Age- and time-specific management of traumatic anterior shoulder instability: The 2024 ESSKA-ESA Formal Consensus. Part 2: Treatment and return to sports.

PURPOSE: To establish age- and time-specific recommendations for the treatment of traumatic anterior shoulder instability (TASI) and for return-to-sport (RTS) decision-making through a formal consensus process among European experts.

METHODS: The European Society of Sports Medicine, Knee Surgery and Arthroscopy-European Shoulder Associates (ESSKA-ESA) formal consensus methodology was followed. A steering group formulated 35 clinically relevant questions, 23 of which addressed treatment and RTS and are reported in Part 2. A structured literature review was conducted. Statements were drafted and graded based on the level of scientific support. Then, the rating group reviewed and refined the statements, followed by validation from the reader group for cultural adaptability. Recommendations were tailored by age group (adolescents, young adults and older adults) and timing of instability (first-time vs. recurrent).

RESULTS: The final global median (range) of the 23 questions was 9 (8-9). Eleven questions achieved strong agreement, 11 relative agreement and 1 uncertain agreement. The grades of recommendations were: A in 0 (0%) statements, B in 30 (35.3%) statements, C in 24 (28.2%) statements and D in 31 (36.5%) statements (each statement could have more than one grade of recommendation). Bone loss and soft tissue lesions were key factors in decision-making. The consensus emphasized individualized thresholds for surgical versus conservative management, highlighting the role of bone augmentation in subcritical (bone loss 10%-15%) (especially in bipolar bone loss) and critical defects (bone loss >20%), lesion-specific soft tissue repair and the limited role of immobilization. RTS criteria included pain-free full range of motion, shoulder stability, strength and sport-specific readiness, typically achieved between 4 and 6 months depending on the procedure and sport demands.

CONCLUSIONS: This ESSKA-ESA European Formal Consensus delivers practical, evidence- and experience-based recommendations for treatment and RTS following TASI according to age- and time-specific (first time and recurrent) scenarios. By integrating recurrence status, bone loss, soft tissue injury and sport type, the consensus provides a clinically valuable framework for individualized decision-making.

LEVEL OF EVIDENCE: Level II.