Submitted:
02 June 2026
Posted:
26 June 2026
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Abstract
Background: Shoulder injuries account for 15–30% of rugby injuries and are associated with recurrent instability, impaired performance, prolonged absence from sport, and long-term functional limitations. Physiotherapy rehabilitation is central to management; however, outcomes may be influenced by variability in rehabilitation approaches and insufficient consideration of psychological and neuromuscular recovery. This review evaluated evidence on physiotherapy rehabilitation following shoulder injuries in rugby players.Methods: This systematic review was prospectively registered with PROSPERO (CRD420261358218). PubMed, MEDLINE, CINAHL, EMBASE, EMCARE, Cochrane Library, HMIC, and Google Scholar were searched from inception to January 2026. Following screening and full-text assessment, five studies met the inclusion criteria. Methodological quality was assessed using the Mixed Methods Appraisal Tool and Oxford Centre for Evidence-Based Medicine Levels of Evidence. Findings were synthesized narratively.Results: Five studies comprising one randomized controlled trial, two observational studies, one cross-sectional study, and one qualitative study were included. Structured physiotherapy rehabilitation was associated with improvements in shoulder stability and upper-limb function. However, persistent proprioceptive deficits, reduced psychological readiness, and perceived shoulder dysfunction were reported despite return-to-play. Individualized rehabilitation, multidisciplinary support, and attention to psychological recovery were identified as important factors influencing outcomes.Conclusion: Physiotherapy rehabilitation may improve recovery following shoulder injury in rugby players. However, multidimensional approaches addressing physical, psychological, and neuromuscular recovery appear necessary to optimize return-to-play readiness.
Keywords:
shoulder injury
; rugby
; physiotherapy
; rehabilitation
; return to play
; systematic review
; proprioception
; psychological readiness
Introduction
Shoulder injuries are among the most common and clinically significant musculoskeletal injuries in rugby, accounting for approximately 15–30% of match-related injuries and contributing substantially to time-loss from sport, recurrent instability, reduced performance, and long-term functional impairment [1,2]. Rugby is a high-intensity collision sport characterized by repeated tackling, scrummaging, rucking, mauling, falling, and contact-related upper-limb loading activities that place considerable biomechanical stress on the shoulder complex [2,4]. Consequently, shoulder injuries remain a major contributor to injury burden across all levels of participation, particularly during collision events such as tackling and scrummaging [2].
The professionalization of rugby has been associated with increases in player body mass, strength, speed, and collision intensity, exposing athletes to greater biomechanical loads during contact events and increasing the risk of traumatic shoulder injuries [2,5]. As a result, glenohumeral instability, rotator cuff pathology, acromioclavicular joint injuries, and labral lesions are prevalent among rugby players and frequently require prolonged rehabilitation and ongoing clinical management [1,4,6].
The substantial burden of shoulder injuries in rugby is closely linked to the anatomical and biomechanical characteristics of the glenohumeral joint. Although the shoulder possesses the greatest physiological range of motion of any major joint, its shallow glenoid structure provides limited inherent stability and relies heavily on dynamic muscular control, neuromuscular coordination, and capsulolabral integrity for joint protection [6,7]. Rugby-specific actions frequently place the shoulder in vulnerable positions of abduction and external rotation, increasing the risk of instability and soft-tissue injury [4]. Repeated exposure to these high-load contact activities may contribute to proprioceptive deficits, altered neuromuscular control, impaired dynamic stability, and recurrent instability episodes [8,9,10]. Furthermore, some impairments may persist beyond apparent physical recovery, potentially compromising an athlete’s ability to tolerate the unpredictable and repetitive demands of rugby participation and increasing the risk of subsequent injury or reduced performance [11,12].
Beyond their physical consequences, shoulder injuries can impose substantial psychological and social burdens on rugby players. Athletes commonly report fear of reinjury, reduced confidence in shoulder function, anxiety regarding return-to-play, and disruptions to athletic identity following injury [12,13]. These factors may influence rehabilitation adherence, movement behaviour, and return-to-play outcomes. Contemporary sports medicine increasingly recognizes recovery as a multidimensional process influenced by biological, psychological, and social factors, with psychological readiness, behavioural responses, and social support playing important roles in successful rehabilitation and return-to-sport outcomes [14,15,16]. Furthermore, evidence suggests that some rugby players continue participating despite ongoing symptoms and dysfunction, indicating that return to participation may not necessarily reflect complete recovery [11].
These developments are reflected in contemporary return-to-sport frameworks, which conceptualize rehabilitation as a process that extends beyond symptom resolution and physical recovery [17]. The Strategic Assessment of Risk and Risk Tolerance (StARRT) framework emphasizes that return-to-play decisions should integrate tissue health, functional performance, sport-specific demands, and athlete-specific contextual factors to facilitate safe participation [18]. Such considerations may be particularly important in collision sports such as rugby, where athletes are exposed to substantial physical and psychological demands during return-to-contact activities.
The rapid growth of women’s rugby has further highlighted the need for a more comprehensive understanding of rehabilitation following shoulder injury. Historically, much of the sports medicine literature has been derived from predominantly male cohorts, despite growing recognition that female athletes may experience distinct psychosocial responses, rehabilitation experiences, and return-to-play challenges [12,16]. Recent qualitative evidence among female rugby union players has highlighted the importance of confidence during return-to-contact activities, fear of reinjury, communication with practitioners, and athletic identity throughout rehabilitation [12]. These findings suggest that rehabilitation frameworks developed primarily from male populations may not fully capture the diverse recovery needs of all rugby athletes.
