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Approach
Sports Health: A Multidisciplinary
http://sph.sagepub.com/content/2/1/39
The online version of this article can be found at:
DOI: 10.1177/1941738109338548
2010 2: 39 originally published online 1 January 2009Sports Health: A Multidisciplinary Approach
Michael M. Reinold and Thomas J. Gill
Part 1: Physical Characteristics and Clinical Examination
Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead-Throwing Athletes,
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by Michael Reinold on January 11, 2010sph.sagepub.comDownloaded from
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Reinold and Gill Jan • Feb 2010
ties other than overhead throwing. Injuries may occur through
acute mechanisms in which the athlete attributes the onset of
the symptoms to a specific throw. Throwing injuries are typ-
ically the result of chronic, repetitive throwing. Patients often
report a gradual onset, with no history of an acute episode of
injury. It can be helpful to ask what phase of the throw elicits
the most symptoms.
Symptoms may initially be subtle and may not alter the
patient’s performance. As the symptoms progress, the patient
may complain that his or her shoulder is “difficult to warm
up” or “get loose” during sport participation, with vague dis-
comfort in the shoulder throughout the throwing motion.
There is often a loss of throwing velocity and a lack of com-
mand while pitching, which becomes more notable as symp-
toms worsen. The chronicity of symptoms often establishes
the severity of the injury, and the repetitive nature of these
athletic activities often results in a gradual progression of
pathology and a decline in performance. A player’s injury
history, pitch counts in recent games, and number of innings
pitched in previous years will give an indication of recent
workloads and fatigue levels.
As symptoms progress, the patient can often localize the
source and timing of discomfort. However, symptoms are typ-
ically vague and diffuse, likely because of a combination of
pathologies that are present in the throwing shoulder. The
positions that are most provocative in overhead throwers are
the fully externally rotated cocked position and the ball release
position (Figure 1). These positions correlate to phases of the
throwing motion when stresses on the shoulder are highest.28
Palpation of the entire shoulder girdle may also elicit symp-
toms and help differentiate involved structures. The postero-
superior glenohumeral joint line, subacromial space, greater
tuberosity, and acromioclavicular joint and tendon of the long
head of the biceps should be palpated for tenderness. For acro-
mioclavicular disorders or bicipital tendonitis, the subjective
examination and palpation may be enough to diagnose the
pathology.
Range of Motion
One of the most distinguishing characteristics of overhead-
throwing athletes is glenohumeral range of motion. Most ath-
letes exhibit excessive ER and decreased internal rotation (IR)
at 90° of abduction in the throwing shoulder.10,13,43,70,89
This has
been shown in baseball players70,89
and tennis players25,26
dur-
ing passive motion70,89
and active motion.25,26
Meister et al55
also
found this adaptation in adolescent baseball players, noting
that the loss of IR was gradual but most dramatic between the
ages of 13 and 14 years old.
Wilk et al89
reported passive range of motion characteristics
of the shoulder in 372 professional baseball players: 129° ± 10°
of ER and 61° ± 9° of IR in the throwing shoulder at 90° abduc-
tion. ER was an average of 7° greater, and IR an average of 7°
less, in the dominant arm when compared to the nondominant
Table 1. The physical characteristics of the shoulder in the asymptomatic overhead-throwing athlete.a
Examination Component Specific Measurement Normative Value
Range of motion External rotation at 90° abduction
Internal rotation at 90° abduction
Total motion
129°-137° (7°-9° > than ND)18,70,89
54°-61° (7°-9° < than ND)18,70,89
183°-198° (bilaterally equal)18,70,89
Joint laxity Sulcus sign
Anterior translation
Posterior translation
61% of pitchers, positive sulcus10
2.8 mm (bilaterally equal)11,12
5.4 mm (bilaterally equal)11,12
Resting scapula position Upward rotation
Anterior tilt
Protraction
6° on D73,79,80
20° on D73,79,80
39° on D73,79,80
Muscular strength External rotation
Internal rotation
Abduction
Adduction
Scapular retraction
Scapular protraction
Scapular elevation
Scapular depression
0%-14% < on D58,69,84,86
3%-9% > on D58,69,84,86
Bilaterally equal58,69,84,86
10%-30% > on D58,69,84,86
0%-3% > on D58,92
0% to -4% < on D58,92
Bilaterally equal58,92
22% > on D58,92
Proprioception Joint reposition sense -2° error < on D2,81,82,b
a
ND, nondominant extremity; D, dominant extremity.
b
Joint reposition sense decreased by 2° of error.
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vol. 2 • no. 1 SPORTS HEALTH
arm. Thus, total rotation range of motion at 90° of abduction is
bilaterally equal in asymptomatic overhead throwers (Figure 2).
The cause of this adaptation has not been established.
Numerous theories regarding the altered range of motion
pattern observed in overhead-throwing athletes have been
reported.†
Several authors have documented humeral osseous
retroversion in the thrower’s shoulder and attribute the altered
range of motion to bony adaptations.18,63,67
Others have theorized
that excessive ER and limited IR are due to anterior capsular lax-
ity and posterior capsule tightness,15
although no clinical studies
have confirmed these findings to date.
The theory of posterior capsular tightness has come into ques-
tion from other researchers who have determined that range of
motion in baseball pitchers—specifically, a loss of IR—does not
correlate with an alteration in posterior glenohumeral transla-
tion.11,12
Borsa et al12
studied glenohumeral translation in a series
of 43 asymptomatic professional baseball pitchers. The authors
reported that posterior translation was twice that of ante-
rior translation. There was also no difference in the amount of
translation between the dominant shoulder and the nondom-
inant shoulder. The authors were unable to show a correlation
between a loss of IR range of motion and posterior laxity.
Reinold et al70
recently examined the passive range of motion
of the shoulder in 31 professional baseball pitchers, before and
immediately after pitching. The researchers reported that rota-
tional range of glenohumeral motion is immediately affected by
overhead throwing. Mean IR range of motion after pitching
significantly decreased (73° ± 16° before, 65° ± 11° after) and
total rotation motion decreased (average, 9°). Mean ER before
throwing (133° ± 11°) did not significantly change after throw-
ing (131° ± 10°). The researchers hypothesized that this decrease
in IR range of motion is due to large eccentric forces being gen-
erated in the external rotators (particularly, the infraspinatus and
teres minor) during the follow-through phase of throwing. The
authors attribute the acute loss of motion to microscopic mus-
cle damage due to eccentric contractions of the posterior shoul-
der musculature. Eccentric muscular contractions have been cor-
related to a rise in passive muscular tension and a loss of joint
range of motion.66
Anecdotally, baseball players often describe
generalized tightness in the musculature of their posterior shoul-
der after pitching. The muscles responsible for ER of the shoulder
exhibit high eccentric muscle activity31,32,41,42,75
during the throwing
motion as the shoulder internally rotates between 6000 and 7000
degrees per second.23,28,64
Yanagisawa et al93
showed long-last-
ing T2 elevations on magnetic resonance imaging of the supra-
spinatus, infraspinatus, and teres minor following baseball pitch-
ing. The authors attributed these findings to muscle damage
that resulted from eccentric muscle contractions. Previous stud-
ies examining the effect of repetitive eccentric contractions have
shown a subsequent loss of joint range of motion in the upper
and lower extremities following testing.38,65,71
The observed range of motion adaptations are likely due to
osseous adaptations in the humeral physes of young athlete’s
throwing shoulder.55,68,70
In addition, throwing itself results in
Figure 1. The 2 critical instances of potential injury during the throwing motion: A, the moment of full arm cocking when the
shoulder reaches maximal external rotation. During this moment, 67 N⋅m of internal rotation torque and 310 N of anterior force
are applied to the shoulder. B, the moment of ball release as the shoulder begins to decelerate. Forces at this moment include
1090 N of compressive force at the shoulder joint to prevent subluxation. (From Fleisig GS, Dillman CJ, Andrews JR. Kinetics of
baseball pitching with implications about injury mechanisms. Am J Sports Med. 1995;23:233-239.)
