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Shoulder - Glenohumeral & Scapulothoracic Rehab with Specific Consideration for Anterior
Capsulolabral Repairs & Throwing Injuries
Table of Contents
1. Glenohumeral/Scapulothoracic Rehab
Pages 38 - 54
CLINICAL COMMENTARY
MICHAEL M. REINOLD, PT, DPT, ATC, CSCSH7<7;B;I97C?BB7"PT, PhD, CSCS, FACSMA;L?D;$M?BA" PT, DPT
HEJ7JEH9K<<CKI9B;I
Coordinator of Rehabilitation Research and Education, Department of Orthopedic Surgery, Division of Sports Medicine, Massachusetts General Hospital, Boston, MA; Rehabilitation
Coordinator/Assistant Athletic Trainer, Boston Red Sox Baseball Club, Boston, MA. 2 Professor, Department of Physical Therapy, California State University, Sacramento, Sacramento,
CA. 3 Clinical Director, Champion Sports Medicine, Director of Rehabilitative Research, American Sports Medicine Institute, Birmingham, AL. Address correspondence to Dr Michael
M. Reinold, Rehabilitation Coordinator/Assistant Athletic Trainer, Boston Red Sox Baseball Club, Fenway Park, 4 Yawkey Way, Boston, MA 02215. Email: mreinold@redsox.com
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 105
CLINICAL COMMENTARY
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The supraspinatus compresses, abducts,
and generates a small ER torque to the
glenohumeral joint. Supraspinatus activity increases as resistance increases during
abduction/scaption movements, peaking
at 30 to 60 of elevation for any given
resistance. At lower elevation angles, supraspinatus activity increases, providing
additional humeral head compression
within the glenoid fossa to counter the
humeral head superior translation occurring with contraction of the deltoid.1 Due
to a decreasing moment arm with abduction, the supraspinatus is a more effective
abductor in the scapular plane at smaller
abduction angles.34,50,65
Relatively high supraspinatus activity
has been measured in several common
rotator cuff exercises3,5,17,33,54,63,70,75,79,87
and in several exercises that are not
commonly thought of as rotator cuff exercises, such as standing forward scapular punch, rowing exercises, push-up
exercises, and 2-hand overhead medicine ball throws.13,17,32,81 These results
suggest the importance of the rotator
cuff in providing dynamic glenohumeral
stability by centering the humeral head
within the glenoid fossa during all upper extremity functional movements.
This is an important concept for the
clinician to understand. The muscles
ability to generate abduction torque in
the scapular plane appears to be greatest with the shoulder in neutral rotation
or in slight IR or ER.50,65 This biomechanical advantage has led to the development of exercises in the plane of the
106 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
<?=KH;'$Direction of the magnitude of the resultant force vector for different glenohumeral joint positions as a
function of different muscle activity, (A) deltoid activity, (B) rotator cuff activity, (C) combined deltoid and rotator
cuff activity. Reprinted with permission from Morrey et al.61
<?=KH;($The position of the resultant force vector of the rotator cuff and deltoid for different positions of arm
elevation with (N) neutral rotation, (I) internal rotation, and (X) external rotation. Reprinted with permission from
Poppen and Walker.66
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 107
CLINICAL COMMENTARY
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The infraspinatus and teres minor comprise the posterior cuff, which provides
glenohumeral compression and resists
superior and anterior humeral head
translation by exerting an inferoposterior force on the humeral head.74 The posterior cuff muscles provide glenohumeral
ER, which functionally helps clear the
greater tuberosity from under the coracoacromial arch during overhead movements, thus minimizing subacromial
impingement.
Based on 3-D biomechanical shoulder
models, the maximum predicted isometric infraspinatus force was 723 N for ER
at 90 of abduction and 909 N for ER at
0 of abduction.34 The maximum predicted teres minor force was much less than
for the infraspinatus during maximum
ER at both 90 (111 N) and 0 abduction
(159 N).34 The effectiveness of the muscles
of the posterior rotator cuff to externally
rotate the arm depends on glenohumeral
position. The superior, middle, and inferior heads of the infraspinatus have their
largest ER moment arm (approximately 2.2 cm) and generate their greatest
torque at 0 abduction.65 As the abduction angle increases, the moment arms of
the inferior and middle heads stay relatively constant, while the moment arm of
the superior head progressively decreases
108 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
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The subscapularis provides glenohumeral compression, IR, and anterior stability
of the shoulder. From 3-D biomechanical
shoulder models, predicted subscapularis force during maximum effort IR
was 1725 N at 90 abduction and 1297
N at 0 abduction.34 Its superior, middle,
and inferior heads all have their largest IR moment arm (approximately 2.5
cm) and torque generation at 0 abduction.65 As the abduction angle increases,
the moment arms of the inferior and
middle heads stay relatively constant,
while the moment arm of the superior
head progressively decreases until it is
about 1.3 cm at 60 abduction.65 These
data imply that the upper portion of the
subscapularis muscle (innervated by the
upper subscapularis nerve) may be a
more effective internal rotator at lower
abduction angles compared to higher abduction angles. However, there is no signicant difference in upper subscapularis
activity among IR exercises performed at
0, 45, or 90 abduction.17,39 Abduction
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 109
CLINICAL COMMENTARY
<?=KH;)$Diagnonal exercise for the subscapularis begins in shoulder external rotation at 90 abduction in the
coronal plane (A) and internal rotation and horizontal adduction are performed simultaneously (B), similar to a
tennis swing.