Physiotherapy rehabilitation is widely regarded as a cornerstone of management following shoulder injury and aims to restore mobility, strength, dynamic stability, proprioception, neuromuscular control, and rugby-specific functional performance before return-to-play [6,7]. Contemporary rehabilitation models increasingly advocate individualized, criteria-based progression that integrates physical, psychological, and sport-specific readiness domains [19]. Nevertheless, rehabilitation approaches remain heterogeneous, varying considerably in content, progression criteria, duration, and outcome measures, reflecting the complexity of shoulder injuries and the absence of universally accepted rehabilitation protocols.
Although research on shoulder rehabilitation in athletic populations continues to expand, much of the available evidence originates from non-contact sports, mixed athletic populations, or general musculoskeletal cohorts. Despite the substantial burden of shoulder injuries in rugby, evidence regarding physiotherapy rehabilitation remains fragmented across studies examining functional recovery, return-to-play outcomes, psychosocial recovery, and rehabilitation experiences. To our knowledge, no contemporary synthesis has comprehensively evaluated physiotherapy rehabilitation outcomes, return-to-play readiness, psychosocial recovery, and rehabilitation experiences following shoulder injuries specifically among rugby players. Furthermore, uncertainty remains regarding the extent to which existing rehabilitation approaches address the physical, sensorimotor, and psychological factors required for safe and sustained rugby participation. Therefore, this systematic review aims to synthesize current evidence on physiotherapy rehabilitation following shoulder injuries in rugby players, examine recovery and return-to-play readiness outcomes, explore barriers and facilitators influencing rehabilitation, and identify evidence gaps to inform clinical practice and future research.
Methods
Research Design
This systematic review synthesized the available evidence on physiotherapy rehabilitation following shoulder injuries in rugby players, with particular emphasis on recovery outcomes, return-to-play readiness, psychosocial factors, and rehabilitation experiences. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines [20]. The review protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO; Registration No. CRD420261358218). The protocol is publicly accessible through the PROSPERO database. No substantive amendments were made to the registered protocol following registration.
Eligibility Criteria
The eligibility criteria were developed using the Population, Intervention, Comparison, Outcomes, and Study Design (PICOS) framework.
Inclusion Criteria
Types of Studies
Original empirical studies published in peer-reviewed journals were eligible for inclusion. Study designs included randomized controlled trials, non-randomized controlled trials, prospective and retrospective cohort studies, case–control studies, qualitative studies, and mixed-methods studies. Conference proceedings containing sufficient methodological and outcome data were also considered. Only studies published in English were included.
Types of Participants
Studies involving rugby players of any age, sex, or competitive level (professional, semi-professional, amateur, or youth) who sustained rugby-related shoulder injuries were included. Eligible shoulder injuries comprised glenohumeral instability or dislocation, rotator cuff injuries, labral tears, acromioclavicular joint injuries, and other shoulder pathologies associated with rugby participation. No geographical restrictions were applied.
Intervention
Studies were eligible if they investigated physiotherapy rehabilitation following shoulder injury among rugby players. Rehabilitation approaches included strengthening exercises, scapular and rotator cuff stabilization programmes, neuromuscular and proprioceptive interventions, manual therapy, mobility and flexibility exercises, sport-specific rehabilitation, and graded return-to-play programmes. Both non-operative and post-surgical rehabilitation pathways were included provided physiotherapy constituted a core component of management. No restrictions were placed on intervention frequency, intensity, duration, setting, or follow-up period.
Comparison
Where applicable, studies comparing different physiotherapy rehabilitation approaches, physiotherapy versus usual care, or physiotherapy versus alternative interventions were included. Studies without formal control groups were also eligible if relevant rehabilitation outcomes were reported.
Outcomes
Studies were included if they reported outcomes relevant to shoulder rehabilitation among rugby players. Primary outcomes of interest included functional recovery measures such as shoulder strength, stability, range of motion, pain, and proprioception, as well as return-to-play outcomes including return-to-play rates, timelines, and clearance criteria. Secondary outcomes included the characteristics of physiotherapy rehabilitation programmes, reinjury rates and recurrence of shoulder instability, performance-related outcomes, and psychosocial factors such as confidence, fear of reinjury, athletic identity, and psychological readiness for return to sport. Additional outcomes relating to barriers and facilitators influencing rehabilitation adherence, progression, and effectiveness were also extracted and synthesized where reported.
Exclusion Criteria
Studies were excluded if they did not involve rugby players or rugby-related shoulder injuries, focused exclusively on surgical outcomes without a physiotherapy rehabilitation component, or investigated interventions unrelated to physiotherapy rehabilitation. Narrative reviews, systematic reviews, scoping reviews, editorials, letters, opinion papers, and case reports were excluded, as were unpublished theses, dissertations, and other non-peer-reviewed reports. Where multiple publications reported findings from the same dataset, only the most comprehensive or most recent publication was retained. Studies that were unavailable in full text or not published in English were also excluded.
