37
The Use of a Functional Testing
Algorithm (FTA) to Make Qualitative
and Quantitative Decisions to Return
Athletes Back to Sports Following
Shoulder Injuries
George J. Davies, DPT, MEd, PT, SCS, ATC, LAT, CSCS, PES, FAPTA  |  Bryan Riemann,
PHD, ATC, FNATA
Many clinicians need to make the decision to return athletes
back to sports following a shoulder injury; however, there are
(1) very few guidelines published, (2) few objective tests docu-
mented to support the clinical decision-making process, and (3)
limited evidence to support this process (PubMed Search 2015,
Obremskey 2005, Bhandari 2009, Sackett 2000).
So what are the very specific criteria we should use to dis-
charge a patient from rehabilitation back to a high-risk activ-
ity like competitive sports? One method to establish criteria for
return to play is to have baseline preparticipation information
and following an injury have the athlete return back to “nor-
mal” for all the parameters. However, this is not always a prac-
tical solution unless comprehensive preseason screening was
performed. Furthermore, being medically cleared to return to
sports does not mean that the patient/athlete is functionally
ready to return to sports! So what happens when an athlete
returns to sports after being “cleared by us” and then gets rein-
jured? If a physician, physical therapist, or athletic trainer allows
an athlete to return to sports, he or she may be legally held respon-
sible if the athlete encounters a serious injury (Creighton 2010).
The purpose of this chapter is to describe one example of a
functional testing algorithm (FTA) (criterion-based approach)
for clinical decision making to return athletes back to sports
following a shoulder injury. We recommend using an algo-
rithm, defined as a process consisting of steps, with each step
depending on the outcome of the previous one. In clinical
medicine, an algorithm is a step-by-step protocol for manage-
ment of a health care problem (Taber’s Cyclopedic Medical
Dictionary 1997).
We are unaware of a published FTA for parameters for
returning someone back to sports following a shoulder injury,
other than these publications (Davies 1998, Davies 1981).
Conceptually, an FTA can be thought of as the basic mea-
surements being representative of impairments, strength/power
testing indicating functional activity limitations, and functional
testing evaluating participation restrictions or disability. Fur-
thermore, an FTA consists of a series of tests (Box 37.1). Time
and soft tissue healing from the injury or from a postsurgical
condition are always considered relative to performing the FTA
testing sequence.
Let’s fast forward 13 years from the original FTA for the
shoulder (Davies 1998) to the present time and Box 37.2 illus-
trates the format that can be used for clinical decision making
for returning athletes back to competition following an injury to
the shoulder in (Davies and Wilk 2013).
Progression during the FTA to the next higher level of test-
ing difficulty is predicated upon passing the prior test in the
series. Each successive test and its associated training regimen
place increasing stress on the patient while at the same time
decreasing clinical control. An example of the process of using
an FTA is illustrated in Fig. 37.1. Empirically, we can reha-
bilitate patients faster than ever because by testing them we
always know where the patient is in the rehabilitation program
and can focus the interventions specifically on the patient’s
particular condition and status. Moreover, the patient only
progresses through the level that is appropriate for him or her.
Not every patient performs every test, but they progress
through the level that is applicable to their functional activi-
ties. As an example, patients who are not overhead throwing
athletes would not perform the overhead throwing tests, such
as the Functional Throwing Performance Index. The remain-
der of this clinical commentary will describe the various com-
ponents of the FTA for clinical decision making to return
athletes back to sports following a shoulder injury using the
limited research available and the empirically based clinical
rationale as to why we are using some of these tests and the
progressions.
FUNCTIONAL TESTING ALGORITHM
METHODS
Basic Measurements
Following consideration of the time post injury and soft tissue
healing, the basic measurements include: visual analog pain
scales/numeric pain rating scales (0 to 10), anthropometric
measurements, active range of motion (AROM), passive range
of motion (PROM), lower extremity strength and balance test-
ing, core stability testing, and quantitative and qualitative move-
ment assessments (Davies 1981, 2013).
237
238 SECTION 3  Shoulder Injuries
BOX 37.1  FIRST FUNCTIONAL TESTING ALGORITHM
FOR RETURN TO PLAY, 1998
Sport-Specific Testing
OKC-Functional Throwing Performance Index
Closed Kinetic Chain—Upper Extremity Stability Test
OKC Isokinetic Testing
Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
From Davies, GJ, Zillmer, DA. Functional Progression of a Patient
Through a Rehabilitation Program. Orthopaedic Physical Therapy
Clinics of North America, 9:103–118, 2000.
BOX 37.2  FIRST FUNCTIONAL TESTING ALGORITHM
FOR RETURN TO PLAY, 2012
Sport Specific Testing
Underkoeffler Overhand Softball Throw for Distance
Functional Throwing Performance Index
1-Arm Seated Shot Put—Medicine Ball Power Test
Closed Kinetic Chain—Upper Extremity Stability Test
OKC 3-D muscle power testing—BBI
OKC Isokinetic Testing
Sensorimotor System Testing: Kinesthetic/Proprioceptive Testing
Basic Measurements
Visual Analog scale
From Davies, GJ, Wilk, KE, Irrgang, JJ, Ellenbecker, TS. The Use of a
Functional Testing Algorithm (FTA) to Make Qualitative and Quantita-
tive Decisions to Return Athletes Back to Sports following Shoulder
Injuries. Sports Physical Therapy Section-APTA, Home Study Course
Chapter, Indianapolis, IN., 2013.
As a general guideline, if there is less than 10% to 15%
bilateral comparison difference between the involved and
uninvolved sides, the patient progresses to the next stage in
the FTA. If there is a greater than 10% to 15% bilateral differ-
ence, then the patient’s rehabilitation program is focused on
the specific parameter (i.e., decreasing swelling, increasing
ROM, etc.).  dynamometry allows for objective documentation of isomet-
Sensorimotor Testing
Sensorimotor system testing can be performed using various
methods, such as the conscious perception of proprioception
testing modes: passive joint replication testing, active joint rep-
lication testing, threshold to sensation of movement (kines-
thesia), end-ROM reproduction (Myers 2006), and movement
screening tests. Much of the research on the shoulder senso-
rimotor system has focused on active angular replication testing
because it is felt that active motion is a more functional method
of assessing the sensorimotor system (Davies 1993, Ellenbecker
2012, Voight 1996).
Performing clinically applicable testing does not require a lot
of additional or high-technology equipment. A protocol should
be established as to what angles are going to be tested. Some pro-
tocols (Voight 1996) use just a few angles, whereas some of the
original research (Davies 1993) used seven angles in the ROM:
flexion < 90 degrees, flexion > 90 degrees, abduction < 90
degrees, abduction > 90 degrees, external rotation < 45 degrees,
external rotation > 45 degrees, and then one measurement for
internal rotation. The patient can be seated or supine and the
shoulder joint is passively taken to a predetermined position in
the ROM, and the patient is asked to concentrate on that spe-
cific angle for 10 seconds. A measurement is performed using a
goniometer or inclinometer. The patient is then returned to the
starting position. The patient then performs active joint replica-
tion. The difference in degrees between the passive pre-position
in the ROM and the active angular replication is calculated. The
sum of the difference in degrees is divided by the number of
angles measured (Davies 1993) and the difference is recorded.
If the patient has deficits in this area, the focus of the rehabilita-
tion continues to address the limitations, whereas if the values
are within normal limits (WNL) the patient is progressed to the
next test in the FTA. 
Open Kinetic Chain Testing
The purpose of performing open kinetic chain isolated muscle
testing is examining each link in the kinematic chain to deter-
mine if there are any weaknesses that may be missed if only
functional testing is performed. The isolated testing is also per-
formed for the following reasons: (1) if one does not test, then
we do not know if there is a deficit; (2) if we do not test, then we
do not know when a deficit is improving or resolved; (3) we can
target the specific muscle that is being tested; (4) we can check
for proximal or distal compensations that may also mask any
weaknesses; and (5) because there is a correlation of isolated
testing to functional activities (Ellenbecker 1988, Mont 1994,
Treiber and Lott 1998, Davies 2011, Birke 2012).
Testing of isolated muscles can be performed with manual
muscle testing (MMT), handheld dynamometry (HHD), or
dynamic isokinetic muscle testing. MMT and HHD can also
be thought of as field tests, whereas the isokinetic testing is
considered laboratory testing. Functional testing is the key,
but function is made up of individual links in the kinematic
chain, therefore the importance of performing isolated testing
as well.
However, some of the limitations of static MMT are that it
is subjective, it only tests one point in ROM, and it does not
correlate with dynamic muscle testing (Birke 2012). Handheld
ric muscle testing. It also has all the limitations of MMT, but
at least it provides objective values from the HHD. Turner
et al. (2009) performed HHD testing for the scapulothoracic
muscles and rank ordered the muscles from the strongest to
the weakest: upper trapezius (UT), serratus anterior (SA),
middle trapezius (MT), rhomboids (R), and lower trapezius
(LT). Furthermore, unilateral ratios were developed: eleva-
tion/depression (UT/LT): 2.62; protraction/retraction (SA/R):
1.45; upward rotation/downward rotation (SA/MT): 1.23.
Riemann et  al. (2010) performed over 2,000 HHD tests of
the internal and external shoulder rotator musculature based
on three selected positions to establish normative data and
unilateral ratios at zero neutral degrees, 30°/30°/30° position
and 90°/90° position. The results demonstrated similar find-
ings for the zero and 30/30/30 positions; however, the forces
and unilateral ratios are significantly different from the 90/90
position.
Open kinetic chain (isolated joint testing) isokinetic test-
ing is one of the best ways to measure isolated dynamic muscle
performance and is considered the gold standard for dynamic
muscle performance testing. If isokinetic testing is not avail-
able, then HHD is preferred. Isokinetic testing results also
correlate with functional performance tests (Wilk 1993, 1995,
 37  The Use of a Functional Testing Algorithm (FTA) to Make Qualitative and Quantitative Decisions 239

DC to
sports

Focused
Within NOT
Specificity
10%-YES within norms
Rehab

Specificity
testing

Focused
Rehab-
Within norms- NOT
Functional
YES within norms
OKC
Exercises

Functional
testing

Focused
Within 21/23- NOT Rehab-
YES within 21/23 CKC
Exercises

CKC
testing

Focused
Within 15– NOT Rehab-
25%-YES within 15–25% Isolated
Exercises

OKC power
testing

NOT Focused
Within
within Rehab-
10%-YES
10%-<3°/<4° Kinesthesia

Sensorimotor
testing

Within NOT Focused

10%-YES within 10% Rehab

Basic
measurements

Fig. 37.1  Sequence of progression through an FTA.

Davies and Ellenbecker 2001, Ellenbecker 2000, Davies 1984,
2009, 2012).
The computerized Cybex 340 Isokinetic Dynamometer and
attachments (CSMI, Stoughton, MA) using the following pro-
tocol have been used for over 40 years, but currently Biodex
Medical Systems (Shirley, NY) are more commonly used. We
recommend four gradient submaximal to maximal effort warm-
ups (25%, 50%, 75%, 100%) and then 5 maximal test repetitions
at 60 degrees/180 degrees/300 degrees/second. The progres-
sive gradient warmups allow for stressing the testing motion
gradually to prevent testing a patient if he or she cannot
perform the test correctly and without pain or inhibition.
Furthermore, performing the gradient warmups allows for
improved reliability of the testing. Descriptive norms for iso-
kinetic testing of the shoulder are listed in numerous references
(Wilk 1993, 1995, Davies and Ellenbecker 2001, Ellenbecker
2000, Davies 1984, 2009, 2012).
Codine et. al. (2005) reviewed 87 articles on isokinetics
and determined that isokinetic evaluation of the shoulder
revealed reliability and validity satisfactory with rigorous
test methodology. Descriptive normative values (Table 37.1)
are dependent on several variables, including age, gender,
240 SECTION 3  Shoulder Injuries
TABLE
37.1 Descriptive Normative Data for the FTPI Test
Norms Males Females
Throws 15 13
Accuracy 7 4
FTPI 47% 29%
Range 33–60% 17–41%
ICCs -> .90
Davies GJ, Hoffman SD: 1993 Neuromuscular Testing and Rehabili-
tation of the Shoulder Complex. J Ortho Sports Phys Ther 18(2)
449–458.
Fig. 37.2  Closed kinetic chain upper extremity stability test.
BMI, and type and intensity of activity (Wilk 1993, 1995,
Davies and Ellenbecker 2001, Ellenbecker 2000, Davies 1984,
2009, 2012).
Furthermore, data analysis can include: bilateral com-
parison, unilateral ratio of agonist/antagonist, torque to body
weight (relative/normalized data), endurance data, and nor-
mative data (Wilk 1993, 1995, Davies and Ellenbecker 2001,
Ellenbecker 2000, Davies 1984, 2009, 2012). Hurd et al. (2011)
demonstrated the importance of normalizing the data relative
to body weight to interpret the test results.  (2009) have started a series of CKC laboratory tests evaluat-
Closed Kinetic Chain Testing
Why should closed kinetic chain (CKC) tests be performed for
the upper extremity (UE) (Ellenbecker 2000, 2001)? There are
numerous activities, such as gymnastics, rowing, mixed mar-
tial arts, karate, Brazilian jujitsu, wrestling, blocking in football,
military training drills, and calisthenics exercises that require
the use of closed kinetic chain movements. Davies devel-
oped the Closed Kinetic Chain Upper Extremity Stability Test
(CKCUEST) (Goldbeck and Davies 2000). The test protocol
consists of lines on the floor that are 3 feet apart (Fig. 37.2).
The participant performs four gradient submaximal to maxi-
mal warmups with men in the standard push-up position and
women in the push-up position from their knees. The subjects
then touch both hands to each line as many times as possible
in 15 seconds with 45 seconds of rest between each of the three
sets. The number of touches from the three trials is then aver-
aged for the test results; the original normative data for men
was 21 touches and for women 23 touches (Sweeny et  al.
2012). The Intraclass Correlational Coefficients (ICCs) for the
CKCUEST were .922. Rousch et al. (2007) tested collegiate base-
ball players and concluded that the CKCUEST appears to be a
clinically useful test for upper extremity (UE) function. Pon-
tillo et al. (2014) also used the CKCUEST for screening Divi-
sion I football players and found the test was a good indicator
of potential for injuries during the season. Using a score of 21
touches, the CKCUEST had a sensitivity of 0.83, a specificity of
0.79, and an odds ratio of 18.75 in determining whether a player
sustained a shoulder injury. Pontillo et  al. (2014) concluded
for this sample the combination of preseason strength, fatigue,
and functional testing was able to identify football players who
would sustain a shoulder injury during the season. Further-
more, Sweeny et al. (2012) used the CKCUEST for rehabilitation
as well as assessing a patient in a case study. Tucci et al. (2014)
evaluated the CKCUEST and showed excellent inter-session
reliability for scores in all samples. Results also showed excellent
intra-session reliability of number of touches for all samples.
Scores were greater in active compared to sedentary, with the
exception of the power score. All scores were greater in active
compared to sedentary and SIS males and females. SEM ranged
from 1.45 to 2.76 touches (based on a 95% CI) and MDC ranged
from 2.05 to 3.91(based on a 95% CI) in subjects with and with-
out SIS. At least three touches are needed to be considered a
real improvement on the CKCUEST scores. Tucci et al. (2014)
concluded the CKCUEST is a reliable tool to evaluate upper
extremity functional performance for sedentary, upper extrem-
ity sport-specific recreational, and sedentary males and females
with SIS. Tucci et al. (2014) also studied the scapular kinematics
and kinetic measures during CKCUEST for three different dis-
tances between the hands: original (36 inches), inter acromial,
and 150% inter-acromial distance between hands. CKCUEST
kinematic and kinetic measures were not different among three
conditions based on distance between hands. However, the test
might not be suitable for initial or mild level rehabilitation due
to its challenging requirements. 
Functional Closed Kinetic Chain Tests
The CKCUEST is considered to be a field test that requires a
minimal amount of time and equipment. Riemann and Davies
ing the kinetics and kinematics of the upper extremity. One of
their first studies evaluated the relationship between two upper
extremity functional performance tests and shoulder and trunk
muscle strength, and a minimal correlation was demonstrated
between the tests. The long-term goals are to correlate some
of the gold standard laboratory tests (isokinetic testing, push-
up ground reaction force production, etc.) with functional
field tests (CKCUEST, seated shot put, etc.) to measure upper
extremity power. Moreover, similar to the lower extremity per-
forming box depth jumps, we modeled some of the original
upper extremity testing to assess more aggressive and func-
tional testing of the upper extremities. The original study by
Koch et  al. (2012) demonstrated the upper extremity ground
reaction forces when performing clap push-ups and depth
drop push-ups ranged between .69 and .78 body weights under
each limb. The ground reaction forces more potently varied
between the limbs (dominant slightly higher than nondomi-
nant) than on the height of the boxes from which the subject
performed the drop landings. The drop landing push-ups were
performed from heights of 3.8 cm, 7.6 cm, 11.4 cm (multiples
of standard framing lumber). While potent differences in peak
 37  The Use of a Functional Testing Algorithm (FTA) to Make Qualitative and Quantitative Decisions
Fig. 37.3  Plyometric box drop tests for the upper extremity.
ground reaction forces were not revealed between the varia-
tions, as the subjects dropped from higher boxes more potent
differences in rates of loading were revealed. In an attempt to
determine if landing strategy changes between the variations
might explain the slight peak ground reaction force variation
differences, Moore et al. (2012) evaluated the elbow kinematics
when performing the various push-up variations. The results
did not reveal elbow kinematic differences, suggesting that per-
haps shoulder kinematics were occurring. The implication of
these two studies to FTA is that a hierarchy of push-ups varia-
tions, progressing from 3.8-cm drop landings to clap, can be
used to assess the ability of the upper extremity to withstand
large forces and rapid loading rates towards the terminal ends
of rehabilitation (see Fig. 37.3).  37.4). A 6-pound medicine ball was placed in one hand, palm
Functional Open Kinetic Chain Testing
However, when starting to evaluate open kinetic chain (OKC)
upper extremity power, there is a lack of research correlating
UE strength and power assessments with sporting perfor-
mance. Abernethy et al. (1995) discussed some of the contro-
versies and challenges of power assessments. Therefore, there
is a need for a device or protocol to discriminate upper extrem-
ity functional power performance within an athletic popula-
tion. Rex et al. (2012) have been searching for a reliable, valid,
responsive, minimal equipment needed, easy to administer
UE power test that can be used as a field test. Consequently, a
multicenter study between Armstrong Atlantic State Univer-
sity, Florida Hospital, and the University of Central Florida
evaluated 180 healthy adult subjects (18 to 45 years old, 111
women, 69 men); 83 were classified as athletes and 97 were
nonathletes for power tests (Ansley et  al. 2009). The follow-
ing upper extremity functional tests were performed by all the
subjects:
• Single-arm seated shot put using dominant arm (6-pound
medicine ball)
• Single-arm seated shot put using nondominant arm
(6-pound medicine ball)
• Push-up tests for three sets of 15 seconds
• Modified pull-up test for three sets of 15 seconds
• Underkoeffler Overhand Softball throw for distance using
the one-step (crow hop) throw approach
• Davies closed kinetic chain upper extremity stability test for
three sets of 15 seconds
As a result of these tests, Negrete et al. (2011) performed a
regression analysis to determine the best “field test” for pre-
dicting performance with the softball throw for distance. The
241
Fig. 37.4  Seated single-arm shot put test.
results indicated that the modified pull-up was the best predic-
tor of functional throwing performance. Perhaps the internal
rotators, which are significant muscles involved in the throwing
motion, are also primary muscles involved in the modified pull-
up motion.
Gillespie et al. (1988) evaluated 57 men for upper extrem-
ity power tests by using a seated shot put medicine ball throw.
They compared a bench power test by moving 50 pounds
through extension of the arms with distance and time mea-
sured compared to an 8-pound seated shot put distance with
angle of release controlled and not controlled. All results were
reliable and valid for both controlled and uncontrolled angles
of release. Negrete et al. (2010) described normative data and
performed a reliability test of the seated shot put (SSP) (see Fig.
up with zero degrees of shoulder abduction. The subjects per-
formed four gradient submaximal to maximal warmup throws
followed by three maximal effort throws and the average dis-
tance was recorded to the nearest meter. Forty-six subjects were
retested and ICCs were used to assess reliability. The ICC for the
seated shot put tests (6 pounds) for the dominant arm was 0.988
and for the nondominant arm was 0.971. Moreover, the mini-
mal detectable changes (MDCs) were calculated for the seated
shot put tests and for the dominant arm was 17 inches and for
the nondominant arm 18 inches. As the single-leg hop test is
used for the limb symmetry index (LSI) of the lower extremity
and has been shown to be sensitive and specific from several
recent studies (Meyer et al. 2011, Arden et al. 2011, Grindem
et al. 2011), we are using the SSP in a similar way for upper
extremity LSI. Furthermore, we have also started normalizing
the test results to the subjects’ body weights and heights as
illustrated in Table 37.2. Hurd et al. (2011) demonstrated the
importance of normalizing the data relative to body weight to
interpret the test results.
Because limited upper extremity functional performance
tests (FPT) exist and FPT involving skill is complicated by
UE dominance, Limbaugh et  al. (2010a) tested collegiate
baseball players with the standing medicine ball shot put
test. The results demonstrated the combination of greater
dominant arm release height, anterior displacement, ante-
rior velocity, vertical displacement, and vertical velocity
likely explains the DOM/NDOM horizontal range differ-
ence. The NDOM arm had greater lateral displacement and
lateral velocity, which may represent compensatory actions.
Limbaugh et al. (2010b) completed further research because
athletes participating in unilateral activities were assessed
to determine if the DOM/NDOM differences are skill and/
or strength/power related. The seated shot put performance
242 SECTION 3  Shoulder Injuries

TABLE
TABLE Normative Data and Allometric Scaling for Functional Throwing Performance Index (FTPI)
37.3
37.2 Single-arm Shot Put (SSP) Test
Norms Males Females
Data determined for males with height of 71 in (181 cm) and
Throws 15 13
weight of 180 lbs (82 kg).
Accuracy 7 4
Dominant arm SSP = 118 in/46 cm
FTPT 47% 29%
Non-dominant arm SSP = 106/42 cm
Range 33-60% 17-41%
Limb symmetry index is within 10%
From Davies GJ, Dickoff-Hoffman S. Neuromuscular testing and
Distance Put Height of Subject Score = Distance/Height
rehabilitation of the shoulder complex. J Orthop Sports Phys Ther.
118 in 181 cm 65% +/– SD 1993;18(2):449–458.
118 in 71 cm 1.66% +/– SD
46 cm 181 cm 25% +/– SD
46 cm 71 in 65% +/– SD If the patient is an overhand throwing athlete, then the
Distance Put Weight of Subject Score = Distance/Weight patient progresses from the FTPI, which is a controlled sub-
maximal test, to the Underkoeffler Overhand Softball Throw
118 in 82 kg 1.44% +/– SD
118 in 180 kg 66% +/– SD for Distance, which is a maximal effort intensity test using
46 cm 82 kg 56% +/– SD multiple joints of the body in a functional throwing motion.
46 cm 180 lb 26% +/– SD This test is performed by using an overhand throw with a
cm, centimeters; in, inches; kg, kilogram; SD, standard deviation.
crow-hop. Four gradient submaximal to maximal warmup
Davies GJ. Personal communications, 2016. throws followed by three maximal volitional testing repeti-
tions are performed and an average is recorded to the nearest
meter. Collins et al. (1978) performed a reliability study with
ICCs above 0.90. 
correlates to other UE measures, such as throwing velocity,
but is it sensitive to detecting bilateral or population differ-
ences? The results demonstrated the DOM arm was signifi-
Sports-Specific Training
cantly better than NDOM in both groups. Sixty-six percent The last stage of the functional testing algorithm is sports-spe-
of the subjects also demonstrated bilateral asymmetry less cific tests using both quantitative and qualitative analysis. This
than 10% of the time. Although our hypothesis expected is individualized to the patient and his/her specific recreational
baseball players, due to the unilateral overhead activity, to or competitive sports. 
perform better, there were no significant differences between
the baseball and non-baseball players. Perhaps baseball play-
ers’ strength and conditioning programs reduced unilateral
Other Considerations
adaptations accompanying baseball activity or the seated Other considerations include psychological and emotional
shot put may not be sensitive enough to detect adaptations factors such as pain, apprehension, fear, and kinesiophobia.
accompanying baseball activity.  The presence of symptoms for longer than 3 months, average
pain intensity, flexion ROM index, and fear-of-pain scores all
Functional Throwing Tests contributed to baseline shoulder function. Lentz et  al. (2009)
evaluated patients with shoulder pain; however, the immedi-
If the athletes are involved in an overhand throwing sport, then ate clinical relevance of these findings is unclear in the reha-
the patients are progressed to the overhand throwing tests. The bilitation of patients with shoulder dysfunctions. More recently,
first throwing test is a submaximal controlled throwing test per- Baghwant et al. (2012) divided patients with shoulder dysfunc-
formed in the clinical setting called the Functional Throwing tions into eight categories. Those with common musculoskeletal
Performance Index (FTPI) (Davies 1993). This test was devel- problems of the shoulder did demonstrate a higher kinesiopho-
oped to be performed in an indoor setting with limited space bia score.
available to assess the overhand throwing motion. This can A component of the comprehensive evaluation of the
also be a variation of a quantitative and qualitative movement patient also includes collection of clinical outcome measures
screening assessment for specificity of throwing performance. to demonstrate the effects of the functional training pro-
The dimensions for the FTPI include a line on the floor 15 feet gram. Assessment of clinical outcome should include a vari-
from wall, 1 foot by 1 foot square, 4 feet from floor. The subject ety of clinician-measured outcomes that focus on measures of
then performs four submaximal to maximal controlled gradient impaired joint and muscle function as well as limited activity,
warmups (25%/50%/75%/100% effort). The player then throws which includes many of the aforementioned performance-
a controlled maximum number of accurate throws for 30 sec- based measures in the FTA. 
onds. Subjects perform three sets of throws and the results are
averaged. The total number of throws is divided by the accu-
rate number of throws and multiplied by 100 to calculate the
Patient-Reported Outcomes
FTPI index illustrated in Table 37.3. Malone et  al. performed The patients’ perception of their clinical outcome is also
test-retest reliability for the FTPI test with a one-month interval important to assess. Patient-reported outcomes measure the
between tests. This is a longer time between tests than is nor- patient’s perception of his or her symptoms, activity, and par-
mally performed with reliability testing; however, the ICCs were ticipation. Patient-reported outcome measures can be gen-
all above 0.80. eral measures of health status that broadly measure physical,
 37  The Use of a Functional Testing Algorithm (FTA) to Make Qualitative and Quantitative Decisions
emotional, and social function or specific measures that focus
primarily on the assessment of physical function. The most
common general patient-reported outcome measure is the
Medical Outcomes Study Short-Form 36 Item (SF-36) Health
Status Measure (Ware 1992, Brazier 1992). The advantages of
using a general patient-reported outcome measure are that it
assesses multiple dimensions of health. As such, these mea-
sures may detect the influences of injury and rehabilitation on
emotional and social function. Additionally, these measures
allow for the comparison of the impact of an injury to the
shoulder to a variety of other musculoskeletal and nonmus-
culoskeletal conditions. The disadvantages of general patient-
reported outcomes are that they tend to be long and more time
consuming to administer and score; they may be susceptible
to ceiling effects, particularly when completed by individuals,
such as athletes, who function at high levels of activity; and the
content may not appear to be relevant to athletes and sports
medicine clinicians.
Specific patient-reported outcome measures include region-
specific measures of symptoms, activity, and participation
affecting the upper extremity or specific conditions affecting the
upper extremity and disease-specific measures for conditions
such as rotator cuff tears or shoulder instability. Examples of
region-specific patient-reported outcome measures appropri-
ate for athletes with injuries of the upper extremity include the
Disabilities of the Arm Shoulder Hand Index (DASH) (Hudak
1996), the DASH Sports Scale (Hudak 1996), the American
Shoulder and Elbow Surgeons (ASES) score (Michener 2002),
and the Kerlan-Jobe Orthopaedic Clinic (KJOC) Assessment for
Overhead Athletes (Domb 2010). Examples of disease-specific
patient-reported outcome measures that may be appropriate
to assess the outcome of athletes include the Western Ontario
Rotator Cuff (WORC) scale (Wessel 2005) and the Western
Ontario Shoulder Instability (WOSI) scale (Kirkley 1998).
The DASH (Hudak 1996) consists of 30 items that mea-
sure upper extremity physical function (212 items), pain and
symptoms (5 items), and social and emotional function (4
items) for people with disorders of the shoulder, elbow, wrist,
and hand. The item scores are summed and transformed to a
scale that ranges from 0 to 100 with higher scores represent-
ing greater symptoms and disability. There is good evidence
for reliability, validity, and responsiveness of the DASH in a
variety of populations. The DASH Sports Scale consists of four
supplemental items that measure the impact of arm, shoulder,
and hand conditions on playing sports. The specific questions
include difficulty using normal technique, playing sport due
to pain, playing sport as well as the individual would like, and
spending usual time practicing or playing sport. Similar to
the DASH, the item scores are summed and transformed to a
scale that ranges from 0 to 100 with higher scores represent-
ing greater disability with sports. While potentially useful to
assess outcome of athletes, there is little evidence for reliabil-
ity, validity, and responsiveness to support interpretation and
use of the DASH Sports Scale.
The ASES score (Michener 2002) is a 10-item measure of
shoulder pain and function. Pain is assessed on a 10-cm visual
analog scale (VAS) and accounts for 50% of the total score. The
remaining 50% of the score is determined by the responses to 10
4-point Likert-scale questions related to physical function. The
pain and physical function scores are summed to create a score
that ranges from 0 to 100 with higher scores indicating less pain
243
TABLE Psychometic Properties for Patient-Reported
37.4 Outcome Measures for the Shoulder
DASH1 ASES2 KJOC3
Reliability4 .82–.98 .84 –.96 .88
Effect Size >.80 >.80 Not Reported
MDC5 2.8–5.2 .94 Not Reported
MCID6 10.2 6.4 Not Reported
1Disabilities
of Arm Shoulder and Hand Index
2American Shoulder and Elbow Surgeons Score
3Kerlin Jobe Orthopaedic Clinic Functional Assessment for Overhead
Athlete
4Values reported are intra-class correlation coefficients
5Minimal detectable change
6Minimum clinical important difference
and higher levels of physical function. There is good evidence
for reliability, validity, and responsiveness of the ASES score to
support its interpretation and use (Michener 2002).
The KJOC Functional Assessment for the Overhead Athlete
(Domb 2010) is a 10-item scale for overhead athletes with disor-
ders affecting the shoulder and elbow. This includes four items
related to pain, one item related to interpersonal relationships
related to athletic performance, and five items related to func-
tion and athletic performance. Each item is scored on a 10-cm
VAS. The items are summed to create a score that ranges from
0 to 100 with higher scores representing better athletic func-
tion and fewer symptoms. Evidence for reliability, validity, and
responsiveness of the KJOC Functional Assessment for the
Overhead Athlete score has been provided by Alberta et al. 2010
and normative scores for overhead throwing athletes without
symptoms were also provided (Cook et al. 2008).
Pyschometrically, there does not appear to be one patient-
reported outcome that outperforms the others (see Table 37.4).
As such, the choice of outcome measure should be determined
by the patient population under consideration and the time
necessary to administer and score the outcome measure.
For an athletic population, the ultimate outcome after
injury and/or surgery is the ability to return to the prior
level of sports in terms of intensity, frequency, duration, and
absence of symptoms. Smith et al. (2012) published an article
on various shoulder scales including the Shoulder Activity
Scale (SAS), which is useful for measuring return to activity in
athletes that participate in overhead throwing sports. The SAS
consists of five questions (carrying 8 lbs., overhead objects,
weightlifting with arms, swinging motion, and lifting greater
than 25 lbs.), each rated in terms of frequency that the activity
is performed, ranging from never/less than once per month to
daily. The items are summed for a total score that ranges from
0 to 20 with higher scores indicating higher activity levels. The
SAS also includes two items related to participation in contact
and overhead sports that are not scored. Test–retest reliability
was determined to be .92 over a 1-week period and the MDC
was determined to be 3.8. The SAS is related to other activity
measures but not age.
Most studies investigating return to activity measure activ-
ity retrospectively by asking individuals after the fact when
they returned to activity. This is complicated by the fact that
over time, an individual’s participation in sports activity may
change for reasons other than the status of the shoulder, such as
changes in lifestyle, free time, and work and family obligations.
244 SECTION 3  Shoulder Injuries
To improve the accuracy of measuring return to activity, pre-
injury activity should be measured immediately after injury,
return to activity should be measured prospectively during the
course of recovery, and achievement of important milestones
such as return to throwing, practice, and competition should be
prospectively documented and the reasons for decreased activ-
ity should be documented.
After passing the aforementioned tests, particularly the sport-
specific tests, with no residual complaints of pain, increased
stiffness or effusion with a decrease in range of motion, and
no functional movement quantitative or qualitative deficits,
the athlete can be progressed back into activities. The athlete
returns to sport-specific training programs first, practice simu-
lations, practices, scrimmages, and then competition in his/her
respective sport.  .inkling.com/.
SUMMARY
The purpose of this clinical commentary describes one approach
to a functional testing algorithm. Typically our clinical decision
making (CDM) (based on history, subjective exam, objective
physical exam, imaging, etc.) states when the athlete is ready
to return to activity. However, if we also have all the functional
tests to support the CDM, it provides quantitative and qualita-
tive data to strengthen the decision to return the athlete back to
activity safely.
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