0 DelphiRev - ShoulderinSport.BERNconsensus - JOSPT - .2022-1

[ consensus statement ]
ARIANE SCHWANK, PT, MSc1-3a • PAUL BLAZEY, PT4a • MARTIN ASKER, PT, PhD5,6 • MERETE MØLLER, PT, PhD7,8
MARTIN HÄGGLUND, PT, PhD9 • SUZANNE GARD, PT, MSc10,11 • CHRISTOPHER SKAZALSKI, PT, DPT8
STIG HAUGSBØ ANDERSSON, PT, PhD8 • IAN HORSLEY, PT, PhD12 • ROD WHITELEY, PT, PhD13,14 • ANN M. COOLS, PT, PhD15
MARIO BIZZINI, PT, PhD16 • CLARE L. ARDERN, PT, PhD17-19 • ON BEHALF OF THE ATHLETE SHOULDER CONSENSUS GROUPb
2022 Bern Consensus Statement

on Shoulder Injury Prevention,
Rehabilitation, and Return to Sport for
Athletes at All Participation Levels
Downloaded from www.jospt.org at on January 6, 2022. For personal use only. No other uses without permission.
P
rofessional and amateur athletes alike are burdened Yet, there is a lack of
byshoulderinjuries.7,44,48,49,78,88 Shoulder pain affects quality evidence to guide
Copyright © 2022 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
athlete performance, training, and daily life.61,64 clinicians, athletes, and

SUPPLEMENTAL
VIDEO ONLINE coaches in managing
More than half of elite collegiate American football
shoulder injury risk or re-
players sustain at least 1 shoulder injury during their turn to sport (RTS) post
career.48 Shoulder injuries are a problem for athletes in sports as diverse injury. The absence of quality evidence
as rugby,54 baseball,34 handball,20 diving,73 water polo,73 and kayaking.41 hinders those who wish to produce clinical
practice guidelines. Previous consensus
U SYNOPSIS: There is an absence of high-quality decision making during the return-to-sport pro- statements have targeted specific shoul-
evidence to support rehabilitation and return-to- cess. This statement is designed to offer clinicians der pathologies4,31,60,89 and the scapula.50
Journal of Orthopaedic & Sports Physical Therapy®
sport decisions following shoulder injuries in ath- the flexibility to apply principle-based approaches However, questions remain:
letes. The Athlete Shoulder Consensus Group was to managing the return-to-sport process within a • Which exercises are most appropriate
convened to lead a consensus process that aimed variety of sporting backgrounds. The principles for supporting primary prevention of
to produce best-practice guidance for clinicians, and consensus of experts working across multiple
athletes, and coaches for managing shoulder shoulder injury in athletes?
sports may provide a template for developing
injuries in sport. We developed the consensus via • Does screening for muscle weakness,
additional sport-specific guidance in the future.
a 2-round Delphi process (involving more than 40
J Orthop Sports Phys Ther 2022;52(1):11-28. such as a loss of rotational strength in
content and methods experts) and an in-person the shoulder, hold value for athletes?
doi:10.2519/jospt.2022.10952
meeting. This consensus statement provides guid-
U KEY WORDS: consensus statement, rehabilita-
• Which load management measures
ance with respect to load and risk management,
supporting athlete shoulder rehabilitation, and tion, return to sport, shoulder injury are relevant for the athlete with shoul-
der injury?
a
Ariane Schwank and Paul Blazey are co–first authors, as they have equally contributed to this statement. bA list of all those who agreed to participate as part of the Athlete
Shoulder Consensus Group can be found in the Acknowledgments. 1MOVement ANTwerp Research Group, Department of Rehabilitation Sciences and Physiotherapy, University
of Antwerp, Antwerp, Belgium. 2Institute for Therapy and Rehabilitation, Kantonsspital Winterthur, Winterthur, Switzerland. 3Pain in Motion International Research Group, Brussels,
Belgium. 4Department of Physiotherapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada. 5Handball Research Group, Musculoskeletal and Sports Injury
Epidemiology Center, Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden. 6Scandinavian College of Naprapathic Manual Medicine, Stockholm,
Sweden. 7Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark. 8Oslo Sports Trauma Research Center, Department of
Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway. 9Sport Without Injury Program, Unit for Physical Therapy, Department of Health, Medicine and Caring Sciences,
Linköping University, Linköping, Sweden. 10SportAdo Center, Department of Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland. 11Physiotherapy, University of
Applied Sciences of Western Switzerland, Geneva, Switzerland. 12English Institute of Sport, Sheffield Hallam University, Sheffield, United Kingdom. 13Rehabilitation Department, Aspetar
Orthopaedic and Sports Medicine Hospital, Doha, Qatar. 14School of Human Movement and Nutrition Sciences, The University of Queensland, Brisbane, Australia. 15Department
of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. 16Human Performance Lab, Schulthess Klinik, Zürich,
Switzerland. 17Musculoskeletal and Sports Injury Epidemiology Center, Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden. 18La Trobe Sport and
Exercise Medicine Research Centre, La Trobe University, Bundoora, Australia. 19Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
Paul Blazey is the Editor of Social Media of the JOSPT and Dr Ardern is the Editor-in-Chief of the JOSPT. The authors certify that they have no affiliations with or financial involvement
in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Ariane Schwank, Kantonsspital
Winterthur, Institute for Therapy and Rehabilitation, Brauerstrasse 15, Winterthur 8401 Switzerland. E-mail: ariane.schwank@student.uantwerpen.be t Copyright ©2022 JOSPT®, Inc
journal of orthopaedic & sports physical therapy | volume 52 | number 1 | january 2022 | 11

• What is best-practice rehabilitation consensus recommendations, we devel- to discuss, elaborate, and provide further
for the athlete with shoulder injury? oped our framework through the lens guidance on topics of nonconsensus. All
• Which criteria should guide quality of RTS as a continuum, paralleled with in-person experts were invited speakers
RTS decisions? rehabilitation.5 at the symposium “Shoulder & Sports”
Sportfisio Swiss (the Swiss Sports hosted by Sportfisio Swiss.
Physiotherapy Association), supported Consensus Process The in-person meeting took place on
by the Journal of Orthopaedic & Sports We employed a modified Delphi process November 21, 2019 in Bern, Switzerland,
Physical Therapy (JOSPT), convened a because (1) the approach afforded ano- 1 day before the symposium. Members
consensus development group to synthe- nymity and (2) allowed us to include a of the in-person meeting participated
size evidence and establish best practice in large group of international experts.65 We in a 6-hour discussion, chaired by con-
shoulder injury prevention, rehabilitation, aimed to work toward agreement without sensus committee organizers (A.S., P.B.,
and RTS. The group’s remit was to develop forcing consensus. Therefore, we did not and C.L.A.) and also hosted by Sportfisio
a principle-based framework to guide peo- prespecify the number of rounds required Swiss. Experts at the in-person meet-
ple who contribute to managing shoulder for consensus. This is a normal part of a ing received information on the points
injury in different sports. The framework consensus process and allows important of consensus, nonconsensus, and dis-
covers 4 key concepts: (1) managing injury differences in clinical care to surface.27 sent after Delphi round 2 (online sur-
risk, (2) managing and progressing load, We modified the standard Delphi pro- vey). In-person discussion focused on
(3) rehabilitation, and (4) RTS. cess (FIGURE 1) to encompass a 2-step pro- crystallizing agreement from the Delphi
cess: first, we conducted and completed 2 survey and surfacing additional areas
Methods rounds of an online Delphi survey, where of nonconsensus to highlight for future
This statement follows the principles we established areas of consensus, non- research. There was no formal voting at
outlined in the 2016 Bern consensus on consensus (experts have mixed responses), the in-person meeting, and all points of
RTS.5 Fundamental definitions and prin- and dissent (all experts are in consensus consensus, unless otherwise stated, were
ciples that underpin RTS for athletes are disagreement with a statement). Second, formed from the wider Delphi survey.
contained in the original statement, and a smaller group of international experts Experts renowned for clinical and/or
we encourage the reader to review the (who had participated in the Delphi pro- research excellence in shoulder conditions
Bern consensus. Consistent with the Bern cess) participated in an in-person meeting in athletes were invited to participate in
the Delphi process (the 2 online surveys).
Design There are different approaches to recruit-