Information Sources and Search Strategy
A comprehensive literature search was conducted across PubMed, MEDLINE, EMBASE, EMCARE, the Cochrane Library, HMIC, and Google Scholar from database inception to 31 January 2026. The final search was conducted on 31 January 2026. Additional records were identified through hand-searching the reference lists of included studies and relevant review articles. Search strategies were developed using a combination of Medical Subject Headings (MeSH) and free-text terms related to rugby, shoulder injuries, physiotherapy rehabilitation, return-to-play, and recovery outcomes. Boolean operators, truncation symbols, and database-specific search syntax were applied to maximize search sensitivity and specificity. For Google Scholar, the first 100 records sorted by relevance were screened for potential eligibility. The complete search strategies for all databases are provided in Supplementary material.
Study Selection
All records retrieved from the database searches were imported into Covidence, where duplicate records were identified and removed. Two reviewers independently screened titles and abstracts against the predefined eligibility criteria. Full-text articles of potentially eligible studies were subsequently assessed independently for inclusion. Any disagreements were resolved through discussion, and where consensus could not be reached, a third reviewer was consulted. The study selection process is illustrated in the PRISMA 2020 flow diagram (Supplementary material), which also details the reasons for exclusion at the full-text screening stage.
Data Extraction
Data were extracted using a standardized data extraction form developed in accordance with guidance from the Cochrane Handbook for Systematic Reviews of Interventions [21]. Extracted data included study characteristics (author, year, country, and study design), participant demographics, shoulder injury characteristics, rehabilitation components, rehabilitation duration, follow-up periods, outcome measures, return-to-play outcomes, psychosocial outcomes, barriers and facilitators to rehabilitation, and key study findings. Data extraction was undertaken independently by two reviewers, with discrepancies resolved through discussion and consultation with a third reviewer where necessary.
Quality Assessment
Methodological quality and risk of bias were assessed using the Mixed Methods Appraisal Tool (MMAT) 2018. The MMAT was selected because it accommodates methodological diversity and enables consistent appraisal across qualitative, quantitative, and mixed-methods study designs (Hong et al., 2018). The tool comprises five methodological criteria specific to each study category, with responses recorded as “Yes,” “No,” or “Can’t Tell” [22]. Quality appraisal was conducted independently by two reviewers (KEF and AIO), with disagreements resolved through discussion and, where necessary, consultation with a third reviewer (VCN).
To facilitate interpretation of the overall strength of evidence, included studies were additionally classified according to the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence, which categorize studies from Level I (highest) to Level V (lowest) based on study design and relative strength of evidence [23].
A formal certainty-of-evidence assessment using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was not undertaken because of the small number of included studies, substantial methodological heterogeneity, and the predominance of qualitative and observational designs. These factors precluded quantitative evidence synthesis and limited the suitability of formal certainty assessment approaches [24].
Data Synthesis
Due to substantial clinical, methodological, and statistical heterogeneity across the included studies, including differences in study design, participant characteristics, rehabilitation protocols, outcome measures, and follow-up durations, quantitative meta-analysis was considered inappropriate. Consequently, findings were synthesized narratively.
The narrative synthesis explored patterns, similarities, differences, and relationships across studies and was organized according to five outcome domains: (1) functional recovery outcomes, (2) return-to-play outcomes, (3) psychosocial outcomes, (4) reinjury and recurrence outcomes, and (5) factors influencing rehabilitation adherence and effectiveness. Findings were interpreted within a biopsychosocial framework to examine the relationship between physical recovery, sensorimotor function, psychological readiness, and return-to-play outcomes following shoulder injury in rugby players. Particular attention was given to evidence relating to residual deficits, psychological readiness, and factors influencing the transition from recovery to return-to-play readiness.
Assessment of Reporting Bias
Assessment of reporting bias was not undertaken because the small number of included studies and the absence of quantitative meta-analysis precluded meaningful evaluation of publication bias.
Reporting of the Review
This systematic review was conducted and reported in accordance with the PRISMA 2020 Statement [20].
Results
Study Selection
The database search identified 1,204 records. Following the removal of 59 duplicate records, 1,145 articles remained for title and abstract screening. Thirty-eight studies progressed to full-text assessment after initial eligibility screening. Following full-text review, five studies met the inclusion criteria and were included in the final synthesis [9,10,11,12,25]. The included studies comprised one randomized clinical trial, one qualitative study, one cross-sectional study, and two observational studies. The study selection process is presented in Figure 1.
Due to substantial clinical, methodological, and statistical heterogeneity across the included studies, including differences in study design, participant characteristics, rehabilitation protocols, outcome measures, and follow-up durations, quantitative meta-analysis was not considered appropriate. Consequently, findings were synthesized narratively.
Study Characteristics
The characteristics of the included studies are summarized in Table 1. Five studies representing diverse methodological approaches were included [9,10,11,12,25]. Collectively, the studies examined physiotherapy rehabilitation, shoulder stability, proprioceptive recovery, return-to-play readiness, perceived shoulder dysfunction, and psychosocial recovery among rugby players following shoulder injury.
The included studies were conducted exclusively in high-income countries, including the United Kingdom [9,11,12], Spain [25], and France [10]. No studies from low- or middle-income countries were identified. Sample sizes ranged from 20 to 86 participants and included professional, amateur, university-level, and elite rugby players, as well as sports medicine practitioners.
Methodological Quality and Level of Evidence
Methodological quality and levels of evidence are presented in Table 2. The included studies demonstrated moderate to high methodological quality. The randomized clinical trial by Suarez-García et al. [25] provided the highest level of evidence (OCEBM Level II) and demonstrated generally strong methodological quality, although some uncertainty remained regarding randomization procedures and assessor blinding. Herrington et al. [9] and Rogowski et al. [10] provided Level III evidence relating to functional, proprioceptive, and psychological outcomes following shoulder injury. Partner et al. [11] contributed Level IV evidence regarding the prevalence of perceived shoulder dysfunction among active rugby players, while White et al. [12] provided Level IV qualitative evidence exploring psychosocial, systemic, and communication-related influences on rehabilitation experiences and return-to-play confidence.
