Shoulder Injuries in the Overhead Athlete T

38 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

[ CLINICAL COMMENTARY ]KEVIN E. WILK, PT, DPT¹ MD² DPT³

MD4 MD4 MD5

Shoulder Injuries in the Overhead Athlete

1Vice President of Education, Physiotherapy Associates, Exton, PA; Associate Clinical Director, Champion Sports Medicine, A Physiotherapy Associates Clinic, Birmingham,AL; Director of Rehabilitation Research, American Sports Medicine Institute, Birmingham, AL; Rehabilitation Consultant, Tampa Bay Rays Baseball Organization, Tampa Bay,FL. ²Orthopaedic Sports Medicine Fellow, Andrews Sports Medicine, Birmingham, AL. ³ Physical Therapy Fellow, Champion Sports Medicine, Birmingham, AL. 4OrthopaedicSurgeon, Andrews Sports Medicine Center, Birmingham, AL. 5Orthopaedic Surgeon, Andrews Sports Medicine Center, Birmingham, AL; Medical Director, Tampa Bay RaysBaseball Organization, Tampa Bay, FL. Address correspondence to Dr Kevin E. Wilk, Champion Sports Medicine, 805 St Vincent’s Drive, Suite C100, Birmingham, AL 35205.E-mail: [email protected]

The overhead throwing motion is a highly skilled movementperformed at extremely high velocity, which requiresflexibility, muscular strength, coordination, synchronicity,and neuromuscular control. The throwing motion generates

extraordinary demands on the shoulder joint. It is because of thesehigh forces, which are repetitively applied, that the shoulder is themost commonly injured joint in professional baseball pitchers.27

isometric contraction (MVIC).34 Lastly,the thrower’s shoulder often exhibitsexcessive motion and laxity. Wilk et al112

stated that the thrower’s shoulder mustbe “loose enough to throw but stableenough to prevent symptoms.” Whetherthe typical injury sustained to the throw-er’s shoulder is due to hyperlaxity orcapsular tightness is currently a contro-versial topic of discussion. Shoulder pa-thology can manifest as pain, diminishedperformance (velocity and accuracy), or adecrease in strength or range of motion.The challenge for medical practitionersis to determine the accurate di!erentialdiagnosis, the cause of the injury, and themost e!ective treatment plan based onthe identified pathology.

In this manuscript, we will discuss thephysical characteristic of the overheadathlete, common pathologies seen, andthe nonoperative, surgical, and postop-erative treatment.

It is important for the clinicianto realize and appreciate the “typical”physical characteristics of the over-

head thrower.

Most throwers exhibit an obvious motiondisparity, whereby shoulder external ro-tation (ER) is excessive and internal rota-tion (IR) is limited when measured at 90°

During the throwing movement, tre-mendous forces are placed on the shoul-der joint at extremely high angularvelocities. The acceleration phaseof the pitch is the fastest move-ment recorded and reaches a peakangular velocity of 7250°/s.41,43 Ithas been estimated that the an-terior translation forces generatedwhen pitching are equal to one-half

body weight (BW) during the late cock-ing phase, and there is a distraction force

equal to BW during the decelerationphase.43 Consequently, throwingrequires a high level of muscleactivation, as indicated by theelectromyographic signal of the

shoulder musculature, which canexceed 80% to 100% of the signal

measured during a maximum voluntary

The overhead throwing motion is anextremely skillful and intricate movement. Whenpitching, the overhead throwing athlete placesextraordinary demands on the shoulder complexsubsequent to the tremendous forces that are gen-erated. The thrower’s shoulder must be lax enoughto allow excessive external rotation but stableenough to prevent symptomatic humeral headsubluxations, thus requiring a delicate balancebetween mobility and functional stability. We referto this as the “thrower’s paradox.” This balance isfrequently compromised and believed to lead tovarious types of injuries to the surrounding tissues.Frequently, injuries can be successfully treatedwith a well-structured and carefully implementednonoperative rehabilitation program. The key tosuccessful nonoperative treatment is a thorough

clinical examination and accurate diagnosis.Rehabilitation follows a structured, multiphaseapproach, with emphasis on controlling inflamma-tion, restoring muscles’ balance, improving softtissue flexibility, enhancing proprioception andneuromuscular control, and e$ciently returningthe athlete to competitive throwing. Athletes oftenexhibit numerous adaptive changes that developfrom the repetitive microtraumatic stresses occur-ring during overhead throwing. Treatment shouldinclude the restoration of these adaptations.

Level 5. J OrthopSports Phys Ther 2009;39(2):38-54. doi:10.2519/jospt.2009.2929

baseball, glenohumeral joint,labral lesions, pitching, rotator cu!

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journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 39

of abduction.11,18,20,54,112 This loss of IR ofthe throwing shoulder has been referredto as glenohumeral internal rotation def-icit (GIRD). Several investigators havedocumented that pitchers exhibit greaterER of the shoulder than do position play-ers.11,54,111 Brown et al18 reported that pro-fessional pitchers exhibited a mean SDof 141° 15° of shoulder ER measured at90° abduction. This was approximately 9°more than for their nonthrowing shoul-der and approximately 9° more than thethrowing shoulder of position players.Recently, Bigliani et al11 reported thatdominant shoulder ER measured at 90°shoulder abduction averaged 118° (range,95°-145°) in pitchers, whereas it averaged108° (range, 80°-105°) for the dominantshoulder of positional players.

Wilk et al105 reported on the gle-nohumeral joint range of motion (ROM)measured in 879 professional baseballpitchers from 2003 to 2008. Pitchers ex-hibited an average SD of 136.9° 14.7°of ER and 40.1° 9.6° of IR when pas-sively assessed at 90° abduction. In pitch-ers, the ER is approximately 9° greater inthe throwing shoulder when compared tothe nonthrowing shoulder, while IR was8.5° greater in the nonthrowing shoulder.In addition, the total motion (ER and IRadded together) in the throwing shoulderwas similar (within 7°) when comparedto total motion of the nonthrowing shoul-der, with the total rotational arc of mo-tion being 176.3° 16.0° on the throwingshoulder and nonthrowing shoulder.114

We refer to this as the “total motionconcept” ( ). Several authors havepreviously reported that total motion isequal comparing the throwing and non-throwing shoulder.4,6,40,77,114

Most throwers exhibit significant laxityof the glenohumeral joint, which permitsexcessive ROM. The hypermobility of thethrower’s shoulder has been referred toas “thrower’s laxity.”112 The laxity of theanterior and inferior glenohumeral jointcapsule may be appreciated by the clini-cian during the stability assessment of the

joint. Andrews et al7 have reported that theexcessive laxity exhibited by the thrower isthe result of repetitive throwing, referringto this as “acquired laxity”; but others havedocumented that the overhead throwerexhibits congenital laxity.11

Borsa et al14,15 reported no di!erencein the throwing shoulder compared tothe nonthrowing shoulder when objec-tive glenohumeral joint laxity testingwas performed on the Telos device ( -

). Furthermore, they noted greaterposterior laxity compared to anteriorlaxity and no association between mea-surements of joint laxity and ROM. Insome cases, pitchers exhibited extremelydiminished glenohumeral joint IR mo-tion, while exhibiting significant pos-terior capsule laxity on Telos testing.Thus, the changes in glenohumeral jointmotion seen in pitching may be due tofactors other than glenohumeral jointcapsular laxity.

