Structural Injury to the Rotator Cuff

Although traumatic tears of the rotator cuff have been reported even in children, structural injury to the cuff is most characteristic in those older than age 40 years. Rotator cuff tears are so characteristic of the elderly population that anyone older than age 60 with shoulder pain can be presumed to have a rotator cuff tear until proved otherwise. Younger patients with cuff symptoms tend to have only irritation of the rotator cuff (tendinosis) rather than structural injury, with their pathology and symptoms frequently being the secondary manifestation of occult primary pathology such as glenohumeral instability, tears of the superior labrum, scapulothoracic dyskinesia, core stability deficits, or poor biomechanics.

Rotator cuff pathology may be of insidious onset, but it is most often produced by a traumatic event or acute overuse, particularly with an abduction/external rotation mechanism. In the elderly, rotator cuff tears frequently occur during falls. Night pain is characteristic of primary rotator cuff pathology and may be severe enough to prevent sleep or awaken the patient from sleep if she or he rolls onto the affected shoulder. Patients with cuff disease find relief by placing the affected arm overhead with the hand behind the head (the so-called Saha position). Pain is minimal with use of the arm below breast level and is maximal between 90 and 120 degrees of active elevation/abduction. Lowering the arm from the overhead position is often more painful than raising it. Patients may describe crepitus, which is associated with chronic full-thickness cuff tears or thickening of the cuff during chronic tendinosis and scarring of the subacromial space.

Pain is localized to the subacromial area or the anterior/lateral corner of the acromion, with radiation down the lateral arm to the vicinity of the deltoid insertion. The pain is characteristically of a dull aching quality, with the superimposition of a sharper stabbing pain with use of the arm in the overhead position or with internal rotation. Rotator cuff pain does not radiate distal to the elbow.

Rotator cuff pain is characteristically mitigated by anti-inflammatory medications, especially subacromial corticosteroid injections, but with diminishing returns over time.

Glenohumeral Instability

Glenohumeral instability is the most common underlying pathology producing shoulder symptoms in patients younger than 30 years of age. In children and teenagers, it is virtually the only likely pathology. In the elderly population, instability is associated with massive rotator cuff tears. In many instances, the symptoms reflective of glenohumeral instability had a traumatic origin of which the patient is aware. Apprehension with use of the arm in a specific position is a subjective sign of instability, but it is important to keep in mind that a great many patients with glenohumeral instability have no subjective awareness of that fact.

When the diagnosis of instability is suspected, an important goal when taking the history is to ascertain: (1) the degree of instability (subluxation versus dislocation), (2) the onset (traumatic versus atraumatic or overuse), (3) the direction or directions of instability (anterior, posterior, or multidirectional), and (4) whether there is a voluntary component.

The most common direction of instability, whether traumatic or occult, is anterior/inferior. The direction of instability can be determined during the history with specific questions related to the arm position that produces symptoms: external rotation, with or without abduction reflects an anterior/inferior laxity pattern (e.g., pain with the cocking position during throwing). Pain during the follow through when throwing or during activities that position the arm in forward flexion/adduction/internal rotation suggests posterior instability. Pain that is associated with activities that apply primarily inferior distraction force to the shoulder, such as carrying a heavy object like a suitcase or a pail of water, suggests inferior capsular laxity and multidirectional instability.

Subtle glenohumeral instability is associated with a nondescript level of discomfort and diffuse pain about the shoulder girdle. The discomfort is characteristically poorly localized and may be scapular and at the posterior joint line, or anterior subacromial mimicking rotator cuff discomfort. Often patients will relate that use of the arm overhead produces numbness and tingling radiating down the arm without a specific dermatomal distribution. This is known as the “dead arm syndrome.” A history of repetitive microtrauma, such as participation in swimming or throwing sports, without proper pre-participation conditioning is characteristically present when atraumatic glenohumeral instability produces symptoms in teenage athletes. Although labral pathology is often associated with glenohumeral instability, its presence cannot generally be predicted by specific questions during the history.

If occult glenohumeral instability was not recognized, there are associated deficits in scapulothoracic function and core stability, or poor technique was not adequately addressed during treatment, there may be a history of failed medication use, rehabilitation, or surgery.