Functional Recovery Outcomes
Three studies evaluated functional recovery using objective measures of shoulder stability, strength, proprioception, and upper-limb performance [9,10,25].
Suarez-García et al. [25] investigated the effects of a four-week physiotherapy programme comprising plyometric, proprioceptive, and strengthening exercises. Shoulder stability was assessed using the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) and the Upper Quarter Y-Balance Test (UQYBT). The intervention group demonstrated significantly greater improvements in both measures than the control group following the intervention, with improvements maintained at four-week follow-up (p < 0.05).
Rogowski et al. [10] assessed shoulder functional status using maximal isometric glenohumeral internal and external rotator strength, the UQYBT, and the Unilateral Seated Shot Put Test. Rugby players with a history of shoulder injury managed non-operatively demonstrated physical performance outcomes comparable to those of healthy rugby players. In contrast, players assessed approximately 4.5 months following shoulder stabilization surgery exhibited significantly lower muscle strength, upper-quarter stability, and mobility than healthy controls (p < 0.001 for all outcomes).
Herrington et al. [9] evaluated shoulder joint position sense among professional rugby union players with a history of shoulder instability who had completed rehabilitation and returned to play. Proprioception was assessed using absolute joint position sense error at 45° and 80° of external rotation. Previously injured shoulders demonstrated significantly greater repositioning errors than contralateral uninjured shoulders at both 45° (6.7 ± 3.4° vs. 3.7 ± 1.8°) and 80° (4.1 ± 0.8° vs. 2.3 ± 1.2°) of external rotation. Injury status significantly affected joint position sense performance (p = 0.002).
Across the included studies, functional recovery outcomes were assessed using measures of shoulder stability, strength, proprioception, and upper-limb performance. Improvements in shoulder stability were reported following physiotherapy intervention, while differences in strength, mobility, upper-quarter performance, and joint position sense were observed between previously injured and uninjured rugby players.
Return-to-Play Readiness
Rogowski et al. [10] assessed return-to-play readiness using the Shoulder Instability–Return to Sport after Injury (SI-RSI) scale. Rugby players with a history of shoulder injury managed non-operatively reported significantly lower SI-RSI scores than healthy rugby players (p < 0.001). Players assessed approximately 4.5 months following shoulder stabilization surgery also demonstrated lower SI-RSI scores alongside reduced muscle strength, upper-quarter stability, and mobility compared with healthy controls (p < 0.001).
Herrington et al. [9] evaluated professional rugby union players who had completed rehabilitation and returned to competitive participation. Although all previously injured athletes had been medically cleared for return to play and had resumed rugby participation, significantly greater joint position sense errors were observed in previously injured shoulders compared with contralateral uninjured shoulders (p = 0.002).
White et al. [12] explored return-to-play experiences among elite female rugby union players and practitioners. Participants reported variability in confidence, perceived readiness, and emotional responses during return-to-contact activities. Recurring themes included uncertainty regarding readiness, fear of reinjury, and factors influencing confidence throughout the return-to-play process.
Across the included studies, return-to-play outcomes were evaluated using measures of psychological readiness, joint position sense, physical performance, and athlete-reported experiences during return-to-contact activities.
Persistent Dysfunction and Hidden Deficits
Three studies reported evidence of ongoing dysfunction or residual impairments among rugby players following shoulder injury [9,10,11].
Partner et al. [11] assessed perceived shoulder function using the Rugby Shoulder Score (RSS) among professional and amateur rugby players. Fifty-five percent of players reported shoulder dysfunction despite remaining available for selection and active participation. Players with a previous shoulder injury reported significantly greater dysfunction than those without a history of injury (median RSS: 48 vs. 20 AU; p < 0.001). Professional players reported higher dysfunction scores than amateur players (40 vs. 20 AU; p = 0.02), while forwards reported greater dysfunction than backs (29 vs. 20 AU; p = 0.036).
Herrington et al. [9] evaluated shoulder joint position sense in previously injured rugby players who had completed rehabilitation and returned to competition. Previously injured shoulders demonstrated significantly greater repositioning errors than contralateral uninjured shoulders at both 45° and 80° of external rotation (p = 0.002).
Rogowski et al. [10] reported that rugby players with a history of shoulder injury managed non-operatively demonstrated physical performance outcomes comparable to healthy rugby players but reported significantly lower SI-RSI scores (p < 0.001). Players assessed approximately 4.5 months following shoulder stabilization surgery demonstrated lower SI-RSI scores together with reduced strength, upper-quarter stability, and mobility compared with healthy rugby players (p < 0.001).
Across the included studies, residual impairments were assessed using measures of perceived shoulder function, joint position sense, psychological readiness, muscle strength, mobility, and upper-quarter performance. Reported impairments were identified among rugby players with a history of shoulder injury following rehabilitation, return-to-play, or continued participation in rugby.
Barriers and Facilitators to Rehabilitation
One study reported barriers and facilitators influencing rehabilitation following shoulder injury in rugby players [12].
