Systematic Review

Return to Play Criteria Following Surgical

Stabilization for Traumatic Anterior Shoulder
Instability: A Systematic Review
Michael C. Ciccotti, M.D., Usman Syed, B.S., Ryan Hoffman, B.S., Joseph A. Abboud, M.D.,
Michael G. Ciccotti, M.D., and Kevin B. Freedman, M.D., M.S.C.E.

Purpose: To identify and describe in the existing literature any criteria used for return to play following surgical stabi-
lization for traumatic, anterior shoulder instability. Methods: We performed a systematic review evaluating surgical
stabilization for primary traumatic anterior shoulder instability in skeletally mature patients with a minimum of 1-year
follow-up using Level I to IV studies in PubMed and EMBASE from January 1994 to January 2017. Results: Fifty-
eight studies with at least 1 explicitly stated criterion for return to play were identified from a review of more than 5,100
published articles. Seven different categories of return to play criteria were identified, the most common of which were
time from surgery (89.6%), strength (18.9%), and range of motion (13.8%). Pain, stability, proprioception, and post-
operative radiographic evaluation were also used. As hypothesized, in 75.8% of the included studies (44/58), time was the
only criterion explicitly used. The most commonly used time for return to play was 6 months. Conclusions: This sys-
tematic review identifies 7 criteria that have been used in the available literature to determine when patients are ready to
return to play; however, consistent with our hypothesis, 75% of studies used time from surgery as the sole listed criterion,
with the most commonly used time point of 6 months postoperative. All of these criteria can be used in future research to
develop a comprehensive checklist of functional criteria in hopes of reducing recurrent injury. Level of Evidence: Level
IV, systematic review.

I nstability of the glenohumeral joint is common

among young, active patients. Data from the National
Collegiate Athletic Association Injury Surveillance
From Thomas Jefferson University Hospital (M.C.C.); The Rothman Insti-
tute at Thomas Jefferson University (U.S., J.A.A., M.G.C., K.B.F.); and Drexel
University College of Medicine (R.H.), Philadelphia, Pennsylvania, U.S.A.
The authors report the following potential conflicts of interest or sources of
funding: J.A.A. is on the board of directors of Mid-Atlantic Shoulder & Elbow
Society and on the scientific advisory board of MinInvasive; is a paid consultant
for Tornier Medicine, Cayenne, and Globus; receives royalties from Globus,
DJO Global, Cayenne, Wolters Kluwer HealtheLippincott Williams & Wil-
kins, and Integra; has stock/stock options in Aevumed; and receives research
support from DePuy, Zimmer, Tornier, Department of Defense, Integra, Or-
thopaedic Research and Education Foundation, and OrthoSpace. M.G.C. re-
ceives board membership fees from the Orthopaedic Learning Center; and
receives research support from Arthrex and Major League Baseball. K.B.F. is a
paid consultant for Mitek Sports Medicine. Full ICMJE author disclosure forms
are available for this article online, as supplementary material.
Received December 1, 2016; accepted August 28, 2017.
Address correspondence to Kevin B. Freedman, M.D., M.S.C.E., Rothman
Institute at 825 Old Lancaster Road, Bryn Mawr, PA 19010, U.S.A. E-mail:
kevin.freedman@rothmaninstitute.com
Ó 2017 by the Arthroscopy Association of North America
0749-8063/161149/$36.00
https://doi.org/10.1016/j.arthro.2017.08.293
System suggests these injuries occur at a rate of 0.12 per
1,000 exposures within that population.1 Greater than
10 days are lost to sport in nearly half of instability
events.1 Furthermore, with nonoperative management,
approximately 95% of patients younger than 20 years
have been shown to suffer from recurrent instability
events.2-4 As a result, many surgeons advocate surgical
stabilization to reduce recurrence and allow the greatest
opportunity for return to play.
Shoulder stabilization surgery necessitates a mini-
mum period of postoperative rehabilitation for biologic
healing to occur, and this is often followed by recon-
ditioning to restore range of motion, strength, and co-
ordination prior to safe return to play. However, it
remains unclear when patients are safe to return to play
without restriction. Many factors can theoretically
predispose to recurrent injury. These include young
age, male gender, inappropriate surgical indications,
technical errors at the time of surgery, untreated
concomitant pathology, biologic factors such as
incomplete healing, participation in high risk activities
such as collision sports, and incomplete rehabilitation
with premature return to play.1-7 In particular, signifi-
cant bone defects on the glenoid or humeral side can

