Objective Return-to-Sport (RTS) Decision Frameworks for Adolescent Shoulder and Elbow Injuries: Tests, Thresholds and...

Adolescent shoulder and elbow injuries are increasing due to sports specialization and year-round training, yet return-to-sport decisions typically rely on adult-derived heuristics that fail to address the unique physiology, growth plate vulnerability, and recovery needs of developing athletes aged 10-19 years.

This review proposes a novel, objective three-pillar RTS framework integrating: (1) foundational tissue capacity, (2) dynamic movement quality and neuromuscular control, and (3) sport-specific load tolerance. We synthesize current evidence to establish provisional, consensus-based adolescent thresholds and provide a practical bedside toolkit for immediate clinical implementation.

We conducted a narrative synthesis of contemporary original evidence, consensus recommendations, and validation studies relevant to adolescent shoulder and elbow rehabilitation. Evidence was critically appraised for youth-specific validation, with explicit distinction between evidence-based interventions and emerging aspirational technologies requiring prospective adolescent cohort validation.

We propose a hybrid benchmarking model combining limb symmetry indices (LSI ≥90%) with population-referenced percentiles (≥25th percentile for age/sex/sport) as provisional, consensus-based thresholds. A three-stage progression is outlined: Clinic-ready (pain-free ROM, isometric IR/ER LSI ≥90%), Training-ready (dynamic rotational LSI ≥90%, preserved scapular kinematics), and Game-ready (sport-specific tolerance with 5% velocity loss during simulated exposure). We provide a low-resource bedside toolkit including belt-stabilized hand-held dynamometry, Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), Push-Up Plus, Athletic Shoulder positions, seated medicine-ball throw, and simple interval tolerance simulations with specific protocols and thresholds. A stepwise algorithm advances from capacity → movement quality → load tolerance with targeted remediation at each gate.

Moving beyond time-based or adult-derived heuristics, this objective multidimensional framework aligns tissue recovery with sport-specific demands through quantifiable metrics. While provisional thresholds require further adolescent validation, the framework offers an evidence-guided pathway that mitigates reinjury risk, restores performance, and supports safe reintegration into sport. Implementation requires adolescent-specific normative databases, stakeholder communication, and cost-effective technological integration for equitable adoption.