White et al. [12] explored rehabilitation experiences among elite female rugby union players and practitioners using qualitative interviews. Reported barriers included limited resources within women’s rugby, communication challenges between players and practitioners, uncertainty regarding rehabilitation progression, and fear associated with return-to-contact activities. Participants also described difficulties related to balancing rehabilitation demands with sporting expectations and concerns regarding confidence during return-to-play.
Reported facilitators included individualized rehabilitation programmes, multidisciplinary support, athlete-centred decision-making, effective communication between players and practitioners, and gradual exposure to rugby-specific activities throughout the rehabilitation process.
Across the identified themes, barriers and facilitators were related to organizational resources, practitioner–athlete interactions, rehabilitation planning, confidence during rehabilitation, and return-to-play preparation.
Reinjury and Long-Term Outcomes
Evidence relating to reinjury and long-term outcomes was limited across the included studies.
Rogowski et al. [10] assessed rugby players with a history of shoulder instability managed either non-operatively or operatively. Players with a history of non-operative management were assessed at a mean of 4.3 years following injury, whereas surgically managed players were assessed at a mean of 4.5 months following shoulder stabilization surgery. Outcome measures included shoulder strength, upper-quarter performance, and psychological readiness for return-to-sport.
The remaining studies primarily evaluated short-term rehabilitation outcomes, cross-sectional measures of shoulder function, or athlete experiences following return-to-play. No study prospectively reported reinjury rates following completion of rehabilitation, and no pooled estimates of recurrence or reinjury were available.
Across the included studies, reporting of long-term outcomes was limited and inconsistent. Available outcomes included shoulder strength, upper-quarter performance, psychological readiness, and self-reported shoulder function, while information relating to recurrent shoulder instability, reinjury incidence, and long-term rehabilitation outcomes was sparse.
Physical Recovery and Return-to-Play Readiness
Findings across the included studies demonstrated differences between measures of physical recovery and indicators of return-to-play readiness.
Suarez-García et al. [25] reported improvements in shoulder stability following a structured physiotherapy programme, while Rogowski et al. [10] found that rugby players with a history of shoulder injury managed non-operatively achieved physical performance outcomes comparable to healthy rugby players. However, Rogowski et al. [10] also reported significantly lower SI-RSI scores among previously injured players (p < 0.001).
Herrington et al. [9] reported significantly greater joint position sense errors in previously injured shoulders despite completion of rehabilitation and return to competitive participation. Partner et al. [11] reported that 55% of rugby players experienced shoulder dysfunction despite remaining available for selection and active participation. White et al. [12] identified themes relating to fear of reinjury, confidence during return-to-play, uncertainty regarding readiness, and athletic identity among elite female rugby players undergoing rehabilitation.
Across the included studies, physical recovery outcomes were assessed using measures of shoulder stability, strength, upper-quarter performance, and proprioception. Readiness-related outcomes were assessed using SI-RSI scores, joint position sense measures, perceived shoulder function, confidence, fear of reinjury, and athlete-reported rehabilitation experiences. These outcomes were reported among athletes who had completed rehabilitation, returned to participation, or remained available for team selection.
Discussion
This systematic review synthesized evidence relating to physiotherapy rehabilitation following shoulder injury in rugby players. Although only five studies met the inclusion criteria, the findings provide important insights into functional recovery, return-to-play readiness, psychosocial recovery, and rehabilitation experiences. Overall, the available evidence suggests that physiotherapy rehabilitation incorporating strengthening, proprioceptive training, neuromuscular exercises, and sport-specific rehabilitation may improve shoulder stability and functional performance among rugby players. However, a consistent finding across the included studies was that restoration of physical function did not necessarily correspond with complete sensorimotor recovery, psychological readiness, or perceived shoulder health.
Recovery Versus Readiness Following Shoulder Injury
The principal finding of this review is that recovery and readiness appear to represent distinct but interrelated constructs following shoulder injury in rugby players. Although physiotherapy interventions were associated with improvements in objective measures of shoulder stability and functional performance, evidence from several included studies identified ongoing deficits in proprioception, psychological readiness, and perceived shoulder function despite rehabilitation completion and return-to-play [9,10,11,12,25]. For example, Herrington et al. [9] reported persistent impairments in joint position sense among previously injured players who had returned to competitive participation, while Rogowski et al. [10] found lower psychological readiness scores despite comparable physical performance outcomes among previously injured athletes. Similarly, Partner et al. [11] reported that more than half of actively participating rugby players experienced some degree of shoulder dysfunction despite remaining available for selection.
These findings are consistent with contemporary return-to-sport models that conceptualize recovery as a multidimensional process extending beyond restoration of physical function. The First World Congress in Sports Physical Therapy consensus statement emphasized that return-to-sport should be viewed as a continuum rather than a single event and should incorporate physical, psychological, and contextual considerations rather than relying solely on impairment resolution [17]. Similarly, the Strategic Assessment of Risk and Risk Tolerance (StARRT) framework advocates integrating tissue health, functional performance, sport-specific demands, and individual risk tolerance when making return-to-play decisions [18].
The findings of the present review extend these concepts to rugby shoulder rehabilitation by demonstrating that indicators of physical recovery do not necessarily align with measures of psychological readiness, perceived shoulder function, or sensorimotor performance. Consequently, return-to-play decisions based exclusively on symptom resolution or physical performance may not fully capture an athlete’s readiness to safely tolerate the physical and psychological demands of rugby participation.