Detachment of the Superior Glenoid Labrum

Tears of the glenoid labrum (i.e., SLAP lesion) do not generally produce unique primary symptoms that distinguish the pathology. Patients may describe pain generally located in the posterior shoulder or “deep inside” the joint. Large labral tears may produce “clicking” or “catching” sensations. Characteristically, they produce secondary rotator cuff symptoms or are associated with a history suggestive of glenohumeral instability. Patients often relate a history of trauma, such as a fall onto an outstretched hand, or a history of longstanding participation in an overhead throwing sport (the “peel-off” lesion associated with a tight posterior capsule).

Scapulothoracic Dyskinesia, Core Stability Deficits, and Other Fitness or Technique-Related Provocations

Scapulothoracic dyskinesia, core stability deficits, and other fitness issues commonly contribute to shoulder symptoms as a result of secondary irritation of the rotator cuff or other muscle–tendon units resulting from biomechanical overload. There is frequently a history of the atraumatic insidious onset of shoulder pain associated with participation in a new recreational or occupational activity.

Adhesive Capsulitis (“Frozen Shoulder”)

The typical “frozen shoulder” is not caused by trauma, although patients will often retrospectively recall some history of minor injury to which they ascribe the symptoms. Characteristically, patients first recognize the problem when they find it difficult to reach behind their back (secondary to an evolving internal rotation deficit). Symptoms are progressive, with “freezing,” “frozen,” and “thawing” stages having been defined to describe the natural history of the problem. Frequently, secondary rotator cuff pain will account for a substantial portion of the subjective symptoms. Patients may also describe posterior shoulder discomfort with a trapezius or periscapular location because those muscles become fatigued when compensating for poor glenohumeral motion. There is a significant association with diabetes and hypothyroidism, and patients should be questioned about those general health conditions. Adhesive capsulitis occurs bilaterally in this group.

Calcific Tendinitis

Calcific tendinitis is characterized by the insidious, but rapid, development of extremely severe subacromial or lateral-sided shoulder pain, characteristically in patients of middle age. Narcotics are often necessary to control the discomfort.

Biceps Tendinosis

With advancing age, pathology in the long head of the biceps becomes a frequent source of pain in the shoulder. Biceps tendinosis is often associated with rotator cuff disease. However, pain originating in the biceps is referred to the anterior arm, as opposed to cuff disease, which is characteristically lateral. It may radiate to the elbow but not typically beyond. Because the biceps is a supinator of the forearm, patients with biceps pathology may complain of symptoms related to rotation of the forearm (i.e., when turning a doorknob).

Acromioclavicular Degenerative Joint Disease

The symptom originating from the AC joint most typically is pain over the superior shoulder that increases with horizontal adduction of the arm toward the opposite side (because that compresses the AC joint) or use of the affected arm high overhead. Injury to the AC joint can occur with a fall onto the lateral shoulder, AC joint arthritis can develop insidiously over a lifetime of use or from prior trauma, and an inflammatory condition known as “osteolysis of the distal clavicle” is associated with weight lifting in young adults. AC joint disease may produce scapulothoracic dyskinesia and secondary rotator cuff discomfort.

Glenohumeral Degenerative Joint Disease

Glenohumeral arthritis is an uncommon condition producing generalized aching shoulder pain and progressive loss of motion. GH arthritis may be associated with a history of previous surgical procedures (open ligament stabilization, arthroscopic repair of large labral tears, and the use of implantable “pain pumps”) and massive rotator cuff tears (cuff tear arthropathy), particularly in elderly women. Symptoms are often maximal at night and more tolerable during daily activities. Systemic rheumatoid arthritis may affect the glenohumeral joint, but particularly in younger individuals, it involves the AC or SC joints.

Cervical Spine Pathology

Cervical spine disease typically produces pain radiating from the neck toward the posterior or superior shoulder. The pain is usually worse at the end of the day and relieved by support of the head at night. Generally, patients will experience pain and stiffness with neck motion. Especially in the elderly, a coincident association with rotator cuff disease is common. When cervical nerve root compression is present, most commonly C5 and C6 are affected, and radicular symptoms (“sharp,” “stabbing,” or “burning pain”) involving the forearm and hand radiate distal to the elbow in a typical dermatomal distribution.

