SPECIAL ISSUE ARTICLE

Care of Shoulder Pain in the

Overhead Athlete
Joseph Chorley, MD, FACSM, FAAP; Richard E. Eccles, MD; and Armand Scurfield, MD

stability of the GH joint. The anatomy

ABSTRACT of the shoulder is analogous to a golf
Shoulder complaints are common in the overhead athlete. Understanding the biome- ball (humeral head) on a tee (glenoid).
chanics of throwing and swimming requires understanding the importance of maintain- Only one-third of the humeral head con-
ing the glenohumeral relationship of the shoulder. Capsular laxity, humeral retrotorsion, tacts the glenoid fossa. Contact surface
glenoid retroversion, glenohumeral internal rotation deficit, and scapular dyskinesis can all area and stability are increased by the
contribute to shoulder dysfunction and pain. Injuries are more likely during peak height labrum, a cartilaginous bumper around
velocity, especially when coupled with overuse, previous injuries not adequately treated, the circumference of the glenoid. The
or change in the demands on the shoulder such as a new technique, bigger field, or longer joint capsule is thin but it has thickened
race. Working with physical therapists, athletic trainers, and coaches to identify and treat areas that form the small GH ligaments.
the etiology of the shoulder dysfunction will help pediatricians return the athlete to activity The anterior and posterior inferior GH
and prevent future injury. [Pediatr Ann. 2017;46(3):e112-e119.] ligaments serve as static stabilizers. The
four rotator cuff (RC) muscles (supra-

A
ccording to one study, when biomechanics of the shoulder are com- spinatus, infraspinatus, teres minor, and
third-year pediatric residents plicated, but by understanding injury subscapularis) are the most important
were surveyed about teaching patterns and performing an appropri- dynamic stabilizers and envelop the hu-
of the musculoskeletal examination, the ate history and physical examination, meral head, making micro-adjustments
shoulder was ranked lowest.1 Shoulder clinicians can identify the etiology of to maintain proper glenohumeral align-
complaints and their examination in pe- the problem. By working with physical ment. The supraspinatus muscle is the
diatric athletes can be challenging. In therapists, athletic trainers, and coaches primary humeral head depressor that
the high school athlete, shoulder inju- to address the causes of the injury, pe- prevents the humeral head from imping-
ries account for 7% of all sports injuries diatricians can optimize treatment and ing the structures of the RC interval (su-
and 13% of baseball injuries.2 Overhead prevent further injury. praspinatus, tendon of the long head of
athletes (throwers, swimmers, volleyball biceps, coraco-acromial ligament, sub-
players, and tennis athletes) have shoul- ANATOMY acromial bursa) on the acromion. The
der complaints related to the “thrower’s The glenohumeral (GH) joint is the teres minor and infraspinatus are ex-
paradox,” which is the delicate balance location of most overhead athletes’ ternal rotators that work to balance the
between the need for upper extremity shoulder problems. The muscles, bones, larger, stronger internal rotators (latis-
mobility to perform, and sufficient sta- and capsular structures of the shoulder simus dorsi, pectoralis major, subscap-
bility to prevent injury.3 Anatomy and work together to maintain mobility and ularis). The glenoid is attached to the
scapula; therefore, scapular motion and
periscapular muscle strength are impor-
Joseph Chorley, MD, FACSM, FAAP, is an Associate Professor of Pediatrics, Baylor College of Medicine. tant for placing the glenoid in proper po-
Richard E. Eccles, MD, is a Fellow, Primary Care Sports Medicine, Baylor College of Medicine. Armand sition so other structures are not injured
Scurfield, MD, is a Fellow, Primary Care Sports Medicine, Baylor College of Medicine. or overworked (trying to keep the ball on
Address correspondence to Joseph Chorley, MD, FACSM, FAAP, Associate Professor of Pediatrics, Bay- the tee). Muscles contributing to scapu-
lor College of Medicine, 6621 Fannin Street, CCC 1710.00, Houston, TX 77030; email: jchorley@bcm.edu. lar motion include the levator scapulae,
Disclosure: Joseph Chorley is a section editor and a contributing author for sports medicine for the serratus anterior, trapezius, rhomboid,
UpToDate journal. The remaining authors have no relevant financial relationships to disclose. and pectoralis minor. Because the scap-
doi: 10.3928/19382359-20170216-01
ula articulates with the thoracic rib cage,

e112 Copyright © SLACK Incorporated


poor forward flexed posture will result
in the scapula tipping forward, causing
the acromion to collapse on the struc-
tures of the RC interval.
Repetitive stress from overhead sports
can gradually lead to anatomic changes
in the shoulder, such as stretching of
the capsule and humeral retrotorsion. A
stretched capsule causes excessive mo-
tion of the humeral head with relation-
ship to the glenoid4 (increased laxity),
which can lead to instability (shifting
out of place) or impingement (pinching
of soft tissue structures). Repetitive ro-
tational stress will result in the humer-
us twisting into extra external rotation
(humeral retrotorsion) and hitting the
posterior glenoid rim, resulting in pos-
terior tipping (glenoid retroversion). A
thrower’s dominant shoulder will usually
develop at least 5° of extra external rota-
tion compared to the nondominant shoul-
der. This extra external rotation (ER) is
a physiologic adaptation that allows for
additional ER without the humerus hav-
ing to rotate further. Extra ER range al-
lows more time for the shoulder to get
to peak velocity during the acceleration
phase (less strain on the shoulder).5,6
However, the same repetitive stress will
result in injury and scarring to the pos-
terior inferior GH ligament, restricting
internal rotation (IR). Glenohumeral in-
ternal rotation deficit (GIRD) has been
defined as a loss of IR of 20° or more,
and has been associated with increased
risk for shoulder and elbow pain.5
Scapular dyskinesis (deviation of the
normal scapular position with shoulder
movement) is an important and often
missed etiology of shoulder impinge-
ment. The most common type is infe-
rior medial scapula dysfunction, which
results in the acromion collapsing into
the rotator cuff interval. Weak inferior
trapezius, tight pectoralis minor, and
forward flexed posture contribute to
scapular dyskinesis.7
PEDIATRIC ANNALS • Vol. 46, No. 3, 2017
SPECIAL ISSUE ARTICLE
PATIENT HISTORY
A thorough patient history is helpful
in discerning the etiology and diagnosis
of an overhead athlete’s problem. Dura-
tion, location, severity, and distribution
of pain help to discern contributing fac-
tors. Neck pathology must always be
considered. Mechanical sensations (eg,
popping and clicking) that are nonpain-
ful are common in normal shoulders.
Painful mechanical sensations, however,
are usually significant. Joint instability
(shifting sensations between the shoul-
der bones) can indicate that the GH sta-
bilizers are not strong enough to meet
the demands of the activity. Other fac-
tors that must be considered include the
following:
1. Age: Peak height velocity (boys
age 12-16 years, girls age 9-13 years)
results in rapid changes in body geom-
etry. Proprioception and flexibility defi-
cits that commonly occur during rapid
growth can contribute to their inability
to perform their sport correctly.
2. Volume: Overtraining is common
in young athletes, especially those who
participate on multiple teams. Each
team may not account for training vol-
ume of the others. Early in the season,
the amount of training is significantly
higher in volume and intensity than in
the off-season. “Moving up” to the next
level comes with larger field size, swim-
ming longer races, and higher expecta-
tions about training ability.
3. New technique: New techniques
take time to perfect and require dili-
gent work and guidance. Transitioning
to a jump serve in volleyball, throw-
ing a slider in baseball, or learning new
strokes in swimming can be challenges
that contribute to injury.
4. Previous injury: Previous injury
predisposes to reinjury. Compensation
can cause stress at a different point in
the kinetic chain (eg, hip pain can lead
to shoulder injury).
DIAGNOSES
Anterior Impingement, Rotator Cuff
Tendonitis, Subacromial Bursitis,
and Biceps Tendonitis
Anterior shoulder impingement is
caused by the pinching of the structures
of the rotator cuff interval between the
humeral head and the acromion.8 Im-
pingement will result in rotator cuff/
biceps tendonitis and/or subacromial
bursitis.9 Maximal shoulder impinge-
ment occurs when the humerus is in-
ternally rotated in the forward flexed
overhead position (streamline swim-
ming position). The humeral head can
migrate superiorly with supraspinatus
dysfunction or the acromion can tip
inferiorly with peri-scapular muscle
weakness. Patients complain of ante-
rior shoulder pain with overhead activi-
ties that may localize to the anterior or
lateral deltoid. Treatment includes rest
from painful activities and correcting
the muscle strength imbalances, fol-
lowed by gradual transition back to ac-
tivity once pain resolves. This may take
a few weeks to a few months, depending
on the number of etiologies contributing
to the dysfunction.
Labral Tears
Labral injury may present with deep,
poorly localized pain with activity.
Labral shoulder pain is similar to ante-
rior impingement but does not respond
to typical treatment for impingement.
Painful catching, locking, or “popping”
with overhead sports activities are clas-
sic complaints in patients with labral
tears.10 The superior labrum anterior to
posterior (SLAP) tear is more common
in throwers because of the result of re-
petitive compressive and shear forces on
the superior labrum from the throwing
motion.11 A magnetic resonance imag-
ing scan with intra-articular contrast can
confirm a labral tear,12 which will typi-
cally require surgical treatment.
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 SPECIAL ISSUE ARTICLE

TABLE 1.

Common Throwing Errors and the Resulting Symptoms

Phase of Throwing
Windup (starts with standing
on the pitching rubber)
Early cocking/stride
Late cocking
Acceleration
Common Errors Symptoms/Diagnoses Intervention/Treatment
Lack of stability in dominant leg Back/hip pain Single leg proprioception training
Shoulder pain later in throwing Iliopsoas and hamstring stretching
motion
Overstriding, stepping away or Back/hip pain Shorten stride
toward dominant arm (opening Shoulder pain later in throwing Step toward home
up) motion
Early internal rotation of the Loss of power
forearm (“pie throwing”)
Lack of full external rotation Fatigue Conditioning
Posterior impingement Fewer innings
Anterior glenohumeral instability Core strengthening
Dropping the elbow Back pain from hyperlordosis Keep shoulder abducted >100° (elbow
Arm behind hips Medial elbow pain high)
Shoulder pain Core strengthening

Deceleration and follow Lack of flexion at the waist Biceps tendonitis Finish throwing motion by getting trunk
through over lead leg in a balanced position

Posterior Impingement
Posterior impingement presents
with posterior/lateral shoulder pain,
primarily in throwing athletes when
the shoulder is abducted and maxi-
mally externally rotated (late cocking
throwing position). This position com-
presses the supraspinatus, infraspina-
tus, and the glenoid rim. These ath-
letes may have GIRD, and specifically
insufficient ER.5 Treatment includes
rest from painful activities, capsular
stretching, and correcting any muscle
strength imbalances, followed by grad-
ual transition back to activity once pain
resolves. Symptomatic improvement
with proper treatment should be seen
in 2 to 4 weeks.
Little League Shoulder
Little League shoulder is an os-
teochondrosis or stress injury of the
proximal humeral epiphysis that is be-
ing diagnosed with increasing frequen-
cy.13 Athletes will complain of pain at
the top of the arm with throwing and
have decreased throwing velocity. On
physical examination, there is tender-
ness when the examiner squeezes the
humeral head. Radiographs are not
required for the diagnosis, but if per-
formed may demonstrate widening and
sclerosis at the growth plate. Treatment
is rest from throwing until no longer
painful with activity or tender to palpa-
tion (usually takes at least 4-6 weeks),
followed by gradual return to throw-
ing. Rehabilitation exercises to correct
any strength imbalances (eg, scapular
winging) and correction of any tech-
nique errors (Table 1) can help prevent
recurrence, along with following ap-
propriate pitch count guidelines.14
BIOMECHANICS
The biomechanics of overhead mo-
tion in throwing a baseball, serving
a volleyball, hitting a tennis ball, or
generating a swim stroke involve more
than the upper extremity. The lower
extremities and trunk generate and
transfer energy to the upper extremities
for optimal sports performance.15 For
example, linear and rotational force
of the lower extremities and trunk ac-
count for 50% to 60% of the total force
generation required for throwing.16
Throwing
Throwing has six distinctive phas-
es: (1) windup, (2) early cocking/
stride, (3) late cocking, (4) accelera-
tion, (5) deceleration and (6) follow
through17,18 (Table 1). Each phase sub-
jects the upper extremity to varying
forces and loads.
In the windup, potential energy is
stored in the rotated torso when bring-
ing the lead leg to maximum hip flex-
ion and adduction while balancing on
the back leg. Injury risk in this phase
is minimal, but lack of balance and
proprioception can lead to increased
shoulder torque and possible injury
during later phases.19
With a baseball pitcher, the stride/
early cocking phase initiates the for-
ward momentum. The shoulder is

e114 Copyright © SLACK Incorporated


abducted, extended, and begins to
externally rotate while the elbow ex-
tends, usually showing the ball to the
shortstop (if the pitcher is right hand-
ed). The lead hip is abducted and ER
occurs to position the foot pointing
toward home plate. Injury can occur
when striding incorrectly. Overstrid-
ing (further than pitcher’s height)
results in the inability to the rotate
hips, which causes excessive force to
the shoulder. Striding away from the
pitching arm (“opening up”) causes
the trunk to get ahead of the shoulder,
overstretching the anterior shoulder
capsule. Striding toward the throwing
side subjects the labrum to excessive
force.
Athletes will often complain of
pain in the late cocking position. This
phase of throwing is when the shoul-
der achieves maximal ER and has its
maximum potential energy, but this is
also the position of posterior impinge-
ment. The arm is externally rotated
almost 160° to 170°, the lead leg acts
to stabilize a fulcrum point, and the
pelvis rotates to face the target. The
throwing arm is maintained at 90° of
abduction, and elbow at 90° to 100°
of flexion.
The acceleration phase is when
the stored potential energy is used
to throw the ball toward the target.
This phase starts with rapid IR of the
shoulder and is terminated with ball
release. The desired force from this
violent motion stresses the IRs of the
shoulder through strong concentric
activation as the shoulder ERs con-
tract eccentrically to maintain proper
GH alignment.
The deceleration phase begins with
ball release, dissipating the energy of
the violent acceleration phase. This
phase lasts until maximal internal ro-
tation and terminal elbow extension is
achieved. The forces on the superior
PEDIATRIC ANNALS • Vol. 46, No. 3, 2017
SPECIAL ISSUE ARTICLE
labrum at the insertion of the long
head of the biceps tendon during this
phase can result in SLAP lesions. The
large eccentric contraction needed to
slow acceleration during this phase
can strain the rotator cuff and poste-
rior deltoid.
Follow through is the final phase
that terminates throwing and positions
the pitcher to be ready to field the ball.
Other Overhead Sports: Football,
Water Polo, Volleyball
The throwing motion of an Ameri-
can football quarterback has a cocking
phase that starts earlier and with less
abduction than that of baseball pitch-
ers. Football throwing injuries are less
commonly due to overuse and typical-
ly result when the throwing motion is
disrupted by an opponent. Volleyball
athletes have similar stress but must
also coordinate a running approach,
jumping, and hitting the ball with feet
off the ground. Water polo players
have shoulder pain related to swim-
ming mechanics as well as difficult
throwing mechanics because their feet
cannot touch the bottom of the pool.10
Swimming
Because competitive swimmers
average around 30,000 strokes per
shoulder per week, shoulder pain is
common.20,21 With 90% of propul-
sive power coming from their upper
extremities,21 swimmers will develop
strong serratus anterior, latissimus
dorsi, pectoralis major, and pectoralis
minor muscles, resulting in the classic
swimmer’s posture (Figure 1). There
are four strokes in competitive swim-
ming: crawl (or “freestyle”), back-
stroke, butterfly, and breaststroke.
Each stroke involves circumduction of
the GH joint with varying degrees of
IR and ER, and scapular protraction/
retraction. Each stroke is divided into
Figure 1. Typical swimmer’s posture and associat-
ed muscle imbalances. Reprinted with permission
from www.SwimmingScience.net.26
two main phases: pull-through and
recovery. Pull-through, where most
problems occur, is further split into
four components: hand entry, catch,
mid-pull, and finish. The recovery
phase occurs above the water, starting
when the hand exits and ending when
the hand re-enters the water. Pain does
not usually occur during recovery but
errors can lead to problems during
pull-through (Table 2).
Regardless of their stroke specialty
in competition, swimmers spend most
of their practice time performing free-
style and backstroke, which are long
axis strokes in which the trunk and
hips rotate around the body’s center
axis (axial plane rotation). Adequate
rotation and timing of reciprocating
arm motion (one arm is pulling while
the other is recovering) are extremely
important to stroke mechanics and
shoulder injury. Butterfly and breast-
stroke require both arms to recover at
the same time. Trunk and hips will not
rotate axially but will undulate in the
sagittal plane. Because the trunk can-
not rotate away from the arms during
pull-through, the shoulder begins ev-
ery pull-through phase in the anterior
impingement position.
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 SPECIAL ISSUE ARTICLE

TABLE 2. prior to a powerful forward propul-

sive kick. 21 The swimmer’s hands
Technique Errors that Increase Risk for Shoulder Pain and never move below the hips, resulting
Injury in Swimmers in the lowest lever-arm length and
Technique Error Intervention tensile force on the shoulder. 20
Stroke inefficiency Looking forward (causes hips Drop chin slightly to look at bot-
(leading to early to drop) tom of the pool PHYSICAL EXAMINATION
fatigue) Shortened stroke Finish with hands below waist Related Structures
Dropping elbows in pull Keep elbows high to grab more
Assessment of the neck and cervi-
through (“slipping water”) water cal spine evaluates for possible re-
Using excessive force Deep pull technique Elbows high but bent in mid-pull ferral source of shoulder pain. This
“Windmill recovery” Use high elbows in recovery
begins with active range of motion
through flexion, extension, rotation,
Increased primary an- Flat shoulders Rotate hips and trunk around axis
terior impingement of the spine and lateral flexion while assessing for
Late breathing Breathe at hand exit
pain. This is followed by palpation of
the paraspinal muscles and spinous
Hands crossing midline at Rotate hips/trunk
hand entry processes, evaluation of strength,
Avoid swinging hands in recovery
(keep elbows high in vertical plane neurovascular integrity, and presence
next to the body) or absence of pain with axial loading
Overreaching at hand entry Stretch from scapula and shoulder (Spurling’s maneuver).
to lengthen stroke elevation not horizontal adduction
Inspection
Inspection of the shoulder requires
that patients wear appropriate cloth-
In freestyle, recovery phase re- sule of the GH joint. 20 The swimmer’s ing so that landmarks can be identi-
quires scapular retraction/elevation trunk also rolls toward the side of the fied (male patients can be shirtless,
and humeral abduction and ER while pull-through shoulder, and the elbow and female patients in tank top that
keeping the elbow high in the vertical is now flexed during pull-through adequately exposes the shoulder).
plane. The pull-through phase starts and extended during recovery. The clinician should evaluate for
at hand entry with scapular protrac- The butterfly has similar shoulder muscular development, deformities
tion, humeral adduction, and internal activity to freestyle, but the arms are or asymmetries, swelling, shoul-
rotation (like raising your hand in not alternating. This places a greater der height, and scapular positioning
class to answer a question). This is demand on the medial scapular sta- (Table 3). Asymmetric development
the anterior impingement position. If bilizers/retractors 20 (rhomboids and can be a clue to pathology. For ex-
the scapula is not protracted, the acro- trapezius muscles). The breaststroke ample, the classic swimmer posture
mion will collapse into the rotator cuff also involves simultaneous movement (Figure 1) with overdevelopment of
interval. With proper trunk rotation, at both shoulders. The pull-through the pectorals and latissimus at the
the humerus is less adducted (raised phase begins with the shoulders in the expense of the lower trapezius and
arm now points to 1 o’clock instead of impingement position. Catch begins rhomboids, increases risk for anterior
noon) and avoids impingement. with keeping the elbows high. The impingement. A patient sitting on the
The backstroke has similar de- swimmer then supinates the hands examination table, leaning back with
mands on the shoulder as freestyle, and internally rotates the shoulders. 21 their hands behind them for support
but the actions are reversed because With elbows flexed to 90°, the swim- usually indicates a weak and disen-
the swimmers are on their backs. The mer moves forward with their upper gaged core. When standing behind
pull-through phase begins with scapu- body out of the water while abduct- the patient, a prominent inferior tip
lar retraction and humeral horizontal ing and extending the shoulder. The of the scapula can indicate poor scap-
abduction and ER. This stroke places swimmer then lunges forward, back ular stability that can lead to GH pa-
increased stress on the anterior cap- under the surface of the water, just thology.

e116 Copyright © SLACK Incorporated


Palpation
Tenderness over the proximal hu-
meral physis indicates Little League
Shoulder. Tenderness over the ante-
rior joint line commonly occurs with
anterior impingement, but also could
indicate labral pathology. Posterior
joint line tenderness is frequently re-
lated to posterior impingement, but
could also indicate less common pa-
thology such as anterior or posterior
GH subluxation. When the humeral
head subluxates, it is stretching the
capsule and RC muscles, which can
be tender on examination. Tenderness
in the subacromial space is common
with subacromial bursitis, anterior im-
pingement, and RC tendonitis. Bicipi-
tal groove tenderness suggests biceps
tendonitis.
Range of Motion and Strength
Testing
Range of motion (ROM) and
strength testing assess active and pas-
sive ROM, noting any asymmetry or
restrictions. To assess per-scapular
strength, have the patient abduct both
shoulders to 180° and back several
times, which can reveal scapular dys-
kinesis when viewed from behind.
Resisted forward flexion in standing
will produce pain in most shoulder
injuries. However, if the pain resolves
with repeat examination while supine,
when the scapula is supported by the
examination table, then peri-scapular
muscle weakness is the likely etiology.
Supraspinatus integrity and strength is
evaluated with the “Empty Can” test.
This test begins with the humerus at
90° abduction, maximally internally
rotated (ie, thumb down), and 45° of
horizontal flexion. The patient resists
while the examiner applies downward
pressure, noting any pain or weakness.
Passive ROM is optimally mea-
sured with the athlete supine, shoulder
PEDIATRIC ANNALS • Vol. 46, No. 3, 2017
SPECIAL ISSUE ARTICLE
Risk Factors for Shoulder Pain or Injury that Can Be
Identified on Physical Examination
Risk Factor
Poor posture
Asymmetric muscular development
Posterior impingement
Scapular dyskinesis
Poor balance on single leg
Decreased shoulder external rota-
tion at 90° abduction
Supraspinatus weakness
abducted to 90°, humerus on table, and
elbow off table. Passive IR and ER on
dominant and nondominant shoulders
are measured (0° being perpendicular
to the table). Ideally, the thrower’s
shoulder should have at least 5° more
ER than the opposite shoulder and less
than 20° loss of IR compared to the
nonthrowing shoulder.5
Provocative and Stability Tests
Provocative and stability tests as-
sist in diagnosing the potential shoul-
der etiology and help determine the
need for advanced imaging (Table 4).
Sensitivity and specificity vary with
each test, with no test being ideal or
the gold standard, so they should be
used as a compliment to the elicited
history and general examination al-
ready obtained.
TABLE 3.
Intervention
Core strengthening of multifidus and transverse
abdominus
Stretch iliopsoas
Improve thoracic mobility
Stretch pectorals and latissimus dorsi
Strengthen lower trapezius and rhomboids
Stretch posterior capsule
Peri-scapular strengthening
Strengthen serratus, lower trapezius, rhomboids
Stretch levator scapulae, pectoralis minor
Improve thoracic mobility
Address poor posture
Strengthen core (gluteal and abdominal oblique
muscles)
Dynamic proprioceptive exercises
Eccentric peri-scapular strengthening
Progress to “Thrower’s 10” program22
Strengthen but also look for other etiologies
TREATMENT AND PREVENTION
Treatment is based on the diagnosis,
but generally requires rest from the irri-
tating activity, while any muscle imbal-
ances or biomechanical deficits are ad-
dressed (Table 4). A physical therapist
experienced with treating upper extrem-
ity injuries in overhead athletes can be
helpful. The thrower’s 10 program22 is
part of the rehabilitation program but
also can be used by all overhead athletes
to address some of the common biome-
chanical issues before they are injured.
Once muscle imbalances are corrected
and pain is resolved, an experienced
coach can analyze the athlete’s tech-
nique. Dedicated video analysis and bio-
mechanical computer modeling can aid
in identifying subtle technique errors.
Return to sport can be considered when
the patient has full range of motion and
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 SPECIAL ISSUE ARTICLE
TABLE 4.
Provocative and Stability Tests for the Shoulder
Test Action
Impingement
Anterior impingement (Hawkin’s Passively forward flex shoulder to 90° with elbow flexed to
test) 90°, then passively internally rotate (this narrows the rotator
cuff interval)
Posterior impingement Patient supine, arm abducted to 90° with maximal ER
Biceps testing
Speed’s test Patient attempts to forward flex shoulder against resistance
while keeping their elbow extended and forearm supinated
Labral tests
O’Brien’s test Patient’s elbow extended and shoulder in 90° forward flex-
ion, 40° horizontal adduction, and maximal internal rotation
(thumb down). The patient resists the clinician’s downward
force. Examination is repeated with the thumb up (neutral
position)
Crank test Apply axial load to the patient’s 90° abducted shoulder
while passively internally and externally rotating
Biceps load Patient starts with shoulder abducted and flexed elbow to
90°. The examiner maximally externally rotates the shoulder
and then provides resistance against elbow flexion
Stability tests
Sulcus sign Relaxed patient with arms at sides allows the examiner to
pull arms while observing the shoulder
Anterior/posterior drawer While grasping the humeral head with one hand and sta-
bilizing the glenoid with the other, examiner translates the
humeral head anteriorly and posteriorly with comparison
to the opposite side
Apprehension (anterior) Supine patient’s arm is passively abducted 90° and maximal
ER applied
Fowler’s relocation After the apprehension test, examiner applies posterior
force on the humerus
Abbreviatons: ER, external rotation; GH, glenohumeral joint; IR, internal rotation.
no pain with activities of daily living, no of the shoulder and correcting the
tenderness on physical examination, and underlying etiology of the shoulder
has completed a progressive return to a dysfunction. Knowing the demands
throwing23,24 or swimming25 program. placed on the shoulder in overhead
sports highlights how even small
SUMMARY errors can result in injury. A team
Treating the overhead athlete re- approach with physical therapists,
quires understanding the biomechanics athletic trainers, and coaches will
e118
Results
Provoked pain over deltoid tubercle or
anterior shoulder can indicate anterior
impingement
Provoked pain over posterior shoulder can
indicate posterior impingement
Pain at bicepital groove can indicate biceps
tendonitis or GH instability
Pain in IR position that goes away in ER
position suggests labral pathology
Pain, catching, or painful clicking is a posi-
tive test for labral injury
Worsening of pain or apprehension sug-
gests labral pathology
Increased space between the acromion
and humeral head indicates inferior GH
instability
Sagittal GH instability
Positive if patient experiences sense of
instability
If apprehension sensation is relieved, this
further supports diagnosis of anterior GH
instability
optimize treatment and facilitate re-
turn to sport.
REFERENCES
1. Demorest RA, Bernhardt DT, Best TM,
Landry GL. Pediatric residency education: is
sports medicine getting its fair share? Pediat-
rics. 2005;115(1):28-33.
2. Comstock RD, Currie DW, Pierpoint LA.
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Summary report: national high school sports-
related injury surveillance study, 2014-2015
school year. www.ucdenver.edu/academics/
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