Polish Orthopedics and Traumatology, 2014; 79: 59-66 www. POLORTHOPTRAUMATOL.

com
Review Article

Received: 2013.11.29
Accepted: 2014.01.15 Problems of the glenohumeral joint in overhead
Published: 2014.05.23
sports literature review. Part II pathology
and pathophysiology
Authors Contribution: Przemysaw Lubiatowski1,2 AEFG, Piotr K. Kaczmarek3 AEF, Marta lzak1 BEF,
A Study Design
B Data Collection
Jan Dugosz1,2 DF, Maciej Brborowicz1 F, Witold Dudziski2 AG,
C Statistical Analysis Leszek Romanowski1 ADG
D Data Interpretation
E Manuscript Preparation
1
D epartment of Traumatology, Orthopaedics and Hand Surgery, Pozna University of Medical Science, Pozna,
F Literature Search Poland
G Funds Collection
2
Department of Orthopaedics, Rehasport Clinic, Pozna, Poland
3
Department of Physiotherapy, Rehasport Clinic, Pozna, Poland

Source of support: The project was funded by the National Science Centre allocated on the basis of the decision
DEC-2011/01/B/NZ7/03596

Summary
In throwing sports shoulder is exposed to enormous and often repetitive overloads. Some sports
(contact sports) are also connected with direct trauma. We are thus dealing with traumatic inju-
ries, overload and degenerative damage. The article discusses the most frequent injuries of the
shoulder characteristic for throwing sports. These are mainly disorders of arm rotation, internal
impingement, lesion of the labrum (SLAP) and rotator cuff tears (PASTA).

Keywords: Internal Impingement Handball Players Biomechanics Proprioception Pathology

Pathophysiology

Full-text PDF: http://www.polorthoptraumatol.com/download/index/idArt/890108

Word count: 3286
Tables:
Figures: 6
References: 53

Authors address: Przemysaw Lubiatowski, Department of Traumatology, Orthopaedics and Hand Surgery, Pozna University of
Medical Science, Pozna, Poland, e-mail: p.lubiatowski@rehasport.pl

59
Polish Orthopedics and Traumatology, 2014; 79: 59-66
Background
Sports that involve throwing expose the shoulder to enor-
mous overload. This is related to throwing technique and
speed. Large force dispersed over a short time exposes the
structures to stretching, compression and repetitive strain
[1,2]. Early participation in competitive sports leads to for-
mation of adaptive changes (internal impingement, GIRD
Glenohumeral Internal Rotation Deficit). In a course of
a career, repeated microinjuries may cause structural tis-
sue damage (SLAP Superior Labrum from Anterior to
Posterior tears, PASTA Partial Articular Supraspinatus
Tendon Avulsion). Some throwing sports contain elements
of direct contact (e.g. handball). In addition, there are also
injuries due to falls, levers or sprains. They may cause con-
tortions, fractures and tendon injuries [3]. The first part of
this report discuses biomechanics of a shoulder joint and
phenomena taking place during a throw. In this part we
describe changes leading to development of various shoul-
der pathologies.
Pathology
Pathophysiology of shoulder injuries in throwing sports
Throwing motions repeated by an athlete in a course of
sports activities induces adaptive changes. In a cocking po-
sition (arm in adduction and external rotation) anterior
part of articular capsule becomes stretched [4]. Inferior
glenohumeral ligament is shifted forward and upward and
the greater tubercle comes in contact with posterosuperior
A B
C D
Figure 1. GIRD syndrome. The affected side is characterized by augmented external rotation (A) and reduced internal rotation (C) compared to the
contralateral side (B and D respectively).
60
part of glenoid cavity. Such phenomenon was described by
Walach [5] as so-called internal impingement.
This term encompasses also other tissue injuries character-
istic of a throwing shoulder [6]. Precise pathogenesis and
proper sequence of events leading to development of pa-
thology have not been yet confirmed. Some experts think
that shoulder instability lies at the background of the dis-
order [7]. Others claim that it is a result of abnormal bio-
mechanics and an injury to the upper part of the labrum
may contribute to development of microinstability or symp-
tomatic shoulder instability [8].
It is considered that the first and basic deviation from the
norm, which initiates the entire cascade of pathological
changes ending in the late phase of cocking, involves ac-
quired contraction of posteroinferior part of articular cap-
sule and associated shortening of the posterior band of in-
ferior glenohumeral ligament complex (PIGHL) [7,8].
Contraction of posteroinferior joint capsule is probably
caused by repeated shear forces acting on posterior shoul-
der structures during deceleration phase and the following
phase. One of the main symptoms accompanying this phe-
nomenon is loss of internal rotation of a shoulder in abduc-
tion (GIRD) (Figure 1) [7]. In some athletes radiological
picture demonstrates ossification in the posterior region of
glenoid cavity. Ossification and accompanying exostoses in
the posterior part of glenoid cavity, the so-called Bennetts in-
jury [9] (Figure 2) are currently considered a bony adaptive

