Development of the shoulder return to contact continuum in rugby: an assessment framework for traumatic anterior glenohumeral joint dislocations

Geldenhuys, Alda Grethe

Development of the shoulder return to contact continuum in rugby: an assessment framework for traumatic anterior glenohumeral joint dislocations

Thesis / Dissertation

2025

Abstract

Rugby is a highly demanding sport, which imposes a high risk of musculoskeletal injuries, particularly due to contact events. Among these, traumatic anterior glenohumeral joint (GHJ) dislocations are among the most significant, as these injuries account for prolonged absence from sport and imposes a high risk of reinjury following return to sport (RTS). There is a need for an assessment framework to facilitate safe and time efficient RTS and in particular return to contact events in rugby. The main aims of the thesis were to explore RTS practices following musculoskeletal injuries in rugby in general and subsequently to develop a return to contact assessment framework following traumatic anterior GHJ dislocations in rugby players to guide health and sport practitioners' decisions. Methods and results To lay the groundwork, we performed a systematic review to investigate management protocols and assessment modalities utilised for RTS following musculoskeletal injuries in rugby as well as related tackle-collision team sports. A cross-sectional observational survey was subsequently conducted to investigate the views, current practices and barriers encountered by health and sport practitioners during RTS following musculoskeletal injuries in rugby settings. Sixty-four practitioners including physiotherapists, orthopaedic surgeons, biokineticists, and sports physicians participated. The criteria rated as both important and commonly utilised in each phase of RTS, namely return to non-contact, return to contact, and return to matches, included time frames, subjective, functional and sport specific criteria. Common barriers encountered by practitioners during RTS included lack of access to resources and time constraints. Due to a paucity of assessment modalities in the literature to guide RTS following upper limb injuries, a scoping review was conducted to explore any modalities utilised to evaluate shoulder and upper limb function in rugby. A range of modalities to evaluate GHJ muscle strength/power, flexibility, endurance and activation, joint ROM and laxity, proprioception and sport specific skill evaluations in rugby were identified. Although the reliability of many of these assessment modalities were established, very few studies investigated their validity and other clinimetric properties. Moreover, only a few assessment modalities demonstrated any association to injury incidence or risk factors in rugby settings. Following the broad exploration, three targeted studies were performed to develop and evaluate a return to contact assessment framework following traumatic anterior GHJ dislocations. Firstly, a three-round Delphi consensus study was conducted to formulate return to contact criteria and to identify assessment modalities to evaluate these criteria. Thirty-three practitioners including physiotherapists, orthopaedic surgeons, biokineticists and sports physicians participated. Twenty-nine out of 40 broad criteria reached consensus for inclusion (based on at least 70.0% agreement). This included subjective, clinical, and functional criteria related to the shoulder and general conditioning, time frames and rugby specific considerations. Assessment modalities such as the anterior apprehension and relocation test, visual analogue scale pain ratings and observation of functional movements were recommended to evaluate criteria. There was less clarity regarding the best way to assess rugby skills. To explore the perspectives of various stakeholders in more depth, three focus groups with 18 health and sport practitioners and five individual interviews with rugby players who experienced GHJ dislocations were conducted. Four main themes emerged. Firstly, the pathway to developing a framework was explored. Secondly, the need to reintroduce contact skills during a progressive, graduated return to contact continuum process, which moves from controlled conditions to uncontrolled conditions, was outlined. Thirdly, the need to re-assess regularly subjective, clinical, and functional criteria to guide progress along this continuum was explored. Fourthly, the potential of communication, goal setting, psychological state, and socioeconomic context to facilitate or impede return to contact and RTS as experienced by injured players were discussed. A novel assessment framework, the Shoulder Return to Contact Continuum in Rugby (Shoulder RCCR) was formulated based on an amalgamation of the findings of these studies. Finally, the face- and content validity of the assessment framework were evaluated through expert feedback. Twenty-two health and sport practitioners provided high ratings of the appropriateness, value, and feasibility of use of this framework. Additionally, seventeen of these practitioners completed a pilot clinical vignette to evaluate the theoretical utility of the framework. Based on the clinical scenario provided, a heterogenous range of return to contact decisions were reported. This may reflect the complexity and multifactorial nature of RTS decisions, difficulty with the prediction of reinjury risk and different interpretations of terminology used. Conclusion: Return to sport decisions following musculoskeletal injuries should be guided by a combination of clinical, functional, psychological and rugby specific criteria alongside time frames. A novel return to contact assessment framework, the Shoulder RCCR, was developed for rugby players with traumatic anterior glenohumeral joint dislocations. The framework provides recommendations for a holistic evaluation of players with multidisciplinary involvement. The reintroduction of rugby skills during a graduated return to contact continuum guided through regular re-assessments is recommended. The incorporation of the players' input and perceived readiness should be emphasised throughout RTS. Return to contact decisions in rugby remain complex and careful reflection and clinical reasoning is advised for of each individual case.

Keywords

Rugby

Reference:

Collections

PhD / Doctoral

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