Summary

Psychological factors are rarely assessed after shoulder instability surgery but play an important role in an athlete's return to sport.

Abstract

Introduction

Shoulder instability is a significant cause of missed time from sport. Identification of the multifactorial influences associated with successful return to sport (RTS) is of significant clinical utility. Recent advances have begun to identify the non-physical factors facilitating successful RTS. Psychosocial factors have been proposed as key components of an athlete’s RTS, yet little is currently known regarding these factors and RTS following shoulder instability surgery.

Objective

The purpose of this systematic review was to determine if psychological factors are associated with RTS after shoulder instability surgery and identify the factors with the greatest impact. Further, we sought to assess the currently available metrics used to assess psychological RTS readiness.

Methods

Systematic review of the PubMed, EMBASE, and Cochrane databases was performed to identify studies reporting phycological factors that impact RTS after shoulder instability surgery. Two authors independently screened abstracts and manuscripts for inclusion. Clinical studies reporting on the psychological determinants of RTS were included. Demographic, clinical, methodological, and psychometric properties of the included studies were extracted. Patients were pooled across included studies and weighted analysis was performed.

Results

969 studies were identified in the initial search, with 24 studies, comprising 2135 patients, included (Table 1). The mean age was 26.0 (17.4-35.5), and 1809 (84.7%) were male (Table 2). Of the 24 studies, there were 20 studies (n = 1784 patients) that reported RTS rates; the remaining 4 studies were included because they further validated the role of psychological assessment in instability recovery. The mean time for RTS was 6.8 (3.7-11.9) months. Overall, there was a 76.3% rate of RTS at any level, and of the 1212 patients that reported the degree to which they returned, 305 (25.2%) were unable to perform at their prior level. Of the 423 patients who did not achieve RTS, 360 (85.1%) cited a psychological reason for not returning (Table 3). Fear of reinjury was the most common reason (154, 42.8%); other psychological factors cited included lack of confidence in their shoulder (46, 12.8%), anxiety (45, 12.5%), depression (44, 12.2%), psychosocial factors that overwhelmed the importance of making a full recovery (48, 13.3%), and lack of interest or motivation in playing (23, 6.4%) (Table 4). The Shoulder Return to Sport after Injury, Western Ontario Shoulder Instability Index, Quick Inventory of Depressive Symptoms Self Report, Degree of Shoulder Involvement in Sports, Tampa Scale of Kinesiophobia-11, and the Veterans Rand, were reported measures for assessing the influence of psychology on RTS. Using these scores served to quantify the importance of preoperative and postoperative factors such as social support, mood, expectations, confidence, risk taking, fear, and anxiety.

Conclusion

Psychological factors play an important role in RTS after shoulder instability surgery with fear of reinjury being the most reported impediment. The psychological characteristics identified through this review may be incorporated into future RTS protocols seeking to address resilience and non-physical factors associated with RTS. Additionally, future prospective trials regarding shoulder instability may consider incorporation of psychometric questionnaires among their study outcomes.