model [67]
(StARRT—the Strategic Assessment of Risk and Risk Tolerance
model) is a useful guide to assist and optimize the RTP process. The
proposed model was created to clarify the processes that clinicians
are supposed to use when making RTP decisions, in a shared
decision-based model, including all stakeholders such as the
athlete, coach, medical staff, eventually sponsors, federation etc. In
an RTP continuum, 2 elements may be defined, emphasizing a
graded, criterion-based progression. In the ‘‘return to participa-
tion’’ phase, the athlete participates in sports at a lower level than
his/her RTP goals. In the ‘‘return to sports’’ phase, the athlete has
returned to his/her defined sport but is not performing at his/her
desired performance level. In the final stage of ‘‘return to
Please cite this article in press as: Cools AM, et al. The challenge of the sporting shoulder: From injury prevention through sport-specific
rehabilitation toward return to play. Ann Phys Rehabil Med (2020), https://doi.org/10.1016/j.rehab.2020.03.009
performance’’, the athlete is performing at or above his/her pre-
injury level [68]. In addition, within a biopsychosocial approach,
physical components should be considered as well as psychologi-
cal and social factors. Psychological readiness is an important
element for optimal RTP. Emotions including fear of re-injury and
cognitive factors including self-efficacy and motivation influence
treatment and outcome after athletic injury [69].
4.2. Practical guidelines for the sporting shoulder
Despite this science-based model to be implemented in
clinical practice, little evidence exists regarding the physical RTP
criteria of the shoulder after injury. In particular, from a clinical
perspective, there is a need for cutoff values to be used as criteria
for the return to train and RTP. With respect to GIRD, cutoff values
range from 188 to 258 depending on the study design and
population [58]. Therefore, in view of maximal protection of the
athlete, but taking into account measurement errors and the
minimal detectable change, side differences in IR ROM should be
less than 208 and the difference in total ROM should not be more
than 108 [22]. Regarding rotator cuff strength, in general,
overhead athletes often exhibit sport-specific adaptations
leading to a relative decrease in the strength of the external
rotators and thus muscular imbalance in the rotator cuff [22]. In
general, with respect to cutoff values distinguishing a healthy
shoulder from a shoulder at risk, an isokinetic ER/IR ratio of 63%
to 72% (depending on the testing position) [13,70,71] or an
isometric ER/IR ratio of 75% to 100% (depending on the testing
position) [72] is advised, with a general rotator cuff strength
increase of 10% of the dominant versus non-dominant throwing
side [62]. In addition, it is important to consider the absolute
values of strength testing. An athlete may have a good ER/IR ratio,
but in general low values of muscle performance and hence be
possibly prone to injuries. Moreover, the clinician should be
aware that isolated strength testing on an isokinetic device or
using a hand-held dynamometer does not correspond highly to
the functional shoulder demands during overhead throwing and
does not incorporate kinetic chain variables. Table 1 summarizes
the recommended tests for the clinical practice, including their
critical values.
4.3. When is an athlete ready to return to sports?
The main concern in the RTP decision is to minimize the risk of
re-injury. Therefore, in the absence of valid screening tools that
may predict the risk of re-injury, the clinician needs to take into
account a few ‘‘rules’’. The advice below is based on the consensus
statement paper from Ardern et al. [68], summarizing the
conclusions of an expert panel consensus meeting at the first
World Congress in Sports Physical Therapy, in Bern, 2016:
 define each RTP process specifically for the sport and the level of
participation. Several contextual factors may influence the
expectations and risk tolerance for RTP;
 RTP is a continuum paralleled to recovery and rehabilitation and
starts with a return to participation, before a return to
performance;
 on some occasions, the RTP decision may be reversed to a
removal-from-sports question. The shared decision-making
process may involve reduction of load, modified training
intensity etc.;
 RTP should be a decision shared with all stakeholders, except in
case of health risk for the athlete. This requires well-defined
roles for the athlete as well as the surrounding medical and
coaching staff. These roles should be identified as early as
possible;
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A.M. Cools et al. / Annals of Physical and Rehabilitation Medicine xxx (2020) xxx–xxx 7

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[23] Frydendal T, Eshoj H, Liaghat B, Edouard P, Sogaard K, Juul-Kristensen B.
The authors declare that they have no competing interest.
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