Figure 2. Radiological picture of Bennett fracture (arrow).
response to excessive stretching of posterior articular cap-
sule, which takes place during deceleration phase as well
as the following phase and may cause secondary damage to
posterior rotator cuff structures and axillary nerve.
Throwing is without a doubt related to excessive external ro-
tation of a shoulder joint. It may be related to contraction of
posterior articular capsule. Burkhart [8] suggests presence
of two mechanisms, as a result of which the tight posteroin-
ferior compartment of the capsule enables excessive external
rotation of a humerus. The first one suggests that shorten-
ing of posteroinferior capsule and PIGHL leads to displace-
ment of the point of contact of humerus and glenoid cavi-
ty posteriorly and superiorly. Under normal conditions this
point remains relatively constant it is located on the infe-
rior half of glenoid cavity. This effect enables the greater tu-
bercle to cover a greater arch on the edge of glenoid cavity
before internal impingement occurs. Such contact may be
physiological. Another mechanism is related to the first. It
leads to displacement of the point of contact between hu-
meral head and glenoid cavity. Excess articular capsule is
formed as a result, enabling greater external rotation.
Glenohumeral internal rotation deficit (GIRD) is the most
important abnormality occurring as a result of constriction
of posteroinferior articular capsule and excessive external
rotation. GIRD involves loss of internal shoulder rotation
in abduction when compared with contralateral, non-dom-
inant shoulder [10]. This deficit significantly surpasses the
benefits of augmented external rotation. In addition, coex-
istence of GIRD and excessive external rotation increases
shear and torsional stress in the posterosuperior part of ro-
tator cuff muscles, resulting in failure of subsurface fibers.
Superior part of glenoid labrum is another place of pos-
sible contusion. The last phase of swinging motion, with
shoulder in abduction and maximal external rotation, ex-
erts such strain on the long head of bicep muscle and its
attachment to the labrum [7]. In this position the vector
of forces exerted by long head of biceps tendon (LHBT)
reaches more posterior and vertical position. As this posi-
tion is achieved, LHBT undergoes rotation, which is then
Lubiatowski P. et al. Problems of the glenohumeral joint in overhead sports
transferred as torsional force to the posterior labrum. This
effect is referred to as peel-back of posterosuperior la-
brum and LHBT. It may lead to superior labral anterior-to-
posterior tear (SLAP) [11].
Rotator cuff tendons are also susceptible to injury. Repeated
stretching and compression may lead to partial tearing of a
tendon on the articular side, which may coexist with SLAP
and internal impingement.
Axis of joint rotation is moved posteriorly and superiorly,
producing excentric rotational motion during arm abduc-
tion. According to Burkhart [8], posterior displacement
of humeral head loosens the anterior part of the capsule.
According to other authors, articular capsule is stretched
by repeated positioning of the arm in extreme abduction
and external rotation [7]. Independent of the pathogen-
esis, it leads to development of so-called microinstability.
Range of displacement is limited. Joint luxation or sublux-
ation does not occur, but subjective symptoms resembling
instability appear. It presents in clinical examination as pos-
itive relocation test.
Presented consecutive changes finally lead to development
of so-called dead arm syndrome [12]. It encompasses any
pathological changes within the shoulder preventing the
athlete from throwing with previous speed and control due
to pain and vague shoulder discomfort [8]. This cascade
may lead to numerous shoulder injuries described above.
Internal impingement
Internal impingement was described by Walch [5] in 1992.
Analysis of arthroscopic pictures revealed that posterosu-
perior, deep part of rotator cuff comes in contact with pos-
terosuperior part of glenoid cavity in arm abduction and
external rotation. Such contact was present both in patients
who reported complaints as well as in those who did not.
Therefore, it is probably a natural phenomenon. It is also
observed in MR pictures [13]. However, in throwing ath-
letes repeated contact may lead to pathological changes.
McFarland [14] suggested distinguishing between physio-
logical contact of posterosuperior structures from clinical
internal impingement syndrome. Jobe [15] distinguished 5
anatomical locations exposed to injury in internal impinge-
ment: posterosuperior labrum, articular surface of rotator
cuff, bone on the posterosuperior glenoid cavity, greater tu-
bercle, anterior labrocapsular complex [16]. Initial discom-
fort caused by the impingement may transform into organ-
ic damage. Posterosuperior contact was linked to damage
of the deep RC layer at the place of contact between the
tendon and glenoid cavity (kissing lesion) [17]. Repeated
tissue contact and traction may also cause injury of postero-
superior labrum (SLAP).
Clinical picture of internal impingement is connected with