DELTOID
110 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
I97FKBEJ>EH79?9CKI9B;I
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The serratus anterior works with the
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 111
CLINICAL COMMENTARY
<?=KH;+$Bilateral serratus anterior punch to 120 abduction begins with hands by the side (A) before extending
elbows and elevating shoulders up to 120 of elevation and full protraction (B).
<?=KH;*$Dynamic hug exercise for the serratus
anterior begins with the elbows in approximately 45
of exion, the shoulder abducted 60 and internally
rotated 45 (A). The humerus is then horizontally
adducted by following an arc movement similar to
a hugging action, until full shoulder protraction is
reached (B).
112 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
JhWf[p_ki
General functions of the trapezius include
scapular upward rotation and elevation
for the upper trapezius, retraction for the
middle trapezius, and upward rotation
and depression for the lower trapezius.
In addition, the inferomedial-directed
bers of the lower trapezius may also
contribute to posterior tilt and external
rotation of the scapula during arm elevation,52 which decreases subacromial impingement risk24,51 and makes the lower
trapezius an important area of focus in
rehabilitation. Relatively high upper
trapezius activity occurs in the shoulder
shrug, prone rowing, prone horizontal
abduction at 90 and 135 of abduction
with ER and IR, D1 diagonal PNF pat-
H^ecXe_ZiWdZB[lWjehIYWfkbW[
Both the rhomboids and levator scapulae function as scapular retractors,
downward rotators, and elevators. Exercises used to strengthen rotator cuff
and scapulothoracic musculature are
also effective in eliciting activity of the
rhomboids and levator scapulae. Relatively high rhomboid activity has been
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 113
CLINICAL COMMENTARY
H;9ECC;D:7J?EDI
to grow, we are seeing advances in exercise selection and the integration of the
whole-body kinetic-chain approach to
strengthening and rehabilitating injuries.
This may involve strengthening multiple
joints simultaneously and during movement patterns that mimic athletic and
functional daily activities of living. The
authors often employ these techniques
when our patients improve in strength
yet continue to have symptoms during
activities. In addition, we often attempt
to further challenge our patients by performing many of the recommended exercise on various unstable surfaces (such as
foam or physioballs), with altered bases
of support (such as sitting, standing, or
single-leg balancing), in an attempt to
recruit whole-body muscle patterns that
interact together to perform active range
of motion while stabilizing other areas of
the body. We believe that these concepts
are important to consider in addition to
straight-plane, isolated movements of
specic muscle groups, and that strength,
posture, balance, and neuromuscular
control are all vital components to any
injury prevention of rehabilitation program. Future research on the validity of
these techniques is needed to justify their
use. We believe that this is the next step
in the evolution of research on the clinical and biomechanical implications of
exercise selection for the glenohumeral
and scapulothoracic musculature.
9ED9BKI?ED
thorough understanding of
the biomechanical factors associated with normal shoulder
movement, as well as during commonly
performed exercises, is necessary to
safely and effectively design appropriate
programs. We have reviewed the normal
biomechanics of the glenohumeral and
scapulothoracic muscles during functional activities, common exercises, and
in the presence of pathology. These ndings can be used by the clinician to design
appropriate rehabilitation and injury
prevention programs. T
114 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
TABLE
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;n[hY_i[
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Supraspinatus
1. Full can
1. Side-lying ER
2. Prone ER at 90
abduction
1. IR at 0 abduction
2. IR at 90 abduction
2. Enhances scapular position and 2. Strengthens in a challenging position for shoulder stability
subacromial space. Less
pectoralis activity
3. IR diagonal exercise
2. Prone ER at 90
abduction
3. Prone horizontal
abduction at 90
abduction with ER
4. Bilateral ER
2. Prone horizontal
abduction at 90
abduction with ER
1. Shrug
1. Effective exercise
2. Prone row
3. Prone horizontal
abduction at 90
abduction with ER
Infraspinatus
and teres
minor
Subscapularis
Lower trapezius
Upper trapezius
3. Prone extension with ER 3. Prone exercise below 90 abduction 3. High EMG activity
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 115
[
H;<;H;D9;I
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journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 117
clinical commentary
Bryce W. Gaunt, PT, SCS1 Michael A. Shaffer, MSPT, OCS, ATC2 Eric L. Sauers, PhD, ATC3
Lori A. Michener, PT, PhD, ATC, SCS4 George M. McCluskey III, MD5 Chuck A. Thigpen, PT, PhD, ATC6,7
Director of Physical Therapy, HPRC at St Francis Rehabilitation Center, Columbus, GA. 2Coordinator of Sports Rehabilitation University of Iowa Sports Medicine, Clinical
Specialist Department of Rehabilitation Therapies University of Iowa Hospitals and Clinics, Iowa City, IA. 3Associate Professor and Chair, Department of Interdisciplinary Health
Sciences, A. T. Still University, Mesa, AZ. 4Associate Professor Department of Physical Therapy, Virginia Commonwealth University-MCV Campus, Richmond, VA. 5Director, St
Francis Shoulder Center, St Francis Orthopaedic Institute, Columbus, GA. 6Clinical Research Scientist, Proaxis Therapy, Greenville, SC. 7Assistant Consulting Professor, Doctor
of Physical Therapy Division, Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC. Address correspondence to Bryce Gaunt, HPRC
at St Francis Rehabilitation Center, PO Box 8068, Columbus, GA 31908-8068. E-mail: bgaunt@hprc.net
1
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
155
2/17/10 2:53:08 PM
clinical commentary
METHODS OF DEVELOPMENT
REHABILITATION
GUIDELINE PRINCIPLES
156 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
2/17/10 2:53:09 PM
TABLE 1
tients desired level of activity and participation. Four principles are of critical
importance for the rehabilitation professional to successfully apply controlled
stress to the shoulder and optimize patient outcome: (1) an understanding of the
surgical procedure, (2) an understanding
of the anatomic structures which must be
protected, how they are stressed, and the
rate at which they heal, (3) the identification and skilled application of techniques
to impart varying levels of stress to the
healing tissues, and (4) managing the initial immobilization period and the rate of
ROM progression (TABLE 1).