Sensorimotor Recovery and Shoulder Function
The findings of this review reinforce the importance of neuromuscular control and proprioceptive recovery following shoulder injury in rugby players. Suarez-García et al. [25] demonstrated improvements in shoulder stability following a structured physiotherapy programme incorporating strengthening, proprioceptive training, and plyometric exercises. In contrast, Herrington et al. [9] reported persistent deficits in joint position sense among previously injured players despite rehabilitation completion and return-to-play. Similarly, Rogowski et al. [10] identified deficits in upper-quarter stability and mobility among players recovering from shoulder stabilization surgery.
These findings are consistent with broader shoulder rehabilitation literature, which suggests that restoration of strength and physical performance does not necessarily correspond with normalization of sensorimotor function. Cools et al. [26] emphasized that rehabilitation following shoulder injury should extend beyond isolated strengthening and incorporate interventions targeting neuromuscular control, proprioception, and dynamic stability. Likewise, Warby et al. [27] highlighted the importance of progressive sensorimotor rehabilitation in athletes recovering from shoulder instability.
Given the collision-based and unpredictable demands of rugby, restoration of sensorimotor function may be particularly important during rehabilitation. Rugby-specific activities such as tackling, rucking, and scrummaging require rapid neuromuscular responses and dynamic shoulder stabilization under high-load conditions. The persistence of proprioceptive and sensorimotor deficits identified in the included studies may therefore have implications for rehabilitation progression and return-to-play decision-making.
Psychological Recovery Following Shoulder Injury
Psychological recovery emerged as a prominent theme across the included studies. Rogowski et al. [10] demonstrated reduced psychological readiness despite restoration of physical performance, while White et al. [12] highlighted fear of reinjury, uncertainty regarding readiness, reduced confidence, and concerns relating to athletic identity among rugby players undergoing rehabilitation. These findings are consistent with the Integrated Model of Psychological Response to Sport Injury, which proposes that injury recovery is influenced by cognitive, emotional, and behavioural responses [15]. Furthermore, Ardern et al. [16] reported that psychological readiness is an important determinant of successful return-to-sport and may influence return-to-play outcomes independently of physical recovery.
Within rugby, where athletes are frequently required to re-engage in high-impact contact situations following injury, psychological readiness may represent an important component of successful return-to-play. The present findings suggest that rehabilitation following shoulder injury should consider psychological as well as physical recovery to support a safe and confident return to participation.
Residual Dysfunction Following Return-to-Play
Partner et al. [11] reported that 55% of active rugby players experienced shoulder dysfunction despite remaining available for selection and competition. This finding suggests that participation status alone may not accurately reflect shoulder function following injury. Similar observations were identified elsewhere in the present review, where previously injured athletes demonstrated deficits in proprioception, psychological readiness, and perceived shoulder function despite rehabilitation completion and return-to-play [9,10,11].
These findings are consistent with previous literature indicating that athletes may continue participating despite ongoing symptoms or functional limitations. Consequently, return-to-play status may not fully capture an athlete’s recovery following shoulder injury. The use of athlete-reported outcome measures, such as the Rugby Shoulder Score, alongside objective assessments of physical performance and psychological readiness, may provide additional information regarding shoulder function and recovery status among rugby players.
Female Rugby Players and Rehabilitation Experiences
The inclusion of White et al. [12] provides valuable insight into rehabilitation experiences among female rugby players, a population that remains underrepresented within the shoulder rehabilitation literature. Participants described concerns relating to confidence during return-to-play, fear of reinjury, communication with practitioners, athletic identity, and access to resources within women’s rugby. Barriers to rehabilitation included resource limitations, uncertainty regarding rehabilitation progression, and challenges associated with return-to-contact activities, while effective communication, individualized rehabilitation programmes, and multidisciplinary support were identified as important facilitators.
These findings emphasize the influence of contextual and psychosocial factors on rehabilitation experiences following shoulder injury. In addition to physical recovery, participants described factors relating to confidence, identity, practitioner support, and organizational resources, suggesting that rehabilitation outcomes may be shaped by broader interpersonal and environmental influences. The continued growth of women’s rugby internationally, coupled with the limited available evidence identified in this review, highlights the need for further research examining rehabilitation outcomes in female athletes [12].
Implications for Physiotherapy Practice
The findings of this review support a multidimensional approach to rehabilitation and return-to-play decision-making following shoulder injury in rugby players. Physiotherapists should continue to assess traditional physical outcomes, including strength, mobility, pain, shoulder stability, and functional performance. However, the available evidence suggests that these measures alone may not fully capture readiness for return-to-play.
Assessment of proprioception, dynamic shoulder control, athlete-reported shoulder function, confidence, fear of reinjury, and psychological readiness may provide additional information regarding recovery status. Incorporating these domains into rehabilitation assessment and progression may facilitate a more comprehensive evaluation of athlete readiness and support individualized return-to-play decisions.
The findings also reinforce the importance of athlete-centred rehabilitation. Effective communication, shared decision-making, progressive exposure to rugby-specific activities, and multidisciplinary collaboration were identified as factors that may support rehabilitation and return-to-play. Consequently, physiotherapists should consider both physical and psychosocial aspects of recovery when planning rehabilitation and facilitating return-to-play following shoulder injury.
Strengths and Limitations
This review provides a focused synthesis of the literature relating to physiotherapy rehabilitation following shoulder injury in rugby players and incorporates both quantitative and qualitative evidence, enabling physical, psychological, and contextual dimensions of recovery to be explored. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT), while levels of evidence were classified using the Oxford Centre for Evidence-Based Medicine framework.
