Dr Ian Horsley, Team GB Deputy Chief Physio, at the Injury Rehab Network
The expert guest speaker for the September event of the Injury Rehab Network was Dr Ian Horsley who kindly provided a presentation about considerations for return to play and shoulder injury rehabilitation.
Ian was Deputy Chief Physio to Team GB at the Tokyo Olympic Games, is Technical Lead Physio (Upper Limb) for the English Institute of Sport, Clinical Director of Back In Action Rehabilitation, in Wakefield, West Yorkshire, associate lecturer at Salford University, and member of the EdCom for EUSSER and BESS Council as an AHP rep.
Ian worked as part of the HQ medical team for Team England at the 2010 and 2014 Commonwealth Games, was a member of the Team GB HQ medical team at the 2012 and 2016 Olympic Games.
He concluded his PhD in 2013 examining the issues around shoulder injuries in professional rugby and has published several articles in peer-reviewed journals on the subject of musculoskeletal injury management and contributed chapters to several books on sports injury management.
Ian’s talk ‘Return to play testing considerations for the sporting shoulder’ explored various shoulder injuries, implications, and strategies for return to play. The presentation from Dr Horsley was the latest event of the Injury Rehab Network delivered in partnership with BASRaT. Over two hundred professionals and students involved with sports rehabilitation joined live and contributed with a range of interesting questions.
Ian guided us through his presentation, which included an interesting mix of images and video content for the audience to learn from and enjoy.
Return to Play Testing Considerations for the Sporting Shoulder
Dr Horsley provided a brief introduction to his work and extensive experience as a sports physiotherapist working in elite sport.
Ian introduced his presentation and the focus on return to play for shoulder injuries and described the prevalence of shoulder injuries in sport. Shoulder injuries are more prevalent in activities with an overhead element such as volleyball, swimming, and rugby.
Dr Horsley described the role of sports rehabilitation professionals in managing the risk of shoulder injuries in sport. Dr Horsley presented the risk factors that should be considered in relation to tissue health (including patient background/ history), tissue stress (associated with the activity/ sport) and risk tolerance (where risk can be managed within acceptable limits).
Ian discussed potential risk factors including injury history, type of injury, shoulder muscle imbalance or weakness, posture, and demographics.
Sports rehabilitators should have a battery of tests to support the identification of and progress made in rehabilitation from sports injuries. Dr Horsley described how tests should not pose further risk to injury, should be validated in relevant populations and that intervention programmes should be proven to be more beneficial.
Ian discussed functional tests/ physical performance tests and stated that these tests should be easy to perform in the clinic, inexpensive and reliable.
Dr Horsley presented the three phases of the rehabilitation continuum:
- Return to participation
- Return to sport
- Return to performance
Ian described the return to participation criteria with the key points being:
- Successful completion of a rehabilitation programme
- Excellent stability with no joint pain during special tests
- Satisfactory scores on functional tests
Ian discussed how there are no validated tests for shoulder injury return to play and that this could be seen as a problem for professionals who seek to take an evidence-based approach. There is however research in this area, and professionals can apply learning from research. For example, clearance criteria for return to sport.
Dr Horsley described the specificity of different sports with the highest risk sports having the highest angular velocity. This data can help to inform the practice of sports rehabilitation professionals.
Kinetic Chain & Isokinetics
Ian described the kinetic chain and how strength and power are generated through the whole body and not just isolated body parts. For example, only 20% of power for push/ chest throw comes from the shoulders with 30% from the core and 50% from the lower body/ legs. Tests should therefore be dynamic and assess performance through the full kinetic chain.
Ian discussed how strength is specific with many factors to consider including resistance type, speed, angles, force, stability, and load.
A hand-held dynamometer can be used to assess strength and Ian described how the equipment can be used for the assessment of shoulder strength. Ian’s presentation also demonstrated the use of a hand grip dynamometer as a useful tool to assess grip strength. There has been shown to be a correlation between grip strength and shoulder strength.
Dr Horsley presented a range of exercise tests and their application including prone ball drop test, wall throws test, CKCUEST, single arm seated shot-put test, upper quadrant Y balance test and one arm hop test. For these tests, professionals will need medicine balls, force decks/ plates, a Y frame, dynamometer, metronome, and weights.
Ian stated that based on current evidence the CKCUEST, unilateral seated shot, one-arm hop test and medicine ball throw may have promise.
Ian also discussed the Athletic Shoulder (ASH) test which is based on downward pressure applied by a patient through their hand with an outstretched arm when lying on the front.