Review relevant literature and ing participants to Delphi panels, and no
design Delphi questionnaire/ agreement on which method is best.13 We
statements aimed to balance research and clinical
Recruit
Identify key end-user groups experience, sex, nationality, and profes-
to participate in the Delphi sional representation. We identified and
process (n = 44)
contacted people with a clinical and/or
Delphi 1 research profile (ie, those who had pub-
Send Delphi round 1 invitations
lished in peer-reviewed scientific journals
(n = 44) and questionnaires
(n = 42 returned) on topics related to shoulder injury in
Collate athletes or presented at sports medicine/
Collate results from Delphi round sports rehabilitation conferences on topics
1. Formulate new statements based related to shoulder injury in athletes); we
on additional themes and constructed a long list of potential partici-
feedback from round 1
Delphi 2 pants, then consulted sports physical ther-
Send Delphi round 2 invitations apy leaders in professional organizations
(n = 39) and questionnaires
(n = 32 returned) for their input and feedback on our long
list. Next, we contacted all people on the
Meet long list and invited them to participate.
Move issues that did not reach
consensus forward to discussion Invitations were sent via e-mail, with an
in person with experts (n = 10) information sheet detailing the purpose,
commitment required by participants,
and benefits of participation (a copy can
FIGURE 1. Flow chart depicting the modified Delphi process.
be provided on request to the correspond-
12 | january 2022 | volume 52 | number 1 | journal of orthopaedic & sports physical therapy

ing author). If anyone declined participa- Round 1 of the Delphi process had 54 meeting in each section. All “consensus
tion, we asked that person to nominate at questions focused on: points” throughout the statement were
least 1 other person whom we should ap- • Risk factors and injury risk reduction derived from the larger Delphi survey.
proach to participate. • Training load
Participants for the in-person meeting • Rehabilitation and management of Section 1: Prevention Is Better
were selected by the Sportfisio Swiss con- the scapula Than Cure—Managing Injury Risk
ference organizing committee as speakers • The rotator cuff, the postdislocation in Athletes With or Without a
for the 2019 conference. shoulder, or general instability History of Shoulder Injury
• Sport-specific rehabilitation and Approaches to injury prevention vary dra-
Gathering Information progression matically between sports and between in-
To obtain information required to con- • RTS criteria juries. Preventing further injury following
struct the statements included in the To ascertain whether there was con- an acute trauma (eg, dislocation) will dif-
first Delphi round, we reviewed evidence sensus agreement with a statement, we fer from the approach to prevent an over-
for managing shoulder injuries in ath- used an 11-point scale (0-10), with an av- use injury. Therefore, we have attempted
letes of all ages and participation levels. erage (mean) rating among experts of 7 to outline principles rather than prescribe
Database (Embase, MEDLINE, SPORT- of 10 set as the threshold for consensus. a “recipe.” There is inevitable overlap be-
Discus, Cochrane Database of Systematic After analyzing the feedback provided by tween primary and secondary injury pre-
Reviews, and Cochrane Central Register participants following round 1, we de- vention. Applying the injury prevention
of Controlled Trials) and gray literature veloped additional questions for round principles in practice can help guide clini-
searches (Google Scholar, to July 2019) 2 and added them to the questions that cians and coaches to the highest-priority
were conducted. Articles were extracted failed to reach consensus in round 1. risks, such as the need to address training
and reviewed by the consensus commit- Round 2 comprised 25 questions; 39 ex- load factors following an overuse injury
tee organizers (A.S., P.B., and C.L.A.), perts participated. See the supplemental versus the need to address a progressive
prioritizing systematic reviews, clinical file for detailed statistics of respondent return to collisions following a glenohu-
practice guidelines, and original research numbers and experts included in all Del- meral dislocation in a contact sport. In
(in that order). Search terms were pur- phi rounds and the in-person meeting. this section, we also address preinjury
posefully broad, using “‘shoulder’ AND screening and shoulder injury prevention
‘return to sport OR play OR activity.’” Terminology and Structure of the programs and their implementation.
Articles that mentioned prevention, re- 2022 Consensus Statement Therefore, this section on managing
habilitation, or management of shoulder There is a wide variety of demands on the shoulder injury risk comprises 4 sub-
injuries in athletes were included for re- sporting shoulder. To account for these sections: (1) what is known and what is
view. Articles with no mention of shoul- demands, we considered type of sport: unknown about risk factors for shoulder
der injury prevention or management in above shoulder height, with or without injury in athletes; (2) screening the ath-
a sporting context and papers focused throwing; below shoulder height, with lete’s shoulder; (3) managing injury risk
solely on surgical management of shoul- or without throwing; and reverse chain. with primary and secondary prevention
der injuries in athletes were excluded. A reverse-chain sport is one where the exercise programs; and (4) implementing
upper limbs act primarily as the point of injury prevention exercise programs.
Designing and Revising the Delphi contact with the environment or playing
Statements for Each Round surface, directly or indirectly (eg, climb- What Is Known and What Is
We used thematic analysis to identify key ing or rowing via use of an oar). We also Unknown About Risk Factors for
themes from the literature search. The accounted for whether sports involved Shoulder Injury in Athletes
themes then informed the specific state- contact or “collision” (FIGURE 2). Knowing the risk factors for injury sup-
ments we constructed for the Delphi ques- We intend the content of this consen- ports successful management of shoulder
tionnaire (supplemental file). There was a sus statement to apply to all sports and injuries in sport.23,35 Attempts have been
need for separate statements due to the all athletes. The consensus is presented made to ascertain specific risk factors in
different demands placed on the shoulder in 4 main sections: (1) managing injury sports such as handball,8 and to predict
by different sports. Therefore, we created risk, (2) managing and progressing load, who might suffer reinjury following acute
2 separate groups of questions focused on (3) shoulder injury rehabilitation, and (4) trauma such as a dislocation.67 Results
(1) athletes in overhead or throwing sports evidence to inform RTS decisions. are conflicting, with a consistent criticism
and (2) athletes in collision sports. The We outline and highlight the points of being that studies too often base their
questionnaire was piloted by an experi- consensus or dissent from Delphi round risk of injury on a single measurement
enced clinician-researcher (M.B.). 1, Delphi round 2, and the in-person per season (predominantly in the pre-

season), which disregards the complex, factors.7,8,62,67 The role of load is fiercely Screening the Athlete’s Shoulder
ever-changing nature of injury risk.7,52,66,94 debated and is considered to play an im- There is an absence of evidence to support
Despite these conflicts, some modi- portant role when it comes to overuse screening for predicting which athletes
fiable risk factors have been proposed. injuries (eg, in the throwing arm)62,92 and will suffer a shoulder injury.52,94 However,
These include loss of (reduced) range in contact sports, where shoulder disloca- screening can help clinicians identify and
of motion (ROM), rotational strength tions are common.67 address pre-existing problems to support
imbalance, muscle weakness compared All potential risk factors should be athletes to RTS after shoulder injury, or
to individual baseline or group norma- discussed in a shared decision-making to facilitate performance improvements.
tive values, changes in load (shoulder framework involving athletes, coaches, The effectiveness of screening remains
and sport-specific measures vary), player and clinicians to identify the most rele- inconclusive.10,72 Around half the Delphi
position, participation level (profes- vant injury risk factors to the athlete and group recommended to screen for scapu-
sional versus amateur), a previous his- to decide whether mitigation strategies lar dyskinesis, whereas the other half was
tory of shoulder pain, and psychosocial are warranted.28 against it.
g B el
row in Tennis Golf
ow
S
h ho
tT Baseball uld
ou
it h
er
Squash Table
/W
He
Baseball
Badminton tennis
igh
ith
pitcher
tW
tW
eig h
it h /
Basket-
ball
Volleyball American
With
der H
Archery
football
Rugby
ou
Above Shoul
Handball
t Throwing
Lacrosse
Australian
American football
Floorball
Cricket football Curling
Soccer
QB Contact Ice hockey
GK Collision
Javelin
Water Judo Field
polo hockey
Diving
Climbing
Swimming
Gymnastics XC
Kayaking skiing
Rowing
Reverse Chain
FIGURE 2. Representation of the demands of different sports, according to their degree of contact, whether they require play above or below the shoulder, and reverse-chain
demands. The size of each circle reflects the relative burden of shoulder injury in each sport. Some sports involve specific position demands, represented in italics (eg, the
American football QB, who experiences greater demand and suffers a higher occurrence of shoulder injuries compared to those playing other positions in American football).
Abbreviations: GK, goalkeeper; QB, quarterback; XC, cross-country.