Nevertheless, several limitations should be acknowledged. Only five studies met the inclusion criteria, reflecting the limited volume of rugby-specific rehabilitation research currently available. Furthermore, substantial heterogeneity existed in study designs, participant characteristics, rehabilitation approaches, outcome measures, and follow-up durations, precluding quantitative meta-analysis.
Interpretation of the findings should also be considered in light of the available evidence base, which consisted predominantly of observational and qualitative studies, with only one randomized clinical trial identified. Consequently, confidence in causal inferences regarding rehabilitation effectiveness remains limited.
Another important limitation relates to geographic representation. All included studies originated from high-income countries, specifically the United Kingdom, Spain, and France. No studies from low- and middle-income countries were identified, limiting the generalizability of findings across diverse healthcare systems and sporting contexts.
Future Research Directions
Future research should prioritize high-quality randomized controlled trials evaluating rugby-specific rehabilitation interventions. Longitudinal studies examining reinjury rates, recurrence of shoulder instability, long-term shoulder health, and the durability of rehabilitation outcomes are also required.
Particular attention should be directed toward multidimensional outcome assessment, including proprioception, psychological readiness, athlete-reported shoulder function, and quality of life. Additional research involving female rugby players is necessary to address the substantial underrepresentation of women within the current evidence base.
Future studies should also investigate rehabilitation implementation and outcomes within low- and middle-income countries to improve the global applicability of evidence-based rehabilitation recommendations.
Conclusion
The evidence synthesized in this review suggests that physiotherapy rehabilitation is associated with improvements in physical function and shoulder stability following shoulder injury in rugby players. However, restoration of physical function alone may not adequately reflect readiness for return-to-play. Persistent deficits in proprioception, psychological readiness, perceived shoulder function, and confidence were reported despite rehabilitation completion, return-to-play, and continued participation in rugby.
These findings support a multidimensional approach to rehabilitation and return-to-play decision-making that incorporates physical, psychological, and contextual factors alongside traditional measures of functional recovery. Further high-quality research is required to strengthen the evidence base and inform the development of rugby-specific rehabilitation and return-to-play frameworks.
Supplementary Materials
The following supporting information can be downloaded at the website of this paper posted on Preprints.org.
Author Contributions
VCN conceived the original idea for the review. OA, KEF and AIO contributed to the development and refinement of the research questions, study design, and search strategy. VCN developed the search strategy. KEF, AIO and QKN were involved with screening and full text review of these articles. KEF wrote the manuscript of the review with edits and inputs from AIO. All authors read and approved the final manuscript (VCN, KEF, AIO, QKN, ACN and OA).
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethics Approval and Consent to Participate
As this study was based on previously published data and did not involve direct interaction with human participants, ethics approval and informed consent were not required. The review adhered to the principles outlined in the Declaration of Helsinki and followed accepted ethical standards for secondary analyses.
Consent for Publication
Not applicable, as no individual person’s data (including images, videos, or personal details) are contained in this manuscript.
Availability of Data and Materials
All data generated or analyzed during this study are included in the published article and its supplementary files. Additional datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Declaration of Conflicting Interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Declaration of Conflicting Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
List of Abbreviations
ACSM: American College of Sports MedicineAROMs: Athlete-Reported Outcome MeasuresBESS: British Elbow and Shoulder SocietyCBT: Cognitive Behavioural TherapyCENTRAL: Cochrane Central Register of Controlled TrialsCI: Confidence IntervalCINAHL: Cumulative Index to Nursing and Allied Health LiteratureCKCUEST: Closed Kinetic Chain Upper Extremity Stability TestCONSORT: Consolidated Standards of Reporting TrialsEMBASE: Excerpta Medica DatabaseEMCARE: Elsevier Nursing and Allied Health DatabaseHMIC: Health Management Information ConsortiumIOC: International Olympic CommitteeLMICs: Low- and Middle-Income CountriesMMAT: Mixed Methods Appraisal ToolN/A: Not ApplicableNRS: Numerical Rating ScaleOCEBM: Oxford Centre for Evidence-Based MedicineOR: Odds RatioPEDro: Physiotherapy Evidence DatabasePICOS: Population, Intervention, Comparison, Outcomes, Study DesignPRISMA: Preferred Reporting Items for Systematic Reviews and Meta-AnalysesPROSPERO: International Prospective Register of Systematic ReviewsPT: Physiotherapy / Physical TherapyRCT: Randomized Controlled TrialROM: Range of MotionRR: Risk RatioSD: Standard DeviationSI-RSI: Shoulder Instability–Return to Sport after Injury ScaleSLAP: Superior Labrum Anterior and PosteriorUK: United KingdomUQYBT: Upper Quarter Y-Balance TestVAS: Visual Analogue ScaleWHO: World Health Organization
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Table 1.
