Journal of Orthopaedic & Sports Physical Therapy

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Copyright 2013 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

clinical commentary

KEVIN E. WILK, PT, DPT, FAPTA1-3 TODD R. HOOKS, PT, OCS, SCS, ATC, MOMT, MTC, CSCS, FAAOMPT4
LEONARD C. MACRINA, MSPT, SCS, CSCS1

The Modified Sleeper Stretch and Modified

Cross-body Stretch to Increase Shoulder
Internal Rotation Range of Motion in the
Overhead Throwing Athlete

he overhead throwing athletes range-of-motion

(ROM) characteristics have been well described
in the literature as having an increase in external
rotation (ER) and a decrease in internal rotation
(IR) in the throwing shoulder compared to the nonthrowing shoul
der.2,7,25 Wilk et al25 have described the concept of total range of motion
(TROM) of the shoulder, which states that the sum of ER and IR ROM
of the throwing shoulder should be within 5 of that of the opposite, nonthrowing
shoulder in the overhead athlete. Wilk et
al23 reported that the passive ROM of the
dominant shoulder in 369 professional
baseball pitchers, when measured at 90
of shoulder abduction, was 132 of ER
and 52 of IR. Although a shift in motion
TTSYNOPSIS: Stretching techniques that focus on
increasing posterior shoulder soft tissue flexibility
are commonly incorporated into prevention and
treatment programs for the overhead athlete.
The cross-body and sleeper stretch exercises
have been described as stretching techniques to
improve posterior shoulder soft tissue flexibility
and to increase glenohumeral joint internal rotation and horizontal adduction range of motion in
the overhead athlete. But, based on the inability
to stabilize the scapula and control glenohumeral
joint rotation with the cross-body stretch and the
potential for subacromial impingement with the
sleeper stretch, the authors recommend modifications to both of these commonly performed

was noted, with the dominant shoulder

having an increase in ER ROM and a
resultant loss in IR ROM, no significant
side-to-side difference in TROM was
noted in that population.23

Common Characteristics
There are numerous reported causes for
stretches. This clinical commentary reviews the
literature on posterior shoulder stretches, describes modifications to both of these commonly
performed stretches, and outlines a strategy to
maintain or improve posterior shoulder soft tissue
flexibility and glenohumeral joint internal rotation
range of motion in the overhead athlete.

TTLEVEL OF EVIDENCE: Therapy, level 5.

J Orthop Sports Phys Ther 2013;43(12):891894. Epub 30 October 2013. doi:10.2519/

jospt.2013.4990

TTKEY WORDS: GIRD, glenohumeral internal

rotation deficit, overhead athlete, posterior
shoulder tightness

the increase in shoulder

ER and the loss of IR
in the overhead athlete.
SUPPLEMENTAL
VIDEO ONLINE
These proposed causes
include osseous adaptations,5,6,18 posterior capsular tightness at
the glenohumeral joint,4,17,21 musculotendinous tightness of the posterior portion
of the rotator cuff and posterior deltoid,19
and postural changes.1 The loss of shoulder IR ROM in the overhead thrower
has been referred to as glenohumeral
internal rotation deficit (GIRD) and was
originally described by Burkhart et al.4
These authors originally described GIRD
as any loss of IR ROM in the throwing
shoulder compared to the nonthrowing
shoulder. Burkhart et al4 suggested that
GIRD may be a primary cause of shoulder pain and shoulder disability in the
overhead thrower and encouraged the
use of a stretching program for the posterior shoulder structures, particularly
the sleeper stretch, to restore IR ROM.
Myers et al16 found a GIRD of 19.7 in
throwers with pathologic internal impingement; similarly, Wilk et al24 reported a GIRD of 18, which correlated to a
1.9-fold increase in injury risk. Based on
these studies, Kibler et al9 have reported
GIRD to be a loss of 18 or greater of IR
in the throwing shoulder compared to the

Champion Sports Medicine, Birmingham, AL. 2Rehabilitative Research, American Sports Medicine Institute, Birmingham, AL. 3Tampa Bay Rays, Tampa Bay, FL. 4Drayer Physical
Therapy Institute, Columbus, MS. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the
subject matter or materials discussed in the article. Address correspondence to Dr Kevin E. Wilk, Champion Sports Medicine, 805 St Vincents Drive, Suite G100, Birmingham,
AL 35205. E-mail: kwilkpt@hotmail.com t Copyright 2013 Journal of Orthopaedic & Sports Physical Therapy
1

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clinical commentary

FIGURE 1. Modified sleeper stretch. (A) The athlete

is slightly rotated posteriorly (20-30 posterior to
the coronal plane of the body) to place the shoulder
in the scapular plane as passive internal rotation
is performed. (B) This position stabilizes the
scapula without causing subacromial impingement
complaints.