Several investigators23,29,85,88,89 have re-ported an osseous adaptation of the hu-

meral head in the thrower’s shoulder.Crockett et al29 reported on 25 profes-sional baseball pitchers who underwentcomputerized tomography (CT) scan todetermine humeral head and glenoid fos-sa retroversion. The investigators notedthat the humeral head on the throwingside exhibited a 17° increase in retrover-sion when compared to the nonthrowingshoulder. Furthermore, when comparingthe pitchers to a group of nonthrowers,the nonoverhead athlete group exhibitedno di!erence in their bilateral retrover-sion values. This could partially providean explanation for the side-to-side di!er-ences noted in the throwers glenohumer-al joint rotational ROM. An increase inhumeral head retroversion would resultin an increase in ER ROM and a decreasein IR. Lastly, Meister et al77 documentedin adolescent baseball players that thegreatest change in glenohumeral jointROM occurs between the ages of 12 and13, when the growth plates are open.

Several investigators have examinedmuscle strength parameters in the over-head throwing athlete with varyingresults and conclusions.1,9,18,28,30,48,107,108

Wilk et al107,108 performed isokinetic test-ing on 83 professional baseball playersas part of their physical examinationsduring spring training. The investigatorsdemonstrated that the ER strength ofthe pitcher’s throwing shoulder was sig-nificantly weaker (P .05) than the non-throwing shoulder by 6%. Conversely, IRof the throwing shoulder was significantly

The total-rotational-motion concept.External rotation (ER) + internal rotation (IR) = totalmotion. Total rotational motion is equal bilaterally.

Glenohumeral laxity testing done on Telosdevice to objectively assess the amount of joint laxity.


[ CLINICAL COMMENTARY ]

stronger (P .05) than the nonthrowingshoulder by 3%. Additionally, adduc-tion strength of the throwing shoulderwas significantly stronger (P .05) thanthat of the nonthrowing shoulder by ap-proximately 9% to 10%. We believe thatan important isokinetic value is the uni-lateral muscle ratio, which describes theantagonist-agonist muscle strength ratioof 1 shoulder. A proper balance betweenagonist and antagonist muscle groups isthought to provide dynamic stabilizationto the shoulder joint. To provide propermuscle balance, the glenohumeral jointexternal rotator muscles should be atleast 65% of the strength of the internalrotator muscles.113 Optimally, the exter-nal-internal rotator muscles strengthratio should be 66% to 75%.108 112,113

1 illustrates the optimal muscle strengthvalues of professional baseball players.Furthermore, Magnusson et al,72 usinga handheld dynamometer, reported thatprofessional pitchers exhibited significantweakness of the supraspinatus muscle onthe throwing side compared to the non-throwing side.

The scapulothoracic musculatureplays a vital role during the overhead

throwing motion.34 Proper scapularmovement and stability are imperativefor asymptomatic shoulder function.56,57

These muscles work in a synchronizedfashion and act as force couples aboutthe scapula, providing both movementand stabilization. Wilk et al117 docu-mented the isometric scapular musclestrength values of 112 professional base-ball players. The results indicated thatpitchers and catchers exhibited signifi-cantly higher strength of the protractorand elevator muscles of the scapula whencompared to position players. All play-ers (except infielders) exhibited signifi-cantly stronger depressor muscles of thescapula on the throwing side comparedwith the nonthrowing side. In addition,we believe that the agonist-antagonistmuscle ratios are important values whenconsidering how the scapula providesstability, mobility, and symptom-freefunction. illustrate thescapular muscle strength values in theoverhead-throwing athlete.

As previously mentioned, the ability ofthe scapula to function as a cohesive unit

with the upper body is essential for theoverhead athlete. To be able to functionproperly, the scapula needs to be in theproper position to assist in the movementof the humerus. Kibler et al57 defined al-terations in motion of the scapula duringcoupled scapulohumeral movements as“scapular dyskinesis.” Numerous authorshave noted the role of scapular dyskinesisand the positive correlation to shoulderpathology.56,57

Oftentimes, the overhead athletehas changes in posture that result in achange of resting position of the scap-ula. Burkhart et al19 has described thesepostural changes as the “SICK” scapula,which stands for scapular malpositionsthat include inferior medial borderprominence, coracoid pain and malpo-sition, and dyskinesis of scapular move-ment. This syndrome often presentsclinically as an asymmetric “dropped”scapula. Bastan et al10 reported the po-sition of the scapula in the overhead ath-lete in 3 planes (rotation, tilt, elevation)for 4 di!erent shoulder positions (rest,90° abduction, 90° abduction with max-imal ER, and 90° abduction with maxi-mal IR). Their results indicated that thescapula of the dominant side, with theshoulder at rest, was significantly moreprotracted (P = .006) and tilted anteri-orly (P = .007); with the shoulder at 90°of abduction, it was more rotated in theupward direction (P = .039); with bothmaximal ER and IR at 90° of abduction,it was more tilted anteriorly (P .001).10

Macrina et al70 reported that once thescapular musculature gets fatigued,scapular position worsened, resultingin greater scapular protraction and an-terior tilting. This anterior tilt positioncorrelates with a loss of glenohumeraljoint IR.13,66 As previously mentioned,there have been numerous studies onthe association between scapular posi-tional change, scapular dyskinesis, andincreased shoulder pathology. Thesestudies further the belief that there isan increased rate of scapular positionchange that may lead to increased shoul-der pathology in the overhead athlete.

Glenohumeral Muscular StrengthValues in Professional Baseball

Players (n = 83)103,104

* Strength ratio of the dominant to the nondominant side for each muscle group.† Data for the dominant (pitching) arm only.‡ Peak torque measured in ft-lb and body weight in lb.

Bilateral comparisons (%)*

External rotation 95-109 85-95 80-90

Internal rotation 105-120 100-115 100-110

Abduction 100-110 100-110

Adduction 120-135 115-130

Unilateral peak torque ratios (%)†

External/internal rotation 63-70 65-72 62-70

Abduction/adduction 82-87 92-97

External rotation/abduction 64-69 66-71

Peak torque-body weight ratios‡

External rotation 18-23 15-20

Internal rotation 27-33 25-30

Abduction 26-32 20-26

Adduction 32-36 28-33


game and season pitch counts, as well asprevious treatments, needs to be deter-mined. It is equally important to see anyimaging studies the patient had prior toevaluation. The imaging studies must becorrelated to the physical examination toestablish an accurate and di!erential di-agnosis. Numerous imaging studies maybe beneficial in establishing the diagno-sis, such as plain radiographs, magneticresonance arthrograms (MRA), or com-puterized tomography scans.

After a thorough medical history has

been obtained, the physical examina-tion will focus the di!erential diagnosisdown to a manageable list of possibilities.Each medical practitioner should have aconsistent progression to follow for ev-ery physical exam ( ). Thereare multiple tests or exam techniques toarrive at a diagnosis, and it is importantthat each medical practitioner use examtechniques that they are familiar withand are capable of duplicating with eachpatient.

Visual observation of the shouldershould be performed first, with specialattention focused on any skin lesions ormuscle atrophy. Next, the shoulder is pal-pated, feeling all bony prominences, withspecial attention on the bicipital groove,greater tuberosity, and acromioclavicular(AC) joint. Pain in these areas can indicatebiceps tendon involvement, rotator cu!involvement, and AC joint arthrosis, re-spectively. ROM, both active (AROM) andpassive (PROM), is observed, focusing onglenohumeral as well as scapulothoracicmotion. Glenohumeral joint PROM isassessed for ER and IR at 90° abductionand for ER at 45° abduction in the scapu-lar plane. When assessing IR, care is takento palpate and stabilize the scapula. Whenassessing PROM, the clinician should as-sess both the quantity of motion and theend feel. Forward flexion, abduction, IR,and ER are important to assess, especiallyfor any deficits that may be evident. Palpa-tion of the shoulder during ROM can un-cover crepitus, which may indicate certainpathologic lesions, such as bursa thicken-ing, rotator cu! tears, and arthritis.