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2017: pp 1-11 1
2 M. C. CICCOTTI ET AL.
predispose toward failure of arthroscopic stabilization
and should be addressed with the appropriate surgical
procedure.7
The purpose of this systematic review was to identify
and describe in the existing literature any criteria used
for return to play following surgical stabilization for
traumatic, anterior shoulder instability. Although au-
thors use an abundance of terms to signify return to
play (return to play, return to sport, return to unre-
stricted activity, full/unlimited activity, etc.), we hy-
pothesized that most surgeons use time-based criteria
alone without using additional functional or
performance-based criteria.
Methods
We performed a systematic review of Level I to IV
studies of patients undergoing surgical stabilization for
primary traumatic anterior shoulder instability. We
searched PubMed and EMBASE for the terms anterior
instability, shoulder stabilization, shoulder instability reha-
bilitation, shoulder stabilization results, Bankart repairs,
labral tears, recurrent instability, surgical management of
shoulder instability, and return to play from January 1994
to January 2017 (Table 1). January 1994 was selected
as 20 years before the conception of the project and the
search was subsequently updated to ensure no recent
studies were missed. Twenty years was selected because
it would include all studies using modern stabilization
techniques and capture the largest number of potential
return to play criteria. We used the definition of return
to play as any statement of return to full, unrestricted
activity including sports, work, etc. For the purpose of
the current review, “return to play” signified the point
at which patients were allowed to participate in any
activity, including sports, without further restriction
Table 1. Search Strategy With MeSH Terminology and
Combinations
Literature Search Strategy: January 1, 2014, to January 1, 2017,
in PubMed and EMBASE
“anterior instability”
AND/OR
“shoulder stabilization”
AND/OR
“shoulder instability rehabilitation”
AND/OR
“shoulder stabilization results”
AND/OR
“Bankart repairs”
AND/OR
“labral tears”
AND/OR
“recurrent instability”
AND/OR
“surgical management of shoulder instability”
AND/OR
“return to play”
postoperatively. An abundance of terms has been used
in the literature (return to play, return to sport, return
to unrestricted activity, full/unlimited activity, etc.),
and these were treated as equivalent if the authors did
not suggest further surgeon-imposed restrictions on
their patients.
Studies were required to be (1) written in the English
language and (2) conducted in a population of adult,
skeletally mature patients with a mean age of 18 years
or greater, (3) with traumatic anterior instability, (4)
undergoing a primary stabilization procedure, and (5)
with a minimum of 1-year follow-up. Studies lacking
explicit return to play criteria, review articles, biome-
chanical studies, technical notes, studies with follow-up
less than 1 year, studies looking exclusively at posterior
or multidirectional instability, studies including patients
with hyperlaxity or atraumatic instability, studies
including multiple patterns of instability, revision pro-
cedures, or studies using thermal capsulorraphy were
excluded. We explicitly included open stabilizations,
including bony procedures, to capture as many return
to play criteria as possible. The procedures used in each
included study are presented in Table 2. Although
many studies included some patients younger than
18 years, any study in which the mean patient age at
the time of surgery was less than 18 years was excluded
as a primarily pediatric study. As many as 39 additional
studies appeared to meet criteria for inclusion but were
excluded for having no explicit return to play criteria.
The reference sections of all selected studies were
reviewed by hand, and all potentially relevant articles
were compiled. The initial search was completed with a
team including a dedicated research fellow (U.S.) and a
medical student (R.H.), under the direct supervision of a
resident physician (M.C.C.). Any questions regarding
inclusion were directed to the senior author (K.B.F.).
The methods section of each article meeting the inclu-
sion criteria was analyzed by the senior author. Only
those studies that were confirmed to meet all criteria
were selected, and the data were compiled from each.
Because of the heterogeneity in reporting of results, a
meta-analysis was not attempted. Preferred Reporting
Items for Systematic reviews and Meta-Analyses
(PRISMA) criteria were followed throughout the
study.65 The primary data of interest were the criteria
explicitly used in each study to determine when patients
were permitted to return to play and any details provided
about these criteria. Additional data extracted included
publication data, demographic data, patient pathology,
procedures performed, and return to play rates.
Results
Study Design
The initial database search yielded 5,100 unique
published articles. Ultimately, 58 studies were identified
Table 2. Individual Study Data With Pathology, Procedure, Demographic Data, and Return to Play Criteria