†
References 10-12, 15, 18, 55, 59, 63, 67, 70, 89.
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Reinold and Gill Jan • Feb 2010
an acute loss of IR motion, most likely attributed to muscular
tightness of the posterior shoulder muscles from the high levels
of eccentric contraction while the arm decelerates.70
An evaluation (unpublished data, 2008) of shoulder range of
motion before and after the competitive season in 20 profes-
sional baseball pitchers was conducted. The season consisted
of 2 months of spring training and 6 months of the compet-
itive season, with pitchers averaging 122 innings. Over the
course of the season, these pitchers performed a daily stretch-
ing program designed to maintain their range of motion, but
they avoided stretching and mobilizing their posterior capsule.
The stretching program was performed daily with 3 to 5 rep-
etitions of 10 seconds in shoulder flexion, ER and IR at 90°
abduction, and cross-body horizontal adduction. At the sea-
son end, there was no change in passive IR motion. Based on
these results, a loss of IR may be a consequence of the eccen-
tric nature of throwing, and a stretching program may help
prevent loss of IR. Shoulder ER increased an average of almost
5° over the course of the season, despite the avoidance of
aggressive ER stretching. Total rotation motion also increased
by 5° in the throwing shoulder, which may be explained by
the repetitive attenuation of the anterior capsule and other
structures of the shoulder over the course of a season.40
When evaluating range of glenohumeral motion, stan-
dard goniometric measurements of active and passive motion
should be performed for all planes of movement. Total rota-
tion motion should be calculated and compared to the non-
dominant shoulder at 90°. Reinold et al70
found that goniomet-
ric measurements of passive ER and IR at 90° of abduction
were reliable in overhead-throwing athletes (intratester reli-
ability intraclass correlation coefficients were .81 and .87).
However, bilateral comparisons of ER and IR are not useful.
If the total rotation motion decreases on the throwing side,
careful measurements of range of motion should be made to
determine if IR has been lost. A loss of IR with a hard end-
point may represent other pathologies, such as a throw-
er’s exostosis27
(ie, calcification of the posteroinferior gleno-
humeral capsular attachment due to chronic traction stress).
If total motion increases, the status of the static stabilizers
should be assessed.
Joint Laxity
The excessive motion observed in overhead-throwing athletes is
commonly attributed to an increase in glenohumeral laxity.53,68,89
This increased motion may represent excessive ER due to ante-
rior capsular laxity.40
Excessive laxity may be the result of repet-
itive throwing (acquired laxity)68
or congenital laxity.10
Bigliani et al10
reported laxity measurements in 72 profes-
sional baseball pitchers and 76 positional players. Sixty-one
percent of pitchers and 47% of positional players exhibited a
positive sulcus sign, indicating laxity of the superior glenohu-
meral ligament. This laxity was present bilaterally, suggesting a
congenital origin.
Borsa et al11,12
recently assessed anterior and posterior cap-
sular laxity in professional baseball pitchers using an objective
mechanical translation device and reported that posterior cap-
sular laxity was significantly greater than anterior capsular lax-
ity despite gross limitations of passive or active IR. The partic-
ipant in this study who had the least IR range of motion had
the greatest amount of posterior translation. Total translation
(anterior and posterior) was equal bilaterally, indicating that
the throwing shoulder was not more lax than the nonthrow-
ing shoulder.
Figure 2. The total motion concept: The dominant shoulder (A) of overhead-throwing athletes exhibits a greater external
rotation (ER) and lesser internal rotation (IR), compared to the nondominant shoulder (B). However, the total motion (external
and internal rotation) is equal bilaterally.
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vol. 2 • no. 1 SPORTS HEALTH
Assessing Laxity
The overhead-throwing athlete has acquired laxity from throw-
ing that is often superimposed on underlying congenital lax-
ity.68,89
To assess shoulder laxity, the clinician should begin
with an exam for generalized joint laxity: hyperextension of
the elbow, knee, fifth finger, apposition of the thumb, and
trunk flexion.8
For the shoulder, a sulcus test is performed at
0° of abduction. In this position, inferior translation is resisted
by the superior glenohumeral ligament. Excessive mobility is
thought to indicate generalized glenohumeral hypermobility.90,91
Next, assessment of glenohumeral translation is performed
with standard anterior drawer,30
anterior fulcrum (Figure
3),85
posterior drawer,30
and posterior fulcrums85
at 0°, 45°,
and 90° of abduction to assess all aspects of the glenohu-
meral ligament complex. Another important test to perform is
the Lachman test of the shoulder (Figure 4).5
The shoulder is
abducted overhead to approximately 120° to 135° of abduc-
tion and full ER and then translated anteriorly. The examiner
notes the amount of humeral translation as well as the end-
point of translation, in comparison to the nondominant shoul-
der. In this position, the integrity of the inferior glenohumeral
ligament and anterior-inferior capsule is tested. The ante-
rior drawer and fulcrum maneuvers can be repeated at 45°
of abduction (to test the middle glenohumeral ligament) and
in adduction (to assess the superior glenohumeral ligament).
Special tests for gross instability, such as the apprehension/
relocation sign,39
should be performed to assess the integrity
of the static stabilizing structures. It is not uncommon for an
overhead-throwing athlete to have a capsulolabral defect from
chronic microtrauma.
The anterior Lachman and anterior fulcrum tests are 2 of the
most important tests to perform because they assess the ante-
rior stabilizing structures of the shoulder in the full ER position,
similar to the vulnerable maximal arm-cocking position during
throwing. The apprehension test is an essential part of the
anterior stability examination.
Scapular Position
Evaluation of scapular position is an important component of
the clinical examination of the overhead-throwing athlete. Past
reports have documented alterations in resting scapula position
Figure 3. The anterior fulcrum test for anterior shoulder laxity and instability: A, the shoulder is positioned in approximately
90° of abduction and external rotation; B, as the arm is brought into horizontal abduction, an anterior force is applied to the
glenohumeral joint in a fulcrum maneuver. The examiner notes the amount of translation and end feel in comparison to the
opposite extremity.85
Figure 4. The anterior Lachman test for anterior shoulder
laxity and instability: The shoulder is positioned in
approximately 120° to 135° of abduction and external
rotation. The proximal and distal aspects of the shoulder
are translated anteriorly. The examiner notes the amount
of translation and end feel in comparison to the opposite
extremity.5
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Reinold and Gill Jan • Feb 2010
in symptomatic patients, which may contribute to some shoul-
der pathologies.16
The combination of scapular depression, ante-
rior tilt, and protraction may contribute to shoulder pathology.16
Bastan et al7
reported that the asymptomatic thrower’s scap-
ula is more protracted and anteriorly tilted at rest, compared
to the nonthrowing side. Seitz et al73
confirmed these findings
in a study using an electromagnetic tracking system that mea-
sured scapular position in 41 asymptomatic professional base-
ball pitchers. Results indicated that in asymptomatic pitchers,
the scapula rests in 6° of superior rotation, 20° of anterior tilt-
ing, and 39° of protraction.
These studies dispute the clinical impression that a protracted
and anteriorly tilted scapular position is indicative of pathology.
Macrina et al50
noted that the scapular is more protracted after
throwing than before. A protracted scapular position may be a
normal adaptation to throwing, which, if untreated, may pro-
gressively increase over the course of a season. This scapular
positioning may be similar to the humeral adaption of IR.
This adaptive scapular position may alter scapular and gle-
nohumeral range of motion and strength. An increase in anterior
tilt of the scapula correlated with an increase in glenohumeral
IR in the dominant shoulder of 98 asymptomatic professional
baseball pitchers.80
A protracted, anterior-tilted scapula also
correlated to a significant decrease in serratus anterior and lower
trapezius strength in asymptomatic baseball pitchers.79
Just as overhead-throwing athletes have adaptations in gleno-
humeral motion, asymptomatic baseball pitchers have an adap-
tive depressed, anteriorly tilted, and protracted scapula (Tables
1 and 2).71,75-77
Measuring scapular position using a digital incli-
nometer (Figure 5) allows comparisons to normative data.73,78-
80
Testing can be performed with the arm in various degrees
of shoulder abduction and rotation to assess scapular position.