Muscle strength is the next componentof the examination. To test the supraspi-natus, the patient is asked to flex theshoulder to 90°, with the arm horizontallyabducted to around 45° and the thumbpointing upward (full can). Resistance isapplied in this position.55,91 Weakness orpain may indicate a lesion of the supraspi-natus muscle. With the arm at the sideand the elbow flexed to 90°, the patientis asked to externally rotate against resis-tance (infraspinatus and teres minor) andinternally rotate against resistance (sub-

lthough acute injuries to theshoulder do occur in the overhead-throwing athlete, it is much more

common for injuries to be secondary tooveruse and fatigue. General informa-tion about the patient, as well as specificinformation about symptoms and throw-ing history, is required to make a correctdiagnosis ( ).45 Important in-formation, such as onset of symptoms,changes in mechanics, development ofa new pitch, training regimen, single-

Strength of the ScapulothoracicMusculature*

* Values are mean SD kg.

Pitchers

Protraction 32.2 4.5 33.6 5.9

Retraction 28.1 3.6 27.2 3.2

Elevation 37.6 6.4 38.1 6.8

Depression 10.0 2.7 8.2 2.3

Catchers

Protraction 30.8 4.5 33.1 4.5

Retraction 28.6 2.3 26.8 3.2

Elevation 39.9 6.8 38.6 3.6

Depression 9.5 1.8 7.3 2.3

Position players

Protraction 26.3 4.5 26.3 5.0

Retraction 25.9 2.7 25.4 2.7

Elevation 29.5 5.4 29.9 5.0

Depression 8.6 2.3 8.2 2.3

Strength Ratios of theScapulothoracic Musculature

Pitchers

Protraction/retraction 87% 81%

Elevation/depression 27% 21%

Catchers



Position players





scapularis). Again, weakness or pain mayindicate a lesion. Resisted ER and IR aresubsequently performed at 90° of abduc-tion and neutral rotation, which is a morefunctional position to assess the overheadathlete. It may be beneficial to assess ERand IR strength at 90° of abduction, withthe patients moving through an arc ofmotion concentrically and eccentricallyagainst resistance.

At this point, the examiner can per-form certain provocative maneuversto assess other possible pathology ( -

). A few selected common testsperformed in the clinic will be discussedbelow in more detail.

To assess subacromial impingement,the Hawkins-Kennedy test is often uti-lized. This subacromial impingementtest has been reported to have 66% to100% sensitivity and 25% to 66% speci-ficity for the diagnosis of impingement,rotator cu! tears, and bursitis.21,69,87 Thepatient’s shoulder joint is forward flexedto 90° and the shoulder is forcibly in-ternally rotated. This maneuver drivesthe greater tuberosity farther under thecoracoacromial ligament, producing im-pingement. Pain with this maneuver mayindicate subacromial impingement.98 Thetest is performed at 90° of abduction inthe scapular plane, sagittal plane, andwith horizontal adduction beyond thesagittal plane, with the more horizon-

tally adducted positions causing greaterimpingement and, therefore, being pos-sibly more provocative for pain.

There are a variety of tests describedto assess for a possible superior labrumanterior posterior (SLAP) tear.33 O’Brien’sactive compression test is frequentlyused.83 The examiner asks the patient toforward flex the a!ected arm 90°, withthe elbow in full extension. The patientthen adducts the arm 10° to 15° medially.The arm is internally rotated so that thethumb is pointing downward. The exam-iner then applies a uniform downwardforce to the arm. The exact same tech-nique is performed again, this time withthe patient placing the palm up towardthe ceiling. The test is considered positiveif pain (located within the subacromial orsuperior glenohumeral joint) is elicitedwith the first maneuver and is reducedor eliminated with the second maneu-ver.99 O’Brien et al83 have reported 100%sensitivity and 97% to 99% specificity forthis test in detecting glenoid labral or ACjoint abnormality. The tests we performto test the integrity of the glenoid labrumare the biceps load test, pronated bicepsload test,116 and resisted ER with supina-tion test.80 These tests, illustrated in -

( ), have beenshown to be highly sensitive for SLAPtears/lesions in the overhead athlete.80

There exist numerous joint stabilitytests. For a complete and thorough de-

scription of these tests the reader is en-couraged to review Wilk et al.113,116 Thosewe routinely perform are the anteriordrawer, fulcrum, relocation, and internalimpingement signs and tests. The mostimportant aspects of these tests are todetermine the extent of laxity present,end point, and, in particular, the tissueelasticity at end range. To assess endpoint elasticity, the fulcrum test is per-formed at 90° of abduction. The posteri-or impingement sign is performed in theplane of the scapula at 90° of abduction,with the examiner passively rotating thearm into maximum ER ( ). Apositive test is indicated by complaintsof pain in the deep posterior shoulder.Meister et al76 have reported 76% sensi-tivity and 85% specificity when perform-ing this test for posterior rotator cu!and/or labrum tears.

Imaging is the next important step in de-termining a diagnosis. Plain radiographswith multiple views of the involved gle-nohumeral joint are mandatory. Routineradiographic evaluation includes ante-rior-posterior (AP), Stryker notch, WestPoint, axillary, and acromial outlet views.These views allow visualization of the gle-nohumeral articulation as well as acromi-al morphology and the inferior glenoid.

Biceps load test performed to assessfor possible SLAP lesion. The patient abducts theshoulder to 90°, fully externally rotates the shoulder,flexes the elbow to 90°, and fully supinates theforearm. The patient is asked to actively flex theelbow against resistance. Pain is positive indicationfor a SLAP lesion.

Pronated biceps load test to assess forpossible SLAP lesion. The patient assumes the sameposition as the biceps load test but fully pronatesthe forearm. The patient is again asked to activelyflex the elbow against resistance. Pain located in thesuperior glenohumeral joint (deep) is indicative of aSLAP lesion.

Resisted external rotation with supinationperformed to assess integrity of the superior labrum.The patient is asked to abduct the arm to 90°,and flex the elbow to 90°, keeping the shoulder inneutral rotation. The examiner resists the patient,while active external rotation of the arm and forearmsupination is performed. Pain is considered a positivesign for a SLAP lesion.


The imaging modality of choice to as-sess soft tissue pathology of the shoulderis magnetic resonance imaging (MRI)with intra-articular contrast (MRA). Thisallows the best view of the rotator cu!tendons and muscles, glenoid labrum,biceps tendon, and other associated pa-thology, such as spinoglenoid cysts. Intra-articular contrast is especially useful todetermine if there is a full-thickness ver-sus partial-thickness tear of the rotatorcu!. Furthermore, the MRA techniqueallows the physician to evaluate the gle-noid labrum to determine if a detachedlabrum or frayed labrum exists. In thethrowing athlete the most common le-sions are partial-thickness rotator cu!tears and glenoid labrum pathology.

There are numerous lesions thatmay occur in the overhead athlete( ).

