Table 1 Vignette descriptions

Vignette 1 (Type II instability)

Twenty-six-year-old male with atraumatic shoulder instability. Works as an accountant and used to play county cricket but stopped due to developing difficulty with throwing. He has avoided excessive overhead use since then. Complains of sensation of instability and discomfort in right shoulder, particularly on reaching overhead and gardening; been going on for a few years.

He had a Magnetic Resonance Arthrogram (MRA) which shows Bankart lesion of the anterior labrum. He has been referred to physiotherapy by an Extended Scope Practitioner. He now wants to get back to fitness and has started running and upper body weight training. He is struggling with weights due to pain. He wonders whether exercise is the right thing for his shoulder.

On examination he has full range of movement, with notably excessive external rotation. He has a positive gleno-humeral internal rotation deficit (GIRD) test. He has positive anterior apprehension test.

Vignette 2 (Type III instability)

Twenty-four-year-old female with bilateral shoulder pain, sensation of instability and history of multiple atraumatic shoulder dislocations. Sometimes attends A&E for help with relocation but normally able to self-relocate, but shoulder will often pop out again shortly after. Owns a dog but struggles to control it on-lead due to feeling shoulder will come out. Unable to work for the past 6 months due to symptoms. Started volunteering at a dog rescue centre but can’t walk the dogs due to shoulder.

Has had episodes of physiotherapy previously, including hydrotherapy and strengthening – feels this hasn’t helped overall. Seen a consultant and told not a surgical candidate as no structural pathology on imaging and referred back for another go at physio. Patient is worried that it won’t help again.

Vignette 3 (Type II - III instability)

Twenty-six-year-old female office worker. History of shoulder bilateral atraumatic shoulder instability with multiple subluxations. Has good social support but lives a relatively sedentary lifestyle. Told was hypermobile when she was younger. No past medical history. Avoids lifting and reaching overhead due to feeling that shoulders will come out.

On examination she has reduced active range of shoulder elevation due to pain, and reports feeling unstable. Range of movement is full passively, with 90 degrees external rotation. Her Beighton score is 7/9. She has a positive sulcus sign, anterior and posterior load and shift, and anterior apprehension and relocation test.