Study Charateristics.
| S/N | Study (Country) | Design & Level of Evidence | Participants & Rugby Level | Injury Characteristics | Rehabilitation / Intervention Characteristics | Follow-up | Outcomes & Measurement Tools | Key Quantitative Findings | Key Biopsychosocial Findings | Clinical Interpretation |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | White et al. (2025), UK [12] |
Qualitative study (Interpretive Hermeneutic Phenomenology); OCEBM Level IV | Elite female rugby union players (n=11) and practitioners (n=9: 4 physiotherapists, 4 S&C coaches, 1 sports physician); Total N=20 | Shoulder injuries resulting in ≥6 weeks absence from rugby; all athletes had returned to play at interview | Real-world multidisciplinary rehabilitation involving physiotherapists, S&C coaches, and medical staff; no standardized intervention | Interviews conducted Oct 2023–Jan 2024; no longitudinal follow-up | Semi-structured interviews; reflective thematic analysis | Not applicable | Four themes identified: (1) systemic barriers in women’s rugby, (2) player–practitioner disconnect, (3) threats to athletic identity, and (4) factors influencing confidence during return-to-play. Data saturation achieved after nine interviews. | Rehabilitation outcomes were strongly influenced by psychosocial and contextual factors. Findings support patient-centred, biopsychosocial rehabilitation and sex-specific return-to-play pathways. |
| 2 | Suarez-García et al. (2021), Spain [25] |
Randomized single-blind clinical trial; OCEBM Level II | Federated male rugby players aged >18 years competing at regional level; N=30 (Intervention=15; Control=15) | Shoulder instability and injury-risk reduction | Structured physiotherapy programme comprising plyometric, proprioceptive, and strengthening exercises; 2 sessions/week; 15 min/session | 4-week intervention plus 4-week follow-up | Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST); Upper Quarter Y-Balance Test (UQYBT) | Significant improvements in CKCUEST and UQYBT scores post-intervention and at follow-up (p<0.05). Intervention adherence 100%; one control dropout. Partial eta-squared effect sizes reported by authors. | No psychosocial outcomes assessed. | Demonstrates that targeted physiotherapy can improve shoulder stability and dynamic upper-limb function. Supports inclusion of proprioceptive and neuromuscular training within rugby rehabilitation programmes. |
| 3 | Partner et al. (2022), UK [11] |
Cross-sectional survey; OCEBM Level IV | Professional (n=34) and amateur (n=52) rugby league and union players; Total N=86 | Perceived shoulder dysfunction among actively competing players | No intervention; observational assessment of shoulder function and symptoms | Mid-season assessment | Rugby Shoulder Score (RSS); self-reported performance impact; injury history | 55% reported shoulder dysfunction despite being available for selection. Players reporting performance limitation had higher RSS scores than those without limitation (61 vs 40 AU; p=0.02). Previous injury associated with worse RSS (48 vs 20 AU; p<0.001). Professionals reported greater dysfunction than amateurs (40 vs 20 AU; p=0.02). Forwards reported greater dysfunction than backs (29 vs 20 AU; p=0.036). | Suggests normalization of shoulder symptoms and dysfunction within rugby culture. | Strong evidence that many rugby players continue participating despite ongoing dysfunction, highlighting limitations of traditional injury surveillance and return-to-play approaches. |
| 4 | Rogowski et al. (2020), France [10] |
Cross-sectional retrospective comparison; OCEBM Level III | Male amateur and university rugby players and healthy controls; mean age 22.3 ± 3.9 years; Total N=86 | Previous shoulder instability managed operatively or non-operatively | Participants had completed routine rehabilitation; rehabilitation content not standardized or described in detail | Non-operative group: mean 4.3 years post-injury; Operative group: mean 4.5 months post-surgery | Shoulder Instability–Return to Sport after Injury Scale (SI-RSI); Isometric ER/IR strength; Upper Quarter Y-Balance Test; Unilateral Seated Shot Put Test | Non-operatively managed athletes demonstrated physical performance comparable to controls but significantly lower SI-RSI scores. Operatively managed athletes demonstrated deficits in strength, stability, and psychological readiness at 4.5 months post-surgery. | Persistent psychological deficits remained despite restoration of physical function. | Provides evidence for a disconnect between physical recovery and psychological readiness, supporting multidimensional return-to-play assessment. |
| 5 | Herrington et al. (2010), UK [9] |
Mixed-design comparative study (within- and between-group); OCEBM Level III | Professional rugby union players: asymptomatic rugby players (n=15), previously injured and rehabilitated players (n=15), and non-rugby controls (n=15); Total N=45 | Previous shoulder instability including SLAP lesions and glenohumeral dislocations | All injured players had completed physiotherapy and/or surgical rehabilitation and had been medically cleared for return-to-play for ≥2 months | Injuries occurred 3–24 months before assessment | Joint Position Sense (JPS) testing at 45° and 80° external rotation; absolute error score (degrees) | Previously injured shoulders demonstrated significantly greater JPS error than contralateral uninjured shoulders (45°: 6.7±3.4° vs 3.7±1.8°; MD=3.0°; 80°: 4.1±0.8° vs 2.3±1.2°; MD=1.8°). Injury status significantly influenced JPS (p=0.002). Uninjured rugby players demonstrated superior proprioception compared with non-rugby controls. | Persistent proprioceptive deficits remained despite successful return-to-play. | Suggests conventional rehabilitation and return-to-play criteria may inadequately assess sensorimotor recovery following shoulder injury. |
Table 2.
Methodological Quality Assessment of the Randomized Controlled Trial Using MMAT (2018).
| Study | Appropriate Randomization | Groups Comparable at Baseline | Complete Outcome Data | Outcome Assessors Blinded | Participant Adherence to Intervention | OCEBM Level |
|---|---|---|---|---|---|---|
| Suarez-García et al. (2021) [25] |
Can't Tell | Yes | Yes | Can't Tell | Yes | II |
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