Tendonitis, tendonosis, and bursitis are3 separate clinical entities for which thenames are often incorrectly used inter-changeably. Tendonitis is inflammationof the tendon. In many cases, it is actuallythe tendon sheath that is inflamed andnot the tendon itself. Bursitis is inflam-mation of the subacromial bursa. Ten-donosis implies intratendonous disease,such as intrasubstance degeneration ortearing.

The patient clinical presentation oftendonitis or tendonosis of the rotatorcu! are pain with overhead activity andweakness secondary to pain. The symp-toms in the thrower are pain during thelate cocking phase of throwing, when thearm is in maximal ER, or pain after ballrelease, as the muscles of the rotator cu!slow the arm during the decelerationphase.37 Weakness of the supraspinatusand infraspinatus are common findingsin throwers with shoulder pathology;but asymmetric muscle weakness in thedominant shoulder is often seen in the

healthy thrower. Di!erential diagnosisof tendonitis versus tendonosis is basedon MRI and duration and frequency ofsymptoms. On MRI, the patient withtendonitis will exhibit inflammation ofthe tendon sheath (the paratenon); con-versely, when tendonosis is present, thereexists intrasubstance wear (signal) of thetendon.

Tendonitis/tendonosis is most fre-quently an overuse injury in the overheadathlete and does not usually represent anacute injury process. The symptoms fre-quently occur early in the season, whenthe athlete’s arm is not conditioned prop-erly.114 These injuries may also occur at theend of the season, as the athlete begins tofatigue. If the athlete does not participatein an in-season strengthening program tocontinue proper muscular conditioning,tendonitis/tendonosis may also develop.Specific muscles (external rotator mus-cles and scapular muscles) may becomeweak and painful due to the stresses ofthrowing.114

Muscles of the rotator cu! are activeduring various phases of the throwingmotion.35,42,50 During the late cockingand early acceleration phases, the arm ismaximally externally rotated, potentiallyplacing the rotator cu! in position toimpinge between the humeral head andthe posterior-superior glenoid. Knownas “internal impingement” or “posteriorimpingement,” this may place the rota-tor cu! at risk for undersurface tearing(articular sided). Conversely, in the de-celeration phase of throwing, the rotatorcu! experiences extreme tensile loadsduring its eccentric action, which maylead to injury.36 Rotator cu! tears in theoverhead athlete may be of partial or fullthickness. The history of shoulder paineither at the top of the wind-up (accel-eration) or during the deceleration phaseof throwing should alert the examinerto a rotator cu! source of pain or loss offunction. Any history of trauma, changesin mechanics, loss of playing time, previ-ous treatments, voluntary time o! from

throwing, and history of previous injuryshould be noted.

Rotator cu! tears may be caused byprimary tensile cu! disease (PTCD), pri-mary compressive cu! disease (PCCD),or internal impingement. PTCD resultsfrom the large, repetitive loads placed onthe rotator cu! as it acts to decelerate theshoulder during the deceleration phase ofthrowing in the stable shoulder. The in-jury is seen as a partial undersurface tearof the supraspinatus or infraspinatus.2,7

PCCD is found on the bursal surface ofthe rotator cu! in throwers with stableshoulders. This process occurs secondaryto the inability of the rotator cu! to pro-duce su"cient adduction torque and in-ferior force during the deceleration phaseof throwing. Processes that decrease thesubacromial space increase the risk forthis type of pathology.2 Partial-thicknessrotator cu! tears can also occur from in-ternal impingement.

Internal impingement was first describedin 1992 by Walch and associates in tennisplayers.104 They presented arthroscopicclinical evidence that partial, articular-sided rotator cu! tears were a direct con-sequence of what they termed “internalimpingement.” Internal impingement ischaracterized by contact of the articularsurface of the rotator cu! and the greatertuberosity with the posterior and superi-or glenoid rim and labrum in extremes ofcombined shoulder abduction and ER.49

In overhead throwing athletes, it ap-pears that excessive anterior translationof the humeral head, coupled with exces-sive glenohumeral joint ER, predisposesthe rotator cu! to impingement againstthe glenoid labrum.63 Repeated internalimpingement may be a cause of under-surface rotator cu! tearing and posteriorlabral tears. It is important that the un-derlying laxity of the glenohumeral jointbe addressed at the time of treatment foran internal impingement lesion to pre-vent recurrence of the lesion.7 Burkhartet al20 have proposed that restrictedposterior capsular mobility may result


[ CLINICAL COMMENTARY ]in IR deficits and may cause pathologicincreases in internal rotator cu! contactand injury. The authors of this manu-script believe that the loss of IR is mostoften due to osseous adaptation29,89 andmuscular tightness, as opposed to capsu-lar tightness.

Patients with internal impingementusually describe an insidious onset of painin the shoulder.5 Pain tends to increaseas the season progresses. Symptoms mayhave been present over the past couple ofseasons, worsening in intensity with eachsuccessive year. Pain is usually dull andaching, and is located over the posterioraspect of the shoulder. Late cocking phaseseems to be most painful. Loss of controland velocity is often present secondary tothe inability to fully externally rotate thearm without pain.

On physical examination, pain maybe elicited over the infraspinatus muscleand tendon with palpation. Pain to palpa-tion is more often posterior, in contrastto rotator cu! tendonitis, which usuallyelicits pain to palpation over the greatertuberosity.5 With internal impingement,patients usually have full ROM. In boththe normal and pathologic thrower’sshoulder the dominant arm tends to have10° to 15° more ER and 10° to 15° less IRwith the arm abducted to 90°, comparedwith the nondominant arm.29 The mostcommon presentation is for the overheadathlete to have 1+ to 2+ anterior laxity and2+ posterior laxity. Inferior laxity is oftenpresent. Most provocative tests are nega-tive. The most frequent provocative examto elicit pain is the internal impingementsign,76 described earlier.

SLAP lesions are a complex of injuries tothe superior labrum and biceps anchor atthe glenoid attachment. Andrews and as-sociates4 were the first to describe this le-sion in 1985. They reported arthroscopicfindings in a group of throwing athleteswith shoulder dysfunction. Snyder andassociates94 later classified this injurycomplex as superior labrum anteriorand posterior lesions, and coined the

term SLAP lesion. The arthroscopic ap-pearances of the lesions were originallyclassified into 4 distinct lesion types,with 3 variations later being added.71 Thepathophysiology of SLAP lesions is de-bated frequently, but the essentials of thelesion are agreed upon.

Patients who have SLAP lesions fallinto 2 basic categories. The first consistsof overhead athletes, most commonlybaseball players, with a history of repeti-tive overhead activity and no history oftrauma. The second category involves pa-tients with a history of trauma.49

Burkhart et al20 have described thepeel-back lesion of the superior labrum,which frequently occurs in the overheadathlete ( ). Peel-back lesions areconsidered a type II SLAP lesion. Theathlete often presents to the practitio-ner with complaints of vague onset ofshoulder pain and possibly problemswith velocity, control, or other throwingcomplaints. The patient may complainof mechanical symptoms or pain in thelate cocking phase, often poorly localized.The diagnosis of SLAP lesions can be verydi"cult, as symptoms can mimic rotatorcu! pathology and glenohumeral jointinstability. Definitive diagnosis can onlybe made by arthroscopy.49

Thrower’s exostosis is an extracapsularossification of the posteroinferior gle-noid rarely seen except in older longtimethrowers.75 This condition is a result ofsecondary ossification involving the pos-terior capsule, probably due to repeti-tive trauma.6 The osteophyte is thoughtto originate in the glenoid attachmentof the posterior band of the inferior gle-nohumeral ligament, possibly from trac-tion during deceleration. Patients oftenhave a tight posterior capsule, with cap-sular contracture and asymmetric shoul-der motion with an IR deficit.