Screening for risk factors entails chal- Injury prevention programs (primary Fundamental components of exercise
lenges when interpreting the test results. and secondary) have low risk of harm, are programs to manage shoulder injury risk
No tests or test batteries could reliably be minimally intrusive to implement (eg, in- in overhead and contact/collision sports
recommended to support either a prima- cluding exercises in warm-ups), and offer are outlined in TABLE 1. The principles
ry (preinjury) or secondary (postinjury) potential preventive effects to all athletes. can be extrapolated to other cases, with
screening process. As the literature and The Delphi group agreed that all athletes the caveat that “recipe-style” approaches
the Delphi group remained split, experts should receive injury prevention exercise should be avoided. Each case should be
from the in-person meeting suggested programs, irrespective of whether or not taken on its own merit, and recommen-
that a generic musculoskeletal shoulder they have a history of shoulder injury. dations should be adapted to suit the in-
screen (ie, not injury specific and incor- Depending on the resources available and dividual and the sporting context within
porating a mixture of ROM, strength, the sport setting (eg, professional versus which RTS is being attempted. TABLE 2
power, and other standardized measure- youth sport), it may be appropriate to de- gives an example of a potential preven-
ments such as sport-specific internal vote additional preventive effort to ath- tion program in overhead-throwing ath-
rotation [IR]/external rotation [ER] ra- letes identified as having a higher risk for letes, consisting of 3 exercises that target
tios) may have a place. This could include injury (eg, athletes who start the season important variables such as shoulder
an assessment of shoulder function over with shoulder pain, with muscle strength ROM, plyometric capacity, and the ki-
the whole season, with the frequency to deficits, or who play in a high-risk playing netic chain.
be established for each individual sport position such as the pitcher in baseball).
and player position (risk level). However, Implementing Injury Prevention
the utility and recommended frequency Exercise Programs

Consensus point
of any screening process for the shoulder, While injury prevention exercise programs
Injury prevention programs/exer-
both pre and post injury, require further work under controlled conditions (effica-
cises are appropriate to prescribe
investigation. cy), the evidence for effectiveness (whether
for athletes of all levels to prevent
Information gathered during the the programs work in the real-world sport
shoulder injury.
screening process (eg, preinjury strength environment) remains elusive.2,35 The Del-
levels) may help to refine RTS decisions,
which will be discussed further in the
Expert In-Person Meeting Recommended
RTS section of this statement.
TABLE 1 Components of Exercise Programs to Manage

Shoulder Injury Risk in Overhead Sports
Managing Injury Risk With Primary and
Secondary Prevention Exercise Programs
General Principles Exercise Targets
Primary prevention should be the fo-
• Exercises should be conducted in sport-specific positions • Rotator cuff imbalances, with focus on external
cus of all programs and should begin
• Exercises should cover multiple joints (ie, involve the kinetic chain) rotation strength through the range of motion
from a young age (ie, in youth athletes). • Programs should require minimal equipment • Shoulder girdle strength through the range of
The high prevalence and persistence of • Programs should involve a competitive element, ideally with motion
shoulder problems in adolescent and se- partners where the sport is team based • Dynamic trunk function/capacity specific to
nior elite overhead athletes underscore • Programs should be implemented at least 2 times per week and sport
may form part of the warm-up routine before training or match • Control of eccentric deceleration of the arm
the need to focus on primary preven-
play and part of resistance training (eg, external rotation in 90° of abduction)
tion in youth sport to establish life- • Programs should take no longer than 10 to 15 minutes in total, 5
long practices for maintaining healthy minutes of which may focus on shoulder-specific activities
shoulder function.79,98 Structured, one-
size-fits-all exercise programs appear to
reduce the shoulder injury risk in hand- Example of a Prevention Exercise
ball athletes79 and should be studied in TABLE 2 Program in Overhead-Throwing Athletes,
other athletic populations to draw firm Derived From the Authorship Group
conclusions.
Secondary prevention exercise pro- Target Exercise Videoa
grams may begin immediately follow- Range of motion/motor control External rotation through abduction VIDEO 1
ing shoulder injury or may become more Plyometrics Drop and catch in 90° of shoulder abduction VIDEO 2
of a focus as the athlete progresses to- Open/closed kinetic chain Y Balance Test exercises or adapted versions VIDEO 3
ward a return to participation, sport, or a
Videos can be found at www.jospt.org/doi/10.2519/jospt.2022.10952
performance.

phi group concurred that risk reduction match load (greater than 60% increase
can be achieved when the exercise pro- compared with the average of the previ- Consensus point
grams are performed twice weekly (mini- ous 4 weeks) are associated with an in- To obtain estimates of the applied
mum dose). Effective prevention programs creased shoulder injury rate.55,98 load, measures should include the
must support the education of coaches number of repetitions (eg, throws),
and athletes, target known barriers such Consensus point the magnitude of load applied per
as lack of compliance/adherence,9,11,68 and The balance between capacity repetition (eg, throwing velocity),
improve attitudes and self-efficacy of in- and load plays an important role and the distribution of load over
dividual athletes toward participating in in injury risk management, reha- tissue structures applied per rep-
injury prevention programs.36,57,85,86 Imple- bilitation, RTS, and performance etition (eg, type of throw).
menting prevention programs also has the enhancement.
potential to improve sport performance The practicality of collecting external
(eg, throwing velocity).3,70 Recommendations based on total load measurements varies between sports.
sporting exposure hours do not account For example, counting the number of
Consensus point for large variations in internal load (eg, pitches and measuring throwing velocity
Plan to implement injury preven- the relative biological stress—physiologi- for each player are reasonable practices in
tion programs at least twice weekly cal or psychological—placed on an ath- baseball, but may not be possible in hand-
on a team level to ensure all athlete during training and competition) ball due to the chaotic nature of game play.
letes receive the minimum dose. between training sessions of equal dura- Experts at the in-person meeting sug-
tion. Measuring load accurately may re- gested that an option for capturing inter-
Section 2: Managing Shoulder- quire multiple external (eg, any external nal load would be to have athletes rate
Specific Load in Athletes stimulus applied to the athlete, such as their session or shoulder-specific rate of
Strategies for monitoring shoulder- laps swum in the pool, balls bowled in perceived exertion (RPE) following a ses-
specific load in overhead athletes lack cricket, etc) and/or internal load mea- sion/match.58 Practical examples include
reliability and validity, prompting calls surements. Do not rely on playing time asking the throwing athlete, “On a scale
for new technologies to be developed.12 or distance covered as a sole measure.59,69 from 0 to 10, how hard (exertion) was this
Shoulder-specific loads vary with the Research remains unclear about what to session on your throwing arm?” or asking
number of throws, playing position, type measure and how to measure it, particu- a swimmer, “On a scale from 0 to 10, how
of training, and intensity of training. larly for internal load in sport.92 hard (exertion) was this session on your
High overall shoulder-specific load ex- There was no consensus about which shoulders?” For the youth athlete, the cli-
posure of more than 16 hours per week55 type of load (internal or external) was nician may ask the same question weekly
(eg, high-speed throws in baseball) and more important to risk or injury manage- rather than after each session; for exam-
large weekly increases in training and/or ment in the shoulder. ple, “How hard (exertion) was the recent

TABLE 3 Measures to Monitor Workload in Different Athlete Populations
Example of Monitoring Workload Youth Athletes Adult Athletesa Professional Athletesb

Overhead sports • Shoulder-specific RPE • Session RPE • GPS tracking
• Pitch counts or serve counts in baseball, • Shoulder-specific RPE • Number of strokes in swimming/water polo
softball, cricket, and tennis • Strength assessment (eg, endurance • Clinical recovery measurements (eg, blood sampling)
• Number of laps in swimming/water polo and power testing using HHD or other • Strength assessment (eg, rate of force development
• Number of training sessions and matches equipment) analysis)
(or hours) played • Wellness questions or questionnaires • Pitch/throw velocity
(eg, sleep, stress, recovery)
Collision sports • Shoulder-specific RPE • Session RPE • GPS tracking
• Number of training sessions and matches • Shoulder-specific soreness NRS • Number of tackles
(or hours) in team sports • Wellness questions or questionnaires • Clinical recovery measurements (eg, blood sampling)
• Number of tackles/checks per training in (eg, sleep, stress, recovery) • Strength assessment
rugby, ice hockey, and lacrosse • Pitch/throw velocity
Abbreviations: GPS, global positioning system; HHD, handheld dynamometry; NRS, numeric rating scale; RPE, rate of perceived exertion.
a
In addition to youth athletes.
b
In addition to adult athletes.

