2022 Bern consensus statement on shoulder injury prevention, rehabilitation, and return to sport for athletes at all participation levels

Key points

1. 01Injury prevention exercise programs should be prescribed to all athletes regardless of injury history, performed at least twice weekly
2. 02No single test or test battery can reliably determine readiness to return to sport after shoulder injury; a battery of sport-specific tests combined with clinical reasoning is required
3. 03Rehabilitation should be guided by irritability level rather than pathoanatomic diagnosis, integrating rotator cuff, scapular, and kinetic chain work simultaneously
4. 04Plyometric exercises should be included from the start of rehabilitation in both throwing and contact sports
5. 05Psychological readiness is a distinct domain that must be assessed alongside physical criteria before return to sport

How it was conducted

Design

Modified Delphi consensus process with 2 online survey rounds plus an in-person expert meeting

Online rounds

Round 1: 54 questions; Round 2: 25 questions with 39 experts participating

In-person meeting

6-hour discussion on November 21, 2019 in Bern, Switzerland, held 1 day before the Sportfisio Swiss symposium

Consensus threshold

Mean rating of 7 out of 10 or higher on an 11-point scale (0-10) set as the threshold for consensus

Literature search

Databases searched: Embase, MEDLINE, SPORTDiscus, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, plus Google Scholar, to July 2019

Scope

Athletes of all ages and participation levels across overhead, throwing, collision, and reverse-chain sports

What they found

• Round 1 comprised 54 questions and Round 2 comprised 25 questions; 39 experts participated in Round 2
• Large weekly increases in training or match load greater than 60% compared with the average of the previous 4 weeks are associated with an increased shoulder injury rate
• Handball players with reduced external rotation strength or scapular dyskinesis could withstand smaller increments in weekly load compared with stronger players (6 handball athletes followed for 31 weeks)
• Consensus was reached that injury prevention programs performed at least twice weekly represent the minimum effective dose
• No consensus was reached on whether scapular dyskinesis screening, isokinetic assessment, or specific ER/IR ratio thresholds should be universally applied across sports
• For overhead/throwing athletes, suggested ER/IR ratio criteria include 0.90 to 1.00 when measured seated with 90 degrees abduction and neutral rotation, and 0.60 to 0.85 when measured seated using the 90-degree/90-degree position; for rugby, an isokinetic ER/IR ratio at 60 degrees per second of approximately 0.75 was suggested

Limitations

• Recommendations are primarily expert opinion rather than high-quality prospective studies, limiting the strength of evidence
• Several key areas including which load measures are most valid, the utility of scapular dyskinesis screening, and ER/IR ratio norms for collision sports did not reach consensus
• Education as a component of return to sport was not discussed in either Delphi round or the in-person meeting and is therefore not covered
• The consensus group was composed of invited experts, introducing potential selection bias; the optimal method for recruiting Delphi participants is not established

Why it matters

For patients

Athletes recovering from shoulder injuries can expect that readiness to return to sport requires meeting criteria across pain, range of motion, strength, kinetic chain function, and psychological readiness, not just the absence of pain.

For clinicians

Clinicians should use irritability level to guide rehabilitation progression, prescribe plyometrics early, monitor load at least weekly, and apply a battery of sport-specific tests rather than relying on any single measure to clear an athlete for return to sport.

For readers

This consensus provides a structured, principle-based framework for shoulder injury management in sport, but highlights major evidence gaps that require prospective longitudinal research before definitive criteria can be established.