This lesion can often mimic internalimpingement. Pain is often found inthe posterior part of the shoulder and isworse in late cocking. Patients often de-

scribe a pinching sensation during throw-ing. Pain usually is relieved by rest. Plainradiographs will assist in di!erentiatingthis lesion from internal impingement.

ubacromial impingement pa-thologies can frequently be treatednonoperatively with or without a

subacromial (extra-articular) injection,often consisting of a mixture of local an-esthetic and a corticosteroid. The anes-thetic and steroid are used to relieve painand inflammation, allowing the patient tomore e!ectively perform a therapy pro-gram. After the injection is performed,a period of rest and rehabilitation isused. It is common for the patient tobe re-evaluated after 2 to 3 weeks. If noimprovement is seen, a second injectionmay be indicated. If the patient fails thisnonoperative course, shoulder arthros-copy with rotator cu! debridement maybe indicated. At the time of surgery, theshoulder can be assessed for other lesionsand any identified pathology addressed.Often, instability and hyperlaxity are un-derlying causes for rotator cu! lesions.

Surgical intervention is only consideredwith a full-thickness rotator cu! tear orwith partial-thickness tears, after thepatient has failed at least 1, but usually2, courses of rehabilitation, followed byan interval throwing program. Prior tophysical therapy for partial-thickness ro-

Arthroscopic view of peel-back lesion ofthe superior labrum.


tator cu! tears, either a subacromial cor-ticosteroid injection or a glenohumeralinjection is frequently performed. If thepatient fails this course of treatment, ar-throscopy is indicated.

The first step in the operative interven-tion is an examination under anesthesia.After the examination under anesthesiahas been performed, diagnostic arthros-copy of the shoulder begins by establish-ing a posterior viewing portal to visualizethe glenohumeral joint. Care is taken tolook at the labrum, with special attentionto the superior labrum, biceps anchor,and articular surface of the rotator cu!.The glenoid and humeral articular sur-faces are also visualized for lesions. Otherstructures visualized include the bicepstendon, superior border of the subscapu-laris tendon, the middle glenohumeralligament, rotator interval, and axillarypouch. An anterior working portal isthen created through the rotator interval.A probe is brought into the joint to as-sess integrity of the superior labrum andbiceps anchor, the rotator cu!, and anyother structures in question. The arthro-scope is then placed in the anterior portalto visualize the posterior structures.

Once any intra-articular pathologyhas been identified, a full-radius shaveris brought in through the anterior portal.Any fraying of the labrum or undersurfaceof the rotator cu! can be debrided backto a stable base. Undersurface rotator cu!tears are evaluated for the percent thick-ness of the tendon that is torn. The nor-mal rotator cu! attaches to the articularmargin of the humerus, and the footprintspans approximately 14 mm from medialto lateral. Partial articular-sided tears canbe measured from the articular margin toassess the percentage of injury (7 mm ex-posed surface from the articular margin,50% tear). Tears of less than 50% thick-ness are debrided, while tears of greaterthan 50% thickness may also be debridedor repaired to the footprint.37 Significantpartial-thickness tears or full-thicknesstears may be repaired arthroscopically orthrough a standard mini-open technique.Arthroscopic repair involves placing the

arthroscope into the subacromial space(in most cases), performing a subacro-mial decompression, and repairing theinvolved rotator cu! tendon or tendonswith side-to-side repair or suture an-chors. More recently, double-row rota-tor cu! repairs have become increasinglypopular. The postoperative outcomes ofrotator cu! repairs in the overhead ath-lete have been reported to be less thanoptimal, with approximately less than15% of athletes returning to play.73

As mentioned earlier, internal impinge-ment is a common pathology seen in theoverhead athlete. The best treatment forthis lesion is a thorough and well-devel-oped nonoperative treatment program.If nonoperative measures fail, surgeryis indicated. As with other shoulder in-juries, an examination under anesthesia,followed by diagnostic arthroscopy, isperformed. Simple arthroscopic debri-dement of rotator cu! tears and labralfraying was originally described to treatinternal impingement.3 Results weremixed with simple debridement, andit became evident that some sort of an-terior stabilization was also required tohelp stabilize the shoulder. Therefore, inconjunction with debridement of the ro-tator cu! or labral lesions, capsulolabralreconstruction51 or thermal capsulo-raphy63 has been recommended. Gener-ally, subacromial decompression does nothave a role in the treatment of internalimpingement.

Once the diagnosis has been established,treatment options are considered. Thenonsurgical treatment of SLAP lesionsdepends upon the type of lesion. Most le-sions in the overhead athlete are type IIand may not respond well to nonsurgicalmanagement.

When pain and dysfunction persistafter a period of rest and rehabilitation,surgical intervention is indicated. As withother shoulder injuries, a physical exami-nation under anesthesia is done, followed

by diagnostic arthroscopy. All of the in-tra-articular structures are visualized andevaluated. Close attention to the superiorlabrum and biceps anchor is warranted.

If a true superior labral detachmentis noted, arthroscopic repair is the pro-cedure of choice. SLAP lesions occurringin the overhead athlete are almost alwaystype II.49 These tears must be repaired.Initially, the lesion must be identified andthe surgeon determines if there is a pri-marily posterior or anterior component.The location of the predominant patholo-gy dictates arthroscopic portal placementand repair techniques. Prior to repair ofthe lesion, a shaver must be used to deb-ride the glenoid neck and prepare a bonybed to which the labrum is reattached.Lesions with anterior extension may ormay not need an additional accessorylateral portal. Suture anchors are placedalong the glenoid rim, and the labrumand biceps complex are secured back tothe glenoid with arthroscopic knots. If thelesion is predominantly located posteriorto the biceps anchor, an accessory poste-rior portal will likely need to be created.Subacromial decompression is generallynot indicated after SLAP repair.

Treatment of athletes with this lesion iscontroversial. The senior author (J.R.A.)believes that the presence of posteriorglenoid exostosis is highly predictive ofan undersurface rotator cu! tear causedby internal impingement and injury tothe posterior labrum.6 Initially, thesepatients are treated with a period of ac-tive rest and supervised rehabilitation.Throwers with posterior glenoid exos-tosis can be conservatively managed forsome time; however, long-term successis limited and surgical intervention maybecome necessary.114

As with other shoulder lesions, whennonsurgical measures fail to relievesymptoms, operative intervention is un-dertaken. Initially, examination underanesthesia is performed, followed by di-agnostic arthroscopy. Any concurrent in-


[ CLINICAL COMMENTARY ]tra-articular pathology is addressed at thetime of arthroscopy. A 70° arthroscope isplaced in the anterior portal to improvevisualization over the posterior glenoidrim. The posterior glenoid exostosis isuncovered through a small capsulotomyat the medial edge of the posteroinferiorcapsule by penetrating the capsule witha shaver just o! the posterior labral at-tachment. A small round burr is thenemployed to debride the exostosis back tothe normal contour of the posterior gle-noid rim.7 Underlying glenohumeral jointinstability is also addressed during thesurgical procedure. The posterior capsuleis generally not repaired, resulting in ane!ective posterior capsular release.

ost shoulder injuries in theoverhead thrower can be success-fully treated nonoperatively. The

rehabilitation program involves a multi-phased approach that is progressive andsequential, and is based on the physicalexamination, the specifically involvedstructures, and the primary cause. Thekey to successful rehabilitation is theidentification of the underlying factorsand structures causing the lesion. Thespecific goals of each of the 4 phases ofthe program are outlined in .Each phase represents a progression, theexercises becoming more aggressive anddemanding, and the stresses applied tothe shoulder joint gradually greater.