The superomedial border of the scapula should be palpated
during abduction to detect “snapping scapular syndrome” asso-
ciated with scapulothoracic bursitis.51
Muscular Strength
Several investigators have examined muscle strength parameters
in the overhead-throwing athlete.‡
Isokinetic testing on profes-
sional baseball pitchers’ throwing shoulders during spring
training showed ER peak torque at an average of 6% lower
(P < .05) than that of the nonthrowing shoulders at 90° of
abduction.84,86
IR peak torque of the throwing shoulder was 3%
higher on average (P < .05) than that of the nonthrowing shoul-
der. The mean optimal ratio between ER and IR peak torque
at 90° of abduction during isokinetic testing was between 66%
and 75%. Adduction torque of the throwing shoulder was 14%
greater than that of the nonthrowing shoulder.
The muscle strength profiles of professional baseball pitchers
using a handheld dynamometer have been studied (unpublished
data, 2009). A 7% dominant-side increase in IR force and a slight
decrease in ER and abduction force (1% to 2% each) was seen
before the competitive baseball season.86
Over the course of the
8-month season (2 months of preseason and 6 months of com-
petition), a 3% to 4% decrease in force in all planes of motion
was seen. Abduction force decreased by 16% at the midpoint of
the season and 21% by the end of the season. All players partic-
ipated in a shoulder injury prevention program designed to min-
imize loss of strength over the course of a season. These results
suggest that although testing of the rotator cuff did not signifi-
cantly change, the loss of abduction strength may be related to
rotator cuff fatigue. Fatigue may result in an inability of the rota-
tor cuff to center and stabilize the glenohumeral joint, poten-
tially resulting in subacromial impingement.
Figure 5. Clinical measurements of anterior/posterior tilt (A) and upward/downward rotation (B) of the scapula using a digital
inclinometer, which is placed along the medial border (to measure tilt) and along the spine of the scapula (to measure rotation).
‡
References 1, 6, 13, 17, 19, 36, 84, 88.
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vol. 2 • no. 1 SPORTS HEALTH
In another study, ER and IR force at 0° and 90° of abduc-
tion was compared in 23 professional baseball pitchers using
a handheld dynamometer.69
A decrease in ER and IR force of
approximately 20% was noted at 90° of abduction, indicating
that the 90° abducted position may be better suited for manual
strength testing.
Strength of the scapular muscles also plays a vital role dur-
ing overhead throwing.22
When compared to positional players,
professional pitchers and catchers have exhibited significantly
greater force during scapular protraction and elevation.92
Manual muscle testing with a handheld dynamometer is used
for ER and IR at 0° and 90° of coronal plane abduction and
scapular plane elevation (full can) for the shoulder. Elevation,
posterior tilt, protraction, and retraction are tested for the
scapula. A handheld dynamometer is valuable for detecting
subtle differences that are often present in overhead-throwing
athletes and that may be missed with manual muscle testing.
The adaptations that occur from repetitive throwing preclude
the meaningful use of bilateral comparisons (Table 2).
The timing of the strength examination must be considered
when assessing results. Pitchers often have profound weakness
on manual strength testing for 2 days following a start, as well
as at the end of the season, presumably due to cuff fatigue.
Proprioception
The overhead thrower relies on enhanced proprioception to
dynamically stabilize the glenohumeral joint in the presence
of capsular laxity and excessive range of motion.20,24,29,68,87,89
One study tested shoulder proprioception in 20 healthy over-
head-throwing athletes by joint repositioning.2
The dominant
shoulder exhibited diminished proprioception and improved
proprioception toward end range of motion.72
Proprioception
significantly decreased after throwing to fatigue, although
deficits returned to normal within 10 minutes after
throwing.81
To assess proprioception one can use repositioning in
several patterns of movement (Figure 6). For example, ER
can be tested with the athlete’s eyes closed. The athlete
assumes the supine position, and the shoulder is abducted
to 90°. The athlete’s shoulder is passively rotated to a point
within his or her ER range, and it is held for 3 to 5 seconds
before returning to the starting position. The athlete is then
instructed to reproduce the previous position, and the dif-
ference between the 2 angles is calculated as the error. This
measurement is repeated at various points within the range
of motion, with an emphasis toward end range, where
Table 2. The effects of acute and chronic throwing on the physical characteristics of the shoulder in the asymptomatic overhead-
throwing athlete.a
Examination Component: Measurement
Normative Value
Before Throwing Immediately After Throwing Over the Course of a Season
Range of motion
External rotation
Internal rotation
Total motion
137°70
54°70
191°70
No change70
45°70
180°70
Increase of 5°70
No change70
Increase of 5°70
Muscular strength
External rotation
Internal rotation
Full can
Abduction
Adduction
Scapular retraction
Scapular posterior tilt
0%-14% < on D58,69,84,86
3%-9% > on D58,69,84,86
Bilaterally equal58,69,84,86
Bilaterally equal58,69,84,86
10%-30% > on D58,69,84,86
0%-3% > on D92
0%-3% > on D92
-11%44
-18%44
-6%44
-12%44
-11%44
-4%44
-4%44
-3% to -4%
-3% to -4%
-3% to -4%
-16% to -21%
-3% to -4%
Resting scapular position
Upward rotation
Anterior tilt
Protraction
6°73,79,80
20°73,79,80
39°73,79,80
No change50
No change50
8%50
Proprioception
Joint reposition sense -2° error2,81,82,b
-4° error82,c
a
D, dominant extremity.
b
Joint reposition sense decreased by 2° of error.
c
Joint reposition sense decreased by 4° of error.
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Reinold and Gill Jan • Feb 2010
proprioception is arguably most important. This measure-
ment technique can also be used for shoulder flexion,
abduction, proprioceptive neuromuscular facilitation
diagonal patterns, and scapula position.
Testing for Rotator Cuff Injuries
Injuries to the rotator cuff can range from tendonitis to a full-
thickness tear. Progressive degeneration can occur in ath-
letes with poor strength and poor injury prevention. Young
athletes often present with inflammation from overuse, with
poor muscle strength, and with a stability imbalance between
the rotator cuff and scapula. Experience suggests that over
the course of a season or career, this degeneration may result
in partial-thickness undersurface tearing. If untreated, full-
thickness rotator cuff tears can develop.3
Internal impinge-
ment of the supraspinatus and infraspinatus on the postero-
superior aspect of the glenoid rim during abduction and ER
may cause pain in the thrower.83
The rotator cuff is active in
resisting glenohumeral subluxation and decelerating the
arm. Patients with internal impingement often respond to
conservative treatment. If the pathology progresses, vague
discomfort along the deltoid insertion is common, especially
in older athletes.
Examination should include the Neer61
and Hawkins34
impingement tests to detect subacromial inflammation. The
empty can test can be used to evaluate the athlete’s tolerance
of overload to the supraspinatus.
Meister et al54
described an internal impingement sign. With
the athlete supine, the arm is abducted to 90° and maximally
externally rotated. This maneuver compresses the posterosu-
perior rotator cuff tendons against the posterosuperior gle-
noid rim. The athlete will often report a vague “deep dis-
comfort”; the test is considered positive if posterior humeral
translation causes a decrease in symptoms (Figure 7). The
fact that this relocation test is indicative of internal impinge-
ment lends credibility to the theory that anterior capsular lax-
ity/microinstability is a likely contributing factor to inter-
nal impingement. In a series of 69 athletes, Meister et al54
reported a sensitivity of 95% and a specificity of 100% in
detecting articular-side rotator cuff pathology using an appre-
hension-relocation test.
Figure 6. Clinical assessment of joint repositioning skill: A, with the patient’s eyes closed, the examiner passively brings the joint
to a point within the patient’s available range of motion. This position is measured and documented, and the joint is brought back
to the starting position. B, the patient is instructed to attempt to reproduce the precise position. Measurements are taken and
compared to the original measurement to determine the of degree error.