Mean Number
Primary Level of No. of Age in Mean Follow-up in of RTP
First Author, Year Pathology Primary Procedure(s) Evidence Patients Years Months (Minimum) Criteria RTP Criteria
Alentorn-Geli,8 2016 Bankart Arthroscopic Bankart repair with suture anchors IV 57 22 Mean not provided (60) 3 ROM, strength, pain
Blonna,9 2016 Bankart Bristow-Latarjet III 60 31.5 63.6 (24) 1 Time
Gerometta,10 2016 Bankart Arthroscopic Bankart repair with suture anchors IV 46 28.9 24.4 (12) 1 Time
Tordjman,11 2016 Bankart Arthroscopic Bankart repair with suture anchors IV 31 24.3 61.2 (21.6) 1 Time
Bessiere,12 2014 Bankart Arthroscopic Bankart repair with suture anchors; III 186 26 72 (48) 1 Time
Bristow-Latarjet
Gamulin,13 2014 Bankart Open Bankart repair with suture anchors IV 52 27.4 154.8 (130.8) 1 Time
Ozturk,14 2013 Bankart Arthroscopic Bankart repair with suture anchors IV 53 19.5 27 (20) 4 Time, ROM,
strength, pain
Ahmed,15 2012 Bankart Arthroscopic Bankart repair with suture anchors IV 174 25.2 44 (24) 1 Time

RETURN TO PLAY AFTER SHOULDER STABILIZATION

Zaffagnini,16 2012 Bankart Open Bankart repair with suture anchors; III 110 36.2 Mean not provided (120) 1 Time
arthroscopic transglenoid suture
Stein,17 2011 Bankart Arthroscopic Bankart repair with suture anchors IV 47 23.2 32 (32) 1 Time
Chechik,18 2010 Bankart Arthroscopic Bankart repair with suture anchors IV 83 23.5 65.2 (16.8) 4 ROM, strength,
stability, pain
Flinkkilä,19 2010 Bankart Arthroscopic Bankart repair with suture anchors IV 182 28 51 (24) 1 Time
Voos,20 2010 Bankart Arthroscopic Bankart repair with suture anchors IV 73 33 33 (24) 3 Time, strength, pain
Bonnevialle,21 2009 Bankart Open Bankart repair with suture anchors IV 75 22.5 84 (60) 1 Time
Monteiro,22 2008 Bankart Arthroscopic Bankart repair with suture anchors II 45 23.5 31.1 (24) 3 Time, ROM, strength
Pagnani,23 2008 Bankart Open Bankart repair with suture anchors IV 103 20.7 Mean not provided (24) 1 Strength
Thal,24 2007 Bankart Arthroscopic Bankart repair with suture anchors IV 73 26.7 Mean not provided (24) 1 Time
Boileau,25 2006 Bankart Arthroscopic Bankart repair with suture anchors IV 100 26.4 36 (24) 1 Time
Hayashida,26 2006 Bankart Arthroscopic Bankart repair with suture anchors IV 52 26 28 (24) 1 Time
Magnusson,27 2006 Bankart Open Bankart repair with suture anchors IV 18 29 90 (80) 1 Time
Mahirogullari,28 2006 Bankart Open Bankart repair with suture anchors; II 64 23.7 26.5 (24) 1 Time
Bristow-Latarjet
Westerheide,29 2006 Bankart Arthroscopic Bankart repair with suture anchors IV 67 27.6 33.3 (20) 1 Time
Garofalo,30 2005 Bankart Arthroscopic Bankart repair with suture anchors IV 20 23.2 43 (36) 2 Time, strength
Kim,31 2003 Bankart Arthroscopic Bankart repair with suture anchors IV 73 26.7 Mean not provided (24) 1 Time
Pötzl,32 2003 Bankart Open Bankart repair with suture anchors IV 83 30 42 (12) 1 Time
Massoud,33 2002 Bankart Open Bankart repair with vertical-apical suture IV 59 27 42 (24) 1 Time
Pagnani,34 2002 Bankart Open Bankart repair with suture anchors IV 58 18.2 37 (24) 1 Strength
Yamashita,35 2002 Bankart Open Bankart repair with suture anchors; II 126 25 41 (24) 1 Time
Bristow-Latarjet
Ejerhed,36 2000 Bankart Open Bankart repair with suture anchors IV 18 29 31 (25) 1 Time
Roberts,37 1999 Bankart Arthroscopic Bankart repair with suture anchors; IV 52 19.9 29.4 (12) 1 Time
open Bankart repair with suture anchors;
arthroscopic transglenoid sutures
Kartus,38 1998 Bankart Open Bankart repair with suture anchors; I 33 29.5 29.5 (18) 1 Time
arthroscopic Bankart repair with suture anchors
Steinbeck,39 1998 Bankart Open Bankart repair with suture anchors; II 62 28.6 38 (24) 1 Time
arthroscopic transglenoid sutures
Sisto,40 1998 Bankart Arthroscopic Bankart repair with suture anchors II 30 33 47 (36) 1 Time
Savoie,41 1997 Bankart Arthroscopic transglenoid sutures IV 163 26.7 58.4 (36) 3 Time, ROM, strength
(continued)

3
Table 2. Continued

4
Mean Number
Primary Level of No. of Age in Mean Follow-up in of RTP
First Author, Year Pathology Primary Procedure(s) Evidence Patients Years Months (Minimum) Criteria RTP Criteria
Mologne,42 1996 Bankart Arthroscopic transglenoid sutures IV 48 26.5 30 (12) 1 Time
Hoffmann,43 1995 Bankart Arthroscopic Bankart repair with suture anchors IV 32 26 24 (12) 1 Time
Karlsson,44 1995 Bankart Open Bankart repair with suture anchors IV 50 26 36 (24) 3 Time, ROM, stability
Ungersböck,45 1995 Bankart Open Bankart repair with suture anchors II 40 34 47 (13) 1 Time
Walch,46 1995 Bankart Arthroscopic transglenoid sutures IV 59 25 49 (29) 1 Time
Arciero,47 1994 Bankart Arthroscopic transglenoid sutures II 36 20.1 32 (15) 1 Time
Mohtadi,48 2014 Bankart and Open Bankart repair with suture anchors; I 162 27.5 24 (24) 4 Time, ROM, strength,
ALPSA arthroscopic Bankart repair with suture anchors proprioception
Lee,49 2011 Bankart and Arthroscopic Bankart repair with suture anchors III 222 23.3 35 (13) 1 Time
ALPSA
Garcia,50 2013 Bankart with Arthroscopic Bankart repair with suture anchors; II 39 27.2 28 (24) 1 Time
engaging Remplissage
Hill-Sachs
Franceschi,51 2012 Bankart with Arthroscopic Bankart repair with suture anchors III 50 26.3 Mean not provided (24) 1 Time
engaging
Hill-Sachs

M. C. CICCOTTI ET AL.
Beranger,52 2016 Bony Bankart Bristow-Latarjet IV 47 27.9 46.8 (24) 1 Time
Dumont,53 2014 Bony Bankart Bristow-Latarjet IV 87 29.4 76.4 (61.2) 1 Time
Kim,31 2014 Bony Bankart Arthroscopic Bankart repair with suture anchors IV 36 26.1 41.7 (24) 1 Time
Mizuno,54 2014 Bony Bankart Bristow-Latarjet IV 60 29.4 240 (216) 1 Radiographic
Moroder,55 2014 Bony Bankart Iliac-derived glenoid bone grafting IV 11 36.7 34.6 (12) 1 Time
Zhao,56 2014 Bony Bankart Iliac-derived glenoid bone grafting IV 65 26.3 38.8 (24) 1 Time
Edouard,57 2013 Bony Bankart Bristow-Latarjet II 69 25 21 (21) 1 Time
Millett,58 2013 Bony Bankart Arthroscopic Bankart repair with suture anchors; IV 15 44 32.4 (24) 1 Time
reduction of bony bankart fragment
Sugaya,59 2005 Bony Bankart Arthroscopic Bankart repair with suture anchors IV 41 22.9 34 (24) 1 Time
Bhatia,60 2013 Bony Bankart Bristow-Latarjet IV 7 24 20.6 (16) 2 Time, Radiographic
with HAGL
Rhee,61 2007 HAGL Arthroscopic HAGL repair; open HAGL repair IV 6 28 39 (30) 2 Strength, ROM
Bottoni,62 2006 Mixed Open Bankart repair with suture anchors; I 64 25.3 29 (24) 1 Time
arthroscopic Bankart repair with suture anchors
Calvo,63 2005 Mixed Arthroscopic transglenoid sutures II 61 27.5 44.5 (24) 1 Time
Field,64 1995 Rotator interval Isolated rotator interval closure IV 15 24 39.6 (26.4) 1 Time
defect
ALPSA, anterior labroligamentous periosteal sleeve avulsion; HAGL, humeral avulsion glenohumeral ligament; ROM, range of motion; RTP, return to play.
 RETURN TO PLAY AFTER SHOULDER STABILIZATION 5

Fig 1. PRISMA diagram. (PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.)

that fully satisfied the inclusion criteria. The full step- 20.6 to 240 months.54,60 Overall, average follow-up
by-step results of the literature review are outlined in weighted by number of patients included in each
the PRISMA diagram (Fig 1). study was 39.7 months.

Patient Demographics Pathoanatomy and Surgical Stabilization

The 58 studies represented 3,850 patients with trau-
matic anterior instability of the shoulder. Patient de-
mographic data is presented in Table 2. All studies
reported a mean age greater than 18 years, and the
mean age ranged from 18.2 to 44 years at time of
surgery.34,58 Six studies failed to explicitly include a
range of ages.16-18,48,50,57 All studies had a minimum
12 months of follow-up, and follow-up ranged from
Procedures
All studies represented traumatic, anterior instability
but included a number of different anatomic pathol-
ogies and a number of different procedures. Pathoa-
natomic data as well as the primary procedure(s)
performed in each study are presented in Table 2.
Sixteen studies included only open procedures.
Thirty-two studies included only arthroscopic
6 M. C. CICCOTTI ET AL.

Table 3. Combinations of Return to Play Criteria in the 1.5 months included athletes participating in sports/
Literature fitness activities that would not place the operative
Combinations of Explicit
shoulder at risk, and 1.5 months represented the
Return to Play Criteria Presented Percentage of Included earliest time postoperatively at which patients were
in the Included Studies Studies (Number of Studies) permitted to return to play.
Time alone 75.8 (44)
Strength alone 3.4 (2) Strength. Eleven studies used strength as a criterion for
Time, ROM, strength 3.4 (2) return to play. The precise terminology used in each
Time, ROM, strength, pain 1.7 (1) study is presented in Table 5. No study described an
Time, ROM, strength, proprioception 1.7 (1) objective means of assessing strength via
ROM, strength, stability, pain 1.7 (1)
dynamometer or similar device.
ROM, strength, pain 1.7 (1)
Time, ROM, stability 1.7 (1) Range of Motion. Range of motion was the third most
Time, strength, pain 1.7 (1)
common criterion for return to play and was explicitly
Time, strength 1.7 (1)
Time, radiographic 1.7 (1) cited in 8 studies. No study stated postoperative goals in
Strength, ROM 1.7 (1) terms of degrees. The precise terminology used in each
Radiographic alone 1.7 (1) study is presented in Table 6.
ROM, range of motion.
Pain. Four studies used pain as a criterion.14,18,20 Three
studies required patients be “pain free” prior to return
procedures. The remaining 10 studies included both to play.14,20 One study described “resolution” of pain
arthroscopic and open procedures. Nineteen studies prior to return.18 No studies described a specific pain
described takedown of the subscapularis tendon and assessment score or tool.
anatomic reapproximation with non-absorbable suture.
Stability. Only 2 studies explicitly used stability as a
Six studies described a split of the subscapularis during
criterion.18,44 One study required “good static stability”
the approach. Only 2 studies that compared an without describing the specific means of assessment.18
arthroscopic with an open procedure involving take-
One study explicitly required “no apprehension on
down of the subscapularis used different postoperative
external rotation.”44
protocols for the 2 techniques, both initially progressing
the arthroscopic group at a slower pace. Radiographic Evaluation. Two studies used post-
operative plain radiograph evaluation as a criterion to
Return to Play Criteria asses graft healing.54,60 Both studies involved a Bristow-
All 58 studies included at least 1 explicitly stated cri- Latarjet procedure. Bhatia and DasGupta used a standard
terion for return to play. Return to play criteria data are anteroposterior view and a Bernageau view.60 Mizuno
presented in Table 2. Forty-seven studies included only et al.54 performed anteroposterior views in neutral,
a single criterion. A total of 7 different types of criteria internal rotation, and external rotation and assessed
were used: (1) time from surgery, (2) range of motion, graft healing on a comparative glenoid profile view.
(3) strength, (4) stability, (5) pain, (6) proprioception, Neither study reported the use of postoperative
and (7) postoperative plain radiographic evaluation to advanced imaging, such as computed tomography.
assess union in bony procedures. A total of 13 different
combinations of the above return to play criteria were Table 4. Return to Play Criteria: Time
reported in the literature and are presented in Table 3.
Although no study explicitly referred to a scoring in- Specific Time Point Percentage of
for RTP as Presented Included Studies
strument as criteria for return to play, many studies
in Each Study (Number of Studies)
used these instruments in the postoperative patient 1.5 months 1.9 (1)
assessment. Only 1 study of the 58 included did not 3 months 3.8 (2)
include a single validated scoring instrument.57 3-6 months 3.8 (2)
4 months 3.8 (2)
4-5 months 3.8 (2)
Time From Surgery. Time from surgery was the most 4-6 months 5.8 (3)
common criterion for return to play, used by 52 studies 5 months 9.6 (5)
and presented in Table 4. Forty-four of these studies 5-6 months 3.8 (2)
6 months 51.9 (27)
used time as the sole explicit criterion. The mode for
6-8 months 1.9 (1)
time from surgery to return to play was 6 months, 6-9 months 1.9 (1)
used in 27 studies. An additional 9 studies reported a 9 months 1.9 (1)
range including 6 months. The time from surgery to 10 months 1.9 (1)
return to play ranged from 1.5 to 12 months.32,43,53 12 months 3.8 (2)
The study that reported return to play as early as RTP, return to play.
 RETURN TO PLAY AFTER SHOULDER STABILIZATION 7

Table 5. Return to Play Criteria: Strength commonly used time for return to play was 6 months.
Although 13 combinations of criteria were identified,
Specific Strength Criteria Percentage of
for RTP as Presented Included Studies none approached consensus.
in Each Study (Number of Studies) We acknowledge clinicians were likely more nuanced
“full” 9.1 (1) in determining the return to play of their individual
“strength recovered” 9.1 (1) patients. However, it is a significant limitation of the
“equal to contralateral side” 9.1 (1) existing literature that postoperative protocols and such
“equal abduction and external rotation” 27.3 (3)
decision making are not more robustly discussed; most
“equal isokinetic internal and 9.1 (1)
external rotation” criteria were subjective in nature and only briefly
“nearly normal” 18.2 (2) described without the methodology necessary to be
“80% of non operated arm” 9.1 (1) reproducible. Furthermore, Lukenchuk et al.66 have
“at least 80% of the strength 9.1 (1) identified substantial variability in outcome reporting
of the contralateral side”
following operatively managed anterior glenohumeral
RTP, return to play. instability, which further complicates clear interpreta-
tion of the literature and the ability to draw substantive
Proprioception. One study used proprioception as a conclusions from pooled data. This remains a barrier to
criterion.48 This study required “proprioceptive control” producing meta-analyses.
of the operated shoulder without further definition or Multiple surgical techniques were included in this
specific means of assessment. Proprioceptive review to identify as many return to play criteria as
assessment was not referred to in any other study. possible. However, surgical management of traumatic,
anterior instability has largely evolved to a choice be-
Return to Play Rates tween arthroscopic Bankart repair and Bristow-Latarjet
Forty-three of the included studies (74.1%) reported procedures. Comparison of these procedures with re-
information on the sports participation of their patients. gard to pain, range of motion, surgical time, cosmesis,
Of these, 36 provided some information on the type of complications, and recurrence has been well covered
sports played and 25 provided information on the elsewhere and is beyond the scope of this re-
preoperative level at which the patients participated. view.5,10,67-72 However, the selection of a soft-tissue
Twenty-two studies provided both the type of sport versus a bony procedure may have consequences for
played as well as the level of participation. Thirty-nine the postoperative return to play process, and the
of the included studies (67.2%) reported on return to Instability Severity Index Score has been advocated for
play rates. Reported return to play rates ranged from determining which is indicated.7
31% to 100%. Of these 39 studies, roughly one-third A growing body of literature regarding return to play
reported return to play rates below 80% (14 studies); following ACL reconstruction has advocated a transi-
one-third reported return to play rates between 80% tion from chronologically based return to play criteria
and 90% (11 studies); and one-third reported return to to a checklist of functionally based criteria.73-75 It re-
play rates 90% or greater (14 studies). Return to play mains to be seen if this approach will reduce recurrent
rates are presented in Figure 2. In 23 of the 39 studies injury, but the rationale is compelling. Such a checklist
(69.7%), some form of grading of return to play relative can guide the kind of progressive, multiphase super-
to their preoperative level of participation was pro- vised rehabilitation program that has been advocated by
vided. The remaining 30.3% presented return to play in numerous sources.76-78 This requires a multidisci-
a dichotomous fashion, that is, the patient did or did not plinary approach including physicians, trainers, and
return to play. Only 11 studies provided information physical therapists and requires patients to demonstrate
regarding the rationale for inability to return to play. an ability to return to play across multiple criteria, in a
Most commonly, this was due to recurrent instability; quantitative manner wherever possible.
however, fear of repeat injury, contralateral shoulder
pathology, knee pathology, and unrelated/nonmedical
reasons were also cited. Table 6. Return to Play Criteria: Range of Motion