Fractures

Fractures about the shoulder are not uncommon in all age groups. Typically, there is a specific history of trauma, but in the osteoporotic elderly or other special situations, the injury may seem to be of minimal force. The mechanism may be direct (a fall or blow to the shoulder) or indirect (a fall on an outstretched arm). Characteristically, pain is immediate after trauma, localized to the specific point of injury, and severe enough to leave little doubt as to the nature of the problem. Diagnosis is confirmed by radiographs.

Range of Motion

Once the intake evaluation is completed, the therapist should be more comfortable anticipating the patient’s response to the therapeutic regimen. One of the main keys to recovery is to normalize motion. Early professions relied on visual estimations or “quick” tests to assess shoulder motion. These tests include combined shoulder movements such as the Apley’s scratch test (Fig. 3-3), reaching across the body to the other shoulder (Fig. 3-4), or reaching behind the back to palpate the highest spinous process (Fig. 3-5). These quick tests are great to observe for overall asymmetry, but they cannot give an idea of isolated losses objectively.

Figure 3-3 Apley’s scratch test.

Figure 3-4 Reaching across the body to the other shoulder to determine range of motion.

Figure 3-5 Reaching behind the back to palpate the highest spinous process to determine range of motion.

Even more important is regaining normal arthrokinematic motions at the shoulder. Active shoulder range of motion is always gathered before passive motions (Manske and Stovak 2006). Active shoulder ROM is seen in Table 3-3 (Manske and Stovak 2006). Many times, gross overall shoulder motion may only appear to be slightly limited, whereas arthrokinematic motion is drastically dysfunctional. For example, it is not uncommon for a patient to have full glenohumeral motion, yet impinge as a result of altered scapulohumeral motion from a restricted inferior or posterior shoulder capsule creating obligate humeral translations.

Therefore, it is imperative to also ensure evaluation of isolated glenohumeral motions is performed. One of the more common problematic limited motions with a variety of shoulder conditions is that of the posterior or inferior shoulder structures. Debate continues as to whether this is a result of capsular or other soft tissues. Regardless, it becomes an issue whenever elevation of the glenohumeral joint is required because it may increase the risk of impingement. Assessment of the posterior shoulder can be done by measuring isolated glenohumeral internal rotation. To perform this test the humerus is taken into passive internal rotation while the scapular is stabilized by grasping the coracoid process and the spine and monitoring for movement (Fig. 3-6). When passive slack from the posterior shoulder is taken up, the humerus will no longer internally rotate or resistance to movement will allow the scapula to tilt forward. When motion is detected or internal rotation has ceased, the examiner measures isolated glenohumeral internal rotation. Wilk et al. (2009) have shown this to be moderately reliable, whereas Manske et al. using the same technique have proved excellent test–retest reliability (Manske et al. 2010). This motion should be compared bilaterally to assess for a deficit between involved and uninvolved shoulders. A difference of greater than 20 degrees of internal rotation is thought to be a precursor to shoulder pathology. Loss of shoulder internal rotation is not always pathologic because some of this motion may be lost as a result of bony changes in the humerus. The concept of total shoulder rotation ROM should also be mentioned. By adding the two numbers of GH internal rotation and external rotation together, a composite of total shoulder motion can be obtained (Fig. 3-7). Ellenbecker et al. (2002), measuring bilateral total rotation range of motion in professional baseball and elite junior tennis players, found that although a dominant arm may show increased external rotation and less internal rotation, the total ROM was not significantly different when comparing the two shoulders. Therefore, one needs to not only address the internal rotation loss, but also should ensure that the total range of motion is not limited. Using normative data from population specific research can assist the therapist in interpreting normal range of motion patterns and identify when sport-specific adaptations or clinically significant adaptations are present (Ellenbecker 2004).

Figure 3-6 Assessment of the posterior shoulder performed by measuring isolated glenohumeral internal rotation.

Figure 3-7 Total rotation range of motion concept.

(Redrawn from Ellenbecker TS. Clinical Examination of the Shoulder. Saunders, St. Louis, 2004, p. 54.)