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vol. 2 • no. 1 SPORTS HEALTH
Figure 7. The internal impingement sign: A, the shoulder is positioned in 90° of abduction and full external rotation. In this
position, a patient with internal impingement will complain of posterosuperior shoulder pain. B, the examiner may then place a
posteriorly directed force on the anterior aspect of the glenohumeral joint to relocate the humeral head within the glenoid fossa.
The patient will report a reduction of symptoms in this position.54
Detecting full-thickness rotator cuff tears based on the ath-
lete’s strength alone is difficult. The majority of overhead-
throwing athletes with full-thickness rotator cuff tears will
present with pain in the lateral aspect of their shoulders,
weakness in empty can testing, and positive impingement
signs. They usually do not present with drop arm37
or
lag signs.35
Superior Labral Injuries
Superior labral (SLAP) lesions can be difficult to detect because
of the presence of concomitant pathology. Andrews et al4
reported that 45% of patients (73% of baseball pitchers) with
SLAP lesions had concomitant partial-thickness tears of the
supraspinatus. Mileski and Snyder56
reported that 29% of their
patients with SLAP lesions exhibited partial-thickness tears,
11% had complete cuff tears, and 22% had Bankart lesions.
Kim et al48
prospectively analyzed SLAP lesions in 139 cases
and found that type I is typically associated with rotator cuff
pathology whereas type III and IV are associated with trau-
matic instability. With type II SLAP lesions, older patients tend
to have associated rotator cuff pathology, and younger patients
are more likely to have instability. Labral pathologies may
result from repetitive overuse but can also result from a single
traumatic event, such as a fall onto the outstretched arm,
sudden traction, or a blow to the shoulder.
Special tests have been described to detect labral pathol-
ogy, including active compression,62
compression-rotation (or
grind),76
Speed’s,76
dynamic Speed’s,91
clunk,4
crank,49
anterior
slide,45
biceps load,47
biceps load II,46
pronated load,91
pain pro-
vocation,57
and resisted supination ER.60
Dessaur and Magarey21
and Jones and Galluch44
reviewed and
noted that the majority of studies reporting highly accurate
tests for SLAP lesions were of low quality and were not sup-
ported by other researchers.52,77
The discrepancy in accurately testing for SLAP lesions may
be due to the difficulty in comparing patient populations.
The testing for SLAP lesions in the overhead-throwing ath-
lete should attempt to reproduce the peel-back mechanism.91
As the shoulder externally rotates in the abducted posi-
tion, torsion occurs at the insertion of the long head of the
biceps into the labrum—peeling back the superior portion.14
Tests that mimic the peel-back mechanism14,74
include biceps
load,47
biceps load II,46
pronated load,91
pain provocation,57
and
resisted supination ER.60
Tests that do not re-create this mech-
anism may produce false negatives.62
The presence of deep
and diffuse glenohumeral joint pain is most indicative of the
presence of a SLAP lesion. Posterior symptoms may be indic-
ative of rotator cuff strain. The active compression test is use-
ful to localize pain and to establish a starting point for specific
SLAP testing.
Two new tests to detect SLAP lesions include the pronated
load91
test and the resisted supination ER test.60
For the pro-
nated load test, the athlete assumes the supine position with
the shoulder abducted to 90° and externally rotated. The fore-
arm is then fully pronated to increase tension on the biceps
and the labral attachment. When maximal ER is achieved, a
resisted isometric contraction of the biceps is used to simu-
late the peel-back mechanism (Figure 8). This test combines
active biceps contraction46,47,57
with the passive ER in the pro-
nated position.
For the resisted supination ER test (Figure 9), the patient is
positioned in 90° of shoulder abduction, 65° to 70° of elbow
flexion, and neutral forearm rotation.60
Maximal active supi-
nation is resisted while passively externally rotating the
by Michael Reinold on January 11, 2010sph.sagepub.comDownloaded from
11. 48
Reinold and Gill Jan • Feb 2010
shoulder. This test simulates the peel-back mechanism of
SLAP injuries by placing maximal tension on the long head
of the biceps.60
A preliminary study of 40 patients revealed
sensitivity (82.8%), specificity (81.8%), positive predictive
value (92.3%), negative predictive value (64.3%), and diag-
nostic accuracy (82.5%).60
IMAGING
Basic examination includes standard radiographs for the over-
head-throwing athlete: the West Point, axillary, Stryker notch,
and IR/ER views in the true anteroposterior plane of the
shoulder (Grashey views).
Magnetic resonance arthrography may also be performed
to provide further detail of the soft tissue structures; it is the
imaging technique of choice for suspected rotator cuff tears,
SLAP lesions, and capsular disruptions.
The diagnostic accuracy of magnetic resonance imaging for
SLAP lesions is unclear,33,72
and definitive diagnosis may require
arthroscopy. Bencardino et al9
retrospectively reviewed preop-
erative magnetic resonance arthrography following shoulder
arthroscopy, reporting sensitivity (89%), specificity (91%), and
accuracy (90%; 47 of 52 patients) in detecting SLAP lesions.
CLINICAL IMPLICATIONS
The physical characteristics (Table 1) of the overhead-throwing
athlete are important factors to consider during a physical exam-
ination. Acute and chronic adaptations may occur following
throwing and over the course of a competitive season (Table 2)
that are not necessarily pathologic.
CONCLUSION
The overhead-throwing athlete presents with several nor-
mal anatomical adaptations that make the physical examina-
tion challenging. Adaptations of range of motion, strength, and
scapular position are common and not necessarily pathologic.
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Reinold et al Mar • Apr 2010
Thus, it is important to maintain motion over the course of
a season. Reinold et al54
theorized that the loss of IR and total
motion after throwing is the result of eccentric muscle damage
as the external rotators and other posterior musculature
attempt to decelerate the arm during the throwing motion.
In general, total motion should be maintained equal to that
of the nondominant shoulder by frequently performing
gentle stretching. Caution should be emphasized against
overaggressive stretching in an attempt to gain mobility, in
favor of stretching techniques to maintain mobility.
It is equally important to regain full range of motion
following injury and surgery. Time frames vary for each
injury. Athletes who are attempting to return to throwing
before regaining full motion have a difficult time returning to
competition without symptoms. The clinician should ensure
that full motion has been achieved before allowing the
initiation of an interval throwing program.
Maintain Strength of the Glenohumeral
and Scapulothoracic Musculature
Because the act of throwing is so challenging for the static and
dynamic stabilizing structures of the shoulder, strengthening
of the entire upper extremity—including shoulder, scapula,
elbow, and wrist—is essential for the overhead thrower. A
proper program is designed per the individual needs of each
athlete, the unique stress of the throwing motion, and the
available research on strengthening each muscle.48
Emphasizing
the external rotators, scapular retractors, and lower trapezius
is important according to electromyographic studies of the
throwing motion.48,50,52
These exercises serve as a foundation
for the strengthening program, to which skilled and advanced
techniques may be superimposed.
Emphasize Dynamic Stabilization
and Neuromuscular Control
The excessive mobility and compromised static stability
observed within the glenohumeral joint often result in injuries
to the capsulolabral and musculotendinous structures of
the throwing shoulder. Efficient dynamic stabilization and
neuromuscular control of the glenohumeral joint is necessary
for overhead athletes to avoid injuries.12
This involves
neuromuscular control: efferent (motor) output in response to
afferent (sensory) stimulation. It is one of the most overlooked
yet crucial components of injury prevention and treatment
programs for the overhead athlete.
Neuromuscular control of the shoulder involves not
only the glenohumeral but also the scapulothoracic joint.
The scapula provides a base of support for muscular
attachment and dynamically positions the glenohumeral
joint during upper extremity movement. Scapular strength
and stability are essential to proper function of the
glenohumeral joint.
