Return to Sports After Upper Extremity Injuries • Upper Extremity Sports Injuries • Rehabilitation Shoulder

Subarna Debbarma (BPT, DNHE)

Return to Sports After Conservative and Surgical Treatment of Upper Extremity Injuries


No matter what sport you participate in, there will come a time when you pick up an injury. Knowing how to treat the injury, ensuring. that the right therapy is employed, and having the injury properly assessed, will all help in making the recovery process a lot quicker . What may seem like a slight muscle twinge can sometimes develop into something a bit nastier if you decide to play on with the injury. As the body gets tired and fatigue sets in, more strain is placed on the muscles and the slight pain you felt earlier could develop into a tear or strain.

The Body’s Healing Process

From the moment a bone breaks or a ligament tears, your body goes to work to repair the damage.At the moment of injury: Chemicals are released from damaged cells, triggering a process called inflammation.Blood vessels at the injury site become dilated; Blood flow increases to carry nutrients to the site of tissue damage.Within hours of injury: White blood cells (leukocytes)travel down the bloodstream to the injury site where they begin to tear down and remove damaged tissue, allowing other specialized cells to start developing scar tissue.Within days of injury: Scar tissue is formed on the skin or inside the body. The amount of scarring may be proportional to the amount of swelling, inflammation, or bleeding within.In the next few weeks, the damaged area will regain a great deal of strength as scar tissue continues to form.Within a month of injury: Scar tissue may start to shrink,bringing damaged, torn, or separated tissues back together.

However, it may be several months or more before the injury is completely healed. As a result, the injury site becomes tight or stiff, and damaged tissues are at risk of reinjury. That is why stretching and strengthening exercises are so important. You should continue to stretch the muscles daily as the first part of your warm-up before exercising.

Two Stages to the Healing Process

•Physical and the Psychological

Even if your physical injuries may have healed, you have to make sure you are mentally ready to start playing again.Mental confidence and toughness of the patient plays a vital role for return to sports.

•During the Acute Phase

The emphasis should be on minimizing swelling and decreasing inflammation. This involves the RICE formula (R = Rest,I = Ice, C = Compression, E = Elevation), together with res tricting activities. Depending on your injury, treatment may also involve surgery, bracing, or casting. Do not wait until your injury is healed to get back into shape. In the second phase of recovery, the athlete should work on regaining full motion and strength of the injured limb or joint. A specific plan should be outlined by a physician, physical therapist, or a certified athletic trainer.

What Are Sports Injuries?

The term sports injury, in the broadest sense, refers to the kinds of injuries that most commonly occur during sports or exercise. Some sports injuries result from accidents, others are due to poor training practices, improper equipment, lack of conditioning, or insufficient warm-up and stretching.

Common Types of Sports Injuries

•Muscle sprains and strains

•Tears of the ligaments that hold joints together

•Tears of the tendons that support joints and allow them to move

•Dislocated joints

•Fractured bones, including vertebrae

What Does Return to Play Mean?

Return to play refers to the point in recovery after an injury or surgery when an athlete is able to participate in their sport or activity at a level similar to that before the injury or the surgery took place.

Injury-Recovery Risk

When an individual returns before adequate healing and recovery, he or she can risk a reinjury and possibly a longer rehabilitation. When dealing with sports injuries, employment of the right game plan from

• Early diagnosis

• Prompt treatment

• Full functional rehabilitation can often safely accelerate an athlete’s return to play

 Before Making a Return to Your Sport

• At least be at a minimum level of fitness

• Have the confidence to perform

• Be sure that you can compete without the risk of causing further injury, or damage to the injured area.

Unique and Different Concept

• Every individual is unique and different

•Every injury is unique and different

•Every sport is unique and different

•In a team event, every sportsman’s role is unique and different.

When are you willing to go back to the same sport that caused the injury? You can prevent REINJURY by holding yourself back in the early stages of a comeback. Prepare a schedule based on the following rules of thumb; then add nonimpact cross-training for extra conditioning.

Return to Play: Making the Tough Decisions

• “When can I play again?” is a question sports medicine physicians are familiar with.

•Those who ask this question are often seeking a definitive answer and usually hoping for a quick return to boot.

•Unfortunately, medicine is not always a craft practiced in black and white but is often an art with a palette in several shades of gray.

•These shades of gray appear not only in the diagnosis and treatment of medical conditions, but also in the return-to play decisions that physicians make

Whom Should You Listen To?

• Coach

• Physiotherapist

•Sports Physician

•Orthopedic Surgeon


•Yourself: your body

Clearance Decisions

•Always put the patient first

•Understand the medical or musculoskeletal problem

•If the issue is unclear or more information is needed, seek consultation.

•Though our active patients’ return-to-play issues are dif-ficult, they correctly remain in the domain of primary care physicians in conjunction with appropriate consultants

• If your patient is seen by a consultant who is not familiar with his or her exercise regimen, consider asking the consultant specific questions for the patient or explaining what the patient’s athletic endeavors require.

Tips from the Pros to Speed Up Your Recovery

• Maintain year-round balanced physical conditioning

• Make sure that injuries are recognized early and treated promptly

• Participate in a full functional rehabilitation program

•Stay fit while injured

•Keep a positive, upbeat attitude

Components of Training

• Duration

• Frequency

• Intensity

Each step should be outlined and monitored by your physician and your physical therapist. Once your range of motion is fairly good, you can start doing gentle stretching and strengthening exercises. When you are ready, weights may be added to your exercise routine to further strengthen the injured area. The key is to avoid movement that causes pain.No matter what type of injury you have there are normally alternative exercises that can be done while still resting the injured area .

