INVITED CLINICAL COMMENTARY

IJSPT CURRENT CONCEPTS IN SHOULDER EXAMINATION

OF THE OVERHEAD ATHLETE
Robert Manske, PT, DPT, MEd, SCS, ATC, CSCS1,2
Todd Ellenbecker, DPT, MS, SCS, OCS, CSCS3.4

ABSTRACT
Examination of the shoulder complex has long been described as challenging. This is particularly true in
the examination of the overhead athlete who has structural differences when compared to a shoulder
patient who is a non-athlete. Complexity with the examination is due to unique biomechanical and struc-
tural changes, multiple joint articulations, multiple pain patterns, and the potential of injury to structures
both inside (intra-articular) and outside (extra-articular) the glenohumeral joint. Repetitive stresses placed
on the shoulders of overhead athletes may affect range of motion, strength, scapular position, and ulti-
mately, the integrity of soft tissue and bony structures in any of the joints that comprise the shoulder com-
plex. Furthermore, many shoulder examination tests thought to be unique to a single structure, joint, or
condition can be positive in multiple conditions. The examination of the overhead athletes shoulder, cou-
pled with a thorough medical history will provide a solid foundation to allow a functional physical therapy
diagnosis and provide clues as to the presence of the lesion (s) causing disability. The purpose of this clini-
cal commentary is to assist the reader to understand the unique physical characteristics of the overhead
athlete, which will lead to a more accurate and reproducible evaluation of athletes who sustain injuries
while participating in overhead sports.
Keywords: Overhead athlete, physical examination, shoulder
Level of Evidence: 5

CORRESPONDING AUTHOR
Robert Manske, PT, DPT, MEd, SCS, ATC, CSCS
Wichita State University – Department of
1
Physical Therapy
Wichita State University – Department of Physical Therapy,
Wichita, KS, USA Via Christi Health Sports and Orthopedic
2
Via Christi Health Sports and Orthopedic Physical Therapy, Physical Therapy
Wichita, KS, USA
3
Physiotherapy Associates Scottsdale AZ, USA Wichita, KS, USA
4
Medical Services – ATP World Tour Email: Robert.manske@wichita.edu

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 554
INTRODUCTION
The overhead and throwing/serving athlete is a
very unique sports patient. In overhead athletes,
the kinetic energy and force created in the lower
extremities, pelvis and trunk is funneled through
the shoulder complex including the glenohumeral,
scapulothoracic, acromioclavicular, and sternocla-
vicular joints ultimately resulting in maximal distal
upper extremity segmental velocity needed for opti-
mal overhead performance. The arm, elbow, wrist,
and hand then add to that force and provide the fine
tuning required in order to direct (or target) the cre-
ated energy into a specific action such as placing a
pitch or serve.1 Stresses placed upon the shoulder
complex of the overhead athlete push the anatomi-
cal limits of the shoulders physiological capacity.
During the throwing motion, angular velocity of the
shoulder reaches over 7000 degrees per second.2,3
The shoulder complex of the overhead athlete has
the reputation of being difficult to examine due to
several reasons. First, the complexity of the joints,
and multiple articulations make it difficult to exam-
ine. Second, the multi-layer envelope of soft tissue
structures makes palpation of individual underly-
ing structures challenging. Third, many of the com-
monly utilized examination special tests have been
proven to be less accurate than previously believed.4
Finally, the over-reliance of medical professionals
on imaging techniques has allowed the physical
examination of the shoulder to become a lost art.
The over-reliance of imaging is concerning since it
is known that up to 34% of painless shoulders will
demonstrate a rotator cuff (RC) tear on magnetic
resonance imaging (MRI).5 In asymptomatic profes-
sional baseball pitchers abnormalities of the glenoid
labrum are seen in 79% of throwers.6 Partial thick-
ness RC tears are missed by MRI in the throwing or
overhead athlete up to 44% of the time.7 In overhead
athletes 40% of dominant shoulders have findings
consistent with partial or full-thickness RC tears,
25% of these findings consistent with Bennett’s
lesion, none of which were symptomatic during test-
ing or for 5 years later.8
Multiple factors related to the shoulders of overhead
athletes may or may not cause symptoms. Several
of these factors may include but not be limited to
inflamed soft tissues, hypomobile or hypermobile
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 555
joints, rotator cuff or scapular strength and endur-
ance deficits, postural dysfunctions, and improper
training. Additionally when and athlete has a pain-
ful shoulder, this pain can be caused by numerous
conditions. Anterior shoulder pain can be caused by
pathology such as tendinosis, partial thickness RC
tears, full thickness RC tears, calcific tendonitis, and
biceps tendon disorders, instability, superior labrum
injuries, and coracoid impingement. To complicate
matters even further, some of these problems occur
from relatively uncommon pathologies rarely seen
by the average clinician. These could include venous
occlusions, arterial lesions, nerve lesions (such as of
the long thoracic nerve or brachial plexus), or tho-
racic outlet syndrome. Finally, note that it is not
uncommon for the physical stresses endured by
the overhead athlete to cause stress fractures of the
humerus or scapula.9,10
History
As with any general musculoskeletal examination,
the most important information used during the
evaluation is obtained during the medical history.
Skilled medical clinicians understand that in most
cases diagnosis of any musculoskeletal problem can
be made accurately through effective questioning
and listening to the athlete. A thorough history of
the athlete’s complaints includes the athlete’s age,
the symptom onset, descriptions of pain and pain
location, and referral symptoms. Some of the follow-
ing are excellent questions to ask during the initial
history portion of the examination of the overhead
athlete (Table 1).
Although most athletic patients are otherwise
healthy, it is prudent to perform a quick review of
general health and other joint involvement as sys-
temic or referral sources of pain can easily create
confusion when examining a variety of shoulder
conditions. This would be pertinent in cases such as
pitchers with neck and or medial elbow symptoms in
addition to their shoulder pain. The clinician should
ensure that the cervical spine or elbow is not con-
tributing to the overall shoulder problem. Further-
more it must be ascertained in the case described
above that the shoulder and elbow symptoms are
not being caused by an undiagnosed cervical spine
problem masked as extremity pain. For example,
overpressure of the cervical spine in the motions of
 Table 1. History Questions for the Overhead Athlete Examination.

Was pain onset traumatic or insidious?

Is there a history of overuse?
Where during activity does athlete have pain? (What phase of the throwing or serving motion?)
Does the shoulder feel unstable?
Does the athlete notice any popping, snapping, catching or clicking?
Are the above symptoms associated with pain or just noise without pain?
Does the athlete have any color changes in the extremity, does it swell, or do they lose sensation?
Has the athlete noticed a loss of throwing velocity or racquet speed?
Has there been any change in form or technique or changes in training frequency, duration or intensity?

flexion and extension and lateral flexion and rota- progress the athlete may have pain with throwing
tion, as well as the quadrant or Spurling tests, are or may even be severe enough that they are now
commonly used to clear the cervical spine and rule unable to throw.
out radicular symptoms.11 Tong et al tested the Spurl-
For baseball and tennis athletes it is not simply
ing maneuver to determine it’s diagnostic accuracy.11
enough to ask if there are symptoms during throw-
The Spurling test had a sensitivity of 30% and speci-
ing or serving. The sports therapist must be more
ficity of 93%. Caution therefore must be used when
detailed and identify where within the throwing or
basing the clinical diagnosis solely on this examina-
serving motion does the symptom occur? Is it in the
tion maneuver. The test is not sensitive but is specific
cocking stages, the follow-through or somewhere in
for cervical radiculopathy and therefore can be used
between? Additionally, asking whether any equip-
to help confirm a cervical radiculopathy. This test is
ment changes have been made such as changes in
an excellent overall screening test that is applicable
string type or tension, racquet style/weight or grip
during examination of the overhead athlete.
changes can have enormous consequences on the
Determining the reactivity of shoulder injury is com- musculoskeletal system in the tennis player.
monly done through several mechanisms. The use of
a pain diagram or analog pain scale will help deter-
Observation and Posture
mine the patient’s perception of amount of pain in
The actual clinical examination begins by assessing
shoulder. Trying to determine the reactivity or irrita-
and observing the shoulder and arm and viewing
bility of a shoulder and surrounding structures helps
posture. A relaxed standing position is a good place
guide how the remainder of the examination should
to determine the posture of the head on the tho-
be organized. In an athlete with a highly reactive
rax. Forward head posture places significant strain
shoulder there is probably considerable pain, prob-
on cervical spine and upper thoracic musculature.
able limitations of motion and strength. In an ath-
The authors typically subjectively grade the amount
lete with a mildly reactive shoulder the pain may
of forward head as normal, minimal, moderate or
be minimal or only present with overhead activity.
severe pending the distance of the external auditory
Their symptoms may be minimal to absent when
meatus from the lateral tip of the acromion. Slight
they are not doing overhead activities, but signifi-
forward head position is not uncommon in overhead
cantly limited when throwing or serving.
athletes. The clinician should then note any abnor-
The symptoms experienced by overhead athletes malities seen in or around the shoulder initially
are generally of insidious onset, and as such they with the athlete’s arms at rest by their sides. Abnor-
may be subtle and initially may not alter an athlete’s malities could include bruising or discolorations,
performance. Symptoms can be vague and described unusual bumps, protrusions, or decreased contour
as inability to “loosen up” or “warm-up”, or they may of muscle that could be caused by swelling, thicken-
complain that they cannot find their normal velocity ing, or muscle atrophy. In most cases the dominant
or they have trouble with control. As they symptoms extremity is positioned slightly lower than the non

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 556
-dominant side, and is associated with and known
as handedness.12 This is especially true of unilater-
ally dominant sports such as baseball and tennis.
Theories for handedness include increased laxity,
increased muscle mass, increased weight, and elon-
gated soft tissue due to repetitive eccentric loading
during sporting activities. Further examination can
be done in the hands-on-hips position (Figure 1)
in which shoulders are abducted about 45 degrees.
Hands are also placed on the hips so that the thumbs
point posteriorly on the iliac crest creating shoulder
internal rotation. In this position it is easy for the
clinician to note asymmetries of rotator cuff or pos-
terior scapular muscles, or abnormal postures such
as scapular internal rotation (winging) or anterior
tilting (tipping). Muscular atrophy in areas such as
infraspinatus or supraspinatus fossa could indicate
rotator cuff tears or suprascapular nerve involve-
ment. This can occur in the face of minimal symp-
toms or discomfort.
Evaluation of the scapulthoracic joint must be per-
formed as an integral component of any complete
shoulder complex examination. Although it is beyond
the scope of this commentary a clear understanding
of scapulohumeral mechanics is extremely useful.
Coupled scapular motions include both rotations and
translational movements. Rotations include upward
and downward rotation, internal and external rota-
tions, and anterior and posterior tilting. Translational
Figure 1. Posterior view of an elite junior tennis player in the
hands on hips position showing significantly lower dominant
(right) shoulder, infraspinatus atrophy, and prominence of the
inferior scapular border.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 557
coupled motions include superior and inferior trans-
lations and protraction and retraction translations.
During any overhead shoulder motion in the healthy
person the scapula must upwardly rotate, tilt posteri-
orly, and externally rotate.13
When muscle performance is impaired by loss of
motor control, strength, or endurance, scapular
dyskinesis will be produced with overhead shoul-
der motions. To better examine the dyskinesis, the
athlete can be asked to repetitively lift the extremi-
ties overhead or an axial load can be applied. Special
tests for scapular dysfunction will be described in
the special testing portion of this commentary.
Range of Motion
One of the unique abilities of being a rehabilitation
clinician is our clear understanding of assessment of
shoulder range of motion. One cannot discount the
crucial information that is gained from a detailed,
isolated assessment of glenohumeral motion in evalu-
ation of the athlete with shoulder complex dysfunc-
tion. Although historically some have described visual
observation of motion during the clinical examina-
tion the authors of this commentary recommend
use of a universal goniometer of some fashion. The
overhead athlete has several distinguishing charac-
teristics related to glenohumeral motion. Most over-
head athletes exhibit an excessive amount of external
rotation (ER) and a decrease in internal rotation (IR)
when measured from 90⬚ of abduction.14,15 This physi-
ological adaptation to the throwing shoulder occurs in
those that play baseball, softball, and tennis.16-21 Fur-
thermore this increase in shoulder ER and decrease
in shoulder IR is seen in both active and passive
motions.17,22,23
An important concept to note regarding the measure-
ment of glenohumeral motion is scapular stabilization
to ensure isolated glenohumeral motion. Wilk et al
has assessed three methods of glenohumeral internal
rotation measurement (no stabilization, humeral head
stabilization and scapular stabilization).24 The most
reliable method of stabilization was use of a “C” shape
grasp with thumb placed on the coracoid process ante-
riorly and the fingers on the posterior scapula. The
athlete is supine on a table with the shoulder in 90
degrees of abduction. The arm is moved into IR and
ER while the second hand is palpating the coracoid
process for scapular motion (Figure 2). When scapular
motion is initially detected the arm is held in place and
the measurement is taken with a handheld goniome-
ter. For completeness shoulder rotation should also be
measured with the arm at 0 degrees of abduction at the
side (Figure 3). Measurements taken using goniometers
consistently show good intra-observer reliability and
modest inter-observer reliability with most measure-
ments demonstrating accuracy only up to 5 degrees.25-26
McFarland suggests that clinically relevant differences
in shoulder range of motion measurements for activi-
ties of daily living may be as high as 15 degrees.4
In a study of 372 professional baseball players, pas-
sive range of motion measurements averaged 129
degrees of ER and 61 degrees of IR.27 In this cohort,
Figure 2. Measurement of isolated glenohumeral A) internal
rotation with palpation of coracoid process for indication of
scapular motion and B) external rotation with palpation scapula
for indication of motion.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 558
Figure 3. Measurement of shoulder external rotation with arm
at 0 degrees.
coincidently, the loss of IR was 7 degrees, while the
gain in ER was 7 degrees in the dominant shoulder
when compared to the non dominant. In simplistic
terms, the amount of total range of motion (TROM)
(glenohumeral internal rotation + glenohumeral
external rotation) was symmetrical. It must be
remembered that this full 180 degrees of shoulder
total rotation is a combination of movements occur-
ring throughout the kinematic chain, including
contributions by the glenohumeral joint, scapulo-
thoracic articulation, and spinal extension motion.
A concept that seems to be creating a lot of contro-
versy in overhead athlete’s rehabilitation is the con-
cept of glenohumeral internal rotation deficit (GIRD).
GIRD has been described by multiple sources as one
of the following: 1) A loss of either 20 or 25 degrees
or more of IR on the dominant arm compared to
the contralateral non dominant side, 2) A dominant
shoulder loss of 10% of the TROM of the contralateral
side.28,29 More recently Kibler et al have defined GIRD
as 3) side-to-side asymmetry of internal rotation loss
greater than 18 degrees.30
Decisions to determine whether glenohumeral hypo-
mobility exists should not use GIRD in isolation. TROM
may be an even more important measurement to con-
sider. Wilk et al found that pitchers whose TROM arc
was limited 5 degrees or more than the uninvolved side
exhibited 2.5 times greater risk of sustaining a shoulder
injury.19 When TROM is equal bilaterally, treatments
designed to increase motion are not recommended as
these may actually create too much mobility which
would increase stress to surrounding soft tissues and
capsular restraints. Therefore a loss of GIRD by itself
may be considered a normal shoulder variant in the
overhead athlete. Manske et al31 has proposed adopting
two forms of GIRD, one which is a normal loss of IR
with a concomitant equal or near equal gain in ER and
symmetrical TROM, and another which would be con-
sidered pathologic in which a concomitant increased
ER has not occurred or there is a significant loss of
TROM on the involved side. Anatomical GIRD (aGIRD)
is a normal loss of IR alone with adequate ER gain and
TROM within 5 degrees of the uninvolved sides. Patho-
logic GIRD (pGIRD) occurs when the shoulder has
GIRD and a concomitant loss of TROM > 5 degrees, or
an increase in external rotation deficiency.
Wilk et al32 recently have introduced a concept
referred to as external rotation deficiency (ERD).
External rotation deficiency is defined as the differ-
ence between ER of the throwing shoulder and the
non-throwing shoulder of less than 5 degrees. When
evaluating a throwers shoulder one would expect to
see an ER difference of greater than 5 degrees which
would indicate that the gain in ER on the throwing
side is enough to tolerate the stress of throwing.
Other important shoulder motions measurements used
to exam an overhead athlete include shoulder elevation
(forward flexion and abduction), and both horizontal
abduction and adduction. Each of these motions should
be easily achieveable both actively and passively to
allow enough mobility to achieve the extremes of phys-
iologic motions required for pitching, serving, etc.
Strength Assessment
When performing a comprehensive examination of
the athletes shoulder a clinically relevant method
of strength assessment must be used. With over 100
years of utilization, manual muscle testing (MMT) is
the method of choice for most practicing clinicians.
Complete coverage of all manual muscle tests used
in the upper extremity is beyond the scope of this
article. However there are several excellent texts
that describe in detail MMT of the entire body.33,34
Although the importance of examining the entire
kinetic chain is recognized, this commentary will
focus upon the importance of the axioscapular, scapu-
lohumeral, and scapulothoracic muscle groups.
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It is important to consider the relationship of both pain
and posture on results of the performance of MMTs. It
is very common for pain or apprehension to invali-
date an athlete’s true strength measurements due to
a reflexive inhibition of motor units in an inflamed or
irritated muscle. Likewise poor posture can place rota-
tor cuff and scapular muscles into a state of length-
ened or shortened positions creating alterations of
normal length tension relationships that theoretically
could alter the ability to produce force during standard
MMT procedures. Kibler et al35 have shown significant
differences in rotator cuff strength when measured in
either protracted or retracted postures of the scapula.
Standardizing scapular positioning during testing is
an important consideration to ensure accuracy with
MMT in the overhead athlete.35 This is an area of con-
troversy as Smith et al and Smith et al, have found that
MMT around the shoulder produce the most force
with the scapula in a neutral position rather than in
either retracted or protracted positions.36,37
A “break test” in which the examiner applies the force to
the limb or a “make” test in which the examiner allows
the patient to exert the force against their limb can both
be used. Because the examiner is not in control of the
force given during the “make” test it may be more dif-
ficult to grade accurately. In instances where the clini-
cian feels that pain may be involved either starting the
“break” test with light resistance or allowing the patient
to exert during the “make” test may be useful to not cre-
ate an exaggerated pain response during testing.
Another commonly overlooked element of MMT is
the use of palpation to ensure you are testing the
appropriate musculature. Especially in instance of
weakness in the muscles which could be caused by
overuse, trauma or neurological issues, palpation is
critical to ensure that testing is eliciting the appro-
priate response or not. This is especially true in the
rare instances of extremely weak muscles due to
neurologic issues such as long thoracic nerve palsy,
thoracic outlet, or suprascapular nerve involvement,
all of which can occur in overhead athletes.
Table 2 describes easy methods to clinically assess
strength of various shoulder muscles during the
clinical evaluation. Although some of these positions
may be different than standard MMT as described in
published textbooks, they are recommended by the
authors of this commentary.
 Table 2. Manual Muscle Testing Technique and Position.

Scapulohumeral Rhythm rhythm is a smooth unimpeded motion of the shoul-

Another critical component of assessment of strength der complex and associated musculature allowing full
or motor control of the scapular muscles is viewing elevation of the shoulder. When an athlete exhibits
scapulohumeral rhythm. Normal scapulohumeral pain, loss of muscle strength or endurance, general

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 560
weakness, inhibition, or loss of motor control this
smooth and coordinated movement becomes dys-
functional. Pathologies such as instability or labral
pathology are common in shoulder patients with dys-
function.38 Furthermore scapular stabilizer muscles
such as the lower trapezius and serratus anterior
are highly susceptible to inhibition in early stages
of shoulder dysfunction resulting in dyskinesis.39,40
Scapular dyskinesis has been defined as “an observ-
able alteration of the position and motion of the scap-
ula relative to the thoracic cage.”41,42 This inhibition
may be demonstrated by a lack of scapular control
and disorganization of normal firing patterns or a loss
of strength and ability to exert torque and stabilize the Figure 4. Kibler type I scapular dyskinesis with inferior angle
scapular during normal movement patterns. protruding dorsally.

Biomechanical analyses have shown that normal

scapulohumeral rhythm occurs at a 2:1 ration with
two degrees of humeral motion for every 1 degree
of scapular motion during shoulder elevation move-
ments.43 During arm elevation the scapula tilts pos-
teriorly around a horizontal axis and rotates laterally
around a vertical axis (external rotation), and the lat-
eral border and acromion upwardly rotate creating
the composite motion of shoulder protraction. Con-
versely during arm depression the scapula adducts,
internally rotates, and tilts anteriorly during the
composite motion of shoulder retraction. When the
scapular stabilizers are dysfunctional a dyskinesis
occurs. Figure 5. Kibler type II scapular dyskinesis with entire medial
border protruding dorsally.
General orthopedic patients may exhibit tremendous
amounts of scapular winging in the face of long tho-
racic nerve or dorsal scapular nerve injury. Scapular shoulder. The superior border of the scapular is more
dyskinesis may be much more subtle to visualize in prominent as it rests or moves in the sagittal plane
the overhead athlete. Kibler has described several (Figure 6). These dysfunctions can be seen during
types of scapular dyskinesis that could potentially resting posture or with active movements of the
be seen in the overhead athlete.44 In a Kibler type I shoulder and scapula. Controversy remains regarding
scapular dyskinesis the inferior angle appears more clear ability to detect these changes in either position
prominent. When viewed from the posterior surface or motor control as reliability studies have shown
of the thorax the inferior angle of the scapula is more lack of agreement between testers.45,46 Some issues
prominent as the acromion tilts anteriorly and down- that may cause discrepancies in reliability are related
ward as it tilts along the sagittal plane (Figure 4). A to populations in which studies were conducted,
Kibler type II scapular dyskinesis is one in which the including healthy professional pitchers who more
entire medial border is prominent when viewed from than likely had very subtle differences in scapular
the dorsal surface as it moves in the transverse plane position. Also in each of the above mentioned stud-
(Figure 5). The Kibler type III scapular dyskinesis ies visual estimates were derived from a single plane.
is the superior border type in which a shrugging or As scapular dyskinesis occurs in multiple planes it is
superior motion is used to initiate movement of the better to evaluate movement in several planes. Also

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 561
 with the assessment of scapular position to try to
further implicate scapular pathology as being part of
the pathological process in a dysfunctional overhead
athletes shoulder. These tests include the Kibler
lateral scapular slide test, scapular assistance test,
scapular retraction test, and the flip sign.

Kibler Lateral Scapular Slide Test (LSST)

A clinical method for testing scapular positioning can
be performed using the Kibler LSST in the neutral
(arms at side), hands on hips position as described
earlier, and 90⬚ elevated positions.41 A tape measure
is used to measure the distance from a thoracic spi-
nous process to the inferior angle of the scapula. A
difference of more than 1 cm to 1.5 cm is considered
abnormal, and may indicate scapular muscular weak-
ness and poor overall stabilization of the scapulotho-
racic joint.41 Several recent studies have questioned
the reliability and validity of this test.48,49

Scapular Assistance Test (SAT)

The SAT involves the assistance of the scapula
Figure 6. Kibler type III scapular dyskinesis with shoulder through the application of an examiners hand to the
shrug. inferior medial aspect of the scapula and second
hand at the superior base of the scapula to provide
it is not uncommon for dyskinesis to show up only an upward rotation assistance type motion while the
after multiple repetitions of shoulder movement pos- patient actively elevates the arm in either the scap-
sibly demonstrating an alteration of endurance of ular plane or sagittal plane (Figure 7).42 Symptom
the scapular stabilizers rather than a pure strength resolution or increased ease in shoulder elevation
issue. Examiners should ensure to watch both move- during testing as compared to the response of the
ments of elevation including both the concentric and patient doing the movement independently with-
eccentric portion. Most often dyskinesis occurs dur- out the assistance of the examiner implies a positive
ing the lowering (eccentric) component of shoulder
movement. Lastly, although Kibler has described
the above mentioned three forms of dyskinesis the
authors of this commentary feel that in many cases a
clear single pattern of dysfunction is not discernible.
Oftentimes there appear to be more than one type
of dyskinetic movement occurring simultaneously,
such as a Kibler type I and II as both the medial bor-
der and the inferior angle are prominent during the
eccentric phase of shoulder movement.

Although Wright and colleagues47 have recently

questioned the usefulness of the scapular physical
examination, the authors feel it is a necessary com-
ponent of the overall assessment of the overhead
athlete. There are several other forms of physical
examination tests that can be done in conjunction Figure 7. Scapular assistance test.

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test. Additionally, a positive SAT occurs when greater
ROM or decreased pain (negation of impingement
type symptoms) occurs during the examiners assis-
tance of the scapular upward rotation. Inter-rater
reliability of the SAT and found coefficient of agree-
ments ranging between 77% and 91% (kappa range
0.53-0.62) for flexion and scapular plane movements
concluding that this test is acceptable for clinical
use.50 The scapular assistance test can also be per-
formed with the athletes shoulder in abduction and
external rotation in a more provocative position
commonly seen during the cocking and acceleration
phase of the throwing motion or tennis serve (Fig-
ure 8). Kibler et al have also shown an increase in
the posterior tilt of the scapula by 7⬚ as well as move-
ment improvement with a decrease in pain ratings
of 56 % (8 mm VAS) during application of stabiliza-
tion by the clinician.51
Scapular Retraction Test (SRT)
The SRT involves retraction of the scapula manu-
ally by the examiner while a movement that previ-
ously was either unable to be performed secondary
to weakness or loss of stability or a movement that
was painful.42,52 Manual retraction of the scapula is
performed by compression of the scapular medial
border as the athlete repeats of the index movement
that provoked symptoms without scapular retrac-
tion (Figure 9). Research by Kibler52 profiling the
kinematic and neuromuscular actions during the
Figure 8. Scapular assist test performed in in abducted and
externally rotated position.
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Figure 9. Scapular retraction test performed in scapular plane
elevation.
SRT showed an increase of 5⬚ of scapular retraction
during application of the clinician’s pressure created
by moving the scapula into retraction during this
maneuver. Additionally, mean increases of 12⬚ of
posterior tilting, and a reduction of scapular IR by 8⬚
occurred during the performance of the SRT. These
favorable kinematic changes during the application
of the SRT place the GH joint in a biomechanically
favorable position for overhead function. Additional
applications of the SRT include stabilizing the scap-
ula in a retracted position during manual muscle
testing (MMT). Kibler et al have reported increases
in muscular strength of the shoulder while perform-
ing the empty can maneuver during the SRT with
mean strength increases of 24% with scapular sta-
bilization.35 The use of this maneuver demonstrates
the important role proximal stabilization plays in
shoulder function and can educate the patient on
the need and result of improved scapular control
and stabilization.
Flip Sign
Kelley et al53 originally described this flip test which
performed by the examiner providing resistance to
ER with the arm at the side, with close visual moni-
toring of the medial border of the scapula during the
ER resistance application (Figure 10). A positive flip
sign is present when the medial border of the scap-
ula “flips” away from the thorax and becomes more
prominent indicating a loss of scapular stability. This
finding would indicate the need for further scapular

Figure 10. Scapular flip sign indicating dynamic scapular sta-
bilization weakness.
evaluation. It would additionally imply that inte-
grated exercise progressions aimed at the serratus
anterior and trapezius force couple (important for
scapular stabilization) may be warranted. Although
originally described for patients with spinal acces-
sory nerve lesions, it is commonly used for those
with apparent general scapular muscle weakness
where excessive scapular dysfunction is observed.
One added clinical sign to watch for is the appar-
ent downward rotation of the scapula during the
flip sign maneuver in patients with spinal accessory
nerve lesions, which results in massive trapezius
weakness and subsequent loss of function.
Proprioceptive Testing
Because of the extreme range of motion that most
overhead athletes exhibit some degree of capsular
laxity also exists. Due to this laxity the glenohumeral
joint has a reliance on joint proprioception and neu-
romuscular control. Assessment of proprioception
and neuromuscular control in the throwing shoul-
der will encompass both afferent and efferent neu-
ral function. These can be assessed through systems
of kinesthesia, joint position sense, and sensation to
resistance of movement.
Joint position sense is the ability of the athlete
to determine where the extremity is oriented in
space. Joint position sense can be tested by use of
repositioning the shoulder in several patterns of
movement. Clinically this is done via joint angular
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 564
replication testing in which the extremity is placed
in a position and held for a short time then moved
back to an initial reference position. The athlete is
then asked to return to the position initially selected.
The examiner then measures the degree of accuracy
on repositioning of the extremity voluntarily by the
athlete. The score given is the difference between
the reference angle and the actual matched angles
by the athletes. In the seminal study on clinical use
of active joint angular reproduction, Davies and
Hoffman tested subjects seated with angles greater
than and less than 90 degrees of flexion, abduction,
followed by external rotation greater than and less
than 45 degrees of abduction and internal rotation.54
Normative data of 100 male subjects without shoul-
der pathology using 7 different angular measures to
assess joint angular reproduction on each subject
resulted in an average error or of 2.7 degrees.
Another method to test kinesthesia of the shoul-
der is through the threshold to detection of passive
motion (TTDPM). This testing is used to assess the
athlete’s ability to detect a passive movement at very
slow velocities. Because this form of testing requires
sophisticated equipment and more elaborate testing
devices the authors have chosen not to describe it
in detail but will refer the readers to literature that
pertain to this form of testing.55-58
Regardless of methods of testing numerous authors
have demonstrated that muscular fatigue has an
effect on proprioception of the glenohumeral joint
and may indicate a need for proprioceptive chal-
lenges/exercises in the rehabilitation of the over-
head athlete.58-62 Additionally this loss of kinesthetic
awareness in the overhead athlete provides rationale
for continued research and into how it may affect
the overhead athlete.
Shoulder Special Tests
Discussion of several types of manual orthopedic
tests is important as their inclusion in the compre-
hensive examination sequence gives the clinician
the ability to determine the underlying cause or
causes of shoulder complex dysfunction. The tests
to be covered in this commentary include impinge-
ment, instability, and labral tests. It is beyond the
scope of this chapter to completely discuss all clini-
cal tests; however several excellent texts can be ref-
erenced by readers wishing for a more complete
discussion.12,63 Tests discussed in this commentary
will be specifically referenced relative to those tests
that are the most important for examination of the
overhead athlete.

Impingement tests
Tests to identify glenohumeral (GH) impingement
primarily involve the re-creation of subacromial
shoulder pain using maneuvers that are known
to reproduce and mimic functional positions in
which significant subacromial compression is pres-
ent. These motions involve forcible forward flexion
(Neer impingement sign),64 (Figure 11) forced IR in
the scapular plane (Hawkins-Kennedy impingement Figure 12. Hawkins-Kennedy impingement test.
sign),65 (Figure 12) forced IR in the sagittal plane (cor-
acoid impingement test),66 (Figure 13) and cross-arm
adduction impingement tests (Figure 14).12 These
tests all involve passive movement of the GH joint.
The Yocum impingement test involves the active
combination of elevation with IR and can provide a
valuable understanding of the patient’s ability to con-
trol superior humeral head translation during active
arm elevation in a compromised position67 (Figure
15). Valadie et al68 has provided objective evidence of
the degree of encroachment and compression of the
rotator cuff tendons against the coracoacromial arch
during several impingement tests. These tests can be
used effectively to reproduce a patient’s symptoms of
impingement and to give important insight into posi-
tions that should be avoided in the exercise progres-
sions used during treatment following evaluation. Figure 13. Coracoid impingement test.

Figure 11. Neer impingement test. Figure 14. Cross-arm adduction impingement test.

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 565

Figure 15. Yocum impingement test.
Interpretation of Clinical Tests (Diagnostic
Accuracy)
The diagnostic accuracy of the impingement tests
have been studied and profiled in a systematic
review by Hegedus et al.69,70 They report the pooled
specificity and sensitivity of the Neer test to be 53%
and 79%, respectively, and for the Hawkins–Ken-
nedy impingement test 59% and 79%. These tests
are important for the identification of rotator cuff
impingement but must be used in combination with
a complete examination to allow the clinician to dis-
criminate between primary, secondary, and internal
impingement for a more accurate and meaningful
diagnosis.71
To further discuss the diagnostic accuracy of the
clinical tests presented in this section of the mono-
graph, several definitions should be discussed.
The specificity of a clinical test measures the abil-
ity of the test to be positive when the patient actu-
ally has the condition being tested for .72 Often the
pneumonic (SPIN) is used which stands for Speci-
ficity, Positive rules the condition IN. Sensitivity
estimates the ability of a clinical test to be negative
when the patient does not have that condition. The
pneumonic for sensitivity is (SNOUT) standing for
Sensitivity Negative rules the condition OUT. While
commonly used, specificity and sensitivity they are
less useful than likelihood ratios because they pro-
vide a less quantifiable estimate of the probability
of a diagnosis.73 Therefore when possible, this com-
mentary has provided key tables including both (+)
and (-) likelihood ratios as well as (+) and (-) predic-
tive value in addition to specificity and sensitivity.
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Use of likelihood ratios can be best summarized or
interpreted whereby a clinical test with a likelihood
ratio of +2.0 or greater might result in an impor-
tant increase in the likelihood that the patient has
the condition being tested for by that clinical test.74
Similarly, a likelihood ratio of -0.50 or less results
in an important decrease in the likelihood that the
patient does not have the condition being tested for
by a negative response to that clinical test. The fact
that no one impingement test has very high metrics
indicates the value of combining the results from
multiple impingement tests to assist or increase the
diagnostic accuracy of the application of impinge-
ment tests for the patient with suspected rotator cuff
disease from compression or impingement origins.
Instability tests
Another major type of clinical test that must be
included during the examination of the shoulder of
the overhead athlete is instability testing. While there
may be gross instability from a traumatic incident such
as a collision with another player, or the ground dur-
ing diving, the main goal for the clinician during the
examination of the overhead athlete with an overuse
type of shoulder injury is to determine the presence of
subtle anterior instability.75 There are two main types
of instability tests that are used and recommended.
These are humeral head translation tests and provoca-
tion tests. Each type is presented in this section.
Humeral Head Translation Tests
Several authors believe that the most important
tests used to identify shoulder joint instability are
humeral head translation tests.76,77 These tests
attempt to document the amount of movement of
the humeral head relative to the glenoid through
the use of carefully applied directional stresses to
the proximal humerus. There are three main direc-
tions of humeral head translation testing, anterior,
posterior, and inferior. Inferior humeral head trans-
lation testing is also referred to as multidirectional
instability or MDI.76 It is important to know some
reference values for the human glenohumeral joint
when doing humeral head translation tests. Harry-
man et al78 measured the amount of humeral head
translation in vivo in healthy, uninjured subjects
using a three-dimensional spatial tracking system.
They found a mean of 7.8 mm of anterior translation
and 7.9 mm of posterior translation when an ante-
rior and posterior drawer test was used. Transla-
tion of the human shoulder in an inferior direction
was evaluated with a multidirectional instability
(MDI) sulcus test. During in vivo testing of inferior
humeral head translation, an average of 10 mm of
inferior displacement was measured. Results from
this detailed laboratory-based research study indicate
that approximately a 1:1 ratio of anterior-to-posterior
humeral head translation can be expected in normal
shoulders with manual humeral head translation
tests. No definitive interpretation of bilateral sym-
metry in humeral head translation is available from
this research. Important clinical recommendations
for utilizing humeral head translation tests include
testing the uninjured shoulder first, using firm but
not overly aggressive holds to promote patient relax-
ation, using fairly rapid accelerative movements
with the humeral head as well as comparing both
the amount of translation and end feel during the
translation test. Without patient relaxation during
testing muscle guarding will likely create inaccuracy
during testing of passive humeral head translation.
Multidirectional Instability Sulcus Tests
(MDI) Sulcus Sign
One key test used to evaluate the stability of the
shoulder is the MDI sulcus test (Figure 16). This
test is the primary test used to identify the patient
with MDI of the GH joint. Excessive translation in
the inferior direction during this test most often
indicates a forthcoming pattern of excessive transla-
tion in an anterior or posterior direction, or in both
anterior and posterior directions.76 This test, when
performed in the neutral adducted position, directly
assesses the integrity of the superior GH ligament
and the coracohumeral ligament.79 These ligaments
are the primary stabilizing structures against inferior
humeral head translation in the adducted GH posi-
tion.79 To perform this test, it is recommended that
the patient be examined in the seated position with
the arms in neutral adduction and resting gently
in the patient’s lap. The examiner grasps the distal
aspect of the humerus using a firm but unassuming
grip with one hand, while several brief, relatively
rapid downward pulls are exerted to the humerus
in an inferior (vertical) direction. A visible “sulcus
sign” (tethering of the skin between the lateral acro-
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 567
Figure 16. Multi-directional instability test at 0 degrees of
abduction.
mion and the humerus from the increase in inferior
translation of the humeral head and the widening
subacromial space) is usually present in patients
with MDI.76,80
Anterior & Posterior Translation (Drawer)
Tests
McFarland et al76 and Gerber and Ganz77 believe that
testing for anterior and posterior shoulder laxity is
best performed with the patient in the supine posi-
tion because of greater inherent relaxation of the
patient. This test allows the patient’s extremity to be
tested in multiple positions of GH joint abduction,
thus selectively stressing specific portions of the
GH joint anterior capsule and capsular ligaments.
Seated humeral head translation tests are typically
referred to as load and shift tests and involve test-
ing of the glenohumeral joint in neutral (0 degrees)
of GH joint abduction. Figure 17 shows the supine
translation technique for assessing and grading the
translation of the humeral head in both anterior and
posterior directions. It is important to note that the
direction of translation must be along the line of
the GH joint, with an anteromedial and posterolat-
eral direction used because of the 30⬚ version of the
glenoid. This is accomplished by ensuring that the
examiner places the patient’s GH joint in the scap-
ular plane as pictured. Testing for anterior transla-
tion is performed in the range between 0⬚ and 30⬚ of
abduction, between 30⬚ and 60⬚ of abduction, and at

Figure 17. Anterior and posterior load and shift performed in
supine.
90⬚ of abduction to test the integrity of the superior,
middle, and inferior GH ligaments, respectively.79,80
Posterior translation testing typically is performed at
90⬚ of abduction because no distinct thickenings of
the capsule are noted, with the exception of the pos-
terior band of the inferior GH ligament complex.79
Grading (assessing the translation) for this test is
performed using the classification of Altchek and
Dines.81 This classification system defines grade I
translation as humeral translation within the glenoid
without edge loading or translation of the humerus
over the glenoid rim. Grade II represents transla-
tion of the humeral head up over the glenoid rim
with spontaneous return on removal of the stress.
The presence of grade II translation in an anterior or
posterior direction without symptoms does not indi-
cate instability but instead merely represents laxity
of the GH joint. Unilateral increases in GH transla-
tion in the presence of shoulder pain and disabil-
ity can ultimately lead to the diagnosis of GH joint
instability.82 Grade III translation, which is not seen
clinically in orthopaedic and sports physical ther-
apy, involves translation of the humeral head over
the glenoid rim without relocation upon removal of
stress. Ellenbecker et al83 tested the intrarater reli-
ability of humeral head translation tests and found
improved reliability when using the main criterion
of whether the humeral head traverses the glenoid
rim. The use of end-feel classification and other esti-
mators decreases intra-rater, and inter-rater reliabil-
ity and interferes with the interpretation of findings
from GH translation testing.83
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 568
Subluxation / Relocation Test
One final instability test to be discussed in this sec-
tion is the subluxation relocation test. This test may
be one of the most important tests used to identify
subtle anterior instability in the overhead-throwing
athlete or the individual with symptoms in overhead
positions. The original apprehension test, which
involves the combined movements of abduction
and external rotation while monitoring the patients
“apprehension” response is best suited to determine
the presence of gross or occult instability of the GH
joint. The subluxation relocation test is a subtle form
of provocation test that does not measure actual
humeral head translation. Originally described by
Jobe,75 the subluxation/relocation test is designed
to identify subtle anterior instability of the GH
joint. Credit for the development and application
of this test is also given to Dr Peter Fowler.75 Fowler
described the diagnostic quandary of microinstability
(subtle anterior instability) versus rotator cuff injury
or both in swimmers and advocated the use of this
important test to assist in the diagnosis. The sublux-
ation/relocation test is performed with the patient’s
shoulder held and stabilized in the patient’s maximal
end-range of ER at 90⬚ of abduction in the coronal
plane. The examiner then provides a mild anterior
subluxation force (Figure 18-A) being sure to exert the
subluxation force to the proximal humerus to create
anterior translational stress or loading. The patient is
then asked if this subluxation force reproduces his or
her symptoms. Reproduction of patient symptoms of
anterior or posterior shoulder pain with subluxation
leads the examiner to reposition his hand on the
anterior aspect of the patient’s shoulder and perform
a posterior-lateral directed force, using a soft, cupped
hand to minimize anterior shoulder pain from the
hand-shoulder (e.g. examiner-patient) interface (see
Figure 18-B). Failure to reproduce the patient’s symp-
toms with end-range ER and 90⬚ of abduction leads
the examiner to reattempt the subluxation maneuver
with 110⬚ and 120⬚ of abduction. This modification
has been proposed by Hamner et al84 to increase the
potential for contact between the undersurface of
the supraspinatus tendon and the posterior superior
glenoid. In each position of abduction (90⬚, 110⬚, and
120⬚ of abduction), the same sequence of initial sub-
luxation and subsequent relocation is performed as
described previously.

Figure 18. Glenohumeral subluxation (A) and relocation (B)
test.
Reproduction of anterior or posterior shoulder pain
with the subluxation portion of this test, with sub-
sequent diminution or disappearance of anterior or
posterior shoulder pain with the relocation maneu-
ver, constitutes a positive test. Production of appre-
hension with any position of abduction during the
anteriorly directed subluxation force phase of testing
would indicate occult anterior instability. The pri-
mary ramifications of a positive test would indicate
subtle anterior instability and secondary GH joint
impingement (anterior pain) or posterior or inter-
nal impingement in the presence of posterior pain
with this maneuver. This test forms one of the key
clinical indicators for identifying posterior impinge-
ment in the throwing athlete coupled with patient
history of deep posteriorly directed pain in the posi-
tion of 90 degrees or more of external rotation in 90
degrees of abduction (arm cocking position). A pos-
terior type II superior labrum anterior to posterior
(SLAP) lesion has also been implicated in patients
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 569
with a positive subluxation/relocation test.85 This
test can form a very important part of the return to
throw or return to serve evaluation. Reproduction of
pain during this maneuver often indicates that the
athlete is not able to return to aggressive overhead
function due to a decrease in shoulder stabilization
and can be used as a clinical test to determine readi-
ness to return to throw by the clinician.
Beighton Hypermoblity Index
Instability testing of the overhead athlete with shoul-
der dysfunction can include a series of tests to assess
the overall mobility or presence of generalized hyper-
mobility as a valuable component or adjunct to the
more specific tests performed during clinical evalua-
tion.63,86,87 The Beighton hypermobility scale or index
was originally introduced by Carter and Wilkinson86
and modified by Beighton and Horan.87 This scale is
comprised of four tests each assessed bilaterally (for
a total of eight), and the trunk flexion test, which are
used to assess the generalized hypermobility of the
individual. These tests include: passive hyperexten-
sion of the 5th MCP joint; passive thumb opposition
to the forearm; bilateral elbow, and knee hyperex-
tension; and standing trunk flexion with knees fully
extended. Thus, there are nine measures that com-
prise the modified Beighton index. Several authors
have documented the psychometric properties of
the Beighton scale with reliability estimates ranging
from 0.74-0.84.88 Several cut-off criterion have been
used to determine how many of the individual tests
must be positive to rate an individual as hypermobile
with no overwhelming consensus.88,89 Some studies
have used 2 of the 9 measures as positive to grade
the individual as hypermobile with other research
using 4/9 to achieve this hypermobile rating.63,87,88
This scale can be used as an important classification
for patients with GH joint instability or in patients
where an understanding of underlying mobility sta-
tus is important to determine progression rates for
ROM or mobilization.63
Rotator Cuff Testing
Several clinical tests are presently recommended for
use to assess the integrity of the rotator cuff muscle
tendon unit. These include tests that assess strength
of the rotator cuff (previously described in the sec-
tion on manual muscle testing) as well as tests to
provoke symptoms and pain reproduction.
Empty Can Test
In addition to using the empty or full can test to
solely assess muscle strength of the rotator cuff,
Itoi et al90 tested the effectiveness of both the full
can and empty can test to predict the presence of a
rotator cuff tear. Their results showed that greater
predictive values were present when only weak-
ness was encountered during the use of both the full
can and empty can tests as compared to when pain
was encountered during testing. There was no sig-
nificant difference in the ability of these two tests
to predict a full thickness rotator cuff tear and the
author concluded that both test positions could be
used for supraspinatus testing.

Subscapularis Tests
Three tests are commonly used to assess the integ-
rity of the subscapularis muscle tendon unit. These
include the Gerber lift-off position (Figure 19),
Napoleon or Belly Press Test (Figure 20), and the
Bear Hugger Sign.91 (Figure 21) Recent research has
assessed the effects of subscapularis muscular acti-
vation in each of these three clinical tests as well as
slight variations (+/-) 10 degree positional changes
to the reference positions described in the literature.
This study concluded that all three tests (Gerber lift Figure 20. Should state: A) Napoleon or B) Belly press test
off / Napoleon & Bear Hugger) isolate the subscapu-
laris and are recommended for use to evaluate the
integrity of the subscapularis muscle tendon unit.
Yoon et al,92 recently published a study testing the
effectiveness of 4 tests to evaluate the integrity of the
subscapularis. These authors found the lift-off test to
be highly specific for identification of a full-thickness

Figure 21. Bear hugger sign.

subscapularis tear and additionally to detect severe

fatty infiltration of that muscle.

Labral Testing
Glenoid labrum tears are among the most difficult
Figure 19. Gerber lift-off test. clinical diagnoses to make, solely using clinical special

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 570
tests This is evidenced by the wide variety and volumi-
nous number of tests reported in the literature. In the
throwing athlete, large anterior translational forces are
present at levels up to 50% of body weight during arm
acceleration of the throwing motion, with the arm in
90⬚ of abduction and ER.2 This repeated translation of
the humeral head against and over the glenoid labrum
can lead to labral injury. Labral injury can occur as
tearing or as actual detachment from the bony glenoid
rim.
In addition to the tearing that can occur in the labrum,
actual detachment of the labrum from the glenoid
rim has been reported. The two most common labral
detachments encountered clinically are the Bankart
lesion and the SLAP lesion. Perthes93 in 1906 was
the first to describe the presence of a detachment
of the anterior labrum in patients with recurrent
anterior instability. Bankart94,95 initially described a
method for surgically repairing this lesion that now
bears his name. A Bankart lesion, which is found in
as many as 85% of dislocations,82 is described as a
labral detachment that occurs at between 2 o’clock
and 6 o’clock on a right shoulder, and between the 6
and 10 o’clock positions on a left shoulder. This ante-
rior-inferior detachment decreases GH joint stability
by interrupting the continuity of the glenoid labrum
and compromising the GH capsular ligaments.82
Detachment of the anterior-inferior glenoid labrum
creates increases in anterior and inferior humeral
head translation—a pattern commonly seen in
patients with GH joint instability.82
In addition to labral detachment in the anterior-infe-
rior aspect of the GH joint, similar labral detach-
ment can occur in the superior aspect of the labrum.
Superior labrum anterior posterior (SLAP) lesions
are defined as superior labrum anterior posterior.
Snyder et al96 classified superior labral injuries into
4 main types with additional classifications being
created as greater identification and study of the
superior labrum has evolved. Snyder reported a
type I labral tear as fraying with types II-IV tears
involving actual detachment of the labrum away
from the glenoid with or without involvement of
the actual biceps tendon.96 One of the consequences
of a superior labral injury is the involvement of the
biceps long head tendon and the biceps anchor in
the superior aspect of the glenoid. This compromise
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 571
of the integrity of the superior labrum and loss of
the biceps anchor lead to significant losses in the
static stability of the human shoulder.97 Cheng and
Karzel97 demonstrated the important role the supe-
rior labrum and biceps anchor play in GH joint sta-
bility by experimentally creating a SLAP lesion at
between 10 and 2 o’clock positions. They found an
11% to 19% decrease in the ability of the GH joint to
withstand rotational force, as well as a 100% to 120%
increase in strain on the anterior band of the infe-
rior GH ligament. This demonstrates a significant
increase in the load on the capsular ligaments in the
presence of superior labral injury.
A brief discussion of the proposed mechanisms of
superior labral injury is indicated as it will assist
the clinician in better understanding the underlying
mechanisms behind the present clinical tests that
are used to provide stress and provoke the superior
labrum. Andrews and Gillogly98 first described labral
injuries in throwers and postulated tensile failure at
the biceps insertion as the primary mechanism of
failure. The theory proposed by Andrews was based
on the important role the biceps plays in decelerat-
ing the extending elbow during the follow-through
phase of pitching, coupled with the large distraction
forces present during this violent phase of the throw-
ing motion. Recent hypotheses have been developed
based on the finding by Burkhart and Morgan et al99
of a more commonly located posterior type II SLAP
lesion in the throwing or overhead athlete. This pos-
teriorly based lesion can best be explained by the
“peel back mechanism” as described by Burkhart
and Morgan.99 The torsional force created when the
abducted arm is brought into maximal ER is thought
to “peel back” the biceps and posterior labrum. Sev-
eral of the tests discussed in this chapter that are
used to identify the patient with a superior labral
injury utilize the position of abduction. External rota-
tion similar to this position is described by Burkhart
and Morgan99 for the peel back mechanism. Kuhn et
al100 compared load vs failure of the superior labrum
after repair was performed cadaverically using both
distraction and peel back simulation models in the
throwing motion. They found significantly lower
load to failure for the peel back pathomechanical
model than is seen with distraction, indicating the
vulnerability of the superior labrum and of subse-
quent labral repair to this type of loading.
TESTS FOR LABRAL PATHOLOGY
General Labral Tests
Many general labral tests such as the clunk test
(Figure 22), circumduction test (Figure 23), and
compression rotation test (Figure 24), utilize a long
axis compression exerted through the humerus to
scour the glenoid and to attempt to trap the torn or
detached labral fragment between the humeral head
and the glenoid, much like a mortar and pestle type
mechanism.63,40,101 The circumduction and clunk
tests literally scour the perimeter of the glenoid try-
ing to trap the labral tear with the compression and
rotation performed by the examiner during the test.
Figure 24. Compression rotation test.
Due to the large ranges of motion in the throwing
motion, use of these types of test to scour the perim-
eter of the glenoid and glenoid labrum are indicated. frequent finding of crepitace and grating during the
One key clinical application with these tests is the movements as well as increases in humeral head
translation that can create “noise” from the joint.
These tests typically when positive will recreate the
pain experienced by the patient. Noise generation
or a feeling of traversing across the glenoid rim does
not indicate a torn labrum and can fool an inexpe-
rienced clinician during the interpretation of the
exam findings. It is important to note laxity, and the
type of crepitus and sensations encountered during
the test along with the patient’s report of pain associ-
ated with the test to fully interpret the results.

Superior Labrum (SLAP) Tests

There are many tests to identify superior labral inju-
ries in the throwing athlete. The common biome-
Figure 22. Clunk test. chanical characteristic or mechanism of SLAP tests
are to either product tension on the bicep long head
tendon, or produce the peel back mechanism.63,40,101
Both of these mechanisms are thought to produce
significant tension and provoke the superior labrum
and reproduce the patients symptoms. These tests
also frequently create a click or audible response
from the shoulder but the consistent feature of most
tests is the recreation of the patient’s pain symp-
toms. Tests that specifically utilize muscular tension
exerted in the bicep long head to tension the supe-
rior labrum include the O’Brien active compression
test102 (Figures 25A and 25B), the Mimori test, speeds
test103 (Figure 26) and the biceps load test (Figure 27).
These tests all place or develop a traction type force
through and active contraction of the bicep muscle
Figure 23. Circumduction test. by the patient resisted by the examiner.63

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 572
 Figure 27. Biceps load test.

Figure 25. O’Brien active compression test. Horizontal adduc-

tion with internal rotation component (A), and horizontal adduc-
tion with external rotation component (B).

Figure 28. External rotation supination test.

Additional tests for the glenoid labrum utilize the

combined position of abduction and external rota-
tion to create or mimic the peel back mechanism of
the cocking position of the throwing motion. These
tests include the ER supination test (Figure 28),104
Figure 26. Mimori test. Dynamic labral shear tests105 (Figure 29) and the

The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 573

Figure 29. Dynamic labral shear test.
Figure 30. Anterior and posterior slide test.
106
crank test. One additional test called the Anterior
slide test73,107 (Figure 30) utilizes internal rotation
rather than external rotation in the hands on hips
position to provoke the labrum through an anterior
and superiorly directed movement by the examiner.
A positive anterior slide test (reproduction of pain
and/or a click or pop) and a combined finding of a
clinical history of popping catching and clicking has
been found to have moderate diagnostic utility for
type II-IV labral lesions.73
Diagnostic data from many of these labral tests has
been reported in several review articles and publi-
cations.63,69-71,73 These articles show the variability
in the clinical diagnostic characteristic / accuracy
of these tests. Of particular importance is the diffi-
culty involved when independent researchers report
psychometric indices comparable to those reported
in the literature by the originator of each test. One
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 574
important variable in the interpretation of these
tests for clinical application is the ability of virtually
any examiner to reproduce the exceptional diagnos-
tic accuracy reported in these tests.
Pandya et al108, Hegedus et al69,70 and Michener et al73
have provided recent reviews of the diagnostic accu-
racy of clinical labral tests. Specificities and sensitivi-
ties for the O’Brien test range between 47-99% and
11-98%, respectively, in the reported review by Hega-
dus et al69 Similar reports for the compression rotation
test found 24-26% and 76-98% in their review of the
literature.69 Each of these studies ultimately compared
the effectiveness of the clinical examination maneuver
versus findings obtained at time of arthroscopic sur-
gery or with magnetic resonance imaging (MRI) and
identifies the difficulty in ultimately using a manual
orthopaedic test to accurately diagnose glenoid labral
tears. Noncontrast MRI has been reported in previ-
ous studies to have shown sensitivities ranging from
42% to 98% and specificity of 71% for the diagnosis
of SLAP lesions.109 Improved diagnostic accuracy has
been reported with the use of contrast MRI or an MRI
arthrogram with sensitivities ranging between 67%
and 92% and specificities of 42% to 91%.110 Further
research will assist the clinician in the utilization of
clusters of labral tests to obtain the most efficient and
effective evaluation of the glenoid labrum.
SUMMARY
A thorough history and physical examination of the
overhead athletes shoulder will provide excellent
insight into the pathology creating the dysfunction.
A consistent systematic approach to the exami-
nation process will facilitate less risk of missing a
diagnosis. The examination of the overhead athlete
should include obtaining an accurate athlete medi-
cal history, and include areas such as assessment of
observation, range of motion, muscle strength and
endurance, sensation and proprioception, palpa-
tion, structural integrity, and special testing. With
patience and practice, sports clinicians can examine
and accurately assess most overhead athlete pathol-
ogy with accurate results.
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