Neuromuscular control techniques should be included in
rehabilitation programs for the overhead athlete—specifically,
rhythmic stabilization, reactive neuromuscular control drills,
closed kinetic chain, and plyometric exercises.12,16,48,51,69,73
Closed kinetic chain exercises stress the joint in a load-bearing
position, resulting in joint approximation.12
The goal is to
stimulate receptors and facilitate co-contraction of the shoulder
force couples.46
Plyometric exercises provide quick, powerful movements
by a prestretch of the muscle, thereby activating the stretch
shortening cycle.20,62,73
Plyometric exercises increase the speed
of the myotactic/stretch reflex, desensitize the Golgi tendon
organ, and increase neuromuscular coordination.73
Figure 1. The total motion concept. The combination of external rotation (ER) and internal rotation (IR) equals total motion and is equal
bilaterally in overhead athletes, although shifted posteriorly in the dominant (A) versus nondominant (B) shoulder. Pathological loss of
internal rotation will result in a loss of total motion (C).
by Michael Reinold on December 29, 2010sph.sagepub.comDownloaded from
17. 103
vol. 2 • no. 2 SPORTS HEALTH
Core and Lower Body Training
The lower extremities are vital in the development of force
during the throwing motion. Core stabilization drills and
lower body training further enhance the transfer of kinetic
energy and proximal stability with distal mobility of the
upper extremity. Any deficits in strength, endurance, or
neuromuscular control of the lower body will have a significant
impact on the forces of the upper extremity and the athlete’s
ability to produce normal pitching mechanics.
Core stabilization is based on the kinetic chain concept:
Imbalance at any point of the kinetic chain results in
pathology. Movement patterns such as throwing require a
precise interaction of the entire kinetic chain to become
efficient. An imbalance of strength, flexibility, endurance,
or stability anywhere within the chain may result in fatigue,
abnormal arthrokinematics, and subsequent compensation.
Off-Season Preparation
The off-season is a valuable time for the athlete to rest,
regenerate, and prepare for the rigors of an upcoming season.
The main components of a player’s off-season include an initial
period of rest, followed by a progressive full-body strength and
conditioning program. The goal of the off-season is to build
enough strength, power, and endurance to compete without
the negative effects of fatigue or weakness from overtraining
or undertraining. Whereas the timing of the in- and off-season
components of an athlete’s yearly cycle may vary greatly
among athletes at different skill levels, the concepts and goals
for the off-season remain the same. Training is based on
Matveyev’s periodization concept with individualized attention
to each athlete’s specific goals (Figure 2).35
At the conclusion of a competitive season, athletes should
remain physically active while taking time away from their
sports. Recreational activities are encouraged, such as
swimming, golfing, cycling, and jogging. This is also a valuable
time to rehabilitate any lingering injury that may have been
managed through the season.
The remainder of the off-season is used to build a baseline of
strength, power, endurance, and neuromuscular control—the
goal of which is to maximize physical performance before the
start of sport-specific activities. Doing so will ensure that the
athlete has adequate physical fitness to withstand the demands
of the competitive season.
In-Season Maintenance
Equally as important as preparing for the competitive season
is maintaining gains in strength and conditioning during the
season. The chronic, repetitive nature of a long season often
results in a decline in physical performance.
Whereas a full-body strength and conditioning program is
imperative, attention should be paid to the throwing shoulder
and the muscles of the glenohumeral and scapulothoracic
joints. Any fatigue or weakness in these areas can lead to
injury through a loss of dynamic stability.
An in-season maintenance program should focus on strength
and dynamic stability while adjusting for the workload of a
competitive season.
Rehabilitation Progression
In addition to eliminating pain and inflammation, the
rehabilitation process for throwing athletes must restore motion,
muscular strength, and endurance, as well as proprioception,
dynamic stability, and neuromuscular control (Table 1). As the
athlete advances, sport-specific drills are added to prepare for a
return to competition. Neuromuscular control drills are performed
throughout, advancing as the athlete progresses, to provide a
continuous challenge to the neuromuscular control system.
Acute Phase
The acute phase of rehabilitation begins immediately following
injury or surgery by abstaining from throwing activities. The
duration of the acute phase depends on the chronicity of the
injury and the healing constraints of the involved tissues.
Figure 2. The concept of periodization as defined by Matveyev35
(A) and customized per the schedule of a professional baseball
player (B).
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Table 1. Treatment guidelines for the overhead athlete.a
Phase 1: Acute Phase
Goals Diminish pain and inflammation
Improve posterior flexibility
Reestablish posterior strength and dynamic stability (muscular balance)
Control functional stresses/strains
Treatment Abstain from throwing until pain-free full ROM and full strength—specific time determined by physician
Modalities Iontophoresis (disposable patch highly preferred)
Phonophoresis
Electrical stimulation and cryotherapy as needed
Flexibility Improve IR ROM at 90° abduction to normal total motion values
Enhance horizontal adduction flexibility
Gradually stretch into ER and flexion—do not force into painful ER
Exercises Rotator cuff strengthening (especially ER) with light-moderate weight
•• Tubing ER/IR
•• Side ER
Scapular strengthening exercises
•• Retractors
•• Depressors
•• Protractors
Manual strengthening exercises
•• Side ER
•• Supine ER at 45° of abduction
•• Prone row
•• Side flexion in the scapular plane
Dynamic rhythmic stabilization exercises
Proprioception training
Electrical stimulation to posterior cuff as needed during exercises
Closed kinetic chain exercises
Maintain core, lower body, and conditioning throughout
Maintain elbow, wrist, and forearm strength
Criteria to progress
to phase 2
Minimal pain or inflammation
Normalized IR and horizontal adduction ROM
Baseline muscular strength without fatigue
Phase 2: Intermediate Phase
Goals Progress strengthening exercises
Restore muscular balance (ER/IR)
Enhance dynamic stability
Maintain flexibility and mobility
Improve core stabilization and lower body strength
Flexibility Control stretches and flexibility exercises
•• Especially for IR and horizontal adduction
•• Gradually restore full ER
(continued)
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Exercises Progress strengthening exercises
Full rotator cuff and scapula shoulder isotonic program—begin to advance weight
Initiate dynamic stabilization program
•• Side ER with RS
•• ER tubing with end range RS
•• Wall stabilization onto ball
•• Push-ups onto ball with stabilization
May initiate 2-hand plyometric throws
•• Chest pass
•• Side to side
•• Overhead soccer throws
Criteria to progress
to phase 3
Full, pain-free ROM
Full 5/5 strength with no fatigue
Phase 3: Advanced Strengthening Phase
Goals Aggressive strengthening program
Progress neuromuscular control
Improve strength, power, and endurance
Initiate light throwing activities
Exercises Stretch prior to exercise program—continue to normalize total motion
Continue strengthening program above
Reinitiate upper-body program
Dynamic stabilization drills
•• ER tubing with end-range RS at 90° abduction
•• Wall stabs in 90° of abduction and 90° of ER
•• Wall dribble with RS in 90° of abduction and 90° of ER
Plyometrics
•• Two-hand drills
•• One-hand drills (90/90 throws, deceleration throws, throw into bounce-back)
•• Stretch postexercise
Criteria to progress
to phase 4
Full ROM and strength
Adequate dynamic stability
Appropriate rehabilitation progression to this point
Phase 4: Return-to-Activity Phase
Goals Progress to throwing program
Continue strengthening and flexibility exercises
Return to competitive throwing
Exercises Stretching and flexibility drills
Shoulder program
Plyometric program
Dynamic stabilization drills
Progress to interval throwing program
Gradually progress to competitive throwing as tolerated
a
ROM, range of motion; IR, internal rotation; ER, external rotation; RS, rhythmic stabilizations; 90/90, 90° of abduction and 90° of external rotation.
Table 1. (continued)
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Range of motion exercises are promptly performed in a
restricted range, according to the theory that motion assists in
the enhancement and organization of collagen tissue and the
stimulation of joint mechanoreceptors and that it may assist in
the neuromodulation of pain.58-60
The rehabilitation program
should allow for progressive loads, beginning with gentle
passive and active-assisted motion.