week on your throwing arm?” To support These results need to be replicated Experts at the in-person meeting
athlete education and calibration with the by future studies that use measures of agreed that clinicians supporting athletes
RPE scale, the modified Borg RPE scale shoulder-specific load. However, if the post shoulder injury should aim to
(0 being no exertion/effort at all and 10 findings are true, one could either adapt 1. Improve sport-specific biomechanics/
being the maximal imaginable exertion/ the load to the capacity of each player or technique
effort) may be used. To date, it is unclear improve the shoulder function of affect- 2. Increase rehabilitation intensity to
how well shoulder-specific RPE repre- ed players to withstand greater loads, challenge athletes at the limit of their
sents the psychophysiological construct but preferably both.93 capacity
of perceived exertion: fatigue, heaviness, We suggest a minimum set of require- 3. Build resilience: increase capacity to
and discomfort.43 Session RPE is strongly ments for efficient workload monitoring load from physiological and psycho-
correlated to summated heart rate zone for youth athletes in overhead and con- logical perspectives
measures within athletes in youth soc- tact/collision sports, and a build-on for 4. Involve the multidisciplinary team in a
cer, rugby, and field hockey.81 However, adult and professional athletes who may shared decision-making process, includ-
RPE, session RPE, or shoulder-specific have additional resources available (TABLE ing coaches and the athlete, to support
RPE may be moderated by factors such 3). These suggestions guide clinicians, integrating rehabilitation and perfor-
as training mode. For instance, RPE can athletes, and coaches to extend the load mance measures that advance the ulti-
increase in athletes who include collisions monitoring principles, and are designed mate goal of return to performance5,28
in training when compared with those to be employed alongside clinical-reason-
running at the same velocity without col- ing principles for the specific individual Seven Key Principles to Restore Strength
lisions.58 Combining RPE with the Rating or team situation. In professional sports, and Sport-Specific Movement Patterns
of Fatigue scale91 may help to capture a workload management is a constant part Informed by the consensus points agreed
closer estimate of perceived exertion.43 of athlete evaluation. Monitoring may be to in the Delphi process, the in-person
Overall, both metrics (session RPE applied daily, using more resource-heavy meeting team identified, discussed, and
and shoulder-specific RPE) can help measures where available. We anticipate defined 7 key principles to guide rehabili-
identify athletes who are struggling to that future research to establish the va- tation planning and progress for athletes
maintain high levels of training, as they lidity and reliability of specific measures with shoulder injuries.
capture the subjective response to the of shoulder load will allow these recom- Key Principle 1: Let Irritability Guide
physiological stimulus. mendations to be refined. Rehabilitation Progression Progress
through rehabilitation is governed by

Consensus point Section 3: Road to Recovery— the level of irritability and is unique to
Monitor load (shoulder-specific Key Principles for Quality the patient; it has little to do with spe-
and athlete total load) on at least a Rehabilitation After Shoulder cific pathology. High irritability is consid-
weekly basis, with data collection Injury in Athletes ered as high pain at rest, night pain, or
carried out by both the performance Clinicians should consider athlete- and high disability. Low irritability includes
team and individual athletes. sport-specific factors when designing a low pain levels, pain that is limited to
rehabilitation program for the injured specific activities or movements, and no
Where resources allow, such as where a athlete. Aim for appropriate load and al- night pain.23 A staged approach has been
team has access to data scientists or where low symptom response and irritability to described for shoulder disorders, with
athletes can self-monitor using question- guide treatment and progression. a rehabilitation classification based on
naires, daily monitoring may occur. irritability.56
Consensus point
Example of How Baseline Strength Tissue-specific involvement may
Consensus point
Affects Load Capacity be considered, but the pathoana-
There is no specific order for when
A study of 679 handball athletes fol- tomic diagnosis should not drive
to include the kinetic chain or to
lowed for 31 weeks assessed baseline and shoulder rehabilitation.
promote scapular kinematics or to
midseason strength and scapular con-
strengthen the rotator cuff. Instead,
trol. Players with reduced ER strength Athletes, especially elite-level athletes,
integrate these strategies simulta-
or scapular dyskinesis could withstand regularly train and compete with asymp-
neously. The structure and timing
smaller increments in weekly load (train- tomatic tissue abnormalities51 that often
of the rehabilitation program will be
ing/match participation measured in misdirect rehabilitation when observed
dictated by the driver (pain, weak-
hours) compared with stronger players on magnetic resonance imaging and oth-
ness, irritability) of the dysfunction.
or those without scapular dyskinesis.62 er diagnostic imaging.

Key Principle 2: Address Clinically Rel- imbalance and asymptomatic scapular
evant Glenohumeral ROM Deficits Using Consensus point dyskinesis.
Active Exercise Therapy Evidence regard- External rotation gain, while a
ing the prospective relationship between normal adaptation, should be Consensus point
preseason ER and IR ROM measures and managed (to ensure the athlete Consider the scapula as part of a
subsequent shoulder injuries in overhead can cope with the additional joint holistic approach to rehabilitating
and throwing sports is inconsistent.7,17,97 range) using active exercise thera- the shoulder complex, for example,
Range-of-motion loss or gain is common in pies to avoid future injury. strengthening the kinetic chain to
athletes with current shoulder complaints. improve scapular mechanics.75
The term glenohumeral internal rotation Clinicians may consider including
deficit (GIRD)76 elicits much confusion. strength-based exercises to restore
Clear language is key when interpreting ROM deficits. Pay attention to end- Consensus point
this alongside ER gain (ERG) and total range flexion and abduction deficits The effect of scapular dyskinesis on
rotational ROM.96,97 Structural changes that commonly present in overhead performance is unclear.2,46,53,62,87
appear normal in the dominant arm of sports (eg, baseball, swimming, and
overhead and throwing athletes (eg, hu- volleyball). When the setting allows, Key Principle 4: Select the Appropri-
meral torsion), leading to a perceived in- clinicians may consider measuring hu- ate Exercise (Open Chain Versus Closed
crease in ER ROM and a decrease in IR meral torsion when making decisions Chain) Exercise selection will depend
ROM within the dominant shoulder.45 on whether an athlete has attained full on the specific injury and rehabilitation
ROM, or how much ERG and GIRD are phase. A safe place to begin for an athlete
Consensus point present.45,96,97 with anterior instability may be with low-
Both GIRD and ERG are physi- Key Principle 3: Do Address the load closed-chain exercises, while early
ological tissue responses. Evidence Scapula in Rehabilitation but Do Not open-chain exercises may be tolerated
is lacking to clearly differentiate Screen for Dyskinesis Screening for well by an athlete with acromioclavicular
physiological from pathological scapular dyskinesis in athletes with- joint instability.
adaptation. out shoulder symptoms may provide End-stage exercise selection should be
little to no value. Dyskinesis is present guided by the demands of the sport.99 A
There was no consensus on whether to in 53% of healthy people 71 and 61% of list of all the exercise suggestions made
manage symptomatic GIRD with active overhead athletes. 18 In overhead ath- by experts during the Delphi process can
or passive treatment. letes, sport may contribute to muscle be located in the supplemental file.

Examples of Rehabilitation Exercises Suggested by Experts Present
TABLE 4
at the In-Person Meeting or by the Authorship Team
Target Exercise Description Videoa

Early rehabilitation
Range of motion, functional strength, strength Standing with the arm elevated and with the hand on a ball against the wall (resistance bands) VIDEO 4
training Hand/foot: stretching for the last degrees of arm elevation and upward scapular rotation
Plyometrics Sidelying ER plyometrics with ball VIDEO 5
Open/closed kinetic chain High plank with ER in 90°/90° VIDEO 6
Progress in rehabilitation
Range of motion, functional strength, motor Y raises with tube VIDEO 7
retraining
Plyometrics Overhead-throwing sports: fast concentric, slow eccentric ER in 90°/90° VIDEO 8
Open/closed kinetic chain

Push-up and backward walk VIDEO 9
Collision sports: clap push-up VIDEO 10
Abbreviation: ER, external rotation.