Guiding Principle 1
Understanding the surgical procedure is
important for the rehabilitation specialist.
An arthroscopic anterior capsulolabral repair begins with a thorough arthroscopic
examination of the glenohumeral joint,
which is performed to assess the extent
of pathology (ie, labral detachment and
capsular attenuation) and to develop a
plan for restoring stability.67 During the
Guiding Principle 2
Understanding the anatomic structures
that must be protected, how they are
stressed, and the rate at which they heal
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
157
2/17/10 2:53:10 PM
clinical commentary
Guiding Principle 3
Correct selection and use of techniques to
apply varying levels of stress to the surgical repair is important for a successful
outcome. Following surgical repair, the
healing capsulolabral structures require
appropriate stress to stimulate optimal
healing, while protecting the repair from
excessive tension. The gradual application of stress is a stimulus for further
proliferation and differentiation of fibroblasts.19,35 A gradual increase in applied
stress, in a process analogous to Wollf s
law of bone healing,96 results in enhanced
structural integrity of the capsulolabral
complex as additional collagen fibers
are laid down in response to controlled
stresses. However, it is equally important
to understand that with excessive stress
to the capsulolabral complex, either in
158 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
2/17/10 2:53:11 PM
Guiding Principle 4
Appropriate management of the initial
immobilization period and ROM progression are also important for the rehabilitation specialist because the tensile
strength of the arthroscopic anterior
capsulolabral repair is reduced through
the first 12 postoperative weeks.32 Therefore, it is important to protect the surgical repair from undue stress during the
first 2 phases of this rehabilitation guideline (12 weeks total) by controlling the
rate at which ROM is regained. Gaining
ROM too quickly can limit the normal
tissue-healing process and lead to capsuloligamentous attenuation. 93 Therefore, an initial period of immobilization
is common after arthroscopic anterior
capsulolabral repair to facilitate healing
of the surgically repaired tissues,40,45,52,65,76
theoretically allowing the surgically reattached labrum a chance to bind to the
glenoid and the plicated layers of capsule
to heal to each other.
Absolute immobilization (no gle-
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
159
2/17/10 2:53:12 PM
[
TABLE 2
clinical commentary
90
10-30
Contraindicated
NA
POW 6
135
35-50
45
115
POW 9
155
50-65
75
145
POW 12
WNL
WNL
WNL
WNL
Abbreviations: Abd, abduction; AFE, active forward elevation in the scapular plane; NA, not
applicable; PER, passive external rotation; PFE, passive forward elevation; POW, postoperative week;
WNL, within normal limits.
REHABILITATION GUIDELINE
supervised portion of their exercise program. Completion of strengthening program should be assessed by comparing
the exercise program performed to the
protocol. Finally, measurement of shoulder functional loss or disability is best
evaluated with a patient-rated outcome
measure.
Both the clinical milestones and time
frames should be met prior to progression to the next phase. Clinician-rated
impairments should be performed every 1
to 2 weeks, to closely monitor response to
treatment and achievement of milestones.
It is critical to use patient-rated measures
of function and disability to comprehensively assess patient response to treatment. There are numerous patient-rated
measures with established measurement
properties available to assess shoulder
function and disability. Recent studies of
patient-rated measures of shoulder functional loss and disability in patients with
instability or undergoing shoulder surgery indicate that one measure is likely
not superior to another.69,70 The scales
recommended for use are patient-rated
measures specifically for instability, such
as the Western Ontario Instability Index
(WOSI) or a general shoulder measure
such as the ASES Form patient-rated
section.47,48,63
160 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
2/17/10 2:53:12 PM
FIGURE 4. (A) Starting position and (B) 90 of shoulder elevation for the table step back exercise.
of the uninvolved joints of the upper extremity, such as the elbow or wrist, are
recommended during phase 1 but are
considered supplementary activities.
Exercises to achieve scapular control are
encouraged; however, positions and exercises that stress the capsulolabral structures should be avoided, such as scapular
protraction with concomitant horizontal
abduction of the shoulder. Postures or
exercises that include scapular retraction
should be encouraged, as scapular retraction minimizes the amount of shoulder
extension needed for functional tasks and
therefore limits stress on the anteriorinferior capsule and labrum.91 However,
even though scapular elevation and retraction are relatively safe, these activities
should only be completed with very light
or no resistance.