Flexibility exercises for the posterior shoulder musculature
are also performed early. The posterior shoulder is subjected
to extreme repetitive eccentric contractions during throwing,
which may result in soft tissue adaptations and loss of IR
motion,49,54
which may not be due to posterior capsular
tightness. Conversely, it appears that most throwers exhibit
significant posterior laxity when evaluated.8,9
Thus, common
stretches should include horizontal adduction across the body,
IR stretching at 90° of abduction, and the sleeper stretch
(Figures 3 and 4).
The cross-body horizontal adduction stretch may be
performed in a straight plane or integrated with IR at the
glenohumeral joint (Figure 4). Overaggressive stretching with
the sleeper stretch should be avoided (Figure 3). Frequent,
gentle stretching yields far superior results than does the
occasional aggressive stretch. Stretches or joint mobilizations
for the posterior capsule should not be performed unless
the capsule has been shown to be mobile on clinical
examination.
The rehabilitation specialist should assess the resting position
and mobility of the scapula. Throwers frequently exhibit
a posture of rounded shoulders and a forward head. This
posture is associated with muscle weakness of the scapular
retractors and deep neck flexor muscles owing to prolonged
elongation or sustained stretches.48,65
In addition, the scapula
may appear protracted and anteriorly tilted. An anteriorly
tilted scapula contributes to a loss of glenohumeral IR.7,32
This
scapular position is associated with tightness of the pectoralis
minor, upper trapezius, and levator scapula muscles and
weakness of the lower trapezius, serratus anterior, and deep
neck flexor muscle groups.48,65
Tightness of these muscles can
lead to axillary artery occlusion and neurovascular symptoms,
such as arm fatigue, pain, tenderness, and cyanosis.44,56,64
Muscle weakness may result in improper mechanics or
shoulder symptoms. Stretching, soft tissue mobilization,
deep tissue lengthening, muscle energy, and other manual
techniques may be needed in these athletes.
Depending on the severity of the injury, strengthening often
begins with submaximal, pain-free isometrics for all shoulder
and scapular movements. Isometrics should be performed at
multiple angles throughout the available range of motion, with
emphasis on contraction at the end.
Manual rhythmic stabilization drills are performed for internal
and external rotators with the arm in the scapular plane at
30° of abduction (Figure 5). Alternating isometric contractions
facilitate co-contraction of the anterior and posterior rotator
cuff musculature. Rhythmic stabilization drills may also
be performed with the patient supine and with the arm
elevated to approximately 90° to 100° and positioned at 10°
of horizontal abduction (Figure 6). This position is chosen for
the initiation of these drills due to the combined centralized
line of action of both the rotator cuff and deltoid musculature,
generating a humeral head compressive force during muscle
contraction.45,68
The rehabilitation specialist employs alternating
isometric contractions in the flexion, extension, horizontal
abduction, and horizontal adduction planes of motion. As the
patient progresses, the drills can be performed at variable
degrees of elevation, such as 45° and 120°.
Active range of motion activities are permitted when
adequate muscle strength and balance have been achieved.
With the athlete’s eyes closed, the rehabilitation specialist
Figure 3. A, the sleeper stretch for glenohumeral internal rotation; B, the body should be positioned so that the shoulder is in the
scapular plane.
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Figure 4. A, cross-body horizontal adduction stretch; B, the clinician may also perform the stretch with the shoulder in internal
rotation.
Figure 5. Rhythmic stabilization drills for internal and external rotation with the arm at 90° of abduction and neutral rotation (A) and
90° of external rotation (B).
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passively moves the upper extremity in the planes of flexion,
ER, and IR; pauses; and then returns the extremity to the
starting position. The patient is then instructed to actively
reposition the upper extremity to the previous location. The
rehabilitation specialist may perform these joint-repositioning
activities throughout the available range of motion.
Basic closed kinetic chain exercises are also performed
during the acute phase. Exercises are initially performed below
shoulder level. The athlete may perform weight shifts in the
anterior/posterior and medial/lateral directions. Rhythmic
stabilizations may also be performed during weight shifting.
As the athlete progresses, a medium-sized ball may be placed
on the table and weight shifts may be performed on the ball.
Load-bearing exercises can be advanced from the table to the
quadruped position (Figure 7).
Modalities such as ice, high-voltage stimulation, iontophoresis,
ultrasound, and nonsteroidal anti-inflammatory medications
may be employed as needed to control pain and inflammation.
Iontophoresis may be particularly helpful in reducing pain and
inflammation during this phase of rehabilitation.
Intermediate Phase
The intermediate phase begins once the athlete has regained
near-normal passive motion and sufficient shoulder strength
balance. Lower extremity, core, and trunk strength and
stability are critical to efficiently perform overhead activities
by transferring and dissipating forces in a coordinated fashion.
Therefore, full lower extremity strengthening and core
stabilization activities are performed during the intermediate
phase. Emphasis is placed on regaining proprioception,
kinesthesia, and dynamic stabilization throughout the athlete’s
full range of motion, particularly at end range. For the injured
athlete midseason, it is common to begin in the intermediate
phase or at least progress to this phase within the first few
days following injury. The goals of the intermediate phase
are to enhance functional dynamic stability, reestablish
neuromuscular control, restore muscular strength and balance,
and regain full range of motion for throwing.
During this phase, the rehabilitation program progresses to
aggressive isotonic strengthening activities with emphasis on
restoration of muscle balance. Selective muscle activation is also
used to restore muscle balance and symmetry. The shoulder
external rotator muscles and scapular retractor, protractor,
and depressor muscles are isolated through a fundamental
exercise program for the overhead thrower.48,70-72
This exercise
program is based on the collective information derived from
electromyographic research of numerous investigators.¶
These
patients frequently exhibit ER weakness and benefit from side
lying ER and prone rowing into ER. Both exercises elicit high
levels of muscular activity in the posterior cuff muscles.52
Drills performed in the acute phase may be progressed to
include stabilization at end ranges of motion with the patient’s
eyes closed. Rhythmic stabilization exercises are performed
during the early part of the intermediate phase. Proprioceptive
neuromuscular facilitation exercises are performed in the athlete’s
available range of motion and so progress to include full arcs of
motion. Rhythmic stabilizations may be incorporated in various
degrees of elevation during the proprioceptive neuromuscular
facilitation patterns to promote dynamic stabilization.
Manual-resistance ER is also performed during the
intermediate phase. By applying manual resistance during
specific exercises, the rehabilitation specialist can vary the
amount of resistance throughout the range of motion and
incorporate concentric and eccentric contractions, as well as
rhythmic stabilizations at end range (Figure 8). As the athlete
Figure 6. Rhythmic stabilization drills for flexion and extension
with the arm elevated to 100° of flexion in the scapular plane.
Figure 7. Rhythmic stabilization drills for the throwing shoulder
while weightbearing in the quadruped position.
¶
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regains strength and neuromuscular control, ER and IR with
tubing may be performed at 90° of abduction.
Scapular strengthening and neuromuscular control are also
critical to regaining full dynamic stability of the glenohumeral
joint. Isotonic exercises for the scapulothoracic joint are added,
along with manual-resistance prone rowing. Neuromuscular
control drills and proprioceptive neuromuscular facilitation
patterns may also be applied to the scapula (Figures 9 and 10).
Closed kinetic chain exercises are advanced during the
intermediate phase. Weight shifting on a ball progresses to
a push-up on a ball or an unstable surface on a table top.
Rhythmic stabilizations of the upper extremity, uninvolved
shoulder, and trunk are performed with the rehabilitation
specialist (Figure 11). Wall stabilization drills can be performed
with the athlete’s hand on a small ball (Figure 12). Additional
axial compression exercises include table and quadruped,
using a towel around the hand, slide board, or unstable
surface.
Advanced Phase
The third phase of the rehabilitation program prepares the
athlete to return to athletic activity. Criteria to enter this phase
include minimal pain and tenderness, full range of motion,
symmetrical capsular mobility, good strength (at least 4/5 on
manual muscle testing), upper extremity and scapulothoracic
endurance, and sufficient dynamic stabilization.
Full motion and posterior muscle flexibility should be
maintained throughout this phase. Exercises such as IR and
ER with exercise tubing at 90° of abduction progress to
incorporate eccentric and high-speed contractions.
