Research Review By Dr. Brynne Stainsby©


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Date Posted:

April 2023

Study Title:

2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at all Participation Levels


Schwank A, Blazey P, Asker M, et al.

Author's Affiliations:

Departments MOVement ANTwerp Research Group, Department of Rehabilitation Sciences and Physiotherapy, University of Antwerp, Antwerp, Belgium; Institute for Therapy and Rehabilitation, Kantonsspital Winterthur, Winterthur, Switzerland; Pain in Motion International Research Group, Brussels, Belgium; Physiotherapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada; Handball Research Group, Musculoskeletal and Sports Injury Epidemiology Center, Department of Health Promoting Science, Sophiahemmet University, Stockholm, Sweden; and more…

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2022; 52(1): 11-28.

Background Information:

Shoulder injuries commonly impact athletes at amateur and professional levels and can impact athletic performance, training and activities of daily living (1, 2). Despite the prevalence and impact of shoulder injuries, there is a lack of high-quality evidence to guide clinicians, athletes and coaches in appropriate management and return to sport (RTS) following injury.

Sportfisio Swiss (the Swiss Sports Physiotherapy Association), supported by JOSPT convened a consensus development group to synthesize evidence and establish best practices in shoulder injury prevention, rehabilitation, and RTS. The group aimed to develop a principle-based framework to guide:
  1. managing injury risk;
  2. managing and progressing load;
  3. rehabilitation; and
  4. RTS with respect to shoulder injuries.


Prevention of Shoulder Injuries:
  • Risk Factors: Results are conflicting, however, some modifiable risk factors have been proposed, including reduced range of motion (ROM), rotational strength imbalance, muscle weakness, changes in load, player position, professional/amateur status, previous history of shoulder pain and psychosocial factors (3-6). It should be noted that the role of load is highly debated but may be considered important with overuse injuries and with impact (5-7). Potential risk factors should be discussed in a shared decision-making framework to determine whether mitigation strategies are warranted (8).
  • Screening: There is a lack of evidence for predictive screening. Approximately half of the Delphi group recommended screening for scapular dyskinesis to help clinicians identify and address pre-existing issues to support RTS after shoulder injury, while the other half was against it. No tests were identified to support pre- or post-injury screens and as such, the experts present at the in-person meeting suggested a generic musculoskeletal screen including ROM, strength and any other sport-specific measurements.
  • Exercise Programs: Injury prevention programs have a low risk of harm, are minimally invasive, easy to implement and may have preventive potential for all athletes. The Delphi group agreed that all athletes should receive injury prevention exercise programs. Primary prevention (pre-injury) should begin in youth athletes due to the high prevalence and persistence of shoulder problems in adolescent and elite athletes (9, 10). Secondary prevention (post-injury) exercise programs may begin immediately post-injury or may become a focus later in recovery.
  • Implementing Exercise Programs: Although the evidence of exercise program effectiveness remains elusive, the Delphi group concurred that risk reduction can be achieved when the exercise programs are performed at least twice weekly. They also agreed that effective programs must support adherence, the education of coaches and athletes, and improve the attitude/self-efficacy of athletes towards participating in injury prevention programs (11-17).
Managing Shoulder-Specific Load in Athletes:
  • The balance between capacity and load appears to play an important role in injury risk management, rehabilitation, RTS and performance.
  • Shoulder-specific loads vary with number of throws, playing position, type of training and intensity of training. It appears that high overall shoulder-specific load exposure of more than 16 hours per week (18) and large weekly increases in training (i.e. greater than 60% increase compared with the average of the previous four weeks) are associated with increased shoulder injury rate (10, 18).
  • Recommendations based on total sporting exposure hours do not account for variations in internal load (i.e. physiological or psychological stress placed on the athlete during training or competition) – playing time or distance covered should not be the sole measure of load (19, 20).
  • Experts at the in-person meeting suggested that asking athletes to rate their exertion following training/competition may be a potential option to capture internal load. It is unclear how well shoulder specific rate of perceived exertion (RPE) represents the psychophysiological construct of perceived exertion (fatigue, heaviness, discomfort) (21), although RPE has been strongly correlated to summated heart rate zone measures in youth soccer, rugby, and field hockey athletes (22). Shoulder-specific RPE could also be combined with other training-related factors (for example, number of collisions/impacts) (23). Although the literature is unclear, monitoring RPE may help to identify athletes who are challenged to maintain high levels of training by capturing subjective responses to physiological stimuli. This can be collected by coaches, clinicians, training staff or self-monitored to provide minimally invasive and low cost data.
  • In a prospective study of handball athletes, players with reduced external rotation strength or scapular dyskinesis could withstand smaller increments in weekly load (training/match participation measured in hours) compared with stronger players/those without scapular dyskinesis (24). Based on these results, the experts suggested a minimum set of requirements for efficient workload monitoring for youth athletes in overhead and contact sports (including shoulder-specific RPE and repetition or collision counts), as well as for adult and professional athletes (Table 3 in the paper contains other examples). Future research is required to establish the validity and reliability of specific measures of shoulder load.
Key Principles for Quality Rehabilitation After Shoulder Injury:
  • Clinicians should consider athlete and sport-specific factors when designing a rehabilitation program for the injured athlete – a pathoanatomical diagnosis should not drive shoulder rehabilitation.
  • Experts agreed that clinicians supporting athletes post-shoulder injury should aim to improve biomechanics/technique; increase intensity to challenge athletes at the limit of their capacity; build resilience; involve a multidisciplinary team in a shared decision-making process (including the coach and athlete) to support integrating rehabilitation and performance measures (8, 25).
  • Clinicians should regularly test/monitor athletes throughout the rehabilitation process, using reliable and easily repeatable tests. Tools such as a handheld dynamometer, goniometer and outcome measures can be valuable for data collection, and the results should guide treatment planning and progression. If possible, aim to include the same relevant subjective and objective outcome measures that the athlete performs with the team in order to compare to pre-injury levels when possible.
Seven Key Principles to Restore Strength and Sport-Specific Movement Patterns
  1. Let irritability (pain at rest, pain at night, disability) guide the rehabilitation progress. This is a subjective measure based on the athlete’s tolerance.
  2. Address clinically relevant glenohumeral ROM deficits using active exercises, rather than passive therapies.
  3. Address the scapula in rehabilitation but do not screen for dyskinesis, as this may provide little to no clinical value as it is present in 53% of healthy individuals and 61% of overhead athletes (26, 27).
  4. Select appropriate exercises depending on the specific injury and the phase of rehabilitation.
  5. Include plyometric exercises early in the rehabilitation program to help athletes prepare for sport-specific loads
  6. ”Train the Brain”: Capitalize on the brain’s plasticity to reverse the neurological changes that can occur after injury and last longer than the injury itself. Techniques such as gradual exposure to fearful movements, motor imagery and mirror neurons can be incorporated (28-30).
  7. Incorporate sport-specific exercises, beginning with single-plane and progressing to complex, multiplane sport-specific exercises as soon as appropriate.
Return-to-Sport (RTS) Decisions:
  • The progression to RTS should encompass a continuum from return to participation (the athlete is active, but not yet “ready” to RTS fully), to RTS (athlete is returning, but participating below previous or “desired” level), to return to performance (returned to full/”desired” level without restrictions) (25).
  • The Delphi panel outlined six domains (based on consensus) of body structure and function that affect successful RTS following shoulder injury – clinical reasoning is often complex and influenced by context beyond the control of the athlete or clinician.
Six Domains to Consider for the Athlete who is Returning to Sport after Shoulder Injury:
  1. Domain 1 – Pain: The consensus group recommended that athletes in overhead/throwing sports should be pain-free when they are expected to perform at their previous level of competition (i.e. return to performance). Contact-sport athletes should be pain-free before returning to participation or RTS.
  2. Domain 2 – Active Shoulder ROM: The relevance of regaining full shoulder ROM is extremely sport-specific. It should be addressed early in the rehabilitation continuum. Following some injuries (such as surgical repair of traumatic shoulder instability), it may not be possible to achieve full, pre-injury ROM; consider the demands of the sport to guide return to competition.
  3. Domain 3 – Strength, Power and Endurance: All sports with demands on the shoulder have a strength requirement, however, the specific strength, power and endurance components will vary depending on the sport and position. Clinicians should consider that most sports have multiple demands on the shoulder and be sure to account for the load in the deceleration phase of a movement. There was no consensus on the use of ER/IR ratios in contact sports, thus, it may be more appropriate to compare absolute strength measures to pre-injury tests in this population and clinicians should normalize results to body weight if performing between-athlete comparisons (29).
  4. Domain 4 – Kinetic Chain: An efficient kinetic chain generates, aggregates and facilitates controlled mechanical energy transfer along the entire chain and contributes to enhanced performance (i.e. improved velocity or force). Identifying and addressing inadequate movement strategies along the length of the kinetic chain is important to the overall quality of the rehabilitation program (32).
  5. Domain 5 – Psychological Readiness: The athlete must feel comfortable before progression through the RTS continuum. Prior to return to participation, there should be no apprehension with resistance training at the end range of shoulder ROM or throwing at specified intensities. Before RTS and performance, there should be no apprehension during contact and low fear of reinjury (25, 33).
  6. Domain 6 – Sport-Specific: Knowing the demands of the athlete’s sport is critical to support a successful RTS. Consider the demands of the athlete’s sport and position, and compare to pre-injury baselines whenever possible.

Clinical Application & Conclusions:

Shoulder injuries can occur via numerous mechanisms and a thorough understanding of the sport- and position-specific demands is critical to injury prevention and post-injury rehabilitation for an individual athlete. Regardless of the level of competition, clinicians and coaches should consider integrating injury prevention programs/exercises, ideally within the context of team training, as this also has the potential benefit of improving performance.

Following injury, a rehabilitation program should be individualized based on the athlete’s injury, tolerance, and sport demands, particularly as there is a lack of clear evidence or consensus around the “best” exercises or rehabilitation approach. Starting with the specific demands of the sport will form a solid foundation to apply rehabilitation principles in practice. Clinicians should work with coaches and athletes to ensure that the individual is tolerating progression, that exercises are appropriate, and that the athlete is objectively and subjectively demonstrating improvement. The RTS process should follow a continuum from return to participation to RTS to return to performance, with careful monitoring at each stage. Please note that this paper includes several tables and additional resources including exercise examples.

Study Methods:

  • This consensus statement follows principles outlined in the 2016 Bern consensus on RTS (25).
  • A modified Delphi process was performed. First, two rounds of an online Delphi survey were conducted to identify areas of consensus, non-consensus (experts had mixed responses) and dissent (experts in consensus with their disagreement with a statement). Next, a smaller group of international experts who had participated in the original Delphi surveys participated in an in-person meeting to discuss and provide further guidance on topics of non-consensus.
  • The intention of expert recruitment was to balance research and clinical experience, gender, nationality, and professional representation.
  • The in-person meeting focused on crystallizing agreement from the Delphi survey and identifying additional areas of non-consensus to stimulate future research.
  • To obtain evidence required for statement construction in the first Delphi round, a literature review was conducted. Five databases and the grey literature were searched. Articles were reviewed by consensus committee organizers, prioritizing systematic reviews, clinical practice guidelines and original research. Articles without an athletic context and papers focused solely on surgical management were excluded.
  • Key themes were identified from the literature search, which then informed the statements constructed for the Delphi questionnaire. Two separate groups of questions focused on athletes in overhead/throwing sports and athletes in collision sports.
  • Round 1 of the Delphi process had 54 questions focused on: risk factors/injury risk reduction; training loads; rehabilitation and management of the scapula; rotator cuff/post-dislocation shoulder/instability; sport-specific rehabilitation and progression; and RTS criteria. An 11-point scale (0-10) was used with an average rating of 7 set as the threshold for consensus.
  • After analyzing feedback, additional questions were developed for Round 2, which were added to questions that failed to reach consensus in Round 1. Round 2 consisted of 25 questions.
  • Given the wide variety of demands on the athletic shoulder, the authors accounted for the type of sport (above/below shoulder height; with/without throwing); reverse chain (where the upper limbs act primarily as the point of contact with the environment, such as climbing or rowing); with/without contact/collision.

Study Strengths / Weaknesses:

  • Given this paper is a consensus statement, it provides a helpful overview of the available literature, as well as a structured approach to managing shoulder injuries.
  • The authors emphasize the importance of frequent monitoring throughout the rehabilitation process and this paper provides many low cost/minimally invasive suggestions to monitor athletes following injury.
  • A holistic approach, including neurological rehabilitation and subjective assessments of athlete’s apprehension around return to sport is recommended.
  • This paper provides additional resources to support clinicians.
  • The primary limitation of this paper is the lack of high-quality literature available, and as such, clinicians should approach the recommendations with some caution, pending further high quality evidence.
  • Future and more specific research would be valuable to provide specific recommendations for specific sports.

Additional References:

  1. Mohseni-Bandpei MA, Keshavarz R, Minoonejhad H, et al. Shoulder pain in Iranian elite athletes: the prevalence and risk factors. J Manipulative Physiol Ther 2012; 35: 541-548.
  2. Myklebust G, Hasslan L, Bahr R et al. High prevalence of shoulder pain among elite Norwegian female handball players. Scand J Med Sci Sports 2013; 23: 288-294.
  3. Asker M, Brooke HL, Waldén M, et al. Risk factors for, and prevention of, shoulder injuries in overhead sports: a systematic review with best-evidence synthesis. Br J Sports Med 2018; 52: 1312-1319.
  4. Asker M, Holm LW, Källberg H, et al. Female adolescent elite handball players are more susceptible to shoulder problems than their male counterparts. Knee Surg Sports Traumatol Arthrosc 2018; 26: 1892-1900.
  5. Møller M, Nielsen RO, Attermann J, et al. Handball load and shoulder injury rate: a 31-week cohort study of 679 elite youth handball players. Br J Sports Med 2017; 51: 231-237.
  6. Olds MK, Ellis R, Parmar P, et al. Who will redislocate his/her shoulder? Predicting recurrent instability following a first traumatic anterior shoulder dislocation. BMJ Open Sport Exerc Med 2019; 5: e000447.
  7. Udby CL, Impellizzeri FM, Lind M, et al. How has workload been defined and how many workload-related exposures to injury are included in published sports injury articles? A scoping review. J Orthop Sports Phys Ther 2020; 50: 538-548
  8. Dijkstra HP, Pollock N, Chakraverty R, et al. Return to play in elite sport: a shared decision-making process. Br J Sports Med 2017; 51: 419-420.
  9. Sakata J, Nakamura E, Suzuki T, et al. Throwing injuries in youth baseball players: can a prevention program help? A randomized controlled trial. Am J Sports Med 2019; 47: 2709-2716.
  10. Windt J, Gabbett TJ. How do training and competition workloads relate to injury? The workload–injury aetiology model. Br J Sports Med 2017; 51: 428-435.
  11. Asker M, Waldén M, Källberg H, et al. Preseason clinical shoulder test results and shoulder injury rate in adolescent elite handball players: a prospective study. J Orthop Sports Phys Ther 2020; 50: 67-74.
  12. Bekker S, Clark AM. Bringing complexity to sports injury prevention research: from simplification to explanation. Br J Sports Med 2016; 50: 1489-1490.
  13. Owoeye OBA, McKay CD, Verhagen E, et al. Advancing adherence research in sport injury prevention. Br J Sports Med 2018; 52: 1078-1079.
  14. Fortington LV, Donaldson A, Lathlean T, et al. When ‘just doing it’ is not enough: assessing the fidelity of player performance of an injury prevention exercise program. J Sci Med Sport 2015; 18: 272-277.
  15. McKay CD, Steffen K, Romiti M et al. The effect of coach and player injury knowledge, attitudes and beliefs on adherence to the FIFA 11+ programme in female youth soccer. Br J Sports Med 2014; 48: 1281-1286.
  16. Soligard T, Nilstad A, Steffen K, et al. Compliance with a comprehensive warm-up programme to prevent injuries in youth football. Br J Sports Med 2010; 44: 787-793.
  17. Steffen K, Meeuwisse WH, Romiti M, et al. Evaluation of how different implementation strategies of an injury prevention programme (FIFA 11+) impact team adherence and injury risk in Canadian female youth football players: a cluster-randomised trial. Br J Sports Med 2013; 47: 480-487.
  18. Matsuura T, Iwame T, Suzue N, et al. Risk factors for shoulder and elbow pain in youth baseball players. Phys Sportsmed 2017; 45: 140-144.
  19. Michalsik LB, Madsen K, Aagaard P. Technical match characteristics and influence of body anthropometry on playing performance in male elite team handball. J Strength Cond Res 2015; 29: 416-428.
  20. Paquette MR, Napier C, Willy RW, et al. Moving beyond weekly “distance”: optimizing quantification of training load in runners. J Orthop Sports Phys Ther 2020; 50: 564-569.
  21. Halperin I, Emanuel A. Rating of perceived effort: methodological concerns and future directions. Sports Med 2020; 50: 679-687.
  22. Scantlebury S, Till K, Atkinson G, et al. The within-participant correlation between s-RPE and heart rate in youth sport. Sports Med Int Open 2017; 1: E195-E199.
  23. McLaren SJ, Macpherson TW, Coutts AJ, et al. The relationships between internal and external measures of training load and intensity in team sports: a meta-analysis. Sports Med 2018; 48: 641-658.
  24. Møller M, Nielsen RO, Attermann J, et al. Handball load and shoulder injury rate: a 31-week cohort study of 679 elite youth handball players. Br J Sports Med 2017; 51: 231-237.
  25. Ardern CL, Glasgow P, Schneiders A, et al. 2016 consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. Br J Sports Med 2016; 50: 853-864.
  26. Plummer HA, Sum JC, Pozzi F, et al. Observational scapular dyskinesis: known-groups validity in patients with and without shoulder pain. J Orthop Sports Phys Ther 2017; 47: 530-537.
  27. Burn MB, McCulloch PC, Lintner DM, et al. Prevalence of scapular dyskinesis in overhead and nonoverhead athletes: a systematic review. Orthop J Sports Med 2016; 4: 2325967115627608.
  28. Boudreau SA, Farina D, Falla D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Man Ther 2010; 15: 410-414.
  29. Rizzolatti G, Fabbri-Destro M, Cattaneo L. Mirror neurons and their clinical relevance. Nat Clin Pract Neurol 2009; 5: 24-34.
  30. Snodgrass SJ, Heneghan NR, Tsao H, et al. Recognising neuroplasticity in musculoskeletal rehabilitation: a basis for greater collaboration between musculoskeletal and neurological physiotherapists. Man Ther 2014; 19: 614-617.
  31. Edouard P, Frize N, Calmels P, et al. Influence of rugby practice on shoulder internal and external rotators strength. Int J Sports Med 2009; 30: 863-867.
  32. Horsley I. The kinetic chain approach to shoulder evaluation in athletes. InTouch 2019; 168: 4-9.
  33. Gerometta A, Klouche S, Herman S, et al. The Shoulder Instability-Return to Sport after Injury (SIRSI): a valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability. Knee Surg Sports Traumatol Arthrosc 2018; 26: 203-211.

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