Although the rotator cuff does not
specifically require protection following
arthroscopic stabilization, glenohumeral
active ROM and rotator cuff strengthening are purposefully de-emphasized during the early postoperative period because
of the potentially detrimental effect to the
healing tissues.32,92 Light strengthening
and active ROM within the staged ROM
goals would not likely result in excessive
loading; however, in our opinion, it sends
an inconsistent message to the patient
during this early postoperative period
that some strengthening is approved yet
significant restrictions of activities of
daily living and immobilization are necessary. We believe this inconsistency can
lead to excessive arm use, in terms of
both loading and ROM, resulting in too
much stress to the surgical repair. Healing is the first priority in phase 1. During
phase 1, the only form of strengthening
recommended is submaximal isometric
strengthening of the shoulder and elbow,
with the arm adducted to the side in neutral rotation.
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
161
2/17/10 2:53:14 PM
clinical commentary
162 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
2/17/10 2:53:14 PM
FIGURE 5. (A) Starting position and (B) ending position for a high-speed elastic resistance exercise replicating the
throwing motion.
CONCLUSION
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
163
2/17/10 2:53:16 PM
clinical commentary
10.
11.
12.
13.
to acknowledge the members of The American Society of Shoulder and Elbow Therapists (www.asset-usa.org) for their expertise
in the development this international consensus guideline. The authors would also like to
acknowledge Carol Capers, MSMI, CMI, for
creating the figures.
14.
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more information
www.jospt.org
appendix
166 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
2/17/10 2:53:20 PM
appendix (continued)
Physician prescribed or over-the-counter medications
Milestones (Testing Criteria) to Progress to Phase 2
Appropriate healing of the surgical repair by adhering
to the precautions and immobilization guidelines.
Staged ROM goals achieved but not significantly
exceeded
Minimal to no pain (NPRS, 0-2/10) with ROM
Phase 2: POW 6 to POW 12
Goals
Achieve staged ROM goals to normalize passive ROM
and active ROM. Do not significantly exceed:
- PFE: POW 9, 155; POW 12, WNL
- PER at 20 abd: POW 9, 50-65; POW 12, WNL
- PER at 90 abd: POW 9, 75; POW 12, WNL
- AFE: POW 9, 145; POW 12, WNL
Minimize shoulder pain
Begin to increase strength and endurance
Increase functional activities
Interventions to Avoid
Do not perform stretching significantly beyond staged
ROM goals
Do not perform any stretch to gain end range external
rotation or external rotation at 90 of abduction unless
significant tightness is present
Do not allow the patient to use arm for heavy lifting
or any activities that require ROM beyond the staged
ROM goals
Do not perform any strengthening exercises that place
a large load on the shoulder in the position of horizontal
abduction or the combined position of abduction
with external rotation (eg, no push-ups, bench press,
pectoralis flys)
Do not perform scapular plane abduction with internal
rotation (empty can) at any stage of rehabilitation due
to the likelihood of impingement
Specific Interventions
Activities of primary importance
Continued patient education
Passive/active assisted ROM as needed to achieve but
not significantly exceed staged ROM goals
Establish basic rotator cuff and scapular neuromuscular control within the allowed ROM
Supplementary activities:
Introduction of functional patterns of movement
Progressive endurance exercises
Patient education:
Counsel about using the upper extremity for appropriate ADLs in the pain-free ROM (starting with waist-level
activities and progressing to shoulder-level and finally
to overhead activities over time)
Continue education regarding avoidance of heavy lifting
or quick, sudden motions
- Rehabilitation activities should be pain free and performed without substitutions or altered movement
patterns
- Rehabilitation may include both weight-bearing and
nonweight-bearing activities
- Rehabilitation may include both isolated and
complex movement patterns
- Depending upon the goals of the exercise
(control versus strengthening), rehabilitation
activities may also be progressive in terms of
speed once the patient demonstrates proficiency
at slower speeds
- The rotator cuff and scapula stabilizer strengthening program should emphasize high repetitions
(typically 30-50 reps) and relatively low resistance
(typically 1-2 kg)
- No heavy lifting or plyometrics should be performed
during this stage
- Elbow flexion/extension strengthening with elbow by
the side can begin in this phase
Pain management:
Ensure appropriate use of arm during ADLs
Ensure appropriate level of therapeutic interventions
Electrophysical agents as needed
Milestones to Progress to Phase 3
Staged active ROM goals achieved with minimal to no
pain (NPRS, 0-2/10) and without substitution patterns
Appropriate scapular posture at rest and dynamic
scapular control during ROM and strengthening
exercises
Strengthening activities completed with minimal to no
pain (NPRS 0-2/10)
Phase 3: POW 12 to POW 24
Goals
Normalize strength, endurance, neuromuscular control,
and power
Gradual and planned build-up of stress to anterior
capsulolabral tissues
Gradual return to full ADLs, work, and recreational
activities
Interventions to Avoid
Do not increase stress to the shoulder in a short period
or in an uncontrolled manner
Do not perform advanced rehabilitation exercises (such
as plyometrics or exercises requiring end range ROM)
if the patient does not perform these activities during
ADLs, work, or recreation
Do not progress into activity-specific training until
patient has nearly full ROM and strength
Do not perform weightlifting activities that place excessive stress on the anterior capsule. For instance,
latissimus pull-downs, and military press performed
with the hands behind the head stress the anterior
journal of orthopaedic & sports physical therapy | volume 40 | number 3 | march 2010 |
167
2/17/10 2:53:20 PM
clinical commentary
appendix (continued)
capsule with no additional benefit in terms of muscle
activity. Similarly, activities which encourage end
range shoulder extension, such as dips, should also
be avoided
Specific Interventions
Activities of primary importance:
Progressive strengthening and endurance exercises
Progressive neuromuscular control exercises
Activity-specific progression: sport, work, hobbies
Supplementary activities:
Normalize core and scapular stability
Patient education:
Counsel in importance of gradually increasing stress to
the shoulder while returning to normal ADLs, work, and
recreational activities, including heavy lifting, repetitive
activities, and overhead sports
ROM:
Passive ROM, stretching, and joint mobilizations as
needed to address any remaining deficits
Neuromuscular re-education:
Address any remaining deficits of the rotator cuff,
scapula musculature, or trunk musculature
Strength/endurance/power:
Continue shoulder-strengthening program as initiated
in phase 2, with increasing emphasis on high-speed
multiplanar activities that incorporate the entire
kinetic chain
Gradually progress rehabilitation activities to replicate
demanding ADL/work activities
Progressive return to weight-lifting program emphasizing the larger, primary mover upper extremity muscles
(deltoid, latissimus dorsi, pectoralis major)
- Start with relatively lightweight and high repetitions
(sets of 15-25 repetitions), and gradually decrease
repetitions and increase weight after several months
Abbreviations: Abd, abduction; ADL, activities of daily living; AFE, active forward elevation; EMG, electromyography; NPRS, numeric pain rating scale; PER, passive external rotation; PFE,
passive forward elevation; POW, postoperative week; ROM, range of motion; WNL, within normal limits.