Soon after soft tissue shoulder repairs passive motion may predominate. These passive ranges can be performed using Codman circumduction exercises, or passive motion can be gained by working with the therapist. Passive motions can be gained in all classical directions as long as there are no soft tissue limitations that need to be abided by. Other methods of gaining motion are through joint mobilizations from the therapist.

Passive and active assistive exercises initially begin with the patient in a supine position with the arm comfortably at the side with a small towel roll or cushion under the elbow and the elbow flexed. This position reduces the forces crossing the shoulder joint by decreasing the effect of gravity and shortening the lever arm of the upper extremity. As the patient begins to recover pain-free motion, the exercises can be progressed to sitting or standing.

Once active motion can be initiated, the patient is encouraged to work early on pain-free ranges below 90 degrees of elevation. For most patients an early goal is 90 degrees of forward flexion and approximately 45 degrees of external rotation with the arm at the side. For surgical patients, it is the responsibility of the surgeon to obtain at least 90 degrees of stable elevation in the operating room for the therapist to be able to gain this same motion after surgery. At this point in rehabilitation, methods to gain motion include active-assisted range of motion with wands or pulleys, passive joint mobilization, and passive stretching exercises (Figs. 3-8 and 3-9).

Figure 3-8 Exercises to regain motion. Active-assisted range of motion exercises using a pulley system (A) and a dowel stick (B).

Figure 3-9 Passive joint mobilization. A, Forward flexion. B, External rotation with the arm at the side. C, External rotation with the arm in 90 degrees of abduction. D, Cross-body adduction.

Pain Relief

Both shoulder motion and strength can be inhibited by pain and swelling, with pain being the major deterrent. Pain can be the result of the initial injury or from surgical procedures attempting to repair/replace the injured tissue. Pain relief can be achieved by a variety of modalities including rest, avoidance of painful motions (e.g., immobilization; Fig. 3-10), cryotherapy, ultrasound, galvanic stimulation, and oral or injectable medications (Fig 3-11). Previous literature substantiates that continuous cryotherapy following surgical procedures results in immediate and continued cooling of both subacromial space and glenohumeral joint temperatures (Osbahr et al. 2002) and decreases the severity and frequency of pain, which allows more normal sleep patterns and increases overall postoperative shoulder surgery comfort and satisfaction (Singh et al. 2001, Speer et al. 1996).

Figure 3-10 Immobilization of the shoulder for pain relief.

Figure 3-11 Modalities for pain relief. A, Ultrasound. B, Galvanic stimulation. C, Cryotherapy.

Muscle Strengthening

Appropriate timing for initiation of muscle strengthening exercises during shoulder rehabilitation is completely dependent on the diagnosis. A simple uncomplicated impingement syndrome may be able to commence strengthening exercises on day 1, whereas a postoperative rotator cuff repair may require up to 10 weeks before initiation of strengthening of the cuff, allowing the repaired tendon time to heal securely to bone of the greater tuberosity. Strengthening of the muscles around the shoulder can be accomplished through different exercises. Basic safe exercises include isometrics (Fig. 3-12), and closed kinetic chain exercises (Figs. 3-13 and 3-14). The advantage of closed chain exercises is a co-contraction of both the agonist and the antagonist muscle groups that help enhance stability of the glenohumeral joint. This co-contraction closely replicates normal physiologic motor patterns and function to help stabilize the shoulder and limit abnormal and potentially destructive shear forces crossing the glenohumeral joint. A closed chain exercise for the upper extremity is one in which the distal segment is stabilized against a fixed object. During shoulder exercises this stable object may be a wall, door, table, or floor. One example of a closed-kinetic-chain exercise used in an elevated, more functional position is the “clock” exercise in which the hand is stabilized against a wall or table (depending on the amount of elevation allowed) and the hand is rotated to different positions of the clock face (Fig. 3-13). This is done by creating an isometric contraction in the direction of the numbers around the clock face. Alternatively, the therapist can also give manual resistance in the same directions to the patient’s arm as they are stabilizing it by holding on to the wall (Fig. 3-14). These motions are thought to effectively stimulate rotator cuff activity. Initially, the maneuvers are done with the shoulder in less than 90 degrees of abduction or flexion. As healing tissues improve and motion is recovered, strengthening progresses to greater amounts of abduction and forward flexion.

Figure 3-12 Closed chain shoulder exercises. A, Isometric strengