(860)549-8210•oahct.com

Non-OperativeManagementoftheAthleticShoulderand

OverheadAthleteInjuries

RehabilitationProtocol*SeemoredetaileddescriptionsonnextpagesEvaluation:- SubjectiveHistory:- ObservationofMovementandPosture:o Posture,shoulder,spinal,&scapularpositionassessmentso Scapulartests:

§ ScapularAssistanceTest(SAT)§ ScapularRetractionTest(SRT)• Alternatetest:ScapularRepositionTest

§ FlipSign

o GlenohumeralROM:AROMandPROM§ IRandERat30°and90°ofabduction(inside-lying)§ Forwardflexion,ScapularPlaneElevation,Abduction,Adductionacrossthebody§ FunctionalROM:ApleyScratchTest(IR+Ext,Abd+ER)§ ConsiderationofROMdifferenceswithoverheadathletes§ GlenohumeralInternalRotationDeficit(GIRD)

o ManualMuscleTesting(MMT):

§ ForearmMMTandGripStrengthmeasurements§ Supraspinatus:FullCanTest,&DiagonalHorizontalAdductionTest§ Infraspinatus:StandardMMTtesting§ TeresMinor:PatteTest§ Subscapularis:Lift-offTest§ SerratusAnterior:ModifiedWallPush-upTest§ RhomboidsMMT:StandardMMTtesting§ UpperTrapezius:ShoulderShrug§ MiddleTrapeziusMMT:StandardMMTtesting§ LowerTrapeziusMMT:StandardMMTtesting§ PectoralisMajorMMT:StandardMMTtesting§ LatissimusDorsiMMT:StandardMMTtesting§ Deltoid(Anterior,Middle,&Posterior)MMT:§

(860)549-8210•oahct.com

o ShoulderSpecialTest:§ ImpingementTests:• NeerImpingementTest:(passive)• Hawkins-KennedyImpingementSign:(passive)• YocumImpingementTest:(active)• CoracoidImpingementSyndromeTests:

o CoracoidImpingementTesto Cross-ArmAdductionImpingementTest

o BonyInstabilityTests:

§ BonyApprehensionTest§ Inferior/MultidirectionalInstability(MDI)SulcusTest§ AnteriorandPosteriorTranslation(Drawer)Tests

o TendinopathyTests:

§ ExternalRotationLagSign§ Belly-offSign§ Belly-PressModifiedTest§ LateralJobeTest§ BearHugTest(Subscapularis)

o LabralTearTests:

§ ModifiedDynamicLabralShearTest

o SuperiorLabrumAnteriorPosterior(SLAP)Tests:§ PassiveCompressionTest§ PassiveDistractionTest§ JobeRelocationTest§ ActiveCompressionTest§ TheDynamicSpeed’sTest§ ThePronatedLoadTest§ ResistedSupinationExternalRotationTest

o LongHeadoftheBicepsTests:§ Yergason’sTest

o OtherTests:

§ Olecranon-ManubriumPercussionTest§ ShrugSign§ BeightonHypermobilityIndex:(SeeChart)

o FunctionalMovementTests:

§ SeatedRotationalTest§ RollingAssessment:(4directions-supine<->proneUEorLEonly)§ SelectiveFunctionalMovementAssessment(SFMA)§ FunctionalMovementScreen(FMS)§ Y-BalanceAssessment

(860)549-8210•oahct.com

Rehabilitation:o Phase1:AcutePhase:§ Goals:

• 1-Decrease/eliminatepainandinflammation• 2-Improveflexibility/mobilitythroughouttheshoulder,scapula,andspine(cervical,

thoracic,andlumbar)• 3-Improve/Retrainstrengthofdynamicstabilizers(musclebalance)• 4-Controlfunctionalstressors,compensatorypatterns,andpoorposture

§ Treatment:

• FollowedexpectedpassiveROMforindividualathletes(comparedtototalarcofmotion),andexpectedalterationsinshoulderROMs,bythesporttheathleteplays.Theseshouldberestoredpriortostrengthening.

• Abstainfromsportingactivitiesthatcouldcompensaterecovery• Modalities,ifwarranted,includingtapingtechniques• ROM:o ImproveIRROMat90°ofabductiontonormalmeasurements,Sleeperstretch,cross-

bodystretcho GraduallyimprovehorizontaladductionandER(donotforceintopainfulER),improve

flexiono Elbow,wristandforearmROM

• Strengthening:o ScapularSerratusAnteriorandLowerTrapeziusretraining/stabilizationexercises

§ RhythmicStabilization,Isometrics,PNF,specificexercises§ Side-lying,Quadruped,Prone,Standing

o RotatorCuffStrengthening(especiallyER):§ Noweight/bands->lightweight/bands->moderateweight/bands§ Inprone,side-lying,quadruped,orstanding

o Elbow,wristandforearmstrengtheningexerciseso Maintain/retraincoreandlowerbodyexercises

- CriteriaforProgressiontoPhase2:o Minimaltonopainorinflammationo NormalROMforIRandHorizontalAdductiono Novisiblesignsofsignificantweakness,scapularwinging,fatiguewithminimalrepetitions

o Phase2:IntermediatePhase§ Goals:

• Tocontinuetoprogressstrengtheningexercises• Restoremuscularbalance/symmetries:left-right,agonist/antagonist• Improveproximalanddynamicstability• Maintain/improveoverallflexibility/mobility• Continueimprovingcoreandlowerbodystrengtheningandconditioning

(860)549-8210•oahct.com

§ Treatment:

• Painatrestshouldbeeliminatedbeforebeginningstrengthening(hypertrophy)orplyometricexercises

• ROM:o Continuetostretchandimproveflexibilityforshoulderandspinelimitations,gradually

restorefullshoulderERROM• Strengthening:o Continuetoprogressscapular,rotatorcuffanddynamicstabilizingmuscles(canbeat

endrange)o Maybeginwallstabilizationandpush-upexercises,andUEplyometricPhase1Protocol

(SeeSheet)- CriteriatoProgresstoPhase3:o Full,pain-freeROMo Fullstrengthwithnosignofextremefatiguewithstrengthevaluationtestsorcurrentexercises

o Phase3:AdvancedStrengtheningPhase:§ Goals:

• Beginamoreaggressivestrengtheningprogram• Progressneuromuscularandproprioceptivecontrol• Beginexercisescenteredmorearoundstrength,power,endurance,agility

§ Treatment:

• ROM:o ContinuetomaintainnormalROM/Mobilityo Teachpatientroutineforactivewarm-upstretchespre-work/competition,andstatic

cool-down/post-workoutstretches• Strengthening:Besuretopatientgoesthroughstretchingroutinebeforebeginning

strengtheningexerciseso Continueanypreviousstrengtheningexercisesthatareappropriateo Thrower’sTenProgram->progressedtoAdvancedThrower’sTenProgram:(see

attachedsheets)o BeginPhaseII->IIIofUEPlyometricProtocol(Seeattachedsheets)o PatientmaybeginPhaseIofintervalsportsprograms(ThrowingandTennis)

• Assess/ReassessFunctionalMobility:o FunctionalMovementScreen(FMS)o Y-BalanceUEandLEassessmenta. TrunkTesting:(Seeattachedsheets)

i.DeepNeckFlexorTestii.SegmentalMultifidusTestiii.TrunkCurl-upTestiv.Double-LegLoweringTestv.ProneBridgeTestvi.EnduranceofLateralFlexors(SideBridge)vii.ExtensorDynamicEnduranceTest

(860)549-8210•oahct.com

b. UpperExtremityTesting:(Seeattachedsheets)i. AlternativePull-upTestii. Push-upTestiii. BackwardO.H.MedicineBallThrowTestiv. SidearmMedicineBallThrowTestv. SeatedShot-PutThrowTest

- CriteriatoProgresstoReturntoSpecificSportProtocols:o ExpectedactiveROM,withnormalmovementpatterns,shouldberestoredbeforebeginning

hypertrophystrengtheningorplyometricexerciseso Patientshouldbeabletodemonstratepain-freenormalmovementpatternsthroughmulti-

planarmovements,with45-60repetitions(goodendurance),beforeprogressiontoeccentric,plyometric,and/orhighloadexercises

o Patientmustcompleteplyometricprogram(UE&LEifappropriate),Score³16ontheFMSä(withnoasymmetries,Y-Balanceäscoreshouldbeequaltopeersofthesameageandsportalongwithnoasymmetries,score____ontheDASH/PSS(orlow/nodisabilityonchosenselfevaluationassessment)

o Passingofthefunctionaltestslistedabove:Testcanbeovermultiplesessions

• SeeSportSpecificProtocolsClinicalEvaluation:(MoreDescriptiveVersion)- SubjectiveHistory:o GeneralInformation:

§ Age,§ Gender,§ Dominant-handedness,§ Sportplayed&position,§ Numberofyearsplaying,§ Levelofcompetition.

o InjuryInformation:§ Onsetofsymptoms&weretheygradualorsuddenintheironset,§ Historyofpreviousshoulderinjury,§ Locationofsymptoms,§ Description,severity,anddurationofsymptoms,§ Activitiesthatalleviateorworsensymptoms,§ Phasesofthroworswingthatproducethesymptoms,§ Numberofinningspitched/numberofgamesplayedperseason/year,§ Changesincontrol/locationofswings/throws.

(860)549-8210•oahct.com

- ObservationofMovementandPostureo Posturalassessment

§ Shoulderheightbilateralcomparison-(typicallythedominateshoulderislowerthanthenon-dominateshoulder,atrest,particularlywithunilaterallydominateathleteslikebaseballpitchersandtennisplayers)

§ Scapularposition(rotation,positionagainstthethoracicwall/tilting,andmovement:(scapulothoracic,andscapulohumeral))righttoleftcomparison• Kiblerdescribes3primarytypesofscapulardysfunctionsandtestedinrestingstance,

handsontheirhips,andduringbilateralactivemovementsinthesagittal,scapularandfrontalplanes(Below)

• Theuseofanexternalload,suchasholdingafreeweightmaybenecessarytoelicitthescapulardysfunctioninathleteswherethescapulardysfunction/pathologymaybesubtle

• *Scapulardissociationawayfromtheribsistypicallyseenwithsloweccentricloweringoftheextremities,sotheclinicianshouldcarefullyobservealldirectionsofmovementcarefully.

• ScapularPositionConsiderationsfortheOverheadAthlete:TheThrowingsidemayhave­’dprotractionandanteriortilting,especiallywithfatigue.

CharacteristicsatRest CharacteristicswithMovement AxisofMotionName/Dysfunction InferiorAngle(TypeI) Inferiormedialborderof

thescapularisprominentwhenviewedposteriorly

Inferiormedialborderofthescapulamovesdorsally,superioranteriortiltsandtheacromiontiltsdownwardandmovesventrallyoverthethorax

Sagittalplane

MedialBorder(TypeII) Theentiremedialborderofthescapulaisprominentwhenviewedposteriorly

Entiremedialbordermovesdorsallyawayfromthethorax

Transverseplane

SuperiorBorder(TypeIII) Superiorborderofthescapulaisprominentandoftenelevatedcomparedtothecontralateralside

Ashruggingorsuperiormotionisusedtoinitiatemovementoftheshoulderalongwithprominenceofthescapulacomparedtothecontralateralside

Sagittalplane

*Thescapulardysfunctiondoesnotalwayspresentasclearlyaslistedabove,andinmanycases,becauseofthecomplexityofmovementofthescapulothoracicjoint,thepatientcandemonstratemorethanoneclassificationatatime*

(860)549-8210•oahct.com

o (InStanding)Observeshoulderandscapularmuscles-particularlyfocusingonmuscledevelopmentandareasofatrophy.Patientshouldbeobservedwithhandscomfortablebytheirside,aswellas,withhandsontheirhips(placesshouldersin45°-50°ofabductionandslightinternalrotation.ThisallowsthePatienttoletarmsrelaxandwillshowmoreapparentpocketsofatrophyalongthescapularborder.

§ VisibleatrophyintheInfraspinatusfossacouldbeasignsofRotatorCuffDysfunctionorwithsevereatrophytherecouldbesuprascapularnerveinvolvement-furtherdiagnostictestingwouldbewarranted.

- ScapularTests:o ScapularAssistanceTest(SAT):Theclinicianplacesonehandontheinferiormedialaspectof

thescapulaandtheotheronthesuperiorbaseofthescapulatoprovideanupwardrotation(andposteriortilt),whilethepatientelevatedtheirarmeitherinthescapularorsagittalplane.ThetestispositiveifthereisagreaterROMordecreasedpain(eliminationoftheimpingementtypesymptoms),withtheclinician’sassistwithscapularmovement.

o ScapularRetractionTest(SRT):Theclinicianmanuallypositionsthescapulainretraction,(toimprovesupraspinatusstrength,optimizingaweakenedcuffandgivingatruerideaofsupraspinatuspower),andhasthepatientperformanupperextremitymovementthatwouldtypicallyelicittheirsymptoms.

§ TheScapularRepositiontest:(alternativetest):testedwellinastudywith142collegeoverheadathletes.Thistestisperformedwiththepatientinsittingorstanding.Thecliniciangraspsthescapulawiththefingerscontactingtheacromioclavicularjointanteriorlyandthepalmofthehandandthenareminencecontactingthespineofthescapulaposteriorly,withtheforearmobliquelyangledtowardtheinferiorangleofthescapulaforadditionalsupportonthemedialborder.Thepatientwasthenaskedtorepeatamovement/testpositionthatpreviousreproducedtheirpain.Areductionofpainof>1onaVASpainscale,maybeawaytoidentifysuitableinterventionsforaddressingthescapula,suchastaping,strengtheningspecificmuscles,orbracing.

o FlipSign:TheclinicianresistsExternalrotationatthepatient’selbow,whilecarefullymonitoringforapositivetestwhenthescapulaforanysignsofwinging(scapula“flips”awayfromtheribsandbecomesmoreprominent).Apositivetestindicatesalossofscapularstability,andshouldsuggestfurtherevaluationofthescapulamusclesandnerveinnervationsandexerciseintegrationshouldfocusonserratusanteriorandthetrapeziusinitiation/strengthening.Thistestwasoriginallydescribedintestingforspinalaccessorynervelesions.

- GlenohumeralROM:o Goniometricmeasurementsarebestwithscapularstabilizationusinga“C”shapetypegrasp

withfourfingersonthescapulaposteriorlyandthethumbonthecoracoidprocessanteriorly.o MeasurementsshouldbetakenofAROMandPROMofIRandERat90°ofabductionwiththe

patientinside-lying[betterinterandintraraterreliability]:(ERnorm:90°,IRnorm:30°-45°);*seeOHAthleteConsiderationsbelow),scapularplaneelevation:(norm:160°-180°),forwardflexion(norm:160°-180°),abduction:(norm:160°-180°)*documentifpatientexhibitsapainfularc,adductionacrossthebody:(norm:90°),andExtension:(norm:40°-60°).

§ ReliabilityofROMmeasurementsforInternalRotationwasfoundtobehigherwhentakenwiththepatientinthesidelyingposition.Thepatientislyingontheirside,inapositioninwhichtheacromionprocesseswerealignedperpendiculartotheplinth.The

(860)549-8210•oahct.com

shouldershouldbein90°offlexionwith0°ofrotationandtheelbowisflexedto90°.Theolecranonprocessshouldbepositionedofftheedgeofthetable.Theclinicianpassivelyrotatesthehumerusintointernalrotation,whilemaintainingtheshoulderandelbowflexionat90°.Comparisonofbothsideswasmade.

o YoushouldalsocheckfunctionalmovementpatternsofIRandextension(T7forwomen,T9forMen),andAbductionandER(spineofcontralateralscapula),likeintheApleyScratchTest,SFMA,orsimultaneousmovementintheFMS.

o OthermotionsthatarerecommendedforathletesareHorizontal(cross-arm)Adduction-Thiscanbedoneindifferentpositions,however,theoptimalpositionispatientsupinewithscapularstabilizationprovidedbytheclinicianatthelateralborderofthescapulatokeepitinretraction,whilethepatient’sarmisguidedintohorizontaladductionwithoutoverpressure.

o *Theuseofadigitalinclinometerhasbeenshowntohavehighreliability.- ConsiderationsofROMmeasurementswithoverheadathletes:o IthasbeenshownthatinbaseballplayersthattheytypicallyexhibitincreasedERanddecreased

IRonthedominantarmshoulderwhencomparedtothenon-dominantside.*However,thetotalarcofrotationalmotionshouldequalonbotharms.(Nogreaterthan+/-5°)

§ Ex.Ifapatientismeasuredat120°ofERand30°ofIRontheirdominantshoulderand90°ofERand60°IRontheirnon-dominantarm,thetotalarcofmotionbothshouldersequals150°andisconsiderednormalforbaseballpitchers.

o Withregardstotennisplayers,Ellenbeckeretal.foundtheyhadsignificantlylessinternalrotationontheirdominantarm,aswellassignificantlylesstotalarcofrotationalmotioncomparedtotheirnon-dominantarminuninjuredathletes.

§ Theyfoundapproximately10°lesswithIRROMandofthetotalarcofrotationalmotioninthedominantarmofnon-injuredathletescomparedtotheirnon-dominantshoulder.

- GlenohumeralInternalRotationDeficit(GIRD):o Thisconditionhasseveraldefinitionsincluding,greaterthan20°-25°lossininternalrotationon

thedominantsidewhencomparedtothenon-dominantside;oralossof10%ormoreofthetotalrotationROMonthedominantsidecomparedtothenon-dominantside,whichismorewidelyused.

§ So,ifstillusingthenumbersfromthelastexamplealossof15°ormoreonthedominantsidewouldconstituteaconclusionofGIRD.

§ Wilketal.reportedthatalossoftotalarcofmotionof>5°wasfoundtoplaceathletesatahighriskofshoulderinjury.

§ Wilketal.Alsoexpressedthatthereisanincreasedriskofshoulderinjurywhenthetotalarcofmotionwasgreateronthethrowing/dominantsideintheoverheadathlete.

• Thetherapistshouldassessthedynamicstabilityoftheglenohumeraljointintheeathletesanddevelopaprogramaccordingly.

o *AcautionwithGIRDisthatthemobilityrestrictionmayactuallybearesultofthoracicspineand/orribshypomobility/dysfunction,whichcouldpresentasafalsepositiveforGIRD/Posteriorcapsuletightness.Thedysfunctionshouldbetreatedoutandmotionreassessed.Whatappearstobeposteriorcapsuletightnessoftheshoulderoftenresolveswithmobilizationoftheribcagetopromotethoracicrotationtotheoppositeside.(SeethemobilizationsectioninSuggestedSpecificExercises).IftheIRROMlimitationisstillpresent,thanjointmobilizationandposteriorcapsularstretching,andappropriatestrengtheningexercisesshouldbeinitiated.

- ManualMuscleTesting(MMT):

(860)549-8210•oahct.com

o ForearmStrengthTests:GripStrengthandMMT

o Supraspinatus:Theoptimaltestingposition,foundbyKellyetal.,isseatedwithelevationofthearmto90°inthescapularplane(45°horizontaladductionfromthecoronalplane)withERofthehumerussotheirthumbispointedtowardtheceiling.ThisisalsocalledtheFullCanTestingPosition.Theclinicianresistsanupwardmotionexertedbythepatient.

§ TheEmptyCanPositionTesthasalsobeenfrequentlyused,whichisthesamestartingpatientpositionwiththeexceptionofthehumerusbeinginIRwiththethumbpointingdowntothefloor.*Thesetestsreportgreatpredictabilitywithtestingweakness(whichisthecapacitybeingusedhere),versuspain.Bothtestsareconsideredtohaveequivalentdiagnosticaccuracy,howeverconsideringthepainprovocationistypicallyhigherwiththeEmptyCanTest,andthisistestisbeingusedtotestweaknesstheFullCanpositionispreferred.