FIGURE 2. A towel is placed under the elbow to

increase the stretch at the posterior shoulder.

nonthrowing shoulder. In addition, a bilateral comparison of TROM has shown

that an asymmetry of 5 is predictive of
an increased injury rate.24 Recently, Wilk
et al22,24 reported a correlation between
shoulder injuries and TROM deficits in
professional baseball pitchers.
Horizontal adduction ROM has also
been identified as a predictor of increased
injury rates.16,21 Tyler et al21 reported an
average loss in horizontal adduction of
35 in subjects with pathological internal
impingement. Myers and colleagues16 as-

FIGURE 3. (A) A traditional cross-body stretch is

performed without adequate scapular stabilization.
(B) Due to the lack of stabilization during the
traditional cross-body stretch, note the amount of
scapular abduction.

sessed changes in horizontal adduction

motion by calculating the difference in
horizontal adduction between the throwing and nonthrowing arm, and reported
a decrease of 4.2 cm in throwing athletes
with internal impingement.

Stretching Techniques
Stretching techniques for the posterior
shoulder are commonly incorporated

into the maintenance and prevention

program of the overhead athlete to minimize risk of injury.4,11,20,21,24 Burkhart et
al4 described the sleeper stretch, performed with the patient in sidelying on
the throwing side to stabilize the scapula
against the table and both the shoulder
and elbow flexed to 90. In this position,
passive IR is applied to the dominant arm
by using the opposite hand. These authors4 also described the rollover sleeper
stretch, which is similarly performed, except that the shoulder is only flexed 50
to 60 and the patient is rolled forward
30 to 40 from vertical.
Horizontal adduction of the shoulder
is also commonly advocated, with and
without scapular stabilization, to improve flexibility of the posterior shoulder
region.4,21 Tyler et al21 reported that the
cross-body stretch, or horizontal adduction stretch, also improved shoulder IR.
In addition, Manske et al12 reported that
combining horizontal adduction stretching exercises with posteriorly directed
glenohumeral joint mobilization techniques increased shoulder IR. Cadaveric
studies designed to determine the best
position to stretch the posterior shoulder soft tissue structures have quantified the strain on the posterior cuff and
capsule in a number of positions. 3,8,15,20
These studies reported increased strain
on the posterior capsule with the arm at
60 and 90 of elevation combined with
IR.3,8 The greatest strain on the inferior
fibers of the infraspinatus was reported
to occur at 90 of shoulder elevation with
IR.15
Comparative studies have been performed to determine outcomes between
various stretching techniques to improve
posterior shoulder soft tissue flexibility.
Laudner et al10 examined the immediate
effects of the sleeper stretch, performed
3 times for 30 seconds, and found an increase in both horizontal adduction and
IR ROM following the stretches. McClure
et al13 reported a significantly greater increase in IR using the cross-body stretch
as compared to the sleeper stretch. Manske et al12 reported that subjects treated

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with posteriorly directed glenohumeral

joint mobilizations combined with horizontal adduction stretches had greater
increases in IR ROM compared to subjects who performed horizontal adduction stretches only, and this increase in
motion was maintained to a greater extent at 4 weeks postintervention.

with the opposite forearm on top. These

modifications may best isolate the targeted tissues of the posterior shoulder region
as the shoulder is brought into horizontal
adduction (FIGURE 4, ONLINE VIDEO).