168 | march 2010 | volume 40 | number 3 | journal of orthopaedic & sports physical therapy
2/17/10 2:53:21 PM
CLINICAL COMMENTARY
During the throwing movement, tre- body weight (BW) during the late cockmendous forces are placed on the shoul- ing phase, and there is a distraction force
equal to BW during the deceleration
der joint at extremely high angular
phase.43 Consequently, throwing
velocities. The acceleration phase
of the pitch is the fastest moverequires a high level of muscle
ment recorded and reaches a peak
activation, as indicated by the
SUPPLEMENTAL
VIDEO ONLINE
angular velocity of 7250/s.41,43 It
electromyographic signal of the
shoulder musculature, which can
has been estimated that the anexceed 80% to 100% of the signal
terior translation forces generated
when pitching are equal to one-half measured during a maximum voluntary
TIODEFI?I0 The overhead throwing motion is an
extremely skillful and intricate movement. When
pitching, the overhead throwing athlete places
extraordinary demands on the shoulder complex
subsequent to the tremendous forces that are generated. The throwers shoulder must be lax enough
to allow excessive external rotation but stable
enough to prevent symptomatic humeral head
subluxations, thus requiring a delicate balance
between mobility and functional stability. We refer
to this as the throwers paradox. This balance is
frequently compromised and believed to lead to
various types of injuries to the surrounding tissues.
Frequently, injuries can be successfully treated
with a well-structured and carefully implemented
nonoperative rehabilitation program. The key to
successful nonoperative treatment is a thorough
F>OI?97B9>7H79J;H?IJ?9I
HWd][e\Cej_ed
Most throwers exhibit an obvious motion
disparity, whereby shoulder external rotation (ER) is excessive and internal rotation (IR) is limited when measured at 90
Vice 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. Orthopaedic Sports Medicine Fellow, Andrews Sports Medicine, Birmingham, AL. Physical Therapy Fellow, Champion Sports Medicine, Birmingham, AL. 4 Orthopaedic
Surgeon, Andrews Sports Medicine Center, Birmingham, AL. 5 Orthopaedic Surgeon, Andrews Sports Medicine Center, Birmingham, AL; Medical Director, Tampa Bay Rays
Baseball Organization, Tampa Bay, FL. Address correspondence to Dr Kevin E. Wilk, Champion Sports Medicine, 805 St Vincents Drive, Suite C100, Birmingham, AL 35205.
E-mail: kwilkpt@hotmail.com
38 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
BWn_jo
Most throwers exhibit signicant laxity
of the glenohumeral joint, which permits
excessive ROM. The hypermobility of the
throwers shoulder has been referred to
as throwers laxity.112 The laxity of the
anterior and inferior glenohumeral joint
capsule may be appreciated by the clinician during the stability assessment of the
Eii[eki7ZWfjWj_edi
Several investigators23,29,85,88,89 have reported an osseous adaptation of the hu-
CkiYb[Ijh[d]j^
Several investigators have examined
muscle strength parameters in the overhead throwing athlete with varying
results and conclusions.1,9,18,28,30,48,107,108
Wilk et al107,108 performed isokinetic testing on 83 professional baseball players
as part of their physical examinations
during spring training. The investigators
demonstrated that the ER strength of
the pitchers throwing shoulder was signicantly weaker (P.05) than the nonthrowing shoulder by 6%. Conversely, IR
of the throwing shoulder was signicantly
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 39
CLINICAL COMMENTARY
J78B;'
'.&%i
)&&%i
*+&%i
95-109
85-95
80-90
Internal rotation
105-120
100-115
100-110
Abduction
100-110
100-110
Adduction
120-135
115-130
External/internal rotation
63-70
65-72
Abduction/adduction
82-87
92-97
External rotation/abduction
64-69
66-71
62-70
18-23
15-20
Internal rotation
27-33
25-30
Abduction
26-32
20-26
Adduction
32-36
28-33
* Strength ratio of the dominant to the nondominant side for each muscle group.
