Shoulder Pain in the Overhead Athlete

- Exact tissue cause is hard to determine

- Imaging not always helpful

What are important considerations for the Differential diagnosis of shoulder pain in the overhead athlete

- RTC related pain most common

- Labral pathology may coexist

- Long head of the biceps pathology may coexist

- Many athletes have genetic or adaptive shoulder laxity that may or may not be relevant

What are key points about the Differential diagnosis of shoulder pain in the overhead athlete

•Traumatic injury: fall, dislocation etc.

- Neurological signs and symptoms such as potential nerve entrapment

- Suspected bone stress injury (Little leaguer's shoulder, Weightlifter's shoulder)

When might imaging be beneficial for the differential diagnosis of shoulder injuries in overhead athletes

Little Leaguer's Shoulder

Bone stress injury to the proximal humeral epiphysis/metaphysis

Little Leaguer's Shoulder

- Widening of the proximal humeral physis

- Sclerosis and fragmentation of adjacent bone

- Demineralization of bones

Distal Clavicle Osteolysis

- Bone stress injury leading to breakdown of subchondral bone

- Pain and tenderness at the distal clavicle, AC joint region with referral into upper trapezius

Distal Clavicle Osteolysis

- Young, overhead athletes who also weight train. AKA weight-lifter's shoulder

- Can occur in manual laborers

- Can be post-traumatic

- Typical patient interview for a MSK injury with focus on demands of the sport and their current activity level

- How much load do they place on their shoulder?

- Any other loads on their shoulder? weight training

- Do they play/practice year-round or is there an offseason?

- Injury history: recurrent injuries are common

What are key points to include in a Patient Interview for Overhead Athlete

- Similar to the typical person with shoulder pain

- Often will perform higher level functional assessment

- Assessment in the athletes' functional positions (overhead)

- All sports involve full body movements not just the shoulder

- Examine kinetic chain (trunk, lower extremities)

What does a physical exam for shoulder pain in overhead athletes include

Posterior/Internal Impingement Sign

Refers to pain in the posterior shoulder while in the 90/90 position. Very common compliant with overhead athletes

- Functional tests

- Balance tests

- Sport specific functional movements

What tests would you perform in the LE for an overhead athlete?

- Glenohumeral internal rotation deficit (GIRD)

- Total range of motion deficit (TROM)

- RTC strength or control impairments

- Scapular muscle strength or control impairments

- GH laxity

- Adaptive muscle stiffness (related to GIRD and TROM deficit)

What are Common Impairments seen in Overhead Athletes

1. Stiffness of the GH posterior capsule

2. Humeral retro-torsion

3. Stiffness of the posterior shoulder musculature (deltoid and RTC)

What are the 3 proposed mechanisms that all blend together and stem from adaptive tensile loading from overhead activity that can cause Glenohumeral internal rotation deficit (GIRD)

Humeral retro-torsion

Bony adaptation to repeated tensile loading.

>15-20 degree difference in dominant versus non-dominant shoulder IR as measured in 90 degrees of ABD.

What are the criteria for diagnosing Glenohumeral internal rotation deficit (GIRD)

>5 degrees difference in total arc of IR/ER motion in dominant versus non-dominant arm as measured in 90 degrees of ABD.

What are the criteria for diagnosing Total range of motion deficit (TROM)

Scapular dyskinesis

'Observed or measured alterations of scapular resting position and/or dynamic motion'

Dyskinesis very common in people without symptoms

What are key points/considerations about Scapular dyskinesis

- Stable vs. Dynamic in function

- Identifying presence/absence still challenging and relationship to pain is poor

- Motor control approach can be helpful in short term, but long-term applications are unknown

What are important considerations about scapular stabilization

- Thoracic spine positioning?

- RTC activation?

- Scapular repositioning/assistance?

- Incorporation of LE kinetic chain?

What are different methods for Symptom modification in the overhead athlete

- Load management a key factor

- Address common impairments

- Don't attempt to alter athlete's sport specific mechanics unless you really know what you are doing

What are the key principles for the Management of shoulder pain in overhead athletes

- Stop or reduce activity to allow tissues to settle

- Work out plan to resume activity gradually using interval program

What are key considerations for load management for the Management of shoulder pain in overhead athletes

- Stretching/manual therapy for ROM/mobility deficits

- Progressive strengthening and control exercises for RTC and periscapular muscles

- Consider incorporating trunk and LE kinetic chain

What are principles of treatment to address common impairments in overhead athletes

- Calm it down!