Clinical Suggestions

Proposed Modifications to Stretches

The authors of this clinical commentary
have utilized both the sleeper stretch
and the cross-body stretch for the treatment of posterior shoulder tightness,
with modifications to each. The modified sleeper stretch is performed with
the athlete in a sidelying position, trunk
rolled posteriorly 20 to 30, and shoulder elevated to 90. In this position, passive IR is performed using the opposite
arm (FIGURE 1, ONLINE VIDEO). This modified
sleeper stretch is designed to minimize
symptoms of pain that can occur with
the shoulder in a 90 flexed position.13
This trunk position also orients the humerus in the scapular plane, which has
been shown to place increased strain on
the posterior capsule.3,8 To better assist
the patient in proper body positioning, a
clinician may prefer to place a hand on
the patients scapula to assist the patient
into the quarter-turn. However, to better
isolate the stretch to the infraspinatus,
the clinician may increase the amount of
horizontal adduction by placing a towel
under the athletes humerus, which is believed to better isolate the target tissues
(FIGURE 2).15 Although the incorporation
of the horizontal adduction via the use of
a towel roll essentially places the shoulder in a 90 flexed position, as with the
sleeper stretch, instructing the athlete to
lie with the trunk rolled posteriorly 20
to 30 and avoiding the direct sidelying
position may minimize the complaints of
shoulder irritation frequently reported
clinically as a result of the athlete lying
directly on the shoulder. The authors
have found that patients tolerate the
placement of the towel roll much better than the sleeper stretch with rollover
position.

FIGURE 4. Modified cross-body stretch. (A and B)

The athlete stabilizes the scapula against the table as
the shoulder is horizontally adducted, while external
rotation is restricted via counterpressure of the
opposite forearm.

The cross-body stretch is often performed with the athlete in an upright

standing position (FIGURE 3), using the
opposite hand to horizontally adduct the
targeted shoulder. This method has the
disadvantage of not providing scapula
stabilization while the humerus is horizontally adducted. Consequently, accessory abduction of the scapula occurs,
which prevents isolating the intended
stretch to the posterior aspect of the glenohumeral joint. In addition, it allows the
humerus to externally rotate as the shoulder moves into the outer ranges of motion
and tension is generated in the external
rotators of the shoulder posteriorly. The
authors believe that by not stabilizing the
scapula and allowing excessive ER of the
humerus to occur, optimal stretch of the
posterior shoulder is not achieved. In addition, it creates scapular abduction and
IR, which are not desired. Therefore, to
restrict scapular abduction, we suggest
having the athlete in a sidelying position,
and, to restrict ER of the humerus, we
suggest aligning the forearms together

In overhead athletes without shoulder

pain, these stretches are performed for
30 seconds for at least 4 repetitions with
each stretch.10,14 The stretches are performed before and at the end of the exercise program to improve shoulder ROM
and flexibility. The authors prefer dynamic flexibility drills, such as plyometrics and quick movements, directly prior
to throwing activities. But, based on our
clinical experience, in overhead athletes
with shoulder pain and posterior shoulder tightness, the stretches should be
performed for 30 seconds and repeated at
least 8 to 10 times for each stretch. Moore
et al14 have reported utilizing a muscle
energy technique to enhance the effects
of the stretch. We frequently incorporate
muscle energy techniques to augment
the manual stretch of the athlete into
horizontal adduction, as this stretch has
been shown to increase both horizontal
adduction and IR.14 However, the authors
do not commonly perform muscle energy
techniques for the external rotators, as
the authors agree that, clinically, similar
to the findings by Moore and colleagues,14
this technique does not seem to increase
IR ROM.

SUMMARY

aintaining optimal soft tissue

flexibility of the posterior shoulder
in the throwing athlete is critical
to reduce the risk of injury. Because the
exact tissue that causes the pathophysiological loss in shoulder mobility in this
population varies between osseous adaptations, posterior capsular tightness,
musculotendinous tightness, and postural (scapular) adaptations, it is important that the clinician continually assess
and adjust the treatment strategies as
deemed appropriate.9 The goal of this

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clinical commentary

commentary is to provide the treatment

strategies and rationale for maintaining
optimal shoulder mobility in the overhead athlete. Clinically, the authors have
found these stretching techniques to be
extremely beneficial to improving IR
of the shoulder in the overhead throwing athlete, without increasing shoulder
symptoms. Systematic research is necessary to document the efficacy of these
stretches. t

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