One of the goals, to diminish the athlete’spain and inflammation, is accomplishedthrough the use of local therapeuticmodalities such as ice, iontophoresis,nonsteroidal anti-inflammatory drugs(NSAIDs), and/or injections. We preferthe use of iontophoresis for soft tissueinflammation about the shoulder. In ad-dition, the athlete’s activities (such asthrowing and exercises) must be modi-fied to a pain-free level. The thrower isoften instructed to abstain from throwing

until advised by the physician or rehabili-tation specialist. Additionally, stretchingexercises have been shown to assist in re-ducing the athlete’s pain.81

Another essential goal during the firstphase of rehabilitation is to normalizeshoulder motion, particularly shoulder IRand horizontal adduction. It is commonfor the overhead thrower to exhibit loss ofIR of 20° or more, referred to as “GIRD.”This loss of IR has been suggested to be acause of specific shoulder injuries.19

We believe that the loss of IR is mostoften due to osseous adaptations of thehumerus and posterior muscle tight-ness.15 We do not believe that the loss ofIR is routinely due to posterior capsulartightness. It appears that most throwersexhibit significant posterior laxity whenevaluated.15 Thus, to improve IR motionand flexibility, we prefer the stretches il-lustrated in . These stretch-es include the sleeper’s stretch (

) and supine horizontal adductionwith IR. These stretches are performedto improve the flexibility of the poste-rior musculature, which may becometight because of the muscle contractionduring the deceleration phase of throw-ing. We do not recommend performingstretches for the posterior capsule unlessthe capsule has been shown on clinicalexamination to be excessively hypomo-bile. If the posterior glenohumeral jointcapsule is hypomobile, then a posterior-lateral joint mobilization glide techniqueis performed to e!ectively mobilize theposterior capsule.

The rehabilitation specialist, in ad-dition to helping restore glenohumeralmotion, should assess the resting positionand mobility of the scapula. Frequently,we see overhead throwers who exhibit aposture of rounded shoulders and a for-ward head. This posture appears associat-ed with muscle weakness of the scapularretractor muscles due to prolonged elon-gation or sustained stretches. In addition,the scapula may often appear protractedand anteriorly tilted. An anteriorly tiltedscapula has been shown to contribute toa loss of glenohumeral joint IR.13,70 Inoverhead throwers, it is our experiencethat this scapular position abnormalityis associated with pectoralis minor mus-cle tightness and lower trapezius muscleweakness, and a forward head posture.Tightness of the pectoralis minor muscle

Sleeper stretch performed to increaseinternal rotation. The patient is asked to lay on theinvolved side with arm flexed to 90°. The patientgrabs the wrist/forearm of the involved extremity andpushes the extremity into internal rotation. Care isgiven to assume the proper position to lock down thescapula. (B) Sleeper stretch with lift. The examinerlifts the patient’s scapula and repositions it laterally,stabilization of the scapula may be necessary.

Horizontal adduction with internal rotationstretch. The patient flexes the arm to 90°. Therehabilitation specialist applies a stabilizing forceto the lateral border of the scapula while the arm ishorizontally adducted and then applies a gentle forceinto internal rotation.


can lead to axillary artery occlusion andneurovascular symptoms, such as armfatigue, pain, tenderness, and cyano-sis.8,82,93,95 The lower trapezius muscle isan important muscle in arm decelerationin that it controls scapular elevation andprotraction.34 Weakness of the lower tra-pezius muscle may result in improper me-chanics or shoulder symptoms. Thus, therehabilitation specialist should carefullyassess the position, mobility, and strengthof the overhead thrower’s scapula. Weroutinely have throwers stretch theirpectoralis minor muscle and strengthenthe lower trapezius muscle in addition tothe scapular retractors. Furthermore, ascapular brace may be utilized to assistin postural correction.

Additional primary goals of this firstphase are to restore muscle strength,re-establish baseline dynamic stability,and restore proprioception. In the earlyphase of rehabilitation, the goal is to re-establish muscle balance.112,113 Therefore,the focus is on improving the strength ofthe weak muscles such as the external ro-tator muscles, the scapular muscles, andthose of the lumbopelvic region and low-er extremities.112,113 If the injured athleteis extremely sore or in pain, submaximalisometric exercises should be employed;conversely, if the athlete exhibits minimalsoreness, then lightweight isotonic exer-cises may be safely initiated. Additionally,during this phase, we use rehabilitationexercise drills designed to restore theneurosensory properties of the shouldercapsule that has experienced microtrau-ma and to enhance the sensitivity of thea!erent mechanoreceptors.60,62

Specific drills that restore neuromus-cular control during this initial phaseare rhythmic stabilization exercises forthe internal/external rotator muscles ofthe shoulders. Additionally, propriocep-tive neuromuscular facilitation patternsare used with rhythmic stabilizationand slow reversal hold to re-establishproprioception and dynamic stabiliza-tion.58,60,62,96,111,112 The purpose of these ex-ercises is to facilitate agonist/antagonistmuscle coactivation. E"cient coactiva-

tion assists in restoring the balance in theforce couples of the shoulder joint, thusenhancing joint congruency and com-pression.46 Padua et al84 used propriocep-tive neuromuscular facilitation patternsfor 5 weeks and significantly improvedtheir subjects’ shoulder function and en-hanced functional throwing performancetest scores. Uhl et al101 reported improvedproprioception after specific neuromus-cular training that challenged the gle-nohumeral musculature.

Other exercises commonly used dur-ing this first rehabilitation phase in-clude joint repositioning tasks60-62 andaxial loading exercises (upper extremityweight-bearing exercises). Active jointcompression stimulates the articular re-ceptors.26,59 Thus, axial loading exercises,such as weight shifts, weight shifting ona ball, wall push-ups, and quadruped po-sitioning drills, are beneficial in restoringproprioception.106,112,109

In phase 2 of the rehabilitation pro-gram, the primary goals are to progressthe strengthening program, continue toimprove flexibility, and facilitate neu-romuscular control. During this phase,the rehabilitation program is progressedto more aggressive isotonic strengthen-ing activities, with emphasis on restora-tion of muscle balance. Selective muscleactivation is also used to restore musclebalance and symmetry. In the overheadthrower, the shoulder external rotatormuscles and scapular retractor, protrac-tor and depressor muscles are frequentlyisolated because of weakness. We have es-tablished a fundamental exercise programfor the overhead thrower that specificallyaddresses the vital muscles involved inthe throwing motion.106,118 This exerciseprogram was developed based on thecollective12,31,47,53,64,74,78,86,91,100 informationderived from electromyographic researchof numerous investigators and is referredto as the “Thrower’s Ten” program.115 Fre-quently, the patient exhibits ER muscularweakness. The specific exercises we preferare side-lying ER ( ) and prone

rowing into ER. Both have been shown toelicit the highest amount of muscular ac-tivity of the posterior cu! muscles.91

The scapula provides proximal stabil-ity to the shoulder joint, enabling distalsegment mobility. Scapular stability isvital for normal asymptomatic arm func-tion. Several authors have emphasized theimportance of scapular muscle strengthand neuromuscular control in contribut-ing to normal shoulder function.31,56,57,85

Isotonic exercises are used to strengthenthe scapular muscles. Furthermore, Wilket al111 developed specific exercise drillsto enhance neuromuscular control of thescapulothoracic joint. These exercise drillsare designed to maximally challenge thescapulothoracic muscle force couples andto stimulate the proprioceptive and kin-esthetic awareness of the scapula. Thesescapular neuromuscular control drills areillustrated in ( ).