shoulder pain in the late cocking phase [11]. Initially, it may
be associated with discomfort and in extreme situations may
present as dead arm syndrome. Pain is located in the pos-
terior or posterosuperior part of the shoulder. Patient may
complain of shoulder skipping or clicking, which suggests
damage to the labrum. These symptoms impair throwing,
or even make further participation in throwing sports im-
possible and eliminate the athlete from competition.
61
Polish Orthopedics and Traumatology, 2014; 79: 59-66
A deficit of internal rotation may be an indication for shoul-
B position and angled posteriorly. Under such circumstanc-
Figure 3. Arthroscopic image of a SLAP lesion (A type II, B type
IV).
Internal impingement may be accompanied by impaired ro-
tation due to contracture of the posterior part of articular
capsule (GIRD) [18]. GIRD syndrome is diagnosed based on
clinical examination. Patient lies in supine position, arm is
abducted to 90 and the scapula is stabilized through press-
ing against the ground. Subsequently, internal and external
rotation is measured up to the moment of scapular move-
ment. A difference of about 25 compared to the contralat-
eral side is considered clinically significant. Previously de-
scribed Bennetts lesion [9] may be an extreme pathology
of posterior articular capsule (TCTS).
Basis of treatment involves physiotherapy preceded by thor-
ough clinical, biochemical, functional and radiological as-
sessment [19]. In the acute phase of the disorder we must
strive to achieve pain relief. Rest, analgetics and possibly
physiotherapy are indicated. In a so-called pure impinge-
ment syndrome (without structural damage) we need to
restore proper shoulder biomechanics. Management in-
cludes stabilization of the scapula and rotator cuff, prop-
er muscle coordination in closed and open kinetic chains,
correction of TCTS contracture (GIRD), reconstruction of
proper motion patterns [20]. It is sometimes necessary to
remove deficits in other kinetic chain segments (vertebra,
hips, elbows) [21]. Permanent symptoms and significant
62
der arthroscopy. Chronic IGHL contracture may require
cutting of TCTS (in a place corresponding to IGHL) [18].
Injury of the superior labrum
Superior labral anterior-to-posterior (SLAP) lesion was de-
scribed and published by Snyder [22]. Initially, four types
of damage were described: I labral fibrillation, II supe-
rior labral tear and biceps tendon stripping (LHB), III
bucket-handle tear of superior labrum and IV extension
of tear to LHB tendon (Figure 3).
They may be due to various reasons: avulsion fractures or
participation in sports (weightlifters, bodybuilders, throwing
sports). Type II lesion is characteristic for throwing sports.
It is additionally classified into posterior, anterior or joint
posterior and anterior damage. The shoulder set in ABER
position (as in late cocking phase) places LHB in a vertical
es the torsional force is acting on the posterior part of la-
brum at the place of attachment of labrum/LHB complex,
tearing the entire complex away from glenoid cavity. During
ABER motion the shortened IGHL shifts the humeral head
superiorly, augmenting the peel-back effect [23]. Pain is a
clinical symptom of SLAP injuries. Such pain is not partic-
ularly different from the pain in internal impingement. It
may be accompanied by crepitus (palpated and/or heard
by the patient) or clicking. There may be also weakening of
shoulder strength or dead arm syndrome. Management of
SLAP injuries depends on the type of injury and patients
symptoms. Shoulder arthroscopy is of fundamental signif-
icance for treatment of such injuries. Type I and III inju-
ries require exclusively arthroscopic debridement. In type
II injuries arthroscopic stabilization of the damaged part of
labrum with implants is performed. Management in type
IV depends on the state of the labrum and LHB damage.
Options include: labral reinsertion, partial labral resection
with or without LHB tenodesis. It is important to distinguish
SLAP lesion from anatomical anomalies frequently occur-
ring in this area, i.e. sublabral foramen. Such changes must
not be treated as damage or stabilized in any way.
Postoperative management is an essential element of treat-
ment: protection in an orthosis, early and comprehensive
rehabilitation, objective monitoring. Predicted time that
allows for resuming sports activities after surgical treat-
ment is about 46 months if some specific criteria are met
[19], such as: resolution of symptoms and restoration of
full shoulder function (range of motion, strength and re-
sistance to fatigue).
Rotator cuff injuries
Rotator cuff (RC) disorders usually begin from the articular
side, i.e. in the deep muscle layer. Characteristically, rota-
tor cuff injuries occur at the junction of inferior part of su-
praspinatus muscle and superior part of infraspinatus mus-
cle. These injuries may vary significantly: from superficial
cuff fibrillations on the articular side, through partial tear-
ing of rotator cuff from its attachment (PASTA-type injury,
articular site tendon avulsion) (Figure 4), intratendinous
injuries, ending with total rupture of rotator cuff through-
out its thickness [24].

