Table 1 Clinical vignettes and seed questions used to elicit clinical decision-making processes

Vignette 1

Subjective assessment

Patient is a 16-year-old female presenting with worsening right shoulder pain. Recurrent episodes of instability/ partial shoulder displacement for the last 6 years. Not sure about the direction of instability. Competitive netball and swimming since age 12 with onset of pain at age 14. Had multiple physiotherapy sessions over the years for managing exacerbations. Referred by GP for recent worsening of shoulder pain

Could you please answer the following questions:

1. What is your diagnosis for this patient? (Please provide your clinical reasoning i.e. information used to support your diagnosis, associated mechanisms of injury and alternate diagnosis excluded with justification)

a. How would you classify this patient?

b. Would you use an existing framework/classification system, and if so which one?

Objective assessment

Beighton score 4/9 (bilateral elbows and knees)*

Scapular dyskinesis apparent on physiological movements i.e. flexion, abduction

Reluctance to elevate arm through range. Limited active range of movement end ranges of elevation with pain

Vignette 2

Subjective assessment

Patient is a 14 year old male. Contact injury to left shoulder 3 days ago during a rugby match. Tackled opposing player with arm out, felt shoulder come out of place, reduced by itself. Presented to the emergency department. X-ray nothing abnormal detected. No previous shoulder injuries. Referred for rehabilitation

2. What other information/ assessment methods/ investigations would you like to have to inform your diagnosis and management plan?

a.Would you consider 3D motion capture/ electromyography/ neurophysiologist referral and what information would you want?

Objective assessment

Positive apprehension relocation test

Beighton score 2/9 (bilateral knees)*

Limited active range of movement in all planes with limited muscle strength compared to right

Vignette 3

Subjective assessment

Patient is a 17 year old female referred for recent episode of shoulder instability and pain following collision in basketball 2 months ago. Felt shoulder pop out and in when diving for a ball on the ground. Did not attend emergency department. Unable to recall previous significant episodes of trauma. History of similar feelings previously but less severe. Unclear around the level and direction of displacement. Previous episodes associated with normal daily tasks and sports but did not affect activity or participation. Referred by GP to Physiotherapy for shoulder pain and queried shoulder dislocation. Separate referral to orthopaedic consultant pending appointment date

3. What would your management plan and prognosis for this patient be? (Please provide your clinical reasoning i.e. information used to support your management plan/prognosis)

a. Is this informed by any clinical pathways or best practice guidelines?

Objective findings

Positive apprehension relocation test

Beighton score 5/9 (Bilat elbows, knees and hands flat to floor)*

Full active range of movement with pain end of range elevation