a

performing a task to the rhythm of a met- Testing isometric strength at the start
Consensus point ronome or music.14,39,84 of each session will help the clinician to
Include open- and closed-chain ex- Key Principle 7: Sport-Specific Exercis- assess the athlete’s response and recovery
ercises in a rehabilitation program es Incorporate single-plane exercises at from a previous rehabilitation or train-
for overhead/throwing and contact- any point to achieve a specific goal (eg, ing session. The results guide treatment
sport athletes. addressing specific strength, power, or planning. The regularity of testing may
endurance deficits). However, clinicians be resource and budget dependent.
Key Principle 5: Include Plyometrics Ear- must ensure that athletes progress to There was no consensus about whether
ly in a Rehabilitation Program Includ- complex, multiplane exercises and ulti- isokinetic assessment or isokinetic exer-
ing plyometric exercises is crucial to help mately sport-specific movements (with cises are necessary during rehabilitation.
athletes prepare for sport-specific load. good quality) as soon as it is appropri- Isokinetic dynamometry is helpful,
Clinicians may start with low-load ate. Consider power (including rate of but not essential, to measure rehabilita-
plyometric exercises.83,95 These may in- force development) for exercise selection tion progress. Unanswered questions in-
clude small-amplitude drop-and-catch from a joint-protection and performance clude which positions, movements, and
movements in sidelying or fast concen- perspective in preparation for sport. Ex- planes are best to collect shoulder-spe-
tric, slow eccentric elastic band ER in amples of rehabilitation exercises can be cific rehabilitation measurements. The
supine. Progress exercises by adding found in TABLE 4. A detailed list of exercise information gained by testing individual
resistance and changing the body posi- suggestions from the Delphi survey is in muscles in isolation has limited overall
tion to either place more focused load on APPENDIX A (available at www.jospt.org). utility, as shoulder movement, strength,
the shoulder or resemble sport-specific and function are the cumulative result of
movements. Regular Testing and Repeatability the kinetic chain.
of Measures in Rehabilitation Aim to include the same relevant sub-
Consensus point Regularly test and monitor the athlete jective and objective measures in reha-
Plyometric exercises should be throughout rehabilitation, using stan- bilitation that the athlete performs with
included at the start of a shoulder dard measures that are reliable and easily the team (eg, well-being/pain question-
rehabilitation program, in both repeatable. An ideal testing kit for clini- naires, strength measures, sport-specific
throwing and contact sports. cians may include items that are portable throw/attack counts). These data can be
and require little time to complete. benchmarked against preinjury levels to
Key Principle 6: Train the Brain Injury 1. Handheld dynamometer for measur- measure progress and act to facilitate the
provokes changes in the cortical area of ing strength transition along the RTS continuum.5
the brain that outlast the injury itself.42 2. Inclinometer or goniometer for mea- Advances in technology have created
During rehabilitation, there is an oppor- suring ROM opportunities for clinicians to measure
tunity to capitalize on the brain’s plasticity 3. Questionnaires or patient-reported ROM, perform video analysis, and re-
to reverse the brain changes that occur af- outcome measures ceive feedback from athletes from any-
ter injury. Clinicians may apply principles Lists of suggested patient-reported where in the world.
from anterior cruciate ligament reha- outcome measures from the Delphi sur-
bilitation to the shoulder through use of vey are included in APPENDICES B and C Section 4: RTS Decisions
external focus of attention, implicit learn- (available at www.jospt.org). Return to sport occurs along a continu-
ing, differential learning, self-controlled um: from return to participation, to RTS,
learning, and contextual interference.39 Consensus point to return to performance (FIGURE 3).5 These
Gradual exposure to fearful movements Testing will be dictated by an are not separate categories, and should be
that provoke anxiety for the athlete, and athlete’s specific impairments and interpreted as a progressive flow.
use of motor imagery and mirror neurons should be conducted on a weekly The following definitions provide
with mimicking and adapted cognitive- basis (minimum). helpful context:
compartmental therapies, can be incorpo-
rated.14,77,84 Some practical examples may
include completing a task while count-
ing backward, giving external cues rather
than internal cues (eg, “bring the ball to
the upper line on the wall” instead of “raise
your arm”), having an athlete imagine the FIGURE 3. The 3 elements of the return-to-sport continuum. Republished with permission from BMJ Publishing
Group Ltd.5
movement while still wearing a sling, and

• Return to participation: the athlete gether to consider and act on information sport, and athlete when planning RTS. For
participating in rehabilitation, train- gathered from the body structure and a list of recommended tests, see TABLE 5.
ing (modified or unrestricted), or function domains prior to RTS.
sport, but at a level lower than his or The cases reflect the variable demands
Consensus point
her RTS goal. The athlete is physically of sport (FIGURE 2): above shoulder height,
Use a battery of sport-specific
active, but not yet “ready” (medically, with or without throwing; below shoul-
tests to determine when the athlete
physically, and/or psychologically) to der height, with or without throwing; and
is ready to return to unrestricted
RTS. It is possible to train, but this reverse-chain demands. Contact sports
sports participation.
does not automatically mean RTS. carry added risk for the athlete and clini-
• Return to sport: the athlete returning cian to consider when making RTS deci- RTS Criteria: 6 Domains to Consider
to his or her sport, but participating sions. The cases are exemplars for clinical for the Athlete Who Is Returning
below his or her previous or “desired” reasoning, not a recipe. Clinical reason- to Sport After Shoulder Injury
level of performance. ing during RTS is complex and often The 6 domains are not intended as a hi-
• Return to performance: the athlete influenced by external factors (context) erarchy. Depending on the sport and the
playing a full game without restric- beyond the control of the clinician or specific injury, a domain may be more or
tions or throwing the number of pitch- athlete. We illustrate the ideal scenario, less relevant. The criteria in each domain
es in a game at the same velocity as he where the athlete is liberated from exter- may also differ depending on where the
or she did before injury. nal pressures to RTS early. athlete is on the RTS continuum (FIGURE
In this section, we frame 6 domains There is currently no valid single test 3). Agreement on the 6 domains was
of body structure and function that affect or battery of tests for informing RTS de- reached by consensus during the Delphi
the success of an athlete during RTS after cisions following a shoulder injury. Clini- survey, and the content informed the sur-
shoulder injury. Case examples illustrate cians must employ clinical reasoning and vey and the in-person meeting as well as
how clinicians and athletes can work to- select tests that are specific to the task, discussions among the authors.

Sport-Specific Tests Recommended by the Delphi Group for Overhead
TABLE 5
(With or Without Throwing) Athletes and Collision-Sport Athletes
Performance Test ROM/Strength Test Kinetic Chain Sport-Specific Test Example

CKCUEST25 90°/90° concentric/eccentric rotator cuff Push-up test: assessing for ability, quality of Number of pain-free throws/serves at or
VIDEO 11a testing movement, control, and endurance above previous speed
PSET32,33,63 Isometric rotation strength Side plank endurance Throwing at full speed
VIDEO 12a ER/IR at 90°/0°
Shoulder Endurance Test (SET) (endurance Total rotational ROM within 10% of the Plyometric push-up Visual assessment of the “smoothness” of
test for ER in ABD/ER, 90°/90°)26 contralateral side the throwing technique
The Athletic Shoulder Test (ASH-Test)6 ER force measured with HHD in prone at Single-leg squat test Wrestling drills
90°/90° and 90°/0°
VIDEO 13a
Y Balance Test for the upper and lower ER/IR ratio: sport-specific numbers apply Thoracic spine rotation Tackle replication (eg, for American football
extremities40 or rugby)
VIDEO 14a VIDEO 15a
Seated medicine-ball throw 25
IR/ER ratio at 90°/90° in sitting (break Bench press Tackle replication with leg grab
VIDEO 16a test, HHD) VIDEO 18a
VIDEO 17a
Ball abduction-ER test IR/ER ratio in sitting at 90° of abduction and Upper-limb rotation test25 …
VIDEO 19a neutral rotation
VIDEO 20a
Ball taps on wall test … … …
VIDEO 21a
Prone ball-drop test … … …
VIDEO 22a
Abbreviations: CKCUEST, closed kinetic chain upper extremity stability test; ER, external rotation; HHD, handheld dynamometry; IR, internal rotation;
PSET, posterior shoulder endurance test; ROM, range of motion.
a

Domain 1: Pain Gradual-onset shoulder For contact-sport athletes, full shoul-
injuries7 are poorly defined, but the pres- Consensus point der joint ROM is likely a lower priority;
ence of long-lasting pain may hinder ath- Contact-sport athletes can return however, this is likely sport dependent.
letes from fully participating in training and to participation with pain, in a The lack of expectation for full ROM
competition. The consensus group found it controlled environment, but should was stronger among athletes involved
difficult to reconcile differences in the irri- be pain free before RTS or return to in sports played below shoulder height,
tability of pain levels between athletes with performance is attempted. in which the loss of ROM is less likely to
the importance of mental readiness to play impact performance.
with or without pain. Therefore, we recom- Domain 2: Active Shoulder Joint
mend that athletes in overhead/throwing ROM The relevance of regaining full Consensus point
sports should be pain free when they are shoulder joint ROM is extremely sport There is no expectation to achieve
expected to perform at their previous level specific and crucial to address early in full ROM at any stage of the
(or above). However, there are likely situa- the RTS continuum (ie, return to par- RTS continuum in contact-sport
tions where this is not possible. ticipation) (TABLE 7). Many sports do not athletes.
require full ROM to compete; however,

Consensus point others have specific end-range demands Domain 3: Strength, Power, and En-
Overhead/throwing athletes can that are prerequisites for return to per- durance All sports with demands on
return to participation with pain, formance (eg, throwing sports such as the shoulder have a shoulder strength
but should be pain free when at- baseball or swimming). Following some requirement (TABLE 8). Strength, power,
tempting to return to performance. injuries (eg, surgical repair of traumatic and endurance encompass many com-
shoulder instability), full preinjury ROM ponents, such as peak force, rate of force
For return to participation and RTS, is often not achieved—here, consider the development, fatigue resistance, velocity
there was no consensus on whether over- requirements of the sport more than the of contraction, etc. Shoulder strength
head/throwing athletes should be pain athlete’s preinjury capabilities. requirements are sport and position
free, but contact-sport athletes were ex- specific.
pected to be pain free. We recommend In throwers and other sports with a
Consensus point
the Strategic Assessment of Risk and Risk rapid movement of the shoulder, such as
Overhead/throwing athletes do not
Tolerance framework82 for additional tennis and badminton, speed is essen-
need full ROM prior to return to

guidance. TABLE 6 is designed to help sup- tial. So, too, is decelerating the arm dur-
participation, but full ROM should
port the reader to identify some examples ing the follow-through phase. In sports
be restored before RTS.
of decisions around athletes in pain. such as rugby and gymnastics, bracing

Case Examples Illustrating How Pain May Impact the Return-to-Sport
TABLE 6
Decision-Making Process Post Shoulder Injury
Pain Case 1 Case 2 Case 3

Characteristics Below shoulder height, with or without Above shoulder height, with or without throwing: Reverse chain: gymnastics. Gradual-onset rotator cuff
throwing: rugby. Posttraumatic shoul- handball. Throwing-arm rotator cuff tear (grade 2) tendinopathy
der instability
What might the Pain is likely not an important feature un- Given the insidious onset of the injury, the player The gymnast is likely to have pain during specific actions or
athlete report? less it reduces the athlete’s confidence may have reported increasing discomfort and in certain positions (hanging or standing on hands, with or
and willingness to perform sport- pain during throwing, especially during competi- without high-speed impact). For an all-around gymnast,
specific movements (ie, to perform tion. Minor shoulder soreness post training may return to training should be limited to the disciplines not
actions without “guarding”) be acceptable during return to training, with provoking pain. For a professional athlete who specializes
controlled throwing in elevation angles not in a specific discipline (eg, still rings), promote progressive
causing pain and limited contact with opponents. return to sports by limiting the impact of body weight during
Monitoring the posttraining pain is important. the swing, or by the position of the hands, for instance, a
The athlete should be pain free for return to neutral grip rather than an L grip. A return to performance is
competition only likely once the athlete is pain free
What might you Worst pain (NRS) during training activities Pain NRS during direct contact (from the therapist Pain NRS during training (including specific exercises), after
measure? initially), with padding in place as planned to use training, and the day after
in training and games
Abbreviation: NRS, numeric rating scale.

and stability in the presence of exter- section, we use the term strength without
Consensus point
nal perturbation are more important further clarification. We invite clinicians
The ER/IR strength ratios are impor-
than rapid shoulder movements. Power to differentiate based on the individual
tant for athletes in overhead/throw-
is important in weight lifting, while athlete’s requirements.
ing sports, but should not be used in
strength and endurance are important Shoulder strength can be reliably as-
isolation. Absolute strength values
in swimming. sessed with a handheld dynamometer.
also need to be considered to de-
Most sports have more than 1 type of However, strength values depend on the
termine functional shoulder capacity.
strength requirement (eg, handball in- mode of testing (eg, isometric versus ec-
cludes speed, power, and stability, and centric or break testing), the experience There was no consensus on the use
there is a complex interplay between and skill of the clinician and athlete, the of ER/IR ratios in collision sports. In
these variables). In the remainder of this position of testing, and the sport.22,24 this athlete population, it may be pref-

Case Examples Illustrating How to Consider Shoulder Range
TABLE 7
of Motion During the Return-to-Sport Continuum
Active ROM Case 1 Case 2 Case 3

Characteristics Below shoulder height, with or without throwing: Above shoulder height, with or without throwing: Reverse chain: gymnastics. Gradual-onset rotator
rugby. Posttraumatic shoulder instability handball. Throwing-arm rotator cuff tear (grade 2) cuff tendinopathy
What might the Shoulder stiffness; the athlete may not regain (or End-range pain in full elevation or abduction-ER; No ROM limitations for some disciplines (for
athlete report? need to regain) full preinjury ROM articular ROM deficits are not to be suspected, instance, pommel horse), but needs unrestricted,
except limited IR ROM as a sport-specific adapta- “more-than-normal” ROM for other disciplines,
tion (GIRD) such as rings. In particular, the L grip requires full
ROM into elevation and IR
What might you With nonsurgical treatment, the player will likely ROM with special focus on IR and ER in a 90° ab- ROM into elevation, under different demands/posi-
measure? lose active ROM in shoulder elevation. Active ducted position. Common criteria are a side-to-side tions, with full ER or IR
movement may be accompanied by painless difference of <20° of IR in favor of the nondominant
crepitus. Reassurance regarding noise in the side, +5° to 10° of ER in favor of the dominant side,
absence of pain or a sensation of instability and a side-to-side difference of <10° of total ROM
can be provided (IR + ER) in favor of the nondominant side
Abbreviations: ER, external rotation; GIRD, glenohumeral internal rotation deficit; IR, internal rotation; ROM, range of motion.

Case Examples Illustrating How to Consider Upper-Limb/Shoulder Strength,
TABLE 8
Power, and Endurance During the Return-to-Sport Continuum
Strength Case 1 Case 2 Case 3

Characteristics Below shoulder height, with or without Above shoulder height, with or without throwing: handball. Throwing- Reverse chain: gymnastics. Gradual-onset
throwing: rugby. Posttraumatic arm rotator cuff tear (grade 2) rotator cuff tendinopathy
shoulder instability
What might you ask the Athlete-reported confidence during Athlete-reported stability, ability to load and to change speed and Athlete-reported confidence during hanging
athlete about? collisions and while performing usual direction with arm movements (should not give symptoms of and high-impact swinging, handstand-
weight training exercises, especially pain/ache afterward) ing, and high-impact tumbling
the bench press and shoulder fly
What measures of Isometric strength in all planes Isometric strength, mainly into ER and IR, with the following criteria General shoulder strength in all directions.
strength, power, or Countermovement plyometric press-ups for the ER/IR ratio: 0.70 to 0.75 when measured in neutral supine; In gymnastics, symmetric strength
endurance might The Delphi process suggested isokinetic 0.90 to 1.00 when measured seated, with 90° of abduction and values are to be expected, with a slight
you use? (if available) values for an ER/IR neutral rotation; and 0.60 to 0.85 when measured seated, using advantage for the dominant side
strength ratio at 60°/s of approxi- abduction with ER24
mately 0.7 for rugby In professional players, consider measuring eccentric strength with
an isokinetic dynamometer, with a dynamic ratio (eccentric ER/
concentric IR) of 1.00
Consider endurance testing with the shoulder endurance test (endur-
ance test for ER in abduction-ER)26
Abbreviations: ER, external rotation; IR, internal rotation.

erable to compare absolute strength to in the preseason) helps to establish mance (velocity, force).19 Inefficiency in
preinjury test results.29 Due to the het- within-athlete norms and can inform any of the links proximally in the chain
erogeneity of ratios suggested for differ- the RTS process with individual ath- could increase distal demands, requiring
ent sports, we are unable to recommend letes, as opposed to relying on popula- other constituent parts of the chain to
specific values. Absolute or raw values tion norms. increase their contribution to avoid en-
for ER and IR strength and power are Domain 4: Kinetic Chain Hitting and ergy loss.
more important than a universal ER/ throwing biomechanics vivify the kinetic Identifying inadequate movement
IR ratio, as ratios alone do not indicate chain: linked segments that operate in strategies wherever they occur along
readiness to RTS (ie, an athlete who a proximal-to-distal sequence of energy the length of the kinetic chain, and ad-
is weak could still have a perfect ER/ transfer,30 where velocity produced at dressing them, is central to quality
IR ratio if he or she is weak into both the most proximal segment progresses rehabilitation.47
movements). to the distal segments (TABLE 9).74 An Domain 5: Psychological Readiness Ad-
Clinicians choosing to use raw val- efficient kinetic chain generates, ag- dressing psychological readiness to RTS
ues should normalize the results to gregates, and facilitates controlled me- is critical when supporting athletes to
body weight for between-athlete com- chanical energy transfer along the entire RTS (TABLE 10). The athlete must feel
parison. Collecting baseline data (eg, chain, contributing to enhanced perfor- comfortable before progressing to the