Another popular exercise used by ath-letes is the “empty can” exercise. With thisexercise movement, the arm is placed inthe scapular plane with the hand placedin full IR (thumb down). Originally Jobeand Moynes52 reported high levels ofactivation of the supraspinatus musclesduring this exercise. Recently, Reinoldet al90,91 reported that the best exercisefor supraspinatus muscle was insteadthe “full can” exercise. Blackburn et al12

noted that the position with the patientlying prone and with the arm abductedto 100° and full ER produced the highest

Scapular neuromuscular control drills. Theathlete lies on his side with the hand placed on thetable and the clinician applies manual resistance toresist scapular movements (such as protraction andretraction). The athlete is instructed to perform slowand controlled movements.



EMG signal in the supraspinatus musclescompared to the empty can position.

Also during this second rehabilitationphase, the overhead throwing athleteis instructed to perform strengtheningexercises for the lumbopelvic region,including the abdomen and lower backmusculature. Plus, the athlete shouldperform lower extremity strengtheningand participate in a running program,including jogging and sprinting. Upperextremity stretching exercises are con-tinued as needed to maintain soft tissueflexibility.

In phase 3, the advanced strengtheningphase, the goals are to initiate aggressivestrengthening drills, enhance power andendurance, perform functional drills,and gradually initiate throwing activities.During this phase, the athlete performsthe Thrower’s Ten exercise program,continues manual resistance stabiliza-

tion drills, and initiates plyometric drills.Dynamic stabilization drills are alsoperformed to enhance proprioceptionand neuromuscular control. These drillsinclude specific stabilization techniquesthat employ the concept of perturbationsand range stability. These drills includerhythmic stabilization exercise drills bythrowing a ball against the wall (10), push-ups onto a ball, and tubing ERwith end range manual resistance (

). Many of the stabilizationexercises may be performed on a physiob-all. The authors believe that performingthese exercises improves dynamic stabili-zation and increases muscular demands( ). Plyometric trainingmay be used to enhance dynamic stabili-ty, enhance proprioception, and graduallyincrease the functional stresses placed onthe shoulder joint.

Plyometric exercises employ 3 phas-es, all intended to use the elastic reac-tive properties of muscle to generatemaximal force production.16,22,25 The firstphase is the eccentric phase, where arapid prestretch is applied to the muscu-lotendinous unit, stimulating the musclespindle. The second phase is the amorti-zation phase, representing the time be-tween eccentric and concentric phases.This time should be as short as possibleso that the beneficial neurologic e!ects ofprestretch are not lost. The final phase isthe resultant concentric action. Wilk etal111-112,114 established a plyometric exer-cise program for the overhead thrower.The initial plyometric program consistsof 2-handed exercise drills such as chestpasses, overhead soccer throws, side-to-side throws, and side-throws. The goal ofthe plyometric drills is to transfer energyfrom the lower extremities and trunk tothe upper extremity. Once these 2-handedexercise drills are mastered, the athlete isprogressed to 1-handed drills. These drillsinclude standing 1-handed throws in afunctional throwing position, wall drib-bling, and plyometric step-and-throws.Swanik et al97 reported that a 6-weekplyometric training program resulted inenhanced joint position sense, enhanced

kinesthesia, and decreased time to peaktorque generation during isokinetic test-ing. Fortun et al44 noted improved shoul-der IR power and throwing distancesafter 8 weeks of plyometric training incomparison with conventional isotonictraining.

Additionally, muscular enduranceexercises should be emphasized for theoverhead thrower. Lyman et al68 docu-mented that the overhead athlete is atgreater risk for shoulder or elbow injurieswhen pitching when fatigued. Recently,Murray et al79 documented the e!ects offatigue on the entire body during pitch-ing using kinematic and kinetic motionanalysis. Once the thrower was fatigued,shoulder ER decreased and ball velocitydiminished, as did lead lower extrem-ity knee flexion and shoulder adductiontorque. Voight et al103 documented a re-lationship between muscle fatigue anddiminished proprioception. Chen et al24

demonstrated that once the rotator cu!

Ball throw into wall. The patient throwsa 2-pound (0.9 kg) Plyoball (Functional IntegratedTechnologies, Watsonville, CA) against the wall at endrange of external rotation (late cocking).

Seated external rotation on a physioballwith single-leg support. Resisted external rotationis performed with exercise tubing. To enhance thedemands on the shoulder stabilizers, a rhythmicstabilization technique may be performed.

Neuromuscular dynamic stabilizationexercise: exercise tubing resisting shoulder externalrotation with manual resistance at end range.

Scapular horizontal abduction performedon a physioball. This exercise is performed toenhance scapular muscle activity and core stability.


muscles are fatigued, the humeral headmigrates superiorly when arm elevationis initiated. Furthermore, Lyman et al67

reported that the predisposing factorthat correlated to the highest percent-age of shoulder injuries in Little Leaguepitchers was complaints of muscle fatiguewhile pitching. Thus the endurance drillsdescribed here appear critical for theoverhead thrower.

Specific endurance exercise drills weuse include wall dribbling with a Plyoball(Functional Integrated Technologies, Wat-sonville, CA), wall arm circles, upper bodycycle, or isotonic exercises using lowerweights with higher repetitions. Othertechniques that may be beneficial to en-hance endurance include throwing an un-derweighted or overweighted ball (that is, aball that is either less than or more than theweight of an o"cial baseball).17,25,32,39,65,102

These techniques are designed to enhancetraining, coordination, and the transfer ofkinetic energy. Fortun et al44 noted an in-crease in shoulder IR strength and powerafter an 8-week plyometric training pro-gram using a weighted ball. Most com-monly, the underweighted ball is used toimprove the transfer of energy and angularmomentum.32,39,102 Conversely, the over-weighted ball is generally used to enhanceshoulder strength and power.32,39,102

During this third rehabilitation phase,an interval throwing program may be ini-tiated. Before initiating such a program,we occasionally suggest that the athleteperform “shadow” or mirror throwing,which is the action of mimicking throw-ing mechanics into a mirror, but not ac-tively throwing. This is designed to allowthe athlete to work on proper throwingmechanics before throwing a baseball.The interval throwing program92 is ini-tiated once the athlete can fulfill thesespecific criteria: (1) satisfactory clinicalexamination, (2) nonpainful ROM, (3)satisfactory isokinetic test results, and (4)appropriate rehabilitation progress. Theinterval throwing program is designed togradually increase the quantity, distance,intensity, and type of throws needed to fa-cilitate the gradual restoration of normal

biomechanics.Interval throwing is organized into 2

phases: phase 1 is a long-toss program(45-180 ft [15-60 m]) and phase 2 isan o!-the-mound program for pitchers.During this third rehabilitation phase,we usually initiate phase 1 of the inter-val throwing program at 45 ft (15 m) andprogress to throwing from 60 ft (20 m).The athlete is instructed to use a crow-hop type of throwing mechanism and lobthe ball with an arc for the prescribed dis-tance. Flat-ground, long-toss throwing isused before throwing o! the mound to al-low the athlete to gradually increase theapplied loads to the shoulder while usingproper throwing mechanics. In addition,during this phase of rehabilitation, weroutinely allow the position player to ini-tiate a progressive batting program thatprogresses the athlete from swinging alight bat, to hitting a ball o! a tee, to soft-toss hitting, to batting practice.