Feijkh[WdZIYWfkbWhFei_j_ed
As previously mentioned, the ability of
the scapula to function as a cohesive unit
40 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
J78B;(
:ec_dWdj7hc
DedZec_dWdj7hc
33.6 5.9
Pitchers
Protraction
32.2 4.5
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
9.5 1.8
7.3 2.3
Depression
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
8.6 2.3
8.2 2.3
Depression
* Values are mean SD kg.
J78B;)
:ec_dWdj7hc
DedZec_dWdj7hc
Pitchers
Protraction/retraction
87%
81%
Elevation/depression
27%
21%
Protraction/retraction
93%
81%
Elevation/depression
24%
19%
Protraction/retraction
98%
94%
Elevation/depression
29%
27%
Catchers
Position players
9B?D?97B;N7C?D7J?ED
>_ijeho
F^oi_YWb;nWc
After a thorough medical history has
been obtained, the physical examination will focus the differential diagnosis
down to a manageable list of possibilities.
Each medical practitioner should have a
consistent progression to follow for every physical exam (7FF;D:?N 8). There
are multiple tests or exam techniques to
arrive at a diagnosis, and it is important
that each medical practitioner use exam
techniques that they are familiar with
and are capable of duplicating with each
patient.
Visual observation of the shoulder
should be performed rst, with special
attention focused on any skin lesions or
muscle atrophy. Next, the shoulder is palpated, feeling all bony prominences, with
special attention on the bicipital groove,
greater tuberosity, and acromioclavicular
(AC) joint. Pain in these areas can indicate
biceps tendon involvement, rotator cuff
involvement, and AC joint arthrosis, respectively. ROM, both active (AROM) and
passive (PROM), is observed, focusing on
glenohumeral as well as scapulothoracic
motion. Glenohumeral joint PROM is
assessed for ER and IR at 90 abduction
and for ER at 45 abduction in the scapular plane. When assessing IR, care is taken
to palpate and stabilize the scapula. When
assessing PROM, the clinician should assess both the quantity of motion and the
end feel. Forward exion, abduction, IR,
and ER are important to assess, especially
for any decits that may be evident. Palpation of the shoulder during ROM can uncover crepitus, which may indicate certain
pathologic lesions, such as bursa thickening, rotator cuff tears, and arthritis.
Muscle strength is the next component
of the examination. To test the supraspinatus, the patient is asked to ex the
shoulder to 90, with the arm horizontally
abducted to around 45 and the thumb
pointing upward (full can). Resistance is
applied in this position.55,91 Weakness or
pain may indicate a lesion of the supraspinatus muscle. With the arm at the side
and the elbow exed to 90, the patient
is asked to externally rotate against resistance (infraspinatus and teres minor) and
internally rotate against resistance (sub-
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 41
CLINICAL COMMENTARY
scription of these tests the reader is encouraged to review Wilk et al.113,116 Those
we routinely perform are the anterior
drawer, fulcrum, relocation, and internal
impingement signs and tests. The most
important aspects of these tests are to
determine the extent of laxity present,
end point, and, in particular, the tissue
elasticity at end range. To assess end
point elasticity, the fulcrum test is performed at 90 of abduction. The posterior impingement sign is performed in the
plane of the scapula at 90 of abduction,
with the examiner passively rotating the
arm into maximum ER (EDB?D;L?:;E). A
positive test is indicated by complaints
of pain in the deep posterior shoulder.
Meister et al76 have reported 76% sensitivity and 85% specicity when performing this test for posterior rotator cuff
and/or labrum tears.
?cW]_d]
Imaging is the next important step in determining a diagnosis. Plain radiographs
with multiple views of the involved glenohumeral joint are mandatory. Routine
radiographic evaluation includes anterior-posterior (AP), Stryker notch, West
Point, axillary, and acromial outlet views.
These views allow visualization of the glenohumeral articulation as well as acromial morphology and the inferior glenoid.
42 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
The imaging modality of choice to assess soft tissue pathology of the shoulder
is magnetic resonance imaging (MRI)
with intra-articular contrast (MRA). This
allows the best view of the rotator cuff
tendons and muscles, glenoid labrum,
biceps tendon, and other associated pathology, such as spinoglenoid cysts. Intraarticular contrast is especially useful to
determine if there is a full-thickness versus partial-thickness tear of the rotator
cuff. Furthermore, the MRA technique
allows the physician to evaluate the glenoid labrum to determine if a detached
labrum or frayed labrum exists. In the
throwing athlete the most common lesions are partial-thickness rotator cuff
tears and glenoid labrum pathology.
9B7II?<?97J?EDE<B;I?EDI
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J[dZedei_i%8khi_j_i
HejWjeh9kJ[Whi
?dj[hdWb?cf_d][c[dj
Internal impingement was rst described
in 1992 by Walch and associates in tennis
players.104 They presented arthroscopic
clinical evidence that partial, articularsided rotator cuff tears were a direct consequence of what they termed internal
impingement. Internal impingement is
characterized by contact of the articular
surface of the rotator cuff and the greater
tuberosity with the posterior and superior glenoid rim and labrum in extremes of
combined shoulder abduction and ER.49
In overhead throwing athletes, it appears that excessive anterior translation
of the humeral head, coupled with excessive glenohumeral joint ER, predisposes
the rotator cuff to impingement against
the glenoid labrum.63 Repeated internal
impingement may be a cause of undersurface rotator cuff tearing and posterior
labral tears. It is important that the underlying laxity of the glenohumeral joint
be addressed at the time of treatment for
an internal impingement lesion to prevent recurrence of the lesion.7 Burkhart
et al20 have proposed that restricted
posterior capsular mobility may result
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 43
CLINICAL COMMENTARY
IB7FB[i_edi
SLAP lesions are a complex of injuries to
the superior labrum and biceps anchor at
the glenoid attachment. Andrews and associates4 were the rst to describe this lesion in 1985. They reported arthroscopic
ndings in a group of throwing athletes
with shoulder dysfunction. Snyder and
associates94 later classied this injury
complex as superior labrum anterior
and posterior lesions, and coined the
term SLAP lesion. The arthroscopic appearances of the lesions were originally
classied into 4 distinct lesion types,
with 3 variations later being added.71 The
pathophysiology of SLAP lesions is debated frequently, but the essentials of the
lesion are agreed upon.