Aggressive strengthening of the upper body may also be
initiated depending on the needs of the individual patient.
Common exercises include isotonic weight machine bench
press, seated row, and latissimus dorsi pull-downs within a
restricted range of motion. During bench press and seated row,
the athlete should not extend the arms beyond the plane of the
body, to minimize stress on the shoulder capsule. Latissimus
pull-downs are performed in front of the head while the
athlete avoids full extension of the arms to minimize traction
force on the upper extremities.
Figure 8. Manual-resistance side-lying external rotation with
end-range rhythmic stabilizations.
Figure 9. Arm elevation against a wall, with the patient
isometrically holding a light-resistance band into external
rotation to facilitate posterior rotator cuff and scapular
stabilization during scapular elevation and posterior tilting.
Figure 10. Arm-extension wall slides to facilitate proper
scapular retraction and posterior tilting.
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Plyometrics for the upper extremity may be initiated during
this phase to train the upper extremity to dissipate forces.
The chest pass, overhead throw, and alternating side-to-
side throw with a 3- to 5-lb (1.6- to 2.3-kg) medicine ball are
initially performed with 2 hands. Two-hand drills progress to
1-hand drills over 10 to 14 days. One-hand plyometrics include
baseball-style throws in the 90/90 position (90° of abduction
and 90° of ER) with a 2-lb (0.9-kg) ball, deceleration flips
(Figure 13), and stationary and semicircle wall dribbles. Wall
dribbles progress to the 90/90 position. They are beneficial for
upper extremity endurance while overhead.
Dynamic stabilization and neuromuscular control drills
should be reactive, functional, and in sport-specific positions.
Figure 11. Transitioning weightbearing rhythmic stabilization
exercises to nonweightbearing positions simulating the
landing (A), arm-cocking (B), and ball-release (C) phases of the
throwing motion.
Figure 12. Rhythmic stabilization drills in the 90° abducted
and 90° external rotation position on an unstable surface in
the closed kinetic chain position against the wall.
Figure 13. Plyometric deceleration ball flips. The patient
catches the ball over the shoulder and decelerates the arm
(similar to the throwing motion) before flipping back and
returning to the starting position.
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Concentric and eccentric manual resistance may be applied as
the athlete performs ER with exercise tubing, with the arm at
0° abduction. Rhythmic stabilizations may be included at end
range, to challenge the athlete to stabilize against the force of the
tubing as well as the therapist, and may progress to the 90/90
position (Figure 14). Rhythmic stabilizations may also be applied
at end range during the 90/90 wall-dribble exercise. These drills
are designed to impart a sudden perturbation to the throwing
shoulder near end range to develop the athlete’s ability to
dynamically stabilize the shoulder.
Muscle endurance exercises should be emphasized because
the overhead athlete is at greater risk for shoulder and/or
elbow injuries when pitching fatigued.34
Endurance drills
include wall dribbling, ball flips (Figure 15), wall arm circles,
upper-body cycle, or isotonic exercises using lower weights for
higher repetitions. Murray et al42
demonstrated the effects of
fatigue on the entire body during pitching using kinematic and
kinetic motion analysis. Once the thrower is fatigued, shoulder
ER decreases ball velocity and leads to lower extremity knee
flexion, and shoulder adduction torque decreases. Muscle
fatigue also affects proprioception.67
Once the rotator cuff
muscles are fatigued, the humeral head migrates superiorly
when arm elevation is initiated.11
Muscle fatigue was the
predisposing factor that correlated best with shoulder injuries
in Little League pitchers.34
Thus, endurance drills appear
critical for the overhead thrower.
Return-to-Activity Phase
Upon completion of the rehabilitation program—including
minimal pain or tenderness, full range of motion, balanced
Figure 14. Rhythmic stabilization drills during exercise tubing at 90° of abduction and 90° of external rotation (A) and during wall
dribbles (B).
Figure 15. Ball flips for endurance of the external rotators (A)
and scapular retractors (B).
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capsular mobility, adequate proprioception, and dynamic
stabilization—the athlete may begin the return-to-activity
phase.
The return to throwing starts with a long-toss program
(Appendix 1, available at http://sph.sagepub.com/
supplemental) designed to increase distance and number of
throws.55
Athletes typically begin at 30 to 45 ft (9 to 14 m) and
progress to 60, 90, and 120 ft (18, 27, and 37 m). Pitchers
begin a mound throwing program (Appendix 2, available at
http://sph.sagepub.com/supplemental), whereas positional
players progress to greater distances of long-toss and
positional drills. Throwing off the mound includes a gradual
increase in the number and intensity of effort and, finally,
type of pitch. A player will typically throw 3 times a week
with a day off in between, performing each step 2 or 3
times before progressing.
The interval throwing program is supplemented with a high-
repetition, low-resistance maintenance exercise program for
the rotator cuff and scapula. All strengthening, plyometric, and
neuromuscular control drills should be performed 3 times per
week (with a day off in between) on the same day as the ISP.
The athlete should warm up, stretch, and perform 1 set of each
exercise before the interval sport program, followed by 2 sets
of each exercise after the program. This provides an adequate
warm-up but ensures maintenance of necessary range of
motion and flexibility of the upper extremity.
Nonthrowing days are used for lower extremity,
cardiovascular, core stability training, range of motion, and
light strengthening exercises emphasizing the posterior rotator
cuff and scapular muscles. The cycle is repeated throughout
the week with the seventh day designated for rest, light range
of motion, and stretching exercises.
Internal Posterosuperior Glenoid Impingement
Posterosuperior glenoid impingement (internal impingement)
is one of the most frequently observed conditions in the
overhead throwing athlete,#
and may be caused by excessive
anterior shoulder laxity.51
The primary goal of the rehabilitation
program is to enhance dynamic stabilization to control anterior
humeral head translation while restoring flexibility to the
posterior rotator cuff muscles. A careful approach is warranted
because aggressive stretching of the anterior and inferior
glenohumeral structures may result in increased anterior
translation.
The scapular musculature—specifically, the middle trapezius
and lower trapezius—is an area of special focus. Once the
thrower begins the interval throwing program, the clinician or
pitching coach should frequently observe the athlete’s throwing
mechanics. Throwers with internal impingement occasionally
allow their arms to lag behind the scapula (excessive
horizontal abduction). This hyperangulation of the arm may
lead to excessive strain on the anterior capsule and internal
impingement of the posterior rotator cuff.21,22,51,55,69
The best
treatment for internal impingement is a nonoperative program.
Subacromial Impingement
Primary subacromial impingement in the young overhead
throwing athlete is unusual22,37
but may occur with primary
hyperlaxity or loss of dynamic stability.22
The nonoperative treatment is similar to that of internal
impingement, emphasizing scapular strengthening.
Impingement patients exhibit less posterior tilting than do
those without impingement.32
The rehabilitation program
should include pectoralis minor stretching, inferior trapezius
strengthening to ensure posterior scapular tilting, and
minimizing forward head posture. Excessive scapular
protraction produces anterior scapular tilt and diminishes
the acromial-humeral space, whereas scapular retraction
increases it.63
Subacromial impingement can be treated conservatively with or
without a subacromial injection. The injection is used to relieve
pain and inflammation, which in turn allows the patient to more
effectively perform a therapy program after a period of rest.
Overuse Syndrome Tendinitis
Throwers may exhibit the signs of overuse tendinitis in
the rotator cuff and/or long head of the biceps brachii
muscles,4,23,37,49
especially early in the season, when the athlete’s
arm may not be in optimal condition.
The thrower will often complain of bicipital pain,
referred to as groove pain. The biceps brachii appears
to be moderately active during the overhead throwing
motion. Bicipital tendinitis usually represents a secondary
condition in the overhead thrower. The primary disorder
may be instability, a superior labral anterior posterior
(SLAP) lesion, or other pathology. The rehabilitation of this
condition focuses on improving dynamic stabilization of
the glenohumeral joint through muscular training drills. A
glenohumeral joint capsule–biceps reflex is present in the
feline.19,28
Investigators demonstrated that the biceps brachii
was the first muscle to respond to stimulation of the capsule
(2.7 milliseconds). The biceps brachii may be activated to
a greater extent when the thrower exhibits hyperlaxity or
inflammation of the capsule. Nonoperative rehabilitation
usually consists of a reduction in throwing activities, the
reestablishment of dynamic stability and modalities to
reduce bicipital inflammation.