Proper Conditioning Aids Injury Recover Time

One thing that can improve your recovery from an injury is a high level of conditioning prior to injury. Not only will being in great shape reduce your risk of injury and lessen the severity of an injury, but it also has been shown to reduce recovery time.

Rest: Although it is important to get moving as soon as possible, you must also take time to rest following an injury.

All injuries need time to heal; proper rest will help the process. Proper balance between rest and rehabilitation is essential

Cold/cryotherapy: Ice packs reduce inflammation by constricting blood vessels and limiting blood flow to the injured tissues. Cryotherapy eases pain by numbing the injured area.It is generally used for only the first 48 h after injury.

Heat/thermotherapy: Heat, in the form of hot compresses,heat lamps, or heating pads, causes the blood vessels to dilate and increases blood flow to the injury site. Increased blood flow aids the healing process by removing cell debris from damaged tissues and carrying healing nutrients to the injury site. Heat also helps to reduce pain. It should not be applied within the first 48 h after an injury.

Electro stimulation: Mild electrical current provides pain relief by preventing nerve cells from sending pain impulses to the brain used to decrease swelling, and to make muscles in immobilized limbs contract, thus preventing muscle atrophy and maintaining or increasing muscle strength.

Ultrasound: High-frequency sound waves produce deep heat that is applied directly to an injured area. Ultrasound stimulates blood flow to promote healing.

Massage: Manual pressing, rubbing, and manipulation soothe tense muscles and increase blood flow to the injury site.

Targeted pain relief: Medicated patches can be applied directly to the injury site.

Sports Injuries Depend on the Type of Sports

• The shoulder is the second most frequently injured joint after the knee

•Of all the sports, rugby has the highest risk per player/hour of injury

•The shoulder comprises 20% of all rugby injuries

• Thirty-five percent of all injuries of the shoulder are recurrent injuries, and if a player has sustained an injury of one shoulder, there is a higher likelihood of the player sustaining an injury of the other shoulder 

• The maneuver most strongly associated with shoulder injuries is the tackle, accounting for 49% of injury episodes in rugby matches

• Other sports involving throwing and sudden movement(cricket, baseball, volley ball, tennis)


• Types of injuries

•Mechanisms of injury

•Conservative Treatment

• Surgical treatment (Different methods)

• Rehabilitation

• Preinjury patient conditioning

Patient’s physical and psychological status

Guidelines for Safe Return to Sports

•You are pain free

• You have no swelling

• You have full range of motion (compare the injured part with the uninjured opposite side)

•You have full or close to full (90%) strength (compare with the uninjured side)

•For upper body injuries – you can perform throwing movements with proper form and no pain

•Keep in mind that even when you feel 100% fit, you may have deficits in strength, joint stability, flexibility, or skill. Take extra care with the injured part for several months.

How to Speed Up Injury Recovery Time

•Stay in shape year-round.

•Pay attention to injury warning signs

•Treat injuries immediately

•Participate in a full injury rehabilitation program

•know when it is safe to return to sports

•Stay fit while injured

•Keep a positive, upbeat attitude 

Some Examples of Upper Limb Postsurgery Rehabilitation Protocol

Arthroscopic Anterior Stabilization

•Preoperative rehabilitation is advisable (Prehabilitation)

•Postoperative schedule

Level 1 Exercises: Day 1–3 Weeks

Mastersling with body belt for 3 weeks

Finger, wrist, and radioulnar movements

Elbow flexion and extension when standing

Teach axillary hygiene

Teach postural awareness and scapular setting

Passive flexion as comfortable to 90°

Passive external rotation to neutral (as comfortable)

Core stability exercises with sling (as appropriate)

No combined abduction and external rotation

Level 2 Exercises: 3–6 Weeks

Body belt removed and wean off sling

Commence active assisted flexion as comfortable

Active assisted abduction to 60°

Active assisted external rotation as comfortable

Commence proprioceptive exercises (minimal weight bearing below 90°)

No combined abduction and external rotation

Level 3 Exercises: 6–12 Weeks

Remove the sling by 6 weeks

Regain scapula and glenohumeral stability, working for shoulder joint control rather than range

Gradually increase ROM (range of motion)

Strengthen rotator cuff muscles

Increase proprioception through open and closed chain exercise

Progress core stability exercises

Ensure and treat posterior tightness, if required


Week 6: Active elevation to preoperative level

Week 12: At least 80% range of external rotation compared to asymptomatic side

Shoulder SLAP Repair

Level 1 Exercises: <3 Weeks

Wean off sling over first 3 weeks

Teach postural awareness and scapular setting

Assess kinetic chain control and provide exercises as required

Regain scapula and glenohumeral stability, working for shoulder joint control rather than range

Passive ROM as tolerated

Progress to Active Assisted Motion as tolerated

Closed Chain exercises as tolerated

Core stability exercises with sling (as appropriate)

Level 2 Exercises: 3 Weeks

Progress to active glenohumeral flexion, abduction, internal and external rotation

Scapular stabilizer exercises

Strengthen rotator cuff muscles

Posterior complex stretching

Increase proprioception through open and closed chain exercise

Level 3: 6 Weeks

Ensure posterior capsule mobility

Manual therapy, if indicated, to eliminate any stiffness

Assess biceps function and add in eccentric biceps

exercises with scapula control if required Assess biceps 

function and add in eccentric biceps exercises with scapula control if required

Progress to Sports-Specific Rehab


Week 6: Full active range of elevation

Week 12: Full active range of movement with dynamic scapula stability throughout range (concentric and eccentric)

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