Patients who have SLAP lesions fall
into 2 basic categories. The rst consists
of overhead athletes, most commonly
baseball players, with a history of repetitive overhead activity and no history of
trauma. The second category involves patients with a history of trauma.49
Burkhart et al20 have described the
peel-back lesion of the superior labrum,
which frequently occurs in the overhead
athlete (<?=KH; ,). Peel-back lesions are
considered a type II SLAP lesion. The
athlete often presents to the practitioner with complaints of vague onset of
shoulder pain and possibly problems
with velocity, control, or other throwing
complaints. The patient may complain
of mechanical symptoms or pain in the
late cocking phase, often poorly localized.
The diagnosis of SLAP lesions can be very
difficult, as symptoms can mimic rotator
cuff pathology and glenohumeral joint
instability. Denitive diagnosis can only
be made by arthroscopy.49
Feij[h_eh=b[de_Z;neijei_i
8[dd[jjiB[i_ed
Throwers exostosis is an extracapsular
ossication of the posteroinferior glenoid rarely seen except in older longtime
throwers.75 This condition is a result of
secondary ossication involving the posterior capsule, probably due to repetitive trauma.6 The osteophyte is thought
to originate in the glenoid attachment
of the posterior band of the inferior glenohumeral ligament, possibly from traction during deceleration. Patients often
have a tight posterior capsule, with capsular contracture and asymmetric shoulder motion with an IR decit.
This lesion can often mimic internal
impingement. Pain is often found in
the posterior part of the shoulder and is
worse in late cocking. Patients often de-
scribe a pinching sensation during throwing. Pain usually is relieved by rest. Plain
radiographs will assist in differentiating
this lesion from internal impingement.
IKH=?97B?DJ;HL;DJ?EDI
HejWjeh9kJ[dZedei_i%
J[dZed_j_i%8khi_j_i
HejWjeh9kJ[Wh
Surgical intervention is only considered
with a full-thickness rotator cuff tear or
with partial-thickness tears, after the
patient has failed at least 1, but usually
2, courses of rehabilitation, followed by
an interval throwing program. Prior to
physical therapy for partial-thickness ro-
44 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
?dj[hdWb?cf_d][c[dj
As mentioned earlier, internal impingement is a common pathology seen in the
overhead athlete. The best treatment for
this lesion is a thorough and well-developed nonoperative treatment program.
If nonoperative measures fail, surgery
is indicated. As with other shoulder injuries, an examination under anesthesia,
followed by diagnostic arthroscopy, is
performed. Simple arthroscopic debridement of rotator cuff tears and labral
fraying was originally described to treat
internal impingement. 3 Results were
mixed with simple debridement, and
it became evident that some sort of anterior stabilization was also required to
help stabilize the shoulder. Therefore, in
conjunction with debridement of the rotator cuff or labral lesions, capsulolabral
reconstruction51 or thermal capsuloraphy63 has been recommended. Generally, subacromial decompression does not
have a role in the treatment of internal
impingement.
IB7FB[i_edi
Once the diagnosis has been established,
treatment options are considered. The
nonsurgical treatment of SLAP lesions
depends upon the type of lesion. Most lesions in the overhead athlete are type II
and may not respond well to nonsurgical
management.
When pain and dysfunction persist
after a period of rest and rehabilitation,
surgical intervention is indicated. As with
other shoulder injuries, a physical examination under anesthesia is done, followed
Feij[h_eh=b[de_Z;neijei_i
8[dd[jjiB[i_ed
Treatment of athletes with this lesion is
controversial. The senior author (J.R.A.)
believes that the presence of posterior
glenoid exostosis is highly predictive of
an undersurface rotator cuff tear caused
by internal impingement and injury to
the posterior labrum.6 Initially, these
patients are treated with a period of active rest and supervised rehabilitation.