Posterior Rotator Cuff Tendinitis
The successful treatment of rotator cuff tendinitis depends on
its differentiation from internal impingement. Subjectively, the
athlete notes posterior shoulder pain during ball release or
the deceleration phase of throwing. In athletes with internal
impingement, the pain occurs during late cocking and early
acceleration. During throwing, excessive forces must be
dissipated and opposed by the rotator cuff muscles.17
There#
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is often significant weakness of the infraspinatus, lower
trapezius, and middle trapezius, as well as tightness of the
external rotators.
Once strength levels have improved, eccentric muscle
training should be emphasized for the external rotators and
lower trapezius (Figure 16). Electromyographic activity in the
teres minor is 84% maximal voluntary contraction and 78%
maximal voluntary contraction in the lower trapezius, during
the deceleration phase of a throw and should thus be the focus
of the strengthening program.14
Acquired Microinstability
The anterior capsule undergoes significant tensile stress in
the late cocking and early acceleration phases of the throwing
motion. This stress can lead to gradual stretching of the
capsular collagen over time, leading to increased anterior
capsular laxity. Several authors25,26,29,30,69
have proposed that
repetitive strain on the anterior capsule causes anterior
capsular laxity and may worsen internal impingement. Reinold
and Gill (unpublished data, 2009) noted that professional
baseball pitchers exhibit an increase of 5° of ER at the end of a
season in comparison to preseason measurements despite the
avoidance of aggressive stretching.49
Mihata et al40
demonstrated in the cadaveric model that
excessive ER results in elongation of the anterior band of the
inferior glenohumeral ligament complex and an increase in
anterior and inferior translation. Anterior displacement may
cause the undersurface of the rotator cuff musculature to
impinge on the posterosuperior glenoid rim.
Several arthroscopic procedures (capsular plication and
thermal capsular shrinkage) have been developed in an
attempt to reduce capsular laxity without overconstraining
the joint.5,30,33,47
Rehabilitation following these procedures
is designed to gradually restore motion, strength, and
neuromuscular control.53,71
Immediately following surgery,
restricted passive motion is allowed but not overaggressive
stretching. Excessive ER, elevation, or extension is not allowed.
By week 6, 75° of ER is the goal. By week 8, 90° of ER at 90°
of abduction should be achieved. Usually between weeks
6 and 8, flexion is 170° to 180°. In the case of the overhead
athlete—particularly, the pitcher—ER to 115° is needed.
This is usually achieved gradually, no earlier than week 12.
The athlete is not stretched aggressively past 115° to 120°
of ER. Rather, the athlete regains “normal” motion through
functional activities within the rehabilitation program, such
as plyometrics. The lack of full ER in the overhead athlete
is a common cause of symptoms during rehabilitation and
throwing.
Isometrics begin in the first 7 to 10 days in a submaximal,
nonpainful manner. At approximately 10 to 14 days
postoperatively, a light isotonic program begins emphasizing
ER and scapular strengthening. At week 5, the athlete is
allowed to progress to the full rotator cuff and scapula exercise
program with plyometrics at 8 weeks using 2 hands and
restricting ER. After 10 to 14 days, 1-hand drills begin. An
aggressive strengthening program is allowed at week 12 and is
adjusted according to the patient’s response. A gradual return
to throwing is expected at week 16, with a return to overhead
sports by 9 to 12 months.55
SLAP Lesions
SLAP lesions involve detachment of glenoid labrum–biceps
complex from the glenoid rim. These injuries occur through
a variety of mechanisms, including falls, traction, motor
vehicle accidents, and sports.72
Overhead throwing athletes
commonly present with a type II SLAP lesion with the biceps
tendon detached from the glenoid rim and a peel back
lesion.10
Conservative management of SLAP lesions is often
unsuccessful—particularly, type II and type IV lesions with
labral instability and underlying shoulder instability. With
surgical repair, the initial rehabilitative concern is to ensure
that forces on the repaired labrum are controlled. The extent
of the lesion, its location, and number of suture anchors are
considered when developing a rehabilitation program. The
patient sleeps in a shoulder immobilizer and wears a sling
during the day for the first 4 weeks following surgery. Range
of motion is performed below 90° of elevation to avoid
strain on the labral repair. During the first 2 weeks, IR and
ER range of motion exercises are performed passively in the
Figure 16. Manual-resistance eccentric contraction of the
lower trapezius.
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vol. 2 • no. 1 SPORTS HEALTH
Current Concepts in the Evaluation and
Treatment of the Shoulder in Overhead-
Throwing Athletes, Part 1: Physical
Characteristics and Clinical Examination
Michael M. Reinold, PT, DPT, ATC, CSCS,* and Thomas J. Gill, MD
The overhead-throwing athlete is a challenging sports medicine patient. The repetitive microtraumatic stresses imposed
on the athlete’s shoulder joint complex during the throwing motion constantly places the athlete at risk for injury. These
stresses may effect several adaptations to normal shoulder range of motion, strength, and scapula position. The clinician
should therefore appreciate the unique physical characteristics of the overhead-throwing athlete to accurately evaluate and
treat throwing-related injuries.
Keywords: glenohumeral joint; scapula; baseball
[ Sports Physical Therapy ]
From the Boston Red Sox Baseball Club, Boston, Massachusetts, and the Division of Sports Medicine, Department of Orthopedic Surgery, Massachusetts General Hospital,
Boston, Massachusetts
*
Address correspondence to Michael M. Reinold, PT, DPT, ATC, CSCS, Boston Red Sox Baseball Club, Fenway Park, 4 Yawkey Way, Boston, MA 02215.
No potential conflict of interest declared.
DOI: 10.1177/1941738109338548
© 2010 The Author(s)
T
he overhead-throwing athlete is a unique and compli-
cated sports medicine patient. The repetitive micro-
traumatic stresses placed on the athlete’s shoulder joint
complex during the throwing motion challenges the physio-
logic limits of the surrounding tissues. During the overhead-
throwing motion, the athlete places excessive stresses on the
shoulder at the end range of motion, with tremendous angu-
lar velocities. Fleisig et al28,29
reported the angular velocity of the
overhead throw reaches over 7000 degrees per second, which
is the fastest recorded human movement. This motion results
in high forces being generated at the shoulder joint, where
the dynamic and static stabilizing structures of the shoulder
are vulnerable.28,29
Fleisig et al28
also reported anterior forces
up to 1 times body weight during external rotation (ER; late
cocking) and up to 1.5 times body weight during the follow-
through phase (distracting the joint). These forces are likely
similar for other overhead-throwing athletes, such as football
quarterbacks, softball players, and tennis players.
Consequently, the preventative care and treatment of these
athletes are challenging. Injury may occur because of muscle
fatigue, muscle weakness, strength imbalances, loss of motion,
soft tissue flexibility, alterations in throwing mechanics, and
poor static stability. Because the overhead-throwing athlete
is unique, the knowledge of the normal physical characteris-
tics, biomechanics, and pathomechanisms of throwing-related
injuries is imperative to accurately assess and treat potential
injuries.
CLINICAL EXAMINATION
The overhead-throwing athlete exhibits several different
physical characteristics—specifically, shoulder range of
motion, scapular position, laxity, strength, and proprioception
(Table 1). These characteristics must be understood to
accurately assess what is a normal physical adaptation rather
than pathology.
History
A thorough history of the patient’s complaints, mechanism of
injury, and chronicity of symptoms is advantageous and can
often lead the clinician to the appropriate examination pro-
cess. The injured overhead-throwing athlete generally presents
with pain, agitated by throwing and subsiding with inactivity;
the athlete also tends to be asymptomatic during all activi-
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