§ TheDiagonalHorizontalAdductionTests:Patientisseatedwiththeelbowextendedandtheirarmfullyexternallyrotated,at35°ofshoulderflexion,andthenadductedacrossthepectoralareaofthebody.Thepatientisthenaskedtolifttheirarmup(intohorizontalabduction)andtheclinicianperformsanisometricresistance.Thepatientisaskedtomaintainthecontractionforapproximately5seconds,tofeelforanyweakness.ThistestshouldbeusedinconjunctionwiththeFull-CanTesttoassesssuprspinatusweakness

o Infraspinatus:Theoptimaltestposition,accordingtoKellyetal.,iswiththepatientseatedwith0°ofGlenohumeralJointelevationandin45°ofIRfromneutral.ThenthepatientpushesintoERandtheclinicianresistthemotionwhilemonitoringtheelbow.Testforweaknessandcompensation.

§ ThereisanalternativetestpositionthatwasdescribedbyJenpetal.,inwhichthepatient’sarmisin90°ofelevationinthesagittalplane,withtheelbowbentandpositionedinthehalfwaypointtomaximalERROM.ThiswasnottestedwithEMGlikeKellyetal.,howevermaybeusefulwithsomeoverheadathletesforafurtherevaluationofinfraspinatusstrength.

o TeresMinor:(PatteTest):thepatent’sshoulderispositionedin90°ofabductioninthescapularplaneand90°ofER.ThepatientpushesintoERwhilethecliniciansupportstheelbowandresiststhemovement.Theclinicianshouldbemonitoringforweaknessaswellascompensatorymotions.

o Subscapularis:Kellyetal.,foundtheoptimaltestistheLift-offTestinwhichapatientisstandingwiththearmIR,extendedbehindtheback,sothedorsumortheirhandisrestinginthemiddleoftheirlowback.Theclinicianthenliftsthedorsumoftheirhandawayfromtheirbackandthepatientisaskedtomaintainthisposition.Thecliniciancanalsoaddresistance,ifthepatientisabletoinitiallyabletoholdtheliftoffposition.

§ Analternativeposition,describedbyStefkoetal.,iswiththedorsumofthepatient’shandplacedupneartheinferiorborderoftheipsilateralscapula,wheretheyfoundthehighestmuscularactivity.

o SerratusAnterior:Patientperformsamodifiedpushupagainstthewall.Theclinicianshouldbenoteifpatientexhibitsanyscapularwinging.

o Rhomboids:Patientispronewitharmextendedandslightlyadductedcontractingtherhomboids.Thepatientresists/holdsthispositionasyoutrytomovethescapulafromthe

(860)549-8210•oahct.com

medialborderlaterally.Weaknessisifpatientisunableorhasdifficultyholdingthescapulainthatpositionwithorwithouttheresistance.

o Trapezius:§ UpperTrapezius:Patientseatedandperformsashouldershrug.Theclinicianresiststhe

motionandnotesweaknessorinabilitytoevenachieveshrugposition.§ MiddleTrapezius:patientispronewithelbowextendedandabductedto90°inexternal

rotation,sothumbisuptowardstheceiling.Patientisaskedtoholdthepositionagainstresistance.Weaknessisifpatientisunabletoachieveorholdpositionwithorwithoutresistance.

§ LowerTrapezius:Patientispronewithelbowextendedandshoulderabductedto120°inexternalrotationsothethumbistowardtheceiling.Thepatientisaskedtoholdthepositionagainstresistance.Weaknessisifthepatientisunabletoachieveormaintainthepositionwithorwithoutresistance.

o PectoralisMajor:Patientisinsupineorstandingposition.Thepatientadductsthearminabout20°offlexionwiththeelbowslightlybentandresiststheclinician’sforcepushinglaterally.Weaknessiswhenhepatientcannotmaintainpositionwithresistance.

o LatissimusDorsi:Patientisinpronewitharmofthesidebeingtestedofftheedgeofthetable.Thepatientisthenaskedtointernallyrotate,adductslightly,andextendtheshouldertheclinicianthenappliesresistance.Weaknessisifthepatientcannotachieveofholdthepositionwithorwithoutresistance.

o Deltoid:Weaknessisifpatientcannotachieveormaintaintheposition.§ AnteriorDeltoid:Theclinicianresistspatientinforwardflexionoftheirshoulder.§ MiddleDeltoid:Theclinicianresistspatientinabductionwiththeirelbowflexedto90°.§ PosteriorDeltoid:Theclinicianresistspatientinshoulderextensionwiththeelbow

flexedat90°.

o *Thesetestscanalsobeperformedinamoreobjectivemeasurementusingahandhelddynamometer(HHD).Thesehavebeenshowntobereliablestrengthmeasurementsandhavehighinter-andintra-raterreliability.Theyalsogivemoreobjectivenumberstothestrengthmeasurements.StatisticalrelationshipshavebeenshownbetweenERandsupraspinatusstrengthmeasurementswithaHHD,andshoulderinjury.TherewasalsoasignificantrelationshipbetweenIR/ERmuscularstrengthratiosandinjuryrisk.SeeSeparatesheetforHHDInstructions.

o IsokineticMuscleTesting:Thiscanbeusedtogetobjectivemeasurementsofdynamicmuscularstrength.Ellenbeckeretal.,comparedisokinetictestingandMMT.Theyassessed54subjectstoexhibit5/5strengthusingMMT,whileisokinetictestsfound13%-15%bilateraldifferenceinERand28%bilateraldifferenceinIR,despitesymmetricalMMTstrengthassessment.

- ShoulderSpecialTests:(RotatorCuffImpingement,AKA:RTCTendinosis/Tendinopathytests,SubacromialImpingementtests,CoracoidImpingementtests,ACJointImpingementtests,LabralTeartests,SLAPLesionstests,BonyInstabilitytests):o ImpingementTests:(Passive):Theprimarygoalsistoattempttore-createthesubacromial

compressionandsymptoms§ NeerImpingementTest:Theclinicianmonitorsthehumeralheadstabilizesthescapula

andpreventsscapularrotationwithonehand,astheypassivelymovethepatient’sarm

(860)549-8210•oahct.com

intomaximalforwardflexion/elevationwiththeotherhand,whichcausesthegreatertuberositytoimpingeagainsttheacromion.Positivetestisreproductionofthepain.

§ Hawkins-KennedyImpingementSign:Theclinicianmonitorsthehumerusandbringsthepatient’sshoulderintoelevatedinthescapularplaneto90°,withtheelbowflexed,andthenforcefullyinternallyrotatesthepatient’sarmrotatingtheshoulder,down,inthesagittalplane.Thetestispositiveifthepatient’spainisreproduced.

§ EvidenceshowsthattheNeerandHawkins-Kennedybothhavehighsensitivitybutlowspecificity,sotheyaresuitableforscreeningbutnotformakingaspecificdiagnosis.Howevertheycanbeusedinaclustertypediagnosisofmultiplepositivetestsincreasethelikelihoodofthediagnosis.

o CoracoidImpingementSyndrome:Patientpresentswithanteriorshoulderpain,withincreasedpainwithforwardelevation,internalrotation,adduction,andpositivefindingswiththenexttwotests.(SeeAttachedAlgorithm)

§ CoracoidImpingementTest:Patientsshoulderispassivelybroughtintoforwardelevation,adductionandinternalrotation.Apositivetestispain,directlyoverthecoracoidprocess,andclickingwiththemovement.

§ Cross-armAdductionImpingement:Patient’sarmisbroughtpassivelyinto90°offlexionandthenforcefullybroughtintohorizontaladductionacrosstheirchest,performedeitherbythepatientortheclinician.Painandlocationisdocumented.ThistestcanshowpossiblecoracoidimpingementorACjointpathology.

o ImpingementTest(Active):§ YocumImpingementTest:Thepatientbeginswiththepalmofthehandofthearm

beingtestedrestingonthetopoftheoppositeshoulder.ThepatientthenmovesintoelevationwithIR,bringingtheirelbowuptowardtheirface.Thistestislookingforprovocationofsymptoms,aswellas,assessesthepatient’sabilitytocontrolthesuperiorhumeralheadtranslationduringactivearmelevation,whileinapositionofimpingement.

- BonyInstabilitytests:o BonyApprehensiontest:Patientiseitherpositionedinsittingorstandingwiththeelbowflexed

to90°.Theclinicianstandsbehindthepatientholdingtheirlateralforearmwithonehandandplacingtheotherhandontheposterioraspectofthehumeralhead.Theclinicianbringsthepatient’sarminto45°ofabductionand45°ofexternalrotation.Apositivetestiswhenthepatientdemonstratesapprehensionwithorwithoutpain.

§ TestRationale:TheauthorchosethepositioningoftheglenohumeraljointtoprovokeinstabilityfromabonyBankartlesionand/oraHill-Sachsbonylesion.Thistestmaybeusedforbothrulinginoroutadiagnosisofbonyinstability.

o Inferior/MultidirectionalInstability(MDI)Sulcustest:Patientisseatedwitharmsinneutraladduction/abductionwiththeirhandsrestingontheirlap.Thecliniciangraspsthedistalaspectofthehumerususingafirmbutnotpainfulgripwithonehand,whiletheotherhandmonitorstheACJoint.Theclinicianthenperformsseveralbriefandrapiddownwardpullsonthehumerusinaninferiordirection.Theclinicianiswatchingforavisiblesulcussign,ortetheringoftheskinbetweentheacromionandtheheadofthehumerus,wideningthesubacromialspace.A>2cmsulcusisconsideredapositivetestandmaybeindicativeofMDI.

(860)549-8210•oahct.com

§ TestRationale:Thistest,whenperformedinneutral,assessestheintegrityofthesuperiorGlenohumeralligamentandthecoracohumeralligament,whicharetheprimarystabilizingligamentsagainstinferiorhumeralheadtranslation.ItIalsobelievedthatexcessivetranslationintheinferiordirectionisanindicationthattheremaybeapatternofforthcomingincreasesintranslationintheanteriorandposteriorpositions,hencethetermMultidirectionalInstability.

o AnteriorandPosteriorTranslation(Drawer)tests:Patientisthesupineposition,becauseofgreaterinherentrelaxationofthepatient.

§ ThetestpositionforAnteriorTranslationisperformedbetween0°and30°ofabduction,in30°-60°ofabduction,andat90°ofabductiontotesttheintegrityofthesuperior,middle,andinferiorglenohumeralligaments,respectively.Thetranslationisperformedwithadownwardpressureontheheadofthehumerusalongtheplaneofthejointline(approximately30°inamedialtolateraldirection).

§ ThetestpositionforthePosteriorTranslationisat90°ofabduction,becausethereisnodistinctthickeningofthecapsule,exceptwiththeposteriorbandoftheinferiorGlenohumeralligament.Thecliniciandirectedforceisanteriorlyalongtheplaneofthejoint(approximately30°inalateraltomedialdirection).

§ Positivetestsareifunilateralincreasesintranslationarepresentinoneormoredirections,inthepresenceofshoulderpain.Increasedtranslationwithoutshoulderpainmerelysuggestslaxity.

- Tendinopathytests:o ExternalRotationLagSign:(supraspinatusandinfraspinatusmuscles):Thepatientissittingor

standingwiththeirelbowflexedto90°andshoulderabducted20°withtheforearmsupinatedsothepalmisup.Thecliniciansupportsandmonitorstheelbowastheypassivelyrotatesthepatient’sarmintofullexternalrotation.Apositivetestiswhenthepatientisunabletomaintainpositionoffullexternalrotationoftheaffectedshoulder.

§ TestRationale:Sensitivity=45%-70%,Specificity=91%-100%

o Bellyoffsign:Thepatientisineithersittingorstanding,withtheclinicianstandinginfrontofthepatient,whilepassivelymovingtheaffectedarminflexion,supportingtheelbowin90°flexion,whiletheotherhandbringsthepatient’sarmintomaximalinternalrotation,sotheirpalmisontherebelly.Thepatientisthenaskedtokeeptheirwriststraightandactivelymaintainthispositionofinternalrotationastheclinicianreleasesthewrist(maintainingtheelbowsupport).Apositivetestoccurswhenthepatientisunabletomaintaintheposition,thewristflexesorlagoccursandthehandisliftedofftheabdomen.

§ TestRationale:Thesubscapularismuscleistheprimaryinternalrotatorandthistestevaluatestheintegrityofthemusculotendinousunit.

o BellyPresstestModified:Thepatientispositionedinsittingorstandingwiththehandontheaffectedsideflatontheirabdomenandtheelbowclosetothebody.Theclinicianstandsontheaffectedsideofthepatientandinstructsthepatienttobringtheelbowforwardstraighteningthewrist.Theclinicianmeasuresthefinalangleofthewristandcomparesittothenon-affectedside.Apositivetestisagreaterthana10°differencebetweensides.

§ TestRationale:Sameasthenon-modifiedversion,withthemodifiedversiongivinganobjectivenumberofdysfunction.

(860)549-8210•oahct.com

o LateralJobeTest:Thepatientispositionedinsittingorstanding,andtheclinicianinstructsthepatienttoabducttheirshoulderto90°inthecoronalplanewiththeelbowflexedto90°andtheshoulderinternallyrotatedsothatthefingerspointtowardthefloorandthethumbismedial.Theclinicianthenappliesaninferiorforcetothedistalarm.Apositivetestfindingispainorweaknessorinabilitytoperformthetest.

§ TestRationale:Sensitivity=81%,Specificity=89%§ Theevidencesuggeststhatforthelastthreetests(Bellypress,Bellypressmodified,

andLateralJobe)canallbeusedforbothrulinginandoutsubscapularisandrotatorcufftendinopathy,respectively.

o TheBear-Hugtest:(subscapularistear):Thepatientisinstandingwiththepalmoftheinvolvedsideplacedontheoppositeshoulderwithfingersextended(sothepatientdoesnotresistbygrabbingtheirshoulder),withtheirelbowinfrontofthebody.Theclinicianasksthepatienttoholdthepositionastheytrytobringtheforearmintoexternalrotation(resistedinternalrotation),withaperpendicularforcetotheforearm.Thetestisconsideredpositiveifthepatientisunabletomaintainthehandagainsttheshoulderorftheyshowweaknessofgreaterthan20%whencomparedtotheunaffectedside.Ifthepatientexperiencedpainwithoutweaknessitshouldbenoted,becausetheirwassomecorrelationwithpainandsmalluppersubscapularistears,althoughitcan’tbequantified,thesurgeonmaywanttobenotifiedofthefinding.

§ TestRationale:Thesubscapularissuperolateralcornerandtheslingofthebicepssharethesamegeneralinsertionpoint,sothatiftheslingisdisrupted,thebicepsmaysubluxmediallycausingtearingoftheuppersubscapularis.Activationofthesubluxatedbicepsduringthebear-hugtestmaycauseexcessiveshearstressesonanalready-damageduppersubscapularis,explainingthepainandweaknessobservedinapositivetest.

§ Thistesthasaspecificityof92%andsensitivityof60%,showingthistestisgoodforrulingasubscapularistearin,andhadbeenshowntodetecttearsizesaslowas30%.Mostsensitivetestforsubscapularispathology.

- LabralTearTests:o ModifiedDynamicLabralShearTest:Patientisstandingwithelbowflexed90°,abductedinthe

scapularplane>120°andexternallyrotatedtotightness.Theclinicianstandsbehindthepatient,guidingtheinvolvedupperextremityintomaximalhorizontalabductionandprovideashearloadtothejointbymaintainingexternalrotationandhorizontalabductionasthearmisloweredfrom120°-60°ofabduction.Apositivetestisreproductionorpainand/orpainfulclickorcatchintheposteriorjointlinebetween120°and90°.

§ TestRationale:Thearmpositionandloadapplicationforthistestwastotrytomimicthepeel-backphenomenonandthebicepsmovementthatcreatetheshearingmechanismofposteriorcuffontheposterosuperiorlabrum.

- SuperiorLabrumAnteriorPosteriorlesion(SLAP)tests:o DiagnosingaSLAPlesion:

§ Whentakingthesubjectivehistorypatientmayreportahistoryoftraumasuchasafallontoanoutstretchedarm,directblowtotheshoulder,fallingontothepointoftheshoulder,oraforcefultractiononthearm.Inthesecasestherewouldbeasuddenonsetofsymptoms.However,patients,especiallyoverheadathletes,mayreportamoregradualonsetofsymptoms,suchaspopping,clicking,orcatching,alongwithpainduring

(860)549-8210•oahct.com

throwing(usuallylatecockingphase),andadecreaseinpowerandaccuracywiththerethrows

o SLAPClassifications:(basic4,however,recentlyadditionalclassificationshavebeenadded):§ TypeI:IsolatedFrayingofthesuperiorlabrum,withafirmattachmentofthelabrumto

theglenoid(typicallydegenerativeinnature)§ TypeII:Adetachmentofthesuperiorlabrumandtheoriginofthelongheadofthe

bicepsbrachiitendonfromtheglenoidcreatinginstabilityofthebiceps-labralanchor§ TypeIII:Abucket-handletearofthelabrumwithanintactbicepsinsertion§ TypeIV:Abucket-handletearofthelabrumthatextendsintothebicepstendon.This

typewillalsohaveinstabilityatthebicep-labrumanchor§ TypeV:SLAPlesionswiththepresenceofaBankartlesionoftheanteriorcapsule

extendingintotheanteriorsuperiorlabrum§ TypeVI:Adisruptionofthebicepsanchorwithananteriorposteriorsuperiorlabralflap

tear§ TypeVII:Lesionsthatextendedanteriorlytoinvolvetheareainferiortothemiddle

glenoidligament§ TypeVIII:AtypeIISLAPtearwithaposteriorlabralextensiontothe6o’clockposition.§ TypeIX:Isacircumferentiallesioninvolvingthefull360°oflabralattachmenttothe

glenoidrim§ TypeX:Ininvolvesasuperiorlabraltearcombinedwithaposteroinferiorlabraltear(a

reverseBankartlesion)§ *ItiscommontohaveconcomitantinjurieswithSLAPlesions,sotheseclassifications

canbebeneficialforcreatingthemotappropriatetreatmentplan*- SpecialTests:o PassiveCompressiontest:Patientisinsidelyingwiththeaffectedsideup.Theclinicianis

standingbehindthepatient,stabilizingtheshoulderbyholdingtheACjointwithonehandandthepatient’selbowwiththeother.Theclinicianexternallyrotatestheshoulderin30°ofabductionandthenpushesthearmproximallywhileextendingtheshoulder.Apositivetestoccurswhenthereispainorapainfulclickintheglenohumeraljoint.

§ TestRationale:Whentheglenohumeraljointisexternallyrotatedandextended(latecockingphase),thelongheadofthebicepstendonisplacedundertensileforceswhilewrappingaroundthelessertuberosityandultimatelyshiftingthesuperiorlabrumfromthesuperiorglenoidrim.Proximalmigrationofthehumerusaggravateshedisplacementoftheunstablelabrumandpassivelydisplacesthesuperiorlabrum.EvidenceshowsthistestcanbeusedforrulingaSLAPlesionin.

o PassiveDistractiontest:Patientissupine,withtheclinicianstandingontheaffectedsideofthepatient.Thepatient’sarmispositionedofftheedgeoftableinto150°abductioninthecoronalplane,withtheelbowextended,theforearmsupinated,andtheupperarmstabilizedtopreventproximalhumerusrotation.Theclinicianthenpronatestheforearm,whilemaintainingtheheadofthehumerusposition.Apositivefindingiswhenthepatientreportspaindeepintheglenohueraljointeitheranteriorlyorposteriorly.

§ TestRationale:Mimicsthepeel-backphenomenonofthesuperiorlabrum.EvidenceshowsthatthistestcanbeusedforbothrulingaSLAPlesioninorout.

o JobeRelocationtest:Thepatientispositionedsupine,withtheirelbowflexedto90°andshoulderabductedto90°.Theclinicianappliesanexternalrotationforce,andanyapprehensionisnoted.Theclinicianthenappliesaposteriorlydirectedforcetotheshoulder.Ifthepatient’s

(860)549-8210•oahct.com

painorapprehensionisreducedinthispositionthan,thetestisconsideredpositive.*Itisimportantthatthepatientreleasestherelocationforcebeforebringingthepatientbacktoneutralpositioning,todecreaseriskofdislocation.

§ TestRationale:Thistestwasfoundtohaveahighersensitivity(85%)forposteriorlesionsthanforanteriorlesions.Throwershavebeenfoundtohavea3timesgreaterlikelihoodfordevelopingTypeIIposteriorlesions.Morganetal.

o ActiveCompressiontest:Thepatientisinsittingorstanding,withtheirshoulderplacedin90°orflexionand10°-20°ofhorizontaladduction.Thepatientthencompletelyinternallyrotatestheirshoulderandpronatestheirforearm.Theclinicianthenappliesastabilizingforcedistallyontheextremity,asthepatientisinstructedtoperformanupwardforceintotheclinician’spressure.Theprocedureisthenrepeatedwiththeshoulderandforearminneutralposition.Apositivetestoccurswithpainreproductionorclickingintheshoulderwiththefirstpositionandreduction/absenceinthesecondposition.ThistestisalsonegativewhenareportofpainislocatedovertheACjointortheposteriorshoulder,asitisnotspecificenoughtosuggestalabral(SLAP)lesion.

§ TestRationale:Thistesthasbeenreportedashavingahighersensitivity(88%)foranteriorlesions.Thetraumapatientshavebeenfoundtobe3Xmorelikelytopresentwithanteriorlesions.Morganetal.

o PainProvocationTest:Thepatientissupinewiththeirshoulderabductedto90°-100°.Theirshoulderisthenpassivelyexternallyrotatedwiththeforearmfullypronatedandthenrepeatedwiththeforearmfullysupinated.Thistestisconsideredpositiveifthesymptomswerepresentormoresevereintheexternallyrotatedpronatedpositionversusthesupinatedposition,secondarytotheadditionalstressplacedonthebicepstendonwiththeshoulderexternallyrotatedandforearmpronated.

§ TestRationale:Thistesthasdemonstratedasensitivityof100%,andaSpecificityof90%fordiagnosisaSLAPlesion.

o TheBicepsLoadIITest:Thepatientisinsupinewiththeirshoulderplacedin120°ofabductionandmaximallyexternallyrotated.Whentheshoulderisinmaximalexternalrotationthepatientisaskedtoperformaresistedisometricbicepscontraction.DeepshoulderpainisindicativeofaSLAPlesion.

§ TestRationale:Thistesthasasensitivityof90%,specificityof97%,PositivePredictiveValueof92%,andNegativePredictiveValueof96%.ThistestwasfoundtohaveahighersensitivitythantheBicepsITest,whichisperformedin90°ofshoulderabduction.

o TheResistedSupinationExternalRotationTest:Thepatientisinsupinewiththeirshoulderabductedto90°,elbowflexedto65°-70°,andforearminneutralrotation.Thepatientisaskedtotrytoforcefullysupinatetheirforearmwhiletheclinicianresistsandpassivelyrotatestheirshoulderintoexternalrotation.Thepatientisthenaskedtodescribetheirsymptomsatendrangeexternalrotation.ApositivetestIifthepatientdescribesanteriorordeepshoulderpain,clickingorcatchingintheshoulder,orareproductionofthesymptomstheyexperienceduringthrowing.Itisanegativetestifthepatientdescribesposteriorpain,apprehension,orifnopainwaselicitedwiththemaneuver

§ TestRationale:Itisbelievedthatthistestsimulatesthepeel-backmechanismofaSLAPlesion.Thistesthasbeenreportedtohave82.8%sensitivity,81.8%specificity,92.3%positivepredictivevalue,and64.3%negativepredictivevalue,withadiagnosticvalueof82.5%whencomparedtootherProvocativetestsforSLAPlesions.

(860)549-8210•oahct.com

o ThePronatedLoadTest:Thepatientisinsupinewiththeirshoulderabductedto90°-110°andpassivelyexternallyrotated,withthepatient’sforearmfullypronatedtoincreasetensiononthebicepsandlabralattachment.Oncethearmisatmaximalpassiveexternalrotation,thepatientisaskedtoperformaresistedisometricbicepscontraction,inanattempttocreatethepeel-backmechanism.

§ TestRationale:Thistestisacombinationoftheactivebicipitalcontractionofthebicepsloadtestandthepassiveexternalrotationinthepronatedpositionofthepainprovocationtest.Apositivetestisadescriptionofpain/discomfortwithintheshoulder.

- OtherTests:o Olecranon-ManubriumPercussiontest:Thepatientispositionedinsittingorstandingwiththe

elbowsflexedto90°.Theclinicianplacesthestethoscopeoverthemanubriumandpercusseseacholecranonprocess.Theclinicianislisteningforadecreaseinpitchorintensityontheaffectedside,whichwouldindicateapositivetest.

§ TestRationale:Ifthereareanybonyabnormalities,theaffectedsideshouldhaveadullersoundthanthenormalside.

§ Thistestmaybeusedtoruleinoroutbonyabnormalities.

o ShrugSign:Patientisinstandingandtheclinicianinstructsthepatienttoabductboththeirarmsinthecoronalplane,withelbowsflexedto90°.Apositivetestiswhenthepatientelevatesthescapulaorshouldergirdleinordertoachieve90°ofabduction.Theclinicianshouldmeasurewithagoniometer,theanglebetweenthearmandthehorizontalpointatwhichtheshrugmomentbegan(orfrom90°ofabductiontotheangleofthehumeruswhentheshrugbegan).

§ TestRationale:Theshrugsigncandetectshoulderabnormalities,especiallythoseassociatedwithlossofrangeofmotionorweaknessonmanualmuscletesting.

§ Thistestmaybeusedtoruleoutstiffness-relateddisordersaswellasrotatorcufftendinopathy.

o BeightonHypermobilityIndex:(SeeChart):Asimplescoretoquantifyjointlaxityand

hypermobility.Itisa9pointsystem,withthehigherthescorethehigherthelaxity.Cameronetal.foundthatatotalBeightonScalescoreof2orgreaterwerenearly21/2timesmorelikelytohavereportedahistoryofglenohumeraljointinstability.

- FunctionalMobilityTests:o SeatedRotationalTest:(ToIdentifythoracolumbarrotationalmobility/dysfunctional

movement).Patientisseatedwithkneesandfeettogether,supportedonthefloor,withtheirbodyerect,armscrossedacrosstheirchest,andlookingstraightahead.Thepatientisaskedtorotatethetrunktotherightandthentotheleft,asfaraspossible.Theclinicianshouldevaluatetheeaseandfluidityofthemovement,aswellas,measuretheamountofmovementwithagoniometer.Theclinicianislookingforsymmetry/asymmetrycomparingrighttoleftrotation.Normalseatedthoracolumbarrotationis30°bilaterally.

o RollingAssessment:Thesemovementsareevaluatedforcontrolledmobility,corestability,andproperlysequencedloadingofthesegmentsofthebodyrequiredtoperformtherollingexercisecorrectly.

§ Rollingoccursarounddiagonalaxes-theaxisforeachrollingexercisesdoesnotinvolvetheextremitythatinitiatesthemovement,(ex.Rightaxis-LeftUEorLEisinitiatingthemovement).

(860)549-8210•oahct.com

1- SupinetoProneleadingwiththeUpperBody:Thismovementisolatesshoulderflexion/horizontaladduction,whichleadstotrunkflexion/rotation,finallytopelvicrotation/hipflexiontobeabletosementallyandsequentialcompletetheroll.Patientislyingsupinewithlegsextendedandslightlyabductedandarmsflexedoverheadandslightlyabducted.Thepatientstartstorollbyliftingtheirheadintoflexionandreachingtheirrightarmacrossthebody,withfacegoingtowardtheiraxilla.Thelowerbodyshouldremainquietandnotcontributetotheroll.Watchthelegsforassistance.Thetherapistshouldbemonitoringthesegmentalqualityofthemovement,abilitytocompletethemovement,substitutionoffromotherareasofthebody,andrespiration(orlackof).Havethepatientrepeattotheoppositeside.Itmayalsoshowjointmobilityissues(shoulder,thoracic,cervical,lumbar,hip)thatneedtobeaddressedbeforecontinuing.

a. Someverbalcuesare:“Lookwithyoureyesandhead”,“Reachyourarmacrossyourbodyandturnyourheadintoyourshoulder”,“Reachthroughyournon-movingarmandlegtoelongatetheaxis”.

2- PronetoSupineleadingwiththeUpperBody:Thismovementbeginswithisolatedshoulderflexion,initiatingtrunkextension/rotation,endingwithpelvicrotationposteriorlytobeabletocompletetherollcorrectly.Patientislyingpronewithbotharmsandlegsstraightandslightlyabductedandheadisinneutralposition.Askthepatienttorolloverontotheirbackusingtherightarmonly,byextendingtheirarmbackandacrossintoadductionwiththeheadfollowing.Thelowerbodyshouldnotcontributetotheroll.Thetherapistshouldbemonitoringthesegmentalqualityofthemovement,abilitytocompletethemovement,substitutionoffromotherareasofthebody,andrespiration(orlackof).Havethepatientrepeattotheoppositeside.Itmayalsoshowjointmobilityissues(shoulder,thoracic,cervical,lumbar,hip)thatneedtobeaddressedbeforecontinuing.

a. Verbalcues:“Liftyourarmandlookupandoveryouroppositeshoulder”,“Reachthroughyournon-movingarmandlegtoelongatetheaxis”

3- SupinetoProneleadingwithLowerBody:Thismovementbeginswithisolatedhipflexion,thenpelvicrotation/lumbarflexion,andfinallywithtrunkflexion/rotationtocorrectlycompletetheroll.Patientislyingsupinewitharmsseparatedoverheadandlegsapart.Askthepatienttorolltothepronepositionstartingwiththeirrightlegonly.Thepatientshouldleadwiththerighthipflexionfollowedbyadductionoftheextendedleg.Theupperbodyshouldnotcontribute.Thetherapistshouldbemonitoringthesegmentalqualityofthemovement,abilitytocompletethemovement,substitutionoffromotherareasofthebody,andrespiration(orlackof).Repeattotheoppositeside.Workwithinthedysfunctionpatternstoimprovemovement.Itmayalsoshowjointmobilityissues(shoulder,thoracic,cervical,lumbar,hip)thatneedtobeaddressedbeforecontinuing.

a. Verbalcues:toreachlongthroughtheaxiswiththenon-movingarmandleg.”4- PronetoSupineleadingwiththeLowerbody:Thismovementbeginswithisolatedhipextension

thenpelvicrotation/lumbarextension,andfinallywithtrunkextension/rotationtocorrectlycompletetheroll.Patientispronewitharmsandlegsslightlyabductedandheadinneutralposition.Askthepatienttorolloverontotheirbackusingtherightlegonly,byextendingandadductingbackacross.Theupperbodyshouldnotcontributetotheroll.Thetherapistshouldbemonitoringthesegmentalqualityofthemovement,abilitytocompletethemovement,substitutionoffromotherareasofthebody,andrespiration(orlackof).Havethepatientrepeattotheoppositeside.Itmayalsoshowjointmobilityissues(shoulder,thoracic,cervical,lumbar,hip)thatneedtobeaddressedbeforecontinuing.

(860)549-8210•oahct.com

a. Verbalcues:“Elongatethroughtheaxisofthenon-movingarmandleg.”

o SelectiveFunctionalMovementAssessment(SFMA)&,o FunctionalMovementScreen(FMS):

§ Toevaluateforglobalandcontributorydysfunctionsandasymmetries.(Seeattachedworksheets)

Rehabilitation:Non-OperativeShoulderInjuries,AthleticShoulders:- SubjectiveEvaluations:DisabilitiesoftheArmShoulderandHand(DASH)withthesportmodule,

orPennsylvaniaShoulderScore(PSS)o MinimalDetectableChange(MDC)fortheDASHis13,howeverthereisnoMDCcurrentlyfor

thesportmodulealone.o TheMDCfortheaggregatetotalforthePSSis12points;orbysection:±5.2pointsforthepain

section,±1.8pointsforthesatisfactionsection,and±8.6pointsforthefunctionsection- Treatment-BasedClassification:Treatinginthecontextofpathology:

HighIrritability3/5tocategorize

ModerateIrritability3/5tocategorize

LowIrritability3/5tocategorize

• Highpain(³7/10)• Constantnightorrest

pain• PainbeforeendROM• AROM<PROM• Highdisability-³

DASH/PSS50%

• Moderatepain(4-6/10)

• Intermittentnightorrestpain

• PinatendROM• AROM¹PROM• Moderatedisability-

DASH/PSS26-49%

• Lowpain(</=3/10)• Nonightpainorrest

pain• Minimalpainatend

ROM• AROM=PROM• Lowdisability-

DASH/PSS</=25%

(860)549-8210•oahct.com

TreatmentFocus TreatmentFocus TreatmentFocus• Painreduction• RestorationofPROM• Neutralstability

exercises:isometricsandAAROM

• Painreduction• EqualizationofAROM

andPROM• Stabilization(scapular,

rotatorcuffprogram):AROM,limitedresistance

• RestoreendterminalROM,

• Improveshouldergirdleendurance,thenpower,

• Initiatereturntoplay,• Respectively

Takenfrom:Non-operativeManagementoftheAthleticShoulder:Thigpen,C&Jenk,D.HomeStudyCourse2013

o *TheAthleticshouldergirdleishighlyreliantonthemusclesoftherotatorcuffandscapular

stabilizers,aswellasscapulothoracic,thoracicspine,acromioclavicularandsternoclavicularmotions/mobility.

o RotatorCuffDisease:(biceps,subacromialbursitis,rotatorcufftendinits/tendinosis,andpartialrotatorcufftears)

§ Proposedmechanismsofinjuryare;Shoulderimpingement,hookedacromion,weakrotatorcuffmuscles,alteredscapulothoracicpositioningandscapulohumeralkinematics,bonespurs,chronicbursalthickening,rotatorcuffthickeningduetocalciumdeposits,tightnessintheposteriorjointcapsule.Thisleadstoabelievesequenceofeventsstartingwithrepetitivemicrotraumatotherotatorcuff,followedbytendonitis,bursitis,osteophyteformation,andthenfinallyrotatorcufftear.• Impingementcanbefromintrinsicfactors:thoserelatedtothehumanbodyor

extrinsicfactors:suchasoccupationoractivity- Commonrelevantextrinsicfactorsforathletesarerotatorcuffweaknessand

scapulardysfunction.

o Instability:Allcapsulolabralpathologies;SuperiorLabralAnteriorPosterior(SLAP)lesions,Multi-directionalInstability(MDI),oranterior-inferiorcapsulolabrallesions.

§ TypicalorderofprevalenceisAnterior/Inferiorligamentwithandwithlabralinvolvement(Bankart),SLAPtears,MDI,andposteriorinstability.

§ Eachdiagnosishasadistinctrecovery,however,theyallhaveasimilarbasicimbalanceofstaticanddynamicstability,creatingsymptomaticincreasedglenohumeraljointlaxity.• MDI-maydemonstrateincreasedside-to-sideglenohumeralinstabilityinmorethan

onequadrant,creatingasecondaryinvolvementofdynamicinstabilityfromoveractivityorsubstitutionpatternsfromtherotatorcuff,biceps,andscapularstabilizingmuscles.

- Patienttypicallypresentswithposteriorshoulderpain,especiallywithsagittalloading,andsubluxations.

- PatientEducation:Fromday1theirneedstobeongoingeducationandcommunicationwiththeathlete,(parentsifunder18orrequestedbypatient),MD,athletictrainers,coaches,andanyotherinvolvedparties,onprecautions,recommendationsforactivity,short-andlong-termprognosis,homeexercises,andlateroncriteriaforreturntoplay.

(860)549-8210•oahct.com

- SpecificInterventions:o ROM:thiswithbebasedonthetreatmentclassificationinthechartabove,however,initially

ROMisapriority,whetheryouarerestoringROMormaintainingfullROM.o MakesureyoutakeintoconsiderationthespecificsporttypicalROMchanges.(See

ConsiderationsofROMmeasurementswithOverheadAthletesSectionintheClinicalEvaluationpartoftheprotocol)

o Inadditiontostretching,athletestypicallyrespondtoavarietyoftechniquesforimprovingmobility,tissueextensibility,jointmobility,andROM.Beforeimplementingtechniques,clinicianshouldbeawareofwhichtissue(s)restrictioniscreatingthelossofROM.Inmanyinstancesacombinationoftechniquesismosteffective.Resultsfromfunctionalassessmentscanbeusedaswelltoguidetreatmentsandprogressionsaswellasotherevaluativefindings.

§ JointMobilizations(ifcapsulerestrictionspresent)GradesI-V• GradesI-II:typicallyfordecreasingpain• GradesIII-V:typicallyfordecreasingcapsularrestrictions.GradeVmobilizations,

thrusttypemanipulation,willmostlybeusedonthecervical,thoracic,lumbarspines,pelvis,andlowerextremitiestomaintain/achievealignmentforproperpostureandjointpositioning.

§ SoftTissueMobilization:MyofascialRelease(MFR),FrictionMassage(DFMorTFM),SoftTissueMassage(STM),MuscleEnergytechnique(MET),DryNeedlingTechnique,Grastonäorotherinstrumentationsofttissuereleasetechniques,ActiveReleaseä,etc.

§ Stretching:Theseshouldnotjustbecenteredontheshoulder.Cervical,thoracic,lumbar,hips,andlowerextremitiesshouldbeevaluatedfortissuerestrictionsandtreatedaccordingly.(SeeSpecificExerciseSheets)forsomeexamplesofexercises/stretches

o MuscleStretching/Retraining:Anyalterationsintiming,recruitment,andenduranceofmuscles

cancauseweaknessanddysfunctions,aswellasdecreaseathletemaximalforceoutputforperformingattheirsport.

§ Usethefindingsfromtheevaluationandtheirritabilityclassificationtodeterminewhenstrengthening/retrainingisbegun,whichmovements/musclesaretreated,andprogression.

§ Painfulunstableshoulderstypicallydemonstrateincreasedactivityintheprimemoversoftheshoulder;pectoralismajor/minor,longheadofthebiceps,deltoids,latisimussdorsianduppertrapezius.Thesearecompensatoryandprotectiveinnature.

§ Overheadathletesalsohaveatendencytopresentwithweaknessanddecreasedtiming/activationofserratusanterior,middle&lowertrapezius,androtatorcuffmusculature.Alterationswiththetiming/activationusuallyreflectanimbalancebetweentheshouldergirdlemusclesresponsibleforstabilizingthescapulothoracicandglenohumeraljoint,andtheprimemoversoftheshoulder.Thiscouldalsobefromjointdysfunctionofthethoracicand/orcervicalspine,aswellasribrotationsorscapularalteredposition.

§ Shoulderstabilizershouldbefacilitatedfirst,rotatorcuff,serratusanterior,andmiddle&lowertrapezius.Oncetheathleteisabletodemonstrategoodstabilization,theexercisescanswitchtofocusingonimprovingtimingandendurance.• Lowresistance(ifany)withhighrepetitionsallowsforre-integrationofmotor

patterns,aswellas,buildingupmuscleendurance.Emphasisisongoodform/motorcontrolandappropriatemusclefiring.

(860)549-8210•oahct.com

• Oncethepatientdemonstratesgoodmotorcontrol(absenceof;compensatorypatterns,scapularwinging,anddecreasedERwithelevation),andisabletoperform45-60repetitions,thenthedifficultyoftheexercisecanbeprogressedwithresistance,moreadvancedmovements/exercises,ortoexercisestomimicsport-specificfunctionalmovements.

- PositionalProgressions:§ Supine/side-lying/prone->quadruped->standing->balance/unstable

surface§ Planarmovements->diagonals->overhead->combinedmovements-

>sportspecificpositions§ Targetingindividualmuscles->combinedmuscleactivation->

movementpatterns->sport-specificmovementpatterns§ Noresistance->lightresistance(weights,bands,medicineballs,etc.)-

>heavierresistanceo KineticChainRestoration:Thisisparamounttobeingabletoperformasequential,multi-

segmental,totalbodymovement,alongwithaproductionoftorqueandforcetobeabletopropelaballorabodyforward.Thelegs,trunkandcoredevelopthepoweranditisultimatelytransferredfromthelegsandtrunkoftheathlete->throughthescapulohumeralstructures->tothearm,directingtheforceoutput,->totheball,racquet,bat,club,etc.

§ Restorationofthesepatternsiswheretheuseofthefunctionalassessmenttestshavethemostvalue:SFMAä,FMSä,Y-balanceä/CKCUEST,oranyothertools/teststhatassesfunctionalmovementpatternsthroughoutthebody

§ Thepatientshouldalsobeassessedforcoreactivationandbreathingtechnique.ThisneedstobeaddressedinitiallybecausetheycanaffectabilitytoimproveROM/tissueextensibility,UEandLEmovements,strengthening,stability,forceproduction,etc.• Breathingandcoreactivationshouldbeassessedinallpositions,withandwithout

performanceofexercises§ Basedontheresultsoftheassessments,hipsandpelvisandalltheassociatedstructures

shouldbethesecondaryfocusastheydirectlysupportcorestability§ Glutealmuscles(majorpowergeneratorsaswellasstabilizers),Hipabductors,adductor,

flexors,extensors,androtators§ Balanceandsingle-legstabilityisalsokeyforrestorationoftheentirekineticchain§ Lowerextremitiesfunctioningatanoptimallevelisakeytopropermechanicsallthe

wayupthekineticchainintheoverheadathlete.

- KeystoSuccessfulRehabilitationCriteria-BasedProgressiontobeabletoprogresspatienttoReturntoSpecificSportProtocolso FollowedexpectedpassiveROMforindividualathletes(comparedtototalarcofmotiononthe

non-involvedsideofthebody),andexpectedalterationsinshoulderROMs,bythesporttheathleteplays.Theseshouldberestoredpriortostrengthening.

o Painatrestshouldbeeliminatedbeforebeginningstrengthening(hypertrophy)orplyometricexercises

o ExpectedactiveROM,withnormalmovementpatterns,shouldberestoredbeforebeginninghypertrophystrengtheningorplyometricexercises

(860)549-8210•oahct.com

o Patientshouldbeabletodemonstratepain-freenormalmovementpatternsthroughmulti-planarmovements,with45-60repetitions(goodendurance),beforeprogressiontoeccentric,plyometric,and/orhighloadexercises

o Patientmustcompleteplyometricprogram(UE&LEifappropriate),Score³16ontheFMSä(withnoasymmetries,Y-Balanceäscoreshouldbeequaltopeersofthesameageandsportalongwithnoasymmetries,score_”no”-“mild”difficultyonallquestionsontheDASH(sports/Artsmodule),(orlow/nodisabilityonchosenselfevaluationassessment)

o Passingofthefunctionaltestslistedbelow:Testcanbeovermultiplesessionsii. TrunkTesting:(Seeattachedsheets)

1. DeepNeckFlexorTest2. SegmentalMultifidusTest3. TrunkCurl-upTest4. Double-LegLoweringTest5. ProneBridgeTest6. EnduranceofLateralFlexors(SideBridge)7. ExtensorDynamicEnduranceTest

iii. UpperExtremityTesting:(Seeattachedsheets)1. AlternativePull-upTest2. Push-upTest3. BackwardOverheadMedicineBallThrowTest4. SidearmMedicineBallThrowTest5. SeatedShot-PutThrowTest

iv. FunctionalLowerExtremity(Strength/Power,Agility/Quickness,ifneeded)v. *Ifpatientisabaseballorsoft-ballpitcher/player

1. FunctionalThrowingPerformanceIndex(FTPI)Test-bestassessedwithvideoanalysis2. Baseballpitchersonly-PT/ATCfillsoutUpperExtremityThrowingAnalysisForm-to

determineareasofthethrowingmotionthatneedtobeaddressedinthesportspecific/returntobaseballpitchingprotocol

• SeeReturntoSpecificSportProtocols

(860)549-8210•oahct.com

References

Bahk,Metal.LaxityTestingoftheShoulder.TheAmericanJournalofSportsMedicine.2007;35(1):131-144Barthetal.DiagnosisofSubscapularisTendonTear:AreAvailableDiagnosticTestsPertinentforaPositiveDiagnosis?.Orthopaedics&Traumatology:Surgery&Research.2012;98S:S178-S185Barthetal.TheBear-HugTest:ANewandSensitiveTestforDiagnosingaSubscapularTear.TheJournalofArthroscopicandRelatedSurgery.2006;22(10):1076-1084Bookhout,M,Chase,L.ExercisePrescriptionasacomplementtoManualMedicine(coursemanual).MichiganStateUniversityCollegeofOsteopathicMedicine.2013Braun,S,Kokmeyer,D,andMillett,J.ShoulderinjuriesintheThrowingAthlete.TheJournalofBone&JointSurgery.2009;91(4):966-978Brumitt,J.Scapular-StabilizationExercises:Early-InterventionPrescription.AthleticTherapyToday.2006;11(5):15-18

(860)549-8210•oahct.com

Carteretal.EffectsofHighvolumeUpperExtremityPlyometricTrainingonThrowingVelocityandfunctionalStrengthRatiosoftheShoulderRotatorsinCollegiateBaseballPlayers.TheJournalofStrengthandConditioningResearch.200721(1):208-215Chang,W.ShoulderImpingementSyndrome.PhysicalMedicineandRehabilitationClinicsofNorthAmerica.2004;15:493-510Chorbaetal.UseofaFunctionalMovementScreeningTooltoDetermineInjuryRiskinFemaleCollegiateAthletes.NorthAmericanJournalofSportsPhysicalTherapy.2010;5(2):47-54Cook,Gray.Movement:FunctionalMovementSystems:Screening,Assessment,andCorrectivestrategies.Aptos,CA:OnTargetPublications,2010Coolsetal.RehabilitationofScapularMuscleBalance:WhichExercisestoPrescribe?.TheAmericanJournalofSportMedicine.2007;35(10):1774-1751Coughlanetal.AComparisonBetweenPerformanceonSelectedDirectionsoftheStarExcursionBalanceTestandtheYBalanceTest.TheJournalofAthleticTraining.2012;47(4):366-371Curtis,T,Roush,J.TheLateralScapularSlideTest:AreliabilityStudyofMaleswithandWithoutShoulderPathology.NorthAmericanJournalofSportsPhysicalTherapy.2006;1(3):140-146Davies,GJ,Ellenbecker,TS,Bridell,D.Poweringup:PlyometricsRedefineRehabforOverheadAthletes.BioMechanics.September2002Deckeretal.SerratusAnteriorMuscleActivityDuringSelectedRehabilitationExercises.TheAmericanJournalofSportsMedicine1999;27(6):784-791Dessaur,W,Magarey,M.DiagnosticAccuracyofClinicalTestsforSuperiorLabralAnteriorPosteriorLesions:ASystematicReview.JournalofOrthopaedicandSportsPhysicalTherapy.2008;38(6):341-352DeMeyetal.TrapeziusMuscleTimingDuringSelectedShoulderRehabilitationExercises.JournalofOrthopaedic&SportsPhysicalTherapy.2009;39(10):743-752Dodson,C,Altchek,D.SLAPLesions:AnUpdateonRecognitionandTreatment.TheJournalofOrthopaedic&SportsPhysicalTherapy.2009;39(2):71-80Economopoulos,K,Brockmeier,S.RotatorCuffTearsinOverheadAthletes.TheJournalofClinicalSportsMedicine.2012;675-692Ekstrometal.SurfaceElectromyographicAnalysisofExercisesfortheTrapeziusandSerratusAnteriorMuscles.JournalofOrthopaedic&SportsPhysicalTherapy.2003;33(5):247-258Eisneretal.PartialRotatorCuffTearsinAdolescents:FactorsAffectingOutcomes.TheJournalofPediatricOrthopaedics.2013;33(1):2-7

(860)549-8210•oahct.com

Ellenbecker,T,&Bailey,L.EvaluationoftheThrowingAthlete’sShoulder(APTASportsPhysicalTherapySection:homestudycourse;chapter1)2013Ellenbeckeretal.GlenohumeralJointTotalRotationRangeofMotioninEliteTennisPlayersandBaseballPitchers.Medicine&ScienceinSports&Exercise.2002:2052-2056Escamillaetal.ShoulderMuscleActivityandfunctionincommonshoulderRehabilitationExercises.SportsMedicine.2009;39(8):663-685Filipaetal.NeuromuscularTrainingImprovesPerformanceontheStarExcursionBalanceTestinYoungFemaleAthletes.JournalofOrthopaedic&SportsPhysicalTherapy.2010;40(9):551-558Forbush,S,White,D,Smith,W.TheComparisonoftheEmptyCanandtheFullCanTechniquesandaNewDiagonalHorizontalAdductionTestforSupraspinatusMuscleTestingUsingCross-SectionalAnalysisThroughUltrasonography.TheInternationalJournalofSportsPhysicalTherapy.2013;8(3):237-247Fortun,CM,Davies,GJ,Kernozek,TW.TheEffectsofPlyometricTrainingontheShoulderInternalRotators.PhysicalTherapyJournal.1998;78(51):63-75Gelen,Eetal.AcuteEffectsofStaticStretching,DynamicExercises,andHighVolumeUpperExtremityPlyometricActivityonTennisServePerformance.JournalofSportsScience&Medicine.2012;11:600-605Gillooly,J,Chidambaram,R,Mok,D.TheLateralJobeTest:AMoreReliableMethodofDiagnosingRotatorCuffTears.InternationalJournalofShoulderSurgery.2010;4(2):41-43Gormanetal.UpperQuarterYBalanceTest:ReliabilityandPerformanceComparisonBetweenGendersinActiveAdults.TheJournalofStrengthandConditioningResearch.2012:26(11):3043-3048Goulbourne,S.Sports-RelatedInjuriesintheYoungAthlete(coursemanual).CrossCountyEducation.2011.Greis,Petal.ValidationoftheLift-OffTestandAnalysisoftheSubscapularisActivityDuringMaximalInternalRotation.1996;24(5):589-593Hegedusetal.PhysicalExaminationTestsoftheShoulder:ASystematicReviewwithMeta-AnalysisofIndividualTests.BritishJournalofSportsMedicine.2008;42:80-92Hegedusetal.WhichPhysicalExaminationTestsProvideClinicianswiththeMostValueWhenExaminingtheShoulder?UpdateofaSystematicReviewwithMeta-AnalysisofIndividualTests.BritishJournalofSportsMedicine.2012;46:964-978Hoogenboom,Betal.UsingRollingtoDevelopNeuromuscularControlandCoordinationoftheCoreandExtremitiesofAthletes.NorthAmericanJournalofSportsPhysicalTherapy.2009;4(2):70-82

(860)549-8210•oahct.com

Itoi,Eetal.WhichisMoreUseful,the“FullCanTest”orthe“EmptyCanTest”,inDetectingtheTornSupraspinatusTendon?.TheAmericanJournalofSportsMedicine.1999;27(1):65-68Jainetal.ClinicalExaminationoftheRotatorCuff.TheAmericanAcademyofPhysicalMedicineandRehabilitation.2013;5:45-56Jungetal.EffectsofScapularStabilizingExercisesinPatientswithPartial-ThicknessRotatorCuffTear.JournalofPhysicalTherapyScience.2012;24:1173-1175Kuhn,J.ExerciseintheTreatmentofRotatorCuffImpingement:ASystematicReviewandaSynthesizedEvidenced-BasedRehabilitationProtocol.JournalofShoulderandElbowSurgery.2009;18:138-160Liebleretal.TheEffectsofThoracicSpineMobilizationonLowerTrapeziusStrengthTesting.TheJournalofManual&ManipulativeTherapy.2001;9(4):207-212Lunden,Jetal.ReliabilityofShoulderInternalRotationPassiveRangeofMotionMeasurementsintheSupineVersusSidelyingPosition.JournalofOrthopaedic&SportsPhysicalTherapy.2010;40(9):589-594Maenhoutetal.QuantifyingAcromiohumeralDistanceinOverheadAthleteswithGlenohumeralInternalRotationLossandtheInfluenceofaStretchingProgram.TheAmericanJournalofSportsMedicine.2012;40(9):2105-2112Maffet,M,Gartsman,G,Moseley,B.SuperiorLabrum-BicepsTendonComplexLesionsoftheShoulder.TheAmericanJournalofSportsMedicine.1995;23(1):93-98.McClureetal.AClinicalMethodforIdentifyingScapularDyskinesis,Part1:Reliability.JournalofAthleticTraining.2009;44(2):160-164Mey,etal.TrapeziusMuscleTimingDuringSelectedShoulderRehabilitationExercises.JournalofOrthopaedic&SportsPhysicalTherapy.2009;39(10):743-752Minicketal.InterraterReliabilityoftheFunctionalMovementScreen.TheJournalofStrengthandConditioningResearch.2010;24(2):479-486Moore,Letal.KinematicAnalysisofFourPlyometricPush-upVariations.InternationalJournalofExerciseScience.2012;5(4):334-343Mooreetal.TheImmediateEffectsofMuscleEnergyTechniqueonPosteriorShoulderTightness:ARandomizedControlledTrial.JournalofOrthopaedic&SportsPhysicalTherapy.2011;41(6):400-407Myeretal.AUser’sGuidetoPerformanceoftheBestShoulderPhysicalExaminationTests.BritishJournalofSportsMedicine.2013;47:903-907

(860)549-8210•oahct.com

Myers,J,Lephart,S.TheroleoftheSensorimotorSystemintheAthleticShoulder.TheJournalofAthleticTraining.2000;35(3):351-363Myers,T,Zemanovic,J,Andrews,J.TheResistedSupinationExternalRotationTest:ANewTestfortheDiagnosisofSuperiorLabralAnteriorPosteriorLesions.TheAmericanJournalofSportsMedicine.2005;33(9):1315-1320Negreteetal,CanUpperExtremityFunctionalTestsPredicttheSoftballThrowforDistance:ApredictiveValidityInvestigation.TheInternationalJournalofSportsPhysicalTherapy.2011;6(2):104-111Okoro,T,Reddy,V,Pimpelnarkar.CoracoidImpingementSyndrome:AliteratureReview.CurrentReviewofMusculoskeletalMedicine.2009;2:51-55Onateetal.real-TimeIntersessionandInterraterReliabilityoftheFunctionalMovementScreen.TheJournalofStrengthandConditioningResearch.2012;26(2):408-415Papadonikolakis,Aetal.PublishedEvidenceRelevanttotheDiagnosisofImpingementSyndromeoftheShoulder.TheJournalofBoneandJointSurgery.2011;93:1-6Pliskyetal.TheReliabilityofanInstrumentedDeviceformeasuringComponentsoftheStarExcursionBalanceTest.NorthAmericanJournalofSportsPhysicalTherapy.2009;4(2):92-99Powell,S,Nord,K,Ryu,R.TheDiagnosis,Classification,andTreatmentofSLAPLesions.OperativeTechniquesinSportsMedicine.2004;12(2):99-110Pretz,R.PlyometricExercisesfortheOverhead-ThrowingAthletes.TheStrengthandConditioningJournal.2006;28(1):36-42Reiman,M,&Manske,R.FunctionalTestinginHumanPerformance.Campaign,IL:HumanKinetics,2009Reinhold,M,Gill,T.CurrentConceptsintheEvaluationandTreatmentoftheShoulderinOverheadThrowingAthletes,Part1:PhysicalCharacteristicsandClinicalExamination.SportHealth.2010;2(1):39-50Reinholdetal.CurrentConceptsintheEvaluationandTreatmentoftheShoulderinOverheadThrowingAthletes,Part2:InjuryPreventionandTreatment.SportHealth.2010;2(2):101-115Reinholdetal.ElectromyographicAnalysisoftheRotatorCuffandDeltoidMusculatureDuringCommonShoulderExternalRotationExercises.TheJournalofOrthopaedic&SportsPhysicalTherapy.2004;34(7):385-394Rigsby,R,Sitler,M,Kelly,J.SubscapularisTendonIntegrity:AnExaminationofShoulderIndexTests.JournalofAthleticTraining.2010;45(4):404-406

(860)549-8210•oahct.com

Scheibeletal.TheBelly-OffSign:ANewClinicalDiagnosticSignforSubscapularisLesions.TheJournalofArthroscopicandRelatedSurgery.2005;21(10):1229-1235Schneidersetal.FunctionalMovementScreenNormativeValuesinaYoungActivePopulation.TheInternationalJournalofSportsPhysicalTherapy.2011;6(2):75-82Shah,S.PlyometricExercises.InternationalJournalofHealthSciencesandResearch.2012;2(1):115-126Snyderetal.SLAPLesionsoftheShoulder.Arthroscopy.1990;4:243-279Strunceetal.TheimmediateEffectsofThoracicSpineandRibManipulationonSubjectswithPrimaryComplaintsofShoulderPain.TheJournalofManual&ManipulativeTherapy.2009;17(4):230-236Swaniketal.TheEffectsofShoulderPlyometricTrainingonProprioceptionandSelectedMusclePerformanceCharacteristics.JournalofShoulderandElbowSurgery.2002;11(6):579-586Tashijan,R.Epidemiology,NaturalHistory,andIndicationsforTreatmentofRotatorCuffTears.ClinicalSportsMedicine.2012;31:589-604Tateetal.EffectoftheScapularRepositionTestonShoulderImpingementSymptomsandElevationStrengthinOverheadAthletes.TheJournalorOrthopaedic&SportsPhysicalTherapy.2008;38(1):4-11Tateetal.AClinicalMethodforIdentifyingScapularDyskinesis,Part2:Validity.JournalofAthleticTraining.2009;44(2):165-173Teyhenetal.TheFunctionalMovementScreen:AReliabilityStudy.JournalofOrthopaedic&SportsPhysicalTherapy.2012;42(6):530-540Thigpen,C,Jenk,D.Non-OperativeManagementoftheAthleticShoulder.(APTASportsPhysicalTherapySection:homestudycourse;chapter2)2013Uhletal.EvaluationofClinicalAssessmentMethodsforScapularDyskinesis.TheJournalofArthroscopicandRelatedSurgery.2009;25(11):1240-1248Voight,M,Hoogenboom,H,Cook,G.TheChopandLiftReconsidered:IntegratingNeuromuscularPrinciplesintoOrthopedicandSportsRehabilitation.NorthAmericanJournalofSportsPhysicalTherapy.2008;3(3):151-159Westricketal.ExplorationoftheY-BalanceTestforAssessmentoftheUpperQuarterClosedKineticChainPerformance.TheInternationalJournalofSportsPhysicalTherapy.2012;7(2):139-147Wilketal.GlenohumeralInternalRotationMeasurementsDifferDependingonStabilizationTechniques.SportsHealth.2009;1(2):131-136

(860)549-8210•oahct.com

Wilketal.CurrentConceptsintheRecognitionandTreatmentofSuperiorLabral(SLAP)Lesions.TheJournalofOrthopaedic&SportsPhysicalTherapy.2005;35(5):273-291Wilketal.TheRecognitionandTreatmentofSuperiorLabral(SLAP)LesionsintheOverheadAthlete.TheInternationalJournalofSportsPhysicalTherapy.2013;8(5):579-600Wilk,K,Arrigos,C.CurrentConceptsintheRehabilitationoftheAthleticShoulder.JournalofOrthopaedic&SportsPhysicalTherapy.1993;18(1):365-378Wilk,K,Hooks,T,Macrina,L.TheModifiedSleeperStretchandModifiedCross-bodyStretchtoIncreaseShoulderInternalRotationRangeofMotionintheOverheadThrowingAthlete.JournalofOrthopaedic&SportsPhysicalTherapy.2013;43(12):891-894Wilk,KE,Meister,K,Andrews,JR.CurrentConceptsintheRehabilitationoftheOverheadThrowingAthlete.TheAmericanJournalofSportsMedicine.2002;30(1):136-151Wilketal.ShoulderInjuriesintheOverheadAthlete.JournalofOrthopaedic&SportsPhysicalTherapy.2009;39(2):38-54