A management is aimed at attenuating pain through rest,
B tion of a tendon into the bone. Implants are used to anchor
Figure 4. Rotator cuff injury (PASTA lesion); MRI arthrography (A) and
arthroscopy (B) pictures.
Mechanism of injury is still under debate. RC tendons are
exposed to injury due to internal impingement in the late
cocking phase and shoulder impingement in the accelera-
tion phase [25,26]. In the late cocking phase RC undergoes
extreme torsion and is subjected to large shear forces [8].
Injury may also occur during deceleration phase, where the
arm is in adduction and internal rotation. Repeated excen-
tric straining and stretching of RC may also cause microin-
juries and, in the end, loss of RC function. Majority of in-
juries are medium-thickness (62% according to Burkhart
[8]). They often accompany SLAP lesions and may be re-
lated to location. Anterior SLAP lesions are associated with
PASTA injuries in the anterior part of supraspinatus muscle
tendon. Posterior SLAP lesions may coexist with partial RC
injury on the border of supraspinatus muscle and infraspi-
natus muscle tendons [8]. Pain of nonspecific location with-
in a shoulder joint is a typical complaint of a throwing ath-
lete with RC injury. In clinical examination there may be
(but does not have to) weakening of abduction movement.
Movement against resistance may be painful. Pain may be
provoked in the following phases of throwing: cocking, ac-
celeration or deceleration. Imaging is decisive for the diag-
nosis. Ultrasound, MR artrography or shoulder arthrosco-
py is performed [27]. In case of partial injuries one should
always begin with physiotherapy. In an early, acute phase
Lubiatowski P. et al. Problems of the glenohumeral joint in overhead sports
analgetic drugs and careful rehabilitation. Further phases
require very complex management preceded by function-
al and biomechanical assessment. Treatment encompass-
es strengthening of specific muscle groups with particular
focus on stabilization of scapula and rotator cuff [28,29].
Restoration of neuromuscular coordination is essential. It
is necessary to achieve or restore proper movement pat-
terns. Resolution of symptoms and normal biomechanical
parameters allow for resuming sports activities. However,
in such case partial injury requires monitoring through pe-
riodic clinical and ultrasonographic follow-up in order to
observe possible progression of injury. Complete, full-thick-
ness injury or partial injury with symptoms not subsiding de-
spite conservative treatment will require surgical treatment
[24,26,3032]. Minute injuries on the articular or subscapu-
lar side may be subjected to arthroscopic debridement only.
Injuries exposing a significant part of greater tubercle re-
quire tendon reinsertion into the bone. In partial injuries
we apply trans-tendinous reinsertion or conversion to full-
thickness injury. Full-thickness injury requires full stabiliza-
the tendon to the bone [23]. Proper postoperative manage-
ment is a necessary element and encompasses two phases
of physiotherapy: 1. protection through the use of ortho-
sis, 2. restoration of range of motion, strength and shoul-
der coordination. All phases should be monitored through
objective assessments: clinical, biomechanical, functional
and radiological [28]. Return to athletic activities is possi-
ble after a minimum of 6 months from surgery. It requires
fulfillment of many requirements such as: relief of symp-
toms, restoration of proper shoulder biomechanics (range
of motion, strength, resistance) and proper tissue healing
(in imaging studies).
Instability
Jobe connected shoulder instability with throwing sports
as one of the mechanisms of pathological changes [33].
Presence of so-called microinstabilities was demonstrated
[7,8]. It results from the fact that repeated movements in
external rotation and abduction in the late cocking phase
cause stretching of articular capsule and anteroinferior cap-
sulolabral complex.
Instability is further escalated by weakened muscle function
and maximum positions of shoulder deflection. In clinical
examination patients may experience pain during appre-
hension test (but not true apprehension) and relief during
relocation test. Most likely the pain is caused by translation