- Relative rest and activity modification

- Mobility (posterior shoulder tightness, thoracic and cervical spine)

- Early loading of RTC and periscapular musculature

What does stage 1 for the rehabilitation of overhead athletes entail when pain and irritability are high

- Gradually reload

- Emphasis on progressive strengthening

- Progress into more functional and less stable positions (overhead)

- Interval return to sports program

What does stage 2 for the rehabilitation of overhead athletes entail

- Diminish pain and inflammation Normalize motion

- Delay muscular atrophy

- Reestablish dynamic stability (muscular balance)

- Control functional stress/strain

What are goals for the treatment of overhead athletes during phase 1: Acute phase

- Cryotherapy, iontophoresis, ultrasound, electrical stimulation

- Flexibility and stretching for posterior shoulder muscles to improve shoulder IR and horizontal ADD

- Rotator cuff strengthening (especially external rotator muscles)

- Scapular muscles strengthening (especially retractor and depressor muscles)

- Dynamic stabilization exercises (rhythmic stabilization)

- Weight-bearing exercises

- Proprioception training

- Abstain from throwing

What are exercise and modalities that can be included in the treatment of overhead athletes during phase 1: Acute phase

- Progress strengthening exercises

- Restore muscular balance

- Enhance dynamic stability

- Control flexibility and stretches

What are goals for the treatment of overhead athletes during phase 2: Intermediate phase

- Continue stretching and flexibility (especially shoulder IR and horizontal ADD)

- Progress isotonic strengthening

- Complete shoulder program

- Thrower's Ten program

- Rhythmic stabilization drills

- Initiate core lumbopelvic region strengthening program

- Initiate LE program

What are exercise and modalities that can be included in the treatment of overhead athletes during phase 2: Intermediate phase

- Aggressive strengthening

- Progress neuromuscular control

- Improve strength, power, and endurance

What are goals for the treatment of overhead athletes during phase 3: Advanced strengthening phase

- Flexibility and stretching Rhythmic stabilization drills

- Thrower's Ten program

- Initiate plyometric program

- Initiate endurance drills

- Initiate short-distance throwing program

What are exercise and modalities that can be included in the treatment of overhead athletes during phase 3: Advanced strengthening phase

- Progress to throwing program

- Return to competitive throwing

- Continue strengthening and flexibility drills

What are goals for the treatment of overhead athletes during phase 4: Return to activity phase

- Stretching and flexibility drills

- Thrower's Ten program

- Plyometric program

- Progress interval throwing program to competitive throwing

What are exercise and modalities that can be included in the treatment of overhead athletes during phase 4: Return to activity phase

- Posterior shoulder stretching

- Shoulder strengthening

- Trunk and lower extremity strengthening

What should be included in an injury prevention program for pitchers that has some evidence

- Shoulder mobility

- RTC and periscapular strength and control

- Incorporation of LE kinetic chain/trunk

- Progressive return to sport programs

What are the key focuses of rehabilitation for shoulder injuries in overhead athletes

The humeral head glides anteriorly, pinching posterior RTC, labrum, and capsule between the humeral head and glenoid

What is the theory behind posterior/internal impingement

Pain in the posterior aspect of the shoulder

What is the key finding during the apprehension test for posterior/internal impingement

Repeat the apprehension test while applying a posterior force to the humeral head

How do you confirm posterior/internal impingement

Posterior shoulder pain should decrease

What should happen when posterior force is applied during the apprehension test

Increased ER and decreased IR

What happens with humeral retro-torsion in overhead athletes

To determine whether changes in ER and IR are due to normal humeral retro-torsion

Why is it important to assess the total arc of motion

If total ROM is similar between the right and left sides, the difference may be acceptable

How can you determine if different ER/IR arcs are acceptable

It is difficult to assess accurately without imaging

Why is humeral retro-torsion difficult to assess clinically

Posterior shoulder muscles experience heavy eccentric tensile loads

Why does posterior shoulder stiffness occur in overhead sports

After training or games due to fatigue of the posterior shoulder muscles

When can loss of IR occur in overhead athletes

It may indicate posterior shoulder weakness, particularly eccentric weakness

What can GIRD indicate

Stretching is commonly used, but strengthening may be more important

How is GIRD commonly treated

Prominence of the medial scapular border at rest, during elevation, or when lowering the arm

What should you look for during a scapular dyskinesis test

Have the person hold 3–5 lb weights in their hands during the test

How can reliability of the scapular dyskinesis test be improved

very poor

What is the quality of evidence for exercise prescription for overhead athletes with shoulder pain

expert opinion

What is most of the evidence for exercise prescription based on

Single-plane, open-chain UE exercises below 90° of elevation and closed-chain UE exercises

What exercises have the strongest evidence for overhead athletes with shoulder pain?

Stretching of the posterior shoulder muscles

What flexibility exercises can be included during Phase 1?

To improve shoulder IR and horizontal ADD

Why stretch the posterior shoulder muscles

External rotator muscles

What rotator cuff muscles should be especially strengthened during Phase 1

Retractor and depressor muscles

What scapular muscles should be especially strengthened during Phase 1

Posterior shoulder stretching

RTC strengthening

Scapular muscle strengthening

What exercises can be included during Phase 1 for overhead athletes