Throwers with posterior glenoid exostosis can be conservatively managed for
some time; however, long-term success
is limited and surgical intervention may
become necessary.114
As with other shoulder lesions, when
nonsurgical measures fail to relieve
symptoms, operative intervention is undertaken. Initially, examination under
anesthesia is performed, followed by diagnostic arthroscopy. Any concurrent in-
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 45
CLINICAL COMMENTARY
DEDEF;H7J?L;
H;>78?B?J7J?EDFHE=H7C
F^Wi['07Ykj[F^Wi[
One of the goals, to diminish the athletes
pain and inammation, is accomplished
through the use of local therapeutic
modalities such as ice, iontophoresis,
nonsteroidal anti-inammatory drugs
(NSAIDs), and/or injections. We prefer
the use of iontophoresis for soft tissue
inammation about the shoulder. In addition, the athletes activities (such as
throwing and exercises) must be modied to a pain-free level. The thrower is
often instructed to abstain from throwing
46 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
F^Wi[(0?dj[hc[Z_Wj[F^Wi[
In phase 2 of the rehabilitation program, the primary goals are to progress
the strengthening program, continue to
improve exibility, and facilitate neuromuscular control. During this phase,
the rehabilitation program is progressed
to more aggressive isotonic strengthening activities, with emphasis on restoration of muscle balance. Selective muscle
activation is also used to restore muscle
balance and symmetry. In the overhead
thrower, the shoulder external rotator
muscles and scapular retractor, protractor and depressor muscles are frequently
isolated because of weakness. We have established a fundamental exercise program
for the overhead thrower that specically
addresses the vital muscles involved in
the throwing motion.106,118 This exercise
program was developed based on the
collective12,31,47,53,64,74,78,86,91,100 information
derived from electromyographic research
of numerous investigators and is referred
to as the Throwers Ten program.115 Frequently, the patient exhibits ER muscular
weakness. The specic exercises we prefer
are side-lying ER (EDB?D;L?:;E) and prone
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 47
CLINICAL COMMENTARY
F^Wi[)07ZlWdY[ZIjh[d]j^[d_d]F^Wi[
In phase 3, the advanced strengthening
phase, the goals are to initiate aggressive
strengthening drills, enhance power and
endurance, perform functional drills,
and gradually initiate throwing activities.
During this phase, the athlete performs
the Throwers Ten exercise program,
continues manual resistance stabiliza-
48 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
biomechanics.
Interval throwing is organized into 2
phases: phase 1 is a long-toss program
(45-180 ft [15-60 m]) and phase 2 is
an off-the-mound program for pitchers.
During this third rehabilitation phase,
we usually initiate phase 1 of the interval throwing program at 45 ft (15 m) and
progress to throwing from 60 ft (20 m).
The athlete is instructed to use a crowhop type of throwing mechanism and lob
the ball with an arc for the prescribed distance. Flat-ground, long-toss throwing is
used before throwing off the mound to allow the athlete to gradually increase the
applied loads to the shoulder while using
proper throwing mechanics. In addition,
during this phase of rehabilitation, we
routinely allow the position player to initiate a progressive batting program that
progresses the athlete from swinging a
light bat, to hitting a ball off a tee, to softtoss hitting, to batting practice.
F^Wi[*0H[jkhd#je#J^hem_d]F^Wi[
Phase 4 of the rehabilitation program,
the return-to-throwing phase, usually
involves the progression of the interval
throwing program. For pitchers, we progress the long-toss program to 120 ft (40
m), whereas position players would progress to throwing from 180 ft (60 m). Once
the pitcher has successfully completed
throwing from 120 ft, the athlete is instructed to throw 60 ft from the windup
on level ground. Once this step is successfully completed, phase II (throwing
from the mound) is performed.92 Position
players continue to progress the long-toss
program to 180 ft, then perform elding
drills from their specic position. While
the athlete is performing the interval
throwing program, the clinician should
carefully monitor the throwers mechanics and throwing intensity. In a study
conducted at our biomechanics laboratory, we objectively measured the throwing intensity of healthy pitchers. When
pitchers were asked to throw at 50%
effort, radar gun analysis indicated that
actual effort was approximately 83% of
their maximum speed. When asked to
IKCC7HO
verhead-throwing athletes
typically present with a unique
musculoskeletal prole. The overhead thrower exhibits ROM, postural,
and strength changes, which appear
to be from adaptations from imposed
demands. This unique client exhibits
unique lesions, and the recognition and
treatment of these lesions may present
a signicant challenge to the clinician.
Based on the accurate recognition of
the lesion and underlying cause of the
pathology, a successful nonoperative or
in some cases operative treatment plan
can be implemented. In this manuscript,
we have attempted to provide the reader
with information regarding the evaluation and treatment of the overhead
throwing athlete. T
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 49
[
H;<;H;D9;I
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CEH;?D<EHC7J?ED
WWW.JOSPT.ORG
7FF;D:?N7
87I;B?D;<EH;IJ78B?I>?D=7J>HEM?D=>?IJEHO?DEL;H>;7:7J>B;J;I
General information
Age
Gender
Dominant-handedness
Position
Years throwing
Level of competition
Injury pattern
Onset of symptoms: acute, chronic
History of trauma or sudden injury
Symptom characteristics
Location of symptoms: anterior, lateral, posterior
Quality of symptoms: sharp, dull, burning
Presence of mechanical symptoms
52 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy
APPENDIX B
Motor Strength
1. Glenohumeral
2. Scapular
3. Arm/forearm
Impingement Signs
1. Neer/Hawkins signs
2. Cross-chest adduction test
3. Internal impingement sign
Stability Tests
1. Sulcus sign
2. Anterior drawer
3. Anterior fulcrum
4. Relocation test
5. Posterior drawer
6. Posterior fulcrum
7. Push-pull test
APPENDIX C
Laxity
Instability
Capsulitis
Superior Labral Tear (SLAP)
Frayed (type I)
Tear (type III, IV)
Detached (type II)
Peel-back
Osseous Lesions
Glenoid osteochondritis dissecans
Bennetts lesion
Biceps Tendon Lesions
Tendinitis
Tendonosis
Subluxation
Neurovascular Lesions
Axillary neuropathy, quadrilateral space
Long thoracic neuropathy
Thoracic outlet syndrome
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 53
CLINICAL COMMENTARY
APPENDIX D
54 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy