Shoulder pain and instability in athletes

ACL-specific consensus defining return to sport as a criteria-based continuum rather than a time point, and setting out testing and shared decision-making for clearance after ACL injury.

• Return to sport is a criteria-based continuum, return to participation, then return to sport, then return to performance, not a single date.
• Clearance should rest on objective testing (strength, hop, movement quality, psychological readiness), not time since surgery alone.
• The decision is shared between clinician and athlete, accounting for the sport's demands and the athlete's risk tolerance.

Our appraisal: Consensus via modified Delphi, so it sets the decision framework rather than validating any single test battery or cut-off. It is most useful as a reminder that a passed clock is not a passed knee; the specific thresholds still lack strong prospective validation.

International expert Delphi consensus defining posterior shoulder instability subtypes and agreeing assessment and rehabilitation priorities.

• Reached consensus on three posterior instability subtypes: traumatic, microtraumatic and atraumatic.
• Strong agreement (around 98 to 100 percent) that atraumatic and microtraumatic cases are managed first with exercise targeting scapular position, humeral head control, rotator cuff and sport or occupation specific training.
• Panel drawn from physiotherapists, orthopaedic surgeons, sports physicians and researchers across several countries.

Our appraisal: A modified Delphi among a modest international expert panel, so it captures where clinicians agree rather than proving any protocol works. Most useful for structuring assessment and rehabilitation of a poorly researched problem; treat the specific exercises as reasoned opinion pending trials.

UK care pathway for atraumatic and muscle-patterning shoulder instability, prioritising specialist physiotherapy over surgery.

• Atraumatic instability is primarily managed with prolonged, specialist-led rehabilitation targeting scapular and rotator cuff control.
• Surgery has a limited, carefully selected role and is not first line, given poorer outcomes in muscle-patterning presentations.
• Emphasises accurate classification, since traumatic, atraumatic and muscle-patterning subtypes need different pathways.

Our appraisal: Expert consensus pathway, not a controlled comparison, so its strong steer towards rehabilitation reflects specialist opinion and the poor track record of surgery in this group rather than head-to-head trial data. Its main value is discouraging premature operations in a population that usually does better with time and targeted physiotherapy.

A GRADE-based clinical practice guideline making a strong recommendation against subacromial decompression surgery for atraumatic, rotator-cuff-related shoulder pain.

• The panel makes a strong recommendation against subacromial decompression surgery for subacromial pain syndrome.
• Evidence from randomised trials, including sham-surgery comparisons, shows no important benefit over placebo surgery or exercise-based care.
• Exercise and conservative management should be the default; surgery does not add meaningful benefit for atraumatic shoulder pain lasting more than three months.

Our appraisal: Unlike most consensus documents this is an explicit GRADE guideline anchored to randomised and sham-controlled evidence, so the strong recommendation carries real weight rather than expert opinion alone. It is a clean example of a common operation losing its place once placebo-controlled trials are done.

Defines and operationalises 'return to sport' as a continuum (return to participation, return to sport, return to performance), with a shared decision-making framework (StARRT).

• Operationalises return to sport as a three-stage continuum applicable across injuries, not just ACL.
• Introduces the StARRT framework (Strategic Assessment of Risk and Risk Tolerance) for the return decision.
• Frames clearance as shared decision-making under uncertainty rather than a purely biological milestone.

Our appraisal: A foundational framework paper rather than an evidence synthesis. Its strength is a shared language for the return-to-sport decision: it tells you how to structure the decision, not what the pass criteria are, so pair it with injury-specific testing evidence.

UK best-practice care pathway for traumatic anterior shoulder dislocation and instability, covering diagnosis, imaging, rehabilitation and referral for stabilisation.

• History is central to diagnosis; a clear traumatic mechanism distinguishes this pathway from atraumatic instability.
• First-line management is structured rehabilitation, with stabilisation surgery considered for recurrent instability, younger athletes and those with significant bone loss.
• Provides diagnostic and management algorithms and expected follow-up, aimed at reducing recurrent dislocation.

Our appraisal: A consensus care pathway from UK specialist societies rather than a synthesis of trial evidence, so it standardises the route through the system more than it settles the surgery-versus-rehabilitation question. Useful for framing referral and expectations; the recurrence-risk factors it flags (age, bone loss, activity) are better evidenced than the specific rehabilitation content.