in the ABER position and posterosuperior impingement.
Pain subsides during the relocation test when translation is
corrected by examiners hand. The concept of microinsta-
bility is challenged by Burkhart [10], who explains the posi-
tive results of clinical tests with decreased strain on anterior
articular capsule and shifting the humeral head upward and
posteriorly. According to this concept, shortened posterior
IGHL bundle shifts the axis of rotation of humeral head in
the mentioned direction, causing the entire capsular com-
plex to loosen and symptoms do not ensue from instabili-
ty, but from painful impingement syndrome. It had signif-
icant clinical implications. Recognizing microinstability as
a fundamental element of pathology prompted authors to
introduce capsuloplasty techniques for correction of this
63
Polish Orthopedics and Traumatology, 2014; 79: 59-66
B Abnormal positioning or mobility of scapula is termed scap-
instability. According to Burkhart [10] such management
is erroneous and treatment should be directed at restora-
tion of proper joint biomechanics (rehabilitation, cutting
of posterior part of IGHL).
True instability is rare and occurs exclusively in athletes train-
ing for a long time due to long-lasting changes.
One type of instability may be related to SLAP lesions. Injury
to the superior part of labrum may generate pseudolaxity
on the anteroinferior, contralateral side of the joint. SLAP
repair restores proper tension of articular capsule.
Another sign of loss of joint stability is posterior instabil-
ity. It may ensue from chronic throwing and the injury
takes place in the deceleration phase (adduction and in-
ternal rotation) [34,35]. Posterior part of articular capsule
is stretched and posterior part of RC becomes tense [25].
Patients may complain of pain and sense of instability dur-
ing such motion. There may be also spontaneous instabil-
ity (voluntary or involuntary) in horizontal adduction or
in other positions forced by throwing. Features of typical
anterior instability are not observed during the examina-
tion (apprehension and relocation test). However, there is
64
Figure 5. Figures showing the instability of the back of the shoulder:
(A) MRI arthrography image, (B) and Kims test, (C)
arthroscopic image.
a possibility of posterior subluxation, reposition with snap-
ping, reverse apprehension and relocation test, augment-
ed posterior translation, etc. The basis of management in
above-mentioned types of instability is physiotherapy. It is
aimed at restoration of normal joint mechanics, elimina-
tion of joint and muscle contractures, muscle stability and
neuromuscular coordination. If such management is unsuc-
cessful or when we are dealing with organic injuries (labral
tearing), surgical treatment should be considered, e.g. sta-
bilization of labrum, capsuloplasty or posteroinferior cap-
sulotomy in case of GIRD syndrome (Figure 5).
Scapulothoracic dyskinesis
ulothoracic dyskinesis [20,3638]. Its presence was dem-
onstrated in patients with subacromial impingement syn-
drome [37,3947], rotator cuff injuries [48] and shoulder
instability [20,48,49].
Causes of dyskinesis include weakening or disbalance of
muscles stabilizing the scapula or too little flexibility of
muscles and capsulotendinous complex in the shoulder
region. Change in scapular kinematics may be also influ-
enced by augmented thoracic kyphosis, acromioclavicular
joint dysfunction, shoulder joint instability, labral injury,
subacromial impingement syndrome or internal impinge-
ment [10,36,50].
Clinically, we distinguish three types of scapular dyskinesis.
Type I involves inferomedial scapula border prominence.
It is usually associated with increased tension of pectoralis
major and minor muscles and weakening of inferior part
of trapezius and anterior serratus muscles, resulting in nar-
rowing of subacromial space during activity above the head.
Type II is characterized by prominence of the entire medi-
al border of the scapula at rest, which becomes even more
obvious following repeated lifting of the upper limb. It is
caused by fatigue of muscles stabilizing the scapula (trape-
zius and rhomboid muscles). The above types of dyskinesis
lead to retraction of a scapula during rest and impair the

normal motion pattern during activity over the head, lead-
ing to impaired positioning of humeral head within the
glenoid cavity and forcing excess muscle work in order to
achieve proper retraction [37]. Type III dyskinesis involves
elevation of the superior part of medial scapular margin. It
is often associated with subacromial impingement syndrome
and rotator cuff injury [5153]. Scapular dyskinesis may be
the primary cause of restricted shoulder function or devel-
op secondary to underlying pathologies. Therefore, com-
plex clinical and radiological studies are necessary to state
proper diagnosis. Any pathology must be adequately treat-
ed and scapular dyskinesis is usually treated without prop-
er rehabilitation protocol. Appropriate movement of the
scapula should be always assessed in the course of shoulder
physiotherapy. Therapy encompasses restoration of tissue
elasticity, training of muscles stabilizing the scapula and co-
ordination exercises.
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Conclusions
Long-term, intense practicing of throwing sports may be
associated with various shoulder pathologies. The mecha-
nism of their development is complicated. Some pathologies
could be adaptive (internal impingement, GIRD) and some
proceed into organic injuries (SLAP, RC injuries). Careful
analysis of symptoms, through clinical examination, biome-
chanical and radiological assessment is always fundamental.
Proper treatment is selected based on those elements. The
basis is almost always conservative treatment. It must be al-
ways comprehensive and adjusted to the deficits of function
of the shoulder and the patient. In some situations surgical
treatment may be necessary, mainly using shoulder arthros-
copy. However, it must always be supplemented with an ap-
propriate rehabilitation program and objective assessment
of shoulder function in patients resuming athletic activities.
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