Return to Play Test Choice Decision Considerations
Dr Horsley described how sports rehabilitation professionals should have a battery of tests and select tests based on the nature of the sporting activity, sport-specific injuries and injuries specific to the individual/ athlete. Professionals should consider the stage of injury in the return to play continuum and the ability of the athlete when selecting return to play tests.
Ian discussed how athletes may pass a test if there is demonstrable progression, load, stability, and repetition. If athletes fail, professionals should reflect on why they have failed with factors including stability, strength, proprioception, mobility/ flexibility, and motor control.
Other tests featured in Ian’s presentation include the OKC test, upper limb rotation test, shoulder endurance test.
Functional Tests/ Physical Performance Tests
Ian described how these tests are designed to closely simulate a sport/ activity and that athletes perform an activity that represents some aspect of the athletic function.
Ian reiterated the point that there are currently no reported validated instruments designed to assess the function of the sporting shoulder for return to play. Dr Horsley advised that sports rehabilitation professionals should focus on the context of the activity and specific actions required.
Sports may be assessed based on the percentage of the activity performed above the shoulder, in line with the shoulder and below the shoulder.
Ian described how once professionals understand the context, they can then select an appropriate test.
Considerations for Return to Play
Dr Horsley summarises the key considerations for return to play following shoulder injuries including:
- Pain – There should be no pain for return to sport although may allow low levels for return to training.
- Active Range of Movement – Full range of movement should be considered in the context of the demands of the specific sport and to be realistic that after surgery, full pre-injury range of movement may not be achieved.
- Strength – All components of strength required for a specific sport should be considered.
- Kinetic Chain – Consider strength throughout the body and the role of the shoulder in providing optimal function.
Dr Horsley discussed the Biopsychological Model from Wiese-Bjornstal et al. This model focuses on a cycle of cognition, affect, behaviour and outcome. Cognition includes the goals athletes may set which may in turn influence feelings, leading to behaviours or actions, then outcomes which may include sports performance and results.
Ian described the importance of psychological aspects and how injured athletes may suffer from mental health problems. This may impact an athlete’s ability and confidence to return to sport. Professionals should consider the athlete’s psychological readiness to return to sport alongside their physical readiness. Building confidence to play and to play injury-free is therefore important.
Ian discussed how a scale-out of 100 can be used to assess athletes’ confidence to return to play with a score of 50-60 suggesting that an athlete may be psychologically ready to return to sport.
Social Determinants of Health
Dr Horsley discussed the importance of social determinants of health and considerations for working with athletes from diverse backgrounds. Ian described how morbidity and mortality are linked to social determinants and that health is often overlooked in sports medicine where the focus is often on psychological and biological factors.
Dr Horsley finished his recommendations for return to play considerations for shoulder injuries in sport:
- Know the sport
- Know the functional requirements of the shoulder for that sport
- Select a Physical Performance Test (PPT) that matches components of the sport
- Know the normative values for that sport
- Know test reliability
- Remember they are a person
Dr Horsley has contributed to a new book – “The Shoulder, Theory and Practice.” Edited by Jeremy Lewis and Cesar Fernandez-de-la-Penas. With contributions from over one hundred internationally respected practitioners.
Register to be notified on publication for 10% off here.
The Shoulder: Theory and Practice presents a comprehensive fusion of the current research knowledge and clinical expertise that will be essential for any clinician from any discipline who is involved with the assessment, management, and rehabilitation of musculoskeletal conditions of the shoulder.
Dr Horsley kindly answered questions following his presentation:
Question 1 – What is your advice for tests to use at various stages during shoulder rehabilitation?
Answer – Determine the entry and exit criteria and decide upon appropriate tests. Tests must be safe, and professionals should be aware of the rehabilitation continuum, where a patient is on the continuum and which tests are appropriate for that stage.
Question 2 – What treatment would you recommend for a sulker sign in rugby?
Answer – Laxity in the shoulder causes changes to proprioception. There is a need to engage muscles and stimulate neuromuscular activity. Dr Horsley treated a rugby player at the Tokyo Olympic Games who had dislocated their shoulder. After work with the player to stimulate muscle activity, the return to play programme was successful in enabling the player to compete.
Question 3 – Are special tests useful?
Answer – These are just tests that may provoke pain. The tests do have a place if used consistently to identify patterns and when used as part of a battery of tests.
Question 4 – Would a wall push test work with an in-line test?
Answer – Yes to inform return to play continuum placement.
Question 5 – Which neuro rehabilitation programme have you used?
Answer – Learnt through work with professionals and experts. Can help to optimise movement by helping the patient to work on quality, to down-regulate the psychological threat posed by the injury and to enable movement without pain.
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The recording of Ian’s presentation is available to view here.
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