Return to Sport After Shoulder Injury

Returning to sport after a shoulder injury — particularly shoulder instability or dislocation — requires more than time alone.

The aim is not simply to participate again. It is to determine whether the athlete has developed the physical and psychological capabilities required for the demands of their sport.

There is currently no single test, strength threshold or time point that can determine when an athlete is ready to return.

Return-to-sport decisions should therefore combine:

• clinical assessment
• physical testing
• psychological readiness
• progressive exposure to sport-specific demand

Time matters after injury — but time alone does not indicate readiness.

Why Return-to-Sport Decisions Matter

The shoulder may be exposed to substantial forces during sport.

Depending on the activity, these demands may include:

• overhead movement
• throwing
• pushing and pulling
• weight-bearing through the arm
• falls
• collisions
• rapid changes in direction
• unexpected or reactive loading
• repeated effort under fatigue

After shoulder injury, rehabilitation needs to prepare the athlete for these demands rather than simply restoring pain-free movement in the treatment room.

A useful way to approach this is to consider four areas:

CONTROL • CAPACITY • CONFIDENCE • DEMAND

CONTROL

Can the athlete control the shoulder in the positions required by their sport?

Shoulder control involves more than simply being able to move the arm through a full range.

It includes the ability to coordinate the shoulder through different positions, tolerate changing loads and respond appropriately when movement becomes faster or less predictable.

For an athlete with previous instability, this may also involve progressively restoring control in positions that initially feel vulnerable or threatening.

CAPACITY

Does the shoulder have sufficient strength, endurance and power?

Physical capacity needs to match the demands of the activity.

This may include:

• rotator cuff strength
• long-lever shoulder strength
• endurance
• power
• weight-bearing capacity
• force absorption
• ability to tolerate repeated loading

Performance on one isolated strength test does not provide a complete picture of readiness.

The shoulder needs enough capacity to perform repeatedly and under the conditions encountered in sport.

CONFIDENCE

Does the athlete trust the shoulder?

Physical recovery and psychological readiness do not always progress at the same rate.

An athlete may regain movement and strength but still feel apprehensive when returning to the position or situation in which the original injury occurred.

Fear of reinjury, kinesiophobia and apprehension have been associated with poorer function, quality of life and return-to-sport outcomes following shoulder instability.¹

Confidence therefore needs to be considered alongside physical testing.

It may need to be rebuilt through progressive exposure to increasingly demanding tasks and repeated successful experiences.

DEMAND

What does the athlete actually need the shoulder to do?

This is one of the most important parts of return-to-sport decision making.

The same shoulder may be ready for one activity but not another.

A swimmer needs repeated overhead capacity.

A rugby player needs to tolerate collision and unpredictable loading.

A cricketer may need repeated high-velocity throwing.

A skier may need to tolerate falls and rapid unexpected loading.

A horse rider may need to manage sudden traction forces while riding or handling a horse.

Passing a physical test does not automatically make an athlete ready for every sport.

The test result only becomes meaningful when it is interpreted against the demand.

Do Control, Capacity and Confidence match the Demand?

Functional Testing and the SARTS Approach

Functional testing can provide useful information during the return-to-sport process.

The Shoulder Arm Return to Sport (SARTS) test battery was developed to provide reliable measures of upper-limb performance that can be used alongside strength testing, clinical assessment and psychological readiness.²

SARTS testing includes tasks designed to challenge different aspects of upper-limb performance.

Biomechanical analysis of the Line Hop and Side Hold Rotation tests demonstrated substantial loading of both the anterior and posterior shoulder musculature during these tasks.³

This makes them useful for examining how the shoulder performs under more demanding conditions than traditional isolated strength testing alone.

However:

No single SARTS test — and no other single shoulder test — can determine whether an athlete is ready to return to sport.

Functional testing should contribute to the decision rather than replace clinical judgement.

Examples of Return-to-Sport Tests

The tests selected will depend on the athlete, the injury and the demands of the sport.

Different tests examine different physical qualities, including strength, power, weight-bearing capacity, reactive control and apprehension.

Push Up Claps

Supine Moving Apprehension Test

Closed Kinetic Upper Extremity Stability Test

Line Hops

Ball Taps

ASH Test

These tests should not be interpreted as a universal return-to-sport battery.

The most appropriate assessment depends on the athlete and the physical demands of the sport.

Return to Sport Is a Process

Return to sport is rarely one moment or one decision.