Specific ROM Criteria Percentage of

Discussion for RTP as Presented Included Studies
This systematic review has identified 7 return to play in Each Study (Number of Studies)
criteria following surgical stabilization for traumatic, “full” 25 (2)
“complete” 12.5 (1)
anterior shoulder instability, the most common of “motion be recovered” 12.5 (1)
which were time from surgery (89.6%), strength “near normal” 25 (2)
(18.9%), and range of motion (13.8%). As hypothe- “90% normal” 12.5 (1)
sized, in 75.8% of the included studies (44/58), time “75% normal” 12.5 (1)
was the only criterion explicitly reported. The most ROM, range of motion; RTP, return to play.
8 M. C. CICCOTTI ET AL.
Fig 2. Reported return to play rates by number of studies.
This systematic review provides the foundation for
creating a comprehensive, functional return to play
checklist for anterior shoulder stabilization by identi-
fying the existing criteria used. Despite being the most
commonly used criterion, and often the only criterion,
time from surgery alone is likely necessary but insuffi-
cient to ensure safe return to play. There is little ques-
tion that the repair must be protected for a period of
time to allow for biologic healing, whether it is soft
tissue or bone. Although the time points used by cli-
nicians are likely appropriate, they appear largely
empirical, and both human and animal-model data to
support time-based criteria are sparse.79
The importance of strength is well known and pro-
vides dynamic stability to a joint lacking in static, bony
stability.80 However, a more precise assessment of
postoperative strength with a dynamometer or iso-
kinetic device would likely allow greater confidence for
return to play. Further research is necessary to establish
the specific thresholds of strength for safe return to play
both relative to preoperative measurements, healthy
controls, or the contralateral extremity and in certain
positions, that is, abduction and external rotation.
Range of motion is a critical component of return to
play. In the included studies, the primary focus was on
achieving symmetric shoulder motion. Although this is
valid, we believe the focus should be on achieving a
functional range of motion for each particular patient.81
The specific sporting activity may define what consti-
tutes such “functional” motion. For example, a football
lineman likely does not require the same motion as an
overhead throwing athlete to safely and successfully
return to play. Furthermore, using the contralateral
extremity as a reference may not be appropriate in all
circumstances as many overhead throwers may
demonstrate well-described, nonpathologic, adaptive
asymmetries. The range of motion necessary for some
activities after knee surgery, such as climbing stairs and
rising from a seated position, has been well quantified.
Namdari et al.81 have done similar work looking at
activities of daily living for the shoulder and found that
less than full range of motion may be acceptable
for many such activities. Similar quantification of
functional range of motion for sport-specific activities
may be possible and ultimately play a substantial role in
individualized return to play.
Instability and pain should both be absent prior to
return to play. Pain, apprehension, and instability are
closely related and should be tested and documented
throughout the postoperative period. Such signs should
serve as a relative or absolute contraindication to return
to play.
Routine radiographic assessment is likely unnecessary
for return to play following a soft tissue procedure.
However, we agree that radiographic evaluation can
play an important role after a bony procedure.
Although no study in this review used advanced im-
aging as an explicit criterion, we recognize that many
surgeons may find it appropriate to use computed to-
mography postoperatively. Both computed tomography
and magnetic resonance imaging play a critical role in
cases of persistent or recurrent instability or pain.
Glenohumeral proprioception is believed to
contribute to stabilization and coordination of shoulder
motion via tensioning of the capsuloligamentous com-
plex as well as dynamic activation of the rotator cuff
and periscapular stabilizers. Unstable shoulders have
demonstrated decreased proprioceptive capabilities,
which may be improved with surgical stabilization.82,83
However, further research is necessary to define a
standardized assessment of proprioception before this
can be reliably used for return to play.
Although no study identified by this systematic re-
view used a scoring instrument as an explicit criterion
for return to play, incorporating such sport- or
shoulder-specific scoring instruments may serve as an
adjunct for return to play decision making. A number of
recently developed scoring instruments provide prom-
ise for both preoperative and postoperative assessment
including the Kerlan-Jobe Orthopaedic Clinic Shoulder
and Elbow, SPORTS, and Degree of Shoulder Involve-
ment in Sports scores.84-88 Using these same in-
struments to assess preoperatively may ultimately be
critical to stratify patients with levels of activities
ranging from occupational injuries to workplace injury
to professional athletics and apply an appropriate re-
turn to play protocol targeted to desire postoperative
level of activity. Future research can be focused to
groups with a particular level of activity to eventually
provide individualized return to play.
Limitations
This study has several limitations. One is the possi-
bility that some authors used more comprehensive,
objective criteria for return to play but simply failed to
describe those criteria in detail. Another potential lim-
itation is the possible exclusion of studies that did in fact
use some criteria for return to play but omitted them
entirely from the final text of the manuscript.
 RETURN TO PLAY AFTER SHOULDER STABILIZATION
Furthermore, this review included studies that evalu-
ated multiple anterior shoulder instability pathologies
and multiple anterior shoulder instability stabilization
procedures; although this introduced some heteroge-
neity, it allowed us to cast the widest possible net to
identify potential return to play criteria for traumatic,
anterior instability. As a result, some criteria may be
more applicable to certain procedures. Finally, the
identified studies included patients with all levels of
activities from professional and collegiate athletes to
weekend warriors and occupational injuries; pop-
ulations with significant differences in activity level
introduce additional heterogeneity.
Conclusions
This systematic review identifies 7 criteria that have
been used in the available literature to determine when
patients are ready to return to play; however, consistent
with our hypothesis, 75% of studies used time from
surgery as the sole listed criterion, with the most
commonly used time point of 6 months postoperative.
All of these criteria can be used in future research to
develop a comprehensive checklist of functional criteria
in hopes of reducing recurrent injury.
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