Phase 4 of the rehabilitation program,the return-to-throwing phase, usuallyinvolves the progression of the intervalthrowing program. For pitchers, we prog-ress the long-toss program to 120 ft (40m), whereas position players would prog-ress to throwing from 180 ft (60 m). Oncethe pitcher has successfully completedthrowing from 120 ft, the athlete is in-structed to throw 60 ft from the windupon level ground. Once this step is suc-cessfully completed, phase II (throwingfrom the mound) is performed.92 Positionplayers continue to progress the long-tossprogram to 180 ft, then perform fieldingdrills from their specific position. Whilethe athlete is performing the intervalthrowing program, the clinician shouldcarefully monitor the thrower’s mechan-ics and throwing intensity. In a studyconducted at our biomechanics labora-tory, we objectively measured the throw-ing intensity of healthy pitchers. Whenpitchers were asked to throw at 50%e!ort, radar gun analysis indicated thatactual e!ort was approximately 83% oftheir maximum speed. When asked to

throw at 75% e!ort, they threw at 90% oftheir maximum e!ort. This indicates thatthese athletes threw at greater intensitiesthan were suggested, which may implydi"culty of controlling velocity at lowerthrowing intensities.

In addition, during this fourth phase,the thrower is instructed to continue allthe exercises previously described to im-prove upper extremity strength, power,and endurance. The athlete is also in-structed to continue the Thrower’s Tenprogram, stretching program, core stabi-lization exercise training, and lower ex-tremity strengthening activities. Lastly,the athlete is counseled on a year-roundconditioning program based on the prin-ciples of periodization.38 Thus, the athleteis instructed when to begin such things asstrength training and throwing.112 To pre-vent the e!ects of overtraining or throw-ing when poorly conditioned, it is criticalto instruct the athlete specifically on whatto do through specific exercises through-out the year. This is especially critical inpreparing the athlete for the followingseason. Wooden et al119 demonstratedthat performing a dynamic variable re-sistance exercise program significantlyincreased throwing velocity.

verhead-throwing athletestypically present with a uniquemusculoskeletal profile. The over-

head thrower exhibits ROM, postural,and strength changes, which appearto be from adaptations from imposeddemands. This unique client exhibitsunique lesions, and the recognition andtreatment of these lesions may presenta significant challenge to the clinician.Based on the accurate recognition ofthe lesion and underlying cause of thepathology, a successful nonoperative orin some cases operative treatment plancan be implemented. In this manuscript,we have attempted to provide the readerwith information regarding the evalu-ation and treatment of the overheadthrowing athlete.



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General informationAgeGenderDominant-handednessPositionYears throwingLevel of competition

Injury patternOnset of symptoms: acute, chronicHistory of trauma or sudden injury

Symptom characteristicsLocation of symptoms: anterior, lateral, posteriorQuality of symptoms: sharp, dull, burningPresence of mechanical symptoms

Presence of weakness or instabilitySeverity of symptomsDuration of symptomsActivities that worsen symptomsActivities that relieve symptomsPresence of neurosensory changesPhases of throwing that produce symptomsInnings pitched per season/yearFrequency of starts/relief appearancesChanges in velocity of pitchesLoss of control/location of pitches

Treatment/rehabilitationAmount of rest from throwingType and duration of rehabilitation

Type, location, and frequency of injectionsRelated symptoms

Cervical spineRadicular symptomsBrachial plexus injuryPeripheral nerve entrapment

Medical informationPast medical/surgical historyMedicationsAllergiesFamily/social historyReview of test, symptoms, and systems


APPENDIX B

Subjective HistoryObservation/InspectionPalpation

1. Sternoclavicular joint2. Acromioclavicular joint3. Clavicle, acromion, coracoid4. Bicipital groove5. Scapula6. Musculature

Range of Motion1. Crepitus2. Glenohumeral motion

a. Activeb. Passive

3. Scapulothoracic motion

Motor Strength1. Glenohumeral2. Scapular3. Arm/forearm

Impingement Signs1. Neer/Hawkins signs2. Cross-chest adduction test3. Internal impingement sign

Stability Tests1. Sulcus sign2. Anterior drawer3. Anterior fulcrum4. Relocation test5. Posterior drawer6. Posterior fulcrum7. Push-pull test

Special Tests, Biceps1. Speed’s test2. Yergason’s test

Special Tests, SLAP1. Clunk test2. O’Brien’s active compression3. Biceps load4. Lemak test5. Pronated biceps load6. Resisted supinated external rotation test

Neurologic ExaminationCervical Spine ExaminationPerformance Testing

1. Isokinetic testing2. Motion analysis testing

PHYSICAL EXAMINATION OF THE THROWING SHOULDER

APPENDIX C

Rotator Cu! LesionsTendonitisTendonosisStrainsBursitis

Rotator Cu! TearsPartial thicknessFull thicknessInternal impingement

Glenohumeral Joint Capsular Lesions

LaxityInstabilityCapsulitis

Superior Labral Tear (SLAP)Frayed (type I)Tear (type III, IV)Detached (type II)Peel-back

Osseous LesionsGlenoid osteochondritis dissecans

Bennett’s lesion

Biceps Tendon Lesions

Tendinitis

Tendonosis

Subluxation

Neurovascular Lesions

Axillary neuropathy, quadrilateral space

Long thoracic neuropathy

Thoracic outlet syndrome

CLASSIFICATION OF MOST COMMON SHOULDER LESIONS IN OVERHEAD ATHLETES



APPENDIX D

Phase 1: Acute phaseGoals:

Diminish pain and inflammationNormalize motionDelay muscular atrophyReestablish dynamic stability (muscular balance)Control functional stress/strain

Exercises and modalities:Cryotherapy, iontophoresis, ultrasound, electrical

stimulationFlexibility and stretching for posterior shoulder muscles

to improve shoulder internal rotation and horizontaladduction

Rotator cu% strengthening (especially external rotatormuscles)

Scapular muscles strengthening (especially retractorand depressor muscles)

Dynamic stabilization exercises (rhythmic stabilization)Weight-bearing exercisesProprioception trainingAbstain from throwing

Phase 2: Intermediate phaseGoals:

Progress strengthening exercisesRestore muscular balanceEnhance dynamic stabilityControl flexibility and stretches

Exercises and modalities:Continue stretching and flexibility (especially shoulder

internal rotation and horizontal adduction)Progress isotonic strengthening

Rhythmic stabilization drillsInitiate core lumbopelvic region strengthening programInitiate lower extremity program

Phase 3: Advanced strengthening phaseGoals:

Aggressive strengtheningProgress neuromuscular controlImprove strength, power, and endurance

Exercises and modalities:Flexibility and stretchingRhythmic stabilization drills

Initiate plyometric programInitiate endurance drillsInitiate short-distance throwing program

Phase 4: Return-to-activity phaseGoals:

Progress to throwing programReturn to competitive throwingContinue strengthening and flexibility drills

Exercises:Stretching and flexibility drills

115 for fullprogram)

Plyometric programProgress interval throwing program to competitive throw-

ing (see Reinold et al92 for full program)

NONOPERATIVE REHABILITATION OF THE OVERHEAD ATHLETE: PHASES AND GOALS

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