Rehabilitation should progressively increase the demand placed on the shoulder.

This may involve progression through:

controlled exercise → higher load → greater speed → reactive tasks → sport-specific drills → training → competition

The exact progression will differ between athletes.

Importantly, an athlete may be able to return to some parts of their sport before others.

Returning to non-contact training, for example, does not necessarily mean the shoulder is prepared for full contact competition.

Similarly, an overhead athlete may tolerate general training before they are ready for repeated high-velocity throwing.

The final stages of rehabilitation should increasingly resemble the environment in which the shoulder needs to perform.

Test Under Demand

Shoulder instability frequently occurs in situations that are difficult to reproduce during standard clinical testing.

Sport introduces:

• speed
• fatigue
• decision making
• competition
• unexpected movement
• contact or collision
• environmental variability

This does not mean that every sporting situation needs to be recreated in the clinic.

It means that rehabilitation and return-to-sport progression should gradually expose the athlete to increasing levels of complexity and unpredictability.

Build Capacity Before Chaos.

Then progressively introduce the chaos.

The Role of Bracing During Return to Sport

For some athletes, shoulder bracing may provide additional external support during the transition back to higher-demand training or competition.

Depending on the brace configuration, it may help limit exposure to a vulnerable range of movement while still allowing the athlete to participate in sport.

Some athletes may also feel more confident when returning to situations in which the shoulder has previously felt unstable.

However, bracing should be viewed as an adjunct to rehabilitation.

A shoulder brace does not replace:

• appropriate strength
• shoulder control
• physical capacity
• psychological readiness
• sport-specific preparation

A brace should solve a problem.

It should not simply be worn because an athlete has previously injured their shoulder.

Read more: When Can a Shoulder Brace Help? →

How Is Readiness to Return Assessed?

There is currently no universally accepted single test or test battery that can declare an athlete ready to return to sport following shoulder instability.⁴

A broader assessment may include:

• range of movement
• rotational strength
• long-lever strength
• endurance
• power
• weight-bearing capacity
• reactive shoulder control
• sport-specific functional testing
• apprehension
• confidence and psychological readiness

These results should then be interpreted against the athlete's actual sporting demands.

The aim is not to pass every possible shoulder test.

The aim is to determine whether the athlete has the capabilities required for the activity they are returning to.

The Key Message

Return to sport after shoulder injury is not a date on a calendar.

It is also not the result of one test.

It is a decision based on the athlete, the shoulder and the sport.

Functional testing can help identify remaining gaps.

Strength testing can quantify physical capacity.

Assessment of apprehension and psychological readiness can identify a lack of confidence that may not be apparent during routine physical testing.

Sport-specific progression can then determine whether these capabilities remain effective as demand increases.

CONTROL • CAPACITY • CONFIDENCE • DEMAND

Look for the gaps. Test under demand.

About Dr Margie Olds

Dr Margie Olds, PhD is a shoulder physiotherapist and researcher specialising in shoulder instability and return to sport.

Her research includes the development of the Shoulder Arm Return to Sport (SARTS) test battery, biomechanical analysis of shoulder return-to-sport tests, recurrence prediction following first-time traumatic anterior shoulder dislocation, and research into psychological readiness following shoulder instability.

References

1. Brindisino F, Garzonio F, Di Giacomo G, Pellegrino R, Olds M, Ristori D. Depression, fear of re-injury and kinesiophobia resulted in worse pain, quality of life, function and level of return to sport in patients with shoulder instability: a systematic review. J Sports Med Phys Fitness. 2023;63(4):598-607.
2. Olds M, Coulter C, Marant D, Uhl T. Reliability of a Shoulder Arm Return to Sport test battery. Physical Therapy in Sport. 2019.
3. Olds MK, Lemaster N, Picha K, et al. Line Hops and Side Hold Rotation Tests Load Both Anterior and Posterior Shoulder: A Biomechanical Study. International Journal of Sports Physical Therapy. 2021.
4. Myers H, Wulff K, Antonelli C, et al. Objective measures for assessing readiness to return to sport after shoulder instability procedures are not standardized: a systematic review. Arthroscopy, Sports Medicine, and Rehabilitation. 2024;6(5):100978.
5. Olds M, Uhl TL. Current clinical concepts: nonoperative management of shoulder instability. Journal of Athletic Training.

This information is intended as general education and does not replace individual medical, physiotherapy or return-to-sport assessment.