Case Examples Illustrating How to Consider the Kinetic
TABLE 9
Chain During the Return-to-Sport Continuum
Kinetic Chain Case 1 Case 2 Case 3

rugby. Posttraumatic shoulder instability handball. Throwing-arm rotator cuff tear (grade cuff tendinopathy
2)
What might you Inability to adequately position the legs and trunk Reduced leg and trunk strength may leave the player Athletes with a “reverse” kinetic-chain demand often
observe? prior to making contact in a tackle may place the vulnerable to “losing” routine collisions and fall- lack core stability and dynamic lower-limb stabil-
athlete in an at-risk position. This can be related ing onto the shoulder ity in an upright position, and have an imbalance
to reduced leg strength and/or reduced aerobic in development of muscle volume and strength
fitness between the upper and lower quadrants
What might you Squat-predicted 1RM (leg strength), 30-15 intermit- Squat-predicted 1RM15 (leg strength), 30-15 intermit- Functional tests in the closed chain, such as the
measure? tent running test (aerobic capacity of the legs) tent running test,16 side-to-side jumps and lateral YBT-UQ and ULRT25
jumps (aerobic capacity of the legs)
Variations of dynamic side planks
Abbreviations: 1RM, 1-repetition maximum; ULRT, upper-limb rotation test; YBT-UQ, Y Balance Test upper quadrant.

Case Examples Illustrating How to Consider the Psychological Component
TABLE 10
of Athlete Readiness During the Return-to-Sport Continuum
Psychological Case 1 Case 2 Case 3

Characteristics Below shoulder height, with or without throwing: Above shoulder height, with or without throwing: Reverse chain: gymnastics. Gradual-onset rota-
rugby. Posttraumatic shoulder instability handball. Throwing-arm rotator cuff tear (grade tor cuff tendinopathy
2)
What might you ask The player should feel comfortable with shoulder The player should feel comfortable with shoulder The gymnast should feel comfortable with
the athlete about? impact situations (eg, falling on the shoulder, impact situations (eg, falling on the shoulder, maximum-speed hanging, swinging, and high-
tackling and wrestling) tackling and wrestling), as well as throwing in impact tumbling
unexpected situations (direction of throwing,
impact from an opponent)
What might you use SIRSI37 Tampa Scale of Kinesiophobia Tampa Scale of Kinesiophobia
to measure?a Tampa Scale of Kinesiophobia90 I-PRRS I-PRRS
I-PRRS38
Abbreviations: I-PRRS, Injury-Psychological Readiness to Return to Sport scale; SIRSI, Shoulder Instability Return to Sport after Injury scale.
a
The scales and outcome measures suggested are examples; other options to capture this concept exist.

next phase of the RTS continuum. Before jury data are unavailable, sport-specific greater sample sizes are needed to refine
return to participation, no apprehension population norms could be a reasonable our knowledge of the RTS process follow-
during resistance training in the end substitute, although these data must be ing shoulder injury.
range of shoulder motion or throwing at interpreted and applied cautiously and
a specified intensity may support psycho- should always be tailored to the level of the Priorities for Future Study
logical readiness to RTS. Before RTS and athlete (ie, norms for throwing velocity in The areas of nonconsensus from our Del-
return to performance, no apprehension professional athletes are unlikely to apply phi process and expert meeting indicate
during contact with opponents and low to the weekend warrior). priorities for future research. We present
fear of reinjury may support psychologi- them here.
cal readiness to RTS.5,37 Limitations • How effective are early/youth preven-
Domain 6: Sport Specific We intend the Education was not discussed explicitly in tion programs at reducing overuse
sport-specific examples to illustrate a either of the Delphi rounds or at the in- shoulder injuries among adult elite
framework that supports clinical reason- person meeting. Much of what we have and amateur athletes?
ing (TABLE 11). Knowing the demands of laid out implicitly signals the need for • Are there individual sports where spe-
the athlete’s sport is crucial to support- education (eg, in load management). We cific shoulder screening is recommend-
ing successful RTS, especially in return to recognize that education is an important ed due to the high demands placed
performance.5 In some sports, the shoul- consideration during the RTS of an ath- specifically on the shoulder joint?
der-specific demands differ substantially lete; however, this was not included by • Which are the best measurements of
across different playing positions, which any of our experts during the Delphi state- internal and external loads to capture
must be considered when deciding on RTS ments in round 1 or 2, and was not con- for supporting return to training, sport,
criteria. As covered in domain 3 (strength, sidered at the in-person meeting in Bern. and performance post shoulder injury?
power, and endurance), compare to the This consensus process was initiated • Do strength or power measurements
athlete’s preinjury values for the key de- due to a lack of underpinning research explain capacity to tolerate load in dif-
mands of the sport, which may entail spe- in the area of RTS post shoulder injury. ferent sports?
cific performance tests such as swimming Our recommendations, therefore, come • Does scapular dyskinesis increase the
50 m in a set time or throwing a specific primarily from expert opinion. More risk of pain following a shoulder in-
distance or velocity in training. If prein- prospective longitudinal studies with jury in sport?

Case Examples Illustrating How to Consider Sport-Specific
TABLE 11
Demands During the Return-to-Sport Continuuma
Sport Specific Case 1 Case 2 Case 3

rugby. Posttraumatic shoulder instability handball. Throwing-arm rotator cuff tear (grade cuff tendinopathy
2)
What data might you Reported confidence (ie, no apprehension) on Reported confidence (ie, no pain) on resuming Completion of a progressive return to gymnas-
gather? resuming sport- and position-specific attack- sport- and position-specific attacking and tics, with full confidence
ing and defensive drills defensive drills Ability to efficiently execute all technical elements
Reported confidence in completing all training, Reported confidence in completing all training, es- of the gymnastic techniques in all disciplines
especially strength and conditioning pecially strength and conditioning and throwing required
Which tests might help CKCUEST25 (VIDEO 11b) CKCUEST (VIDEO 11b) CKCUEST (VIDEO 11b)
you decide whether Collision practice completed Push-ups with claps (VIDEO 10b) ULRT
the athlete is ready Power tests (eg, press jump, countermovement Seated medicine-ball throw25 (VIDEO 16b) YBT-UQ40 (VIDEO 14b)
to return to sport? plyometric press-up, box land), with no issues Consider using position-specific drills YBT-LQ (VIDEO 14b)
on return to contact drills Consider testing the athlete when fatigued
Completion of at least 2 high-level trainings Posterior shoulder endurance test32,33,63 (see
Consider using position-specific drills TABLE 5) (VIDEO 12b)
Consider testing the athlete when fatigued Hop tests for the lower limb to establish effective
power production and assess the ability to
transfer force
Abbreviations: CKCUEST, closed kinetic chain upper extremity stability test; ULRT, upper-limb rotation test; YBT-LQ, Y Balance Test lower quadrant; YBT-
UQ, Y Balance Test upper quadrant.
a
See TABLE 5 for sport-specific return-to-sport test recommendations.
b

Summary development of the full Delphi process Those involved in the in-person meeting
When supporting athletes to manage (article selection, question formation, in Bern were: Clare Ardern (cochair), Martin
shoulder injury (including avoiding survey collation, and feedback), co- Asker, Mario Bizzini (host), Paul Blazey
primary injury, designing appropriate chaired the in-person meeting in Bern, (cochair), Ann Cools, Suzanne Gard, Martin
rehabilitation, and supporting shared and led the development of the manu- Hägglund, Ian Horsley, Merete Møller, and
RTS decisions), we encourage clinicians script. Drs Møller, Asker, Andersson, Ariane Schwank (cochair).
to start by identifying the individual de- Hägglund, Skazalski, Horsley, White-
mands of the sport. Such an approach ley, Cools, and Bizzini and Suzanne
will form a solid base from which to ef- Gard all participated in the Delphi REFERENCES
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consensus statement on return to sport from the

with this statement are designed to sup- the production of this statement.
First World Congress in Sports Physical Therapy,
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@ MORE INFORMATION
88. Struyf F, Tate A, Kuppens K, Feijen S, Michener injuries. Br J Sports Med. 2018;52:1223-1224.
LA. Musculoskeletal dysfunctions associated https://doi.org/10.1136/bjsports-2017-098547
with swimmers’ shoulder. Br J Sports Med. 95. Werin M, Maenhout A, Smet S, Van Holder L, WWW.JOSPT.ORG
BROWSE Collections of Articles on JOSPT’s Website

JOSPTs website (www.jospt.org) offers readers the opportunity to browse
published articles by Previous Issues with accompanying volume and issue
numbers, date of publication, and page range; the table of contents of the
Upcoming Issue; a list of available accepted Ahead of Print articles; and
a listing of Categories and their associated article collections by type
of article (Research Report, Case Report, etc).
Features further curates 3 primary JOSPT article collections:

Musculoskeletal Imaging, Clinical Practice Guidelines, and Perspectives
for Patients, and provides a directory of Special Reports published
by JOSPT.

APPENDIX A
EXERCISE RECOMMENDATIONS FOR INJURY PREVENTION AND

REHABILITATION FROM THE DELPHI SURVEY (ROUND 1)
Low Load
Range of Motion/Strength Training Plyometrics Open/Closed Kinetic Chain
Isometric ER strength Drop catches/release and catch of ball (eg, sidelying with a Plank with arm movements
weighted ball or standing IR/ER in 90°/90°) (VIDEO 2)
Posterior cuff activation in various planes (eg, hitchhiker: Anterior cuff activation (eg, ball taps in 90°/90°) Resisted wall slides
resisted external rotation supported in the 90°/0° or
90°/90° plane)
Variations of glenohumeral ER Elastic bands (fast concentric to slow eccentric) in 90° Push-up variations (including hands in line with head,
• In 45° of abduction/flexion push-up back drop, sling, etc)
• In 90° of abduction/flexion
• Overhead height with an eccentric focus Push-up with a plus
Prone, weighted ER in 90°/90° Plyometric weighted ER in sidelying Deep neck flexor exercises (supine and standing)
Integrated upward scapular rotation control, with well- Supine plyometric ER in 90°/90° Closed kinetic chain exercises (eg, Y Balance Test exer-
controlled ER cises) (VIDEO 14)
Scaption with low load and a focus on scapular control Variations of plyometric catch and release with a long lever (Preactivation) “stick push” partner exercise (both in the
ready position)
IR in the abduction-ER position End-range shoulder flexion with small oscillations (elastic/ (Preactivation) dynamic trunk rotations, with stable upper
ball against the wall/manual resistance) extremities
ER activation in different body positions, with progressively … Prone (gluteus-hamstring machine) single-arm Y isometric
less support hold
• Prone
• Tabletop
• Prone plank
Weighted ER in side plank … …
Abbreviations: ER, external rotation; IR, internal rotation.
High Load
Range of Motion/Strength Training Plyometrics Open/Closed Kinetic Chain
(Preactivation) IR/ER in 90°/90° with tubing in a squat Prone end-range throwing position with rotator cuff on/off Bear crawls
position (ER/IR): speed isometrically
Standing with the arm elevated and with the hand on a ball Posterior shoulder deceleration drills (0.5- to 1.0-kg Unilateral shoulder press (dominant arm) in combination
against the wall (resistance bands) medicine ball) with a step-up (explosive strength)
Hand/foot: stretching for the last degrees of arm elevation
and upward scapular rotation (VIDEO 4)
Weighted ER in 90° of abduction Fast concentric, slow eccentric ball throw in the abduction- W-V exercises: plank on an exercise ball with ER
ER position/plyometric ball catch-and-release exercises
(VIDEO 8)
Overhead elastic shoulder flexion with ER activation Clap push-up/plyometric press-up (VIDEO 10) Turkish get-up
Y raises with tubes or dumbbells (VIDEO 7) Catching exercises with a plyoball in side or prone planking Resistance-band throwing technique with pelvic drive
Long-lever resisted/weighted horizontal abduction and Control of position in cocking Overhead squats
flexion with ER
Y exercise: supine, wall, standing (posterior cuff facilitation Derby shoulder stability program …
through the scaption/flexion plane)
Cable catches (T position) for anterior shoulder protection Throw/catch from behind …
Overhead shoulder diagonals (PNF, diagonal 2: manual … …
resistance/elastic/light dumbbells)
Abbreviations: ER, external rotation; IR, internal rotation; PNF, proprioceptive neuromuscular facilitation; V, position with extension of the elbows; W, posi-
tion with flexed elbows and arms parallel to the body.
journal of orthopaedic & sports physical therapy | volume 52 | number 1 | january 2022 | a1

APPENDIX B
SPORTING ENVIRONMENT–APPROPRIATE PATIENT-REPORTED OUTCOME MEASURES

SUGGESTED BY THE DELPHI GROUP FOR SUPPORTING RETURN-TO-SPORT DECISIONS
The following table is a list of patient-reported outcome measures collected from the online Delphi survey (rounds 1 and 2) and the in-person meeting.
Suggestions are not sport specific.
Function, Disease Specific Psychological PROMs Related to Sports
Kerlan-Jobe Orthopaedic Clinic overhead athlete scores1 Injury-Psychological Readiness to Return to Sport scale38
Shoulder Instability Return to Sport after Injury scale37 Shoulder Instability Return to Sport after Injury scalea
Oslo Sports Trauma Research Centre Overuse Injury Questionnaire21 Psychological readiness/confidence score/self-efficacy scoreb
Functional Arm Scale for Throwers80
Abbreviation: PROM, patient-reported outcome measure.
a
Psychological readiness subscale.
b
Using a 0-to-10 numeric rating scale.
a2 | january 2022 | volume 52 | number 1 | journal of orthopaedic & sports physical therapy

APPENDIX C
SHOULDER-SPECIFIC PATIENT-REPORTED OUTCOME MEASURES SUGGESTED BY

THE DELPHI GROUP FOR SUPPORTING RETURN-TO-SPORT DECISIONS
The following table is a list of patient-reported outcome measures collected from the online Delphi survey (rounds 1 and 2) and the in-person meeting.
Suggestions are not sport specific.
General Shoulder Function Disease Specific
Shoulder Pain and Disability Index Western Ontario Shoulder Instability Index
American Shoulder and Elbow Surgeons standardized shoulder assessment form Melbourne Instability Shoulder Scale
Disabilities of the Arm, Shoulder and Hand questionnaire
Constant-Murley score
Penn Shoulder Score (satisfaction, function, pain)
Patient-Specific Functional Scale

Simple shoulder test
journal of orthopaedic & sports physical therapy | volume 52 | number 1 | january 2022 | a3

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[ consensus statement ]

2022 Bern Consensus Statement

athlete performance, training, and daily life.61,64 clinicians, athletes, and

journal of orthopaedic & sports physical therapy | volume 52 | number 1 | january 2022 | 11

Design There are different approaches to recruit-

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journal of orthopaedic & sports physical therapy | volume 52 | number 1 | january 2022 | 13

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the utility and recommended frequency Exercise Programs

TABLE 1 Components of Exercise Programs to Manage

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Example of Monitoring Workload Youth Athletes Adult Athletesa Professional Athletesb

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through rehabilitation is governed by

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Target Exercise Description Videoa

Open/closed kinetic chain High plank with ER in 90°/90° VIDEO 6

Open/closed kinetic chain

Collision sports: clap push-up VIDEO 10

Abbreviation: ER, external rotation.

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journal of orthopaedic & sports physical therapy | volume 52 | number 1 | january 2022 | 19

Performance Test ROM/Strength Test Kinetic Chain Sport-Specific Test Example

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require full ROM to compete; however,

need full ROM prior to return to

Pain Case 1 Case 2 Case 3

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Active ROM Case 1 Case 2 Case 3

Strength Case 1 Case 2 Case 3

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Kinetic Chain Case 1 Case 2 Case 3

Psychological Case 1 Case 2 Case 3

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Sport Specific Case 1 Case 2 Case 3

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2. Andersson SH, Bahr R, Clarsen B, Myklebust

3. Andersson SH, Bahr R, Olsen MJ, Myklebust G.

consensus statement on return to sport from the

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26 | january 2022 | volume 52 | number 1 | journal of orthopaedic & sports physical therapy

journal of orthopaedic & sports physical therapy | volume 52 | number 1 | january 2022 | 27

98. Windt J, Gabbett TJ. How do training and

BROWSE Collections of Articles on JOSPT’s Website

Features further curates 3 primary JOSPT article collections:

28 | january 2022 | volume 52 | number 1 | journal of orthopaedic & sports physical therapy

EXERCISE RECOMMENDATIONS FOR INJURY PREVENTION AND

journal of orthopaedic & sports physical therapy | volume 52 | number 1 | january 2022 | a1

SPORTING ENVIRONMENT–APPROPRIATE PATIENT-REPORTED OUTCOME MEASURES

a2 | january 2022 | volume 52 | number 1 | journal of orthopaedic & sports physical therapy

SHOULDER-SPECIFIC PATIENT-REPORTED OUTCOME MEASURES SUGGESTED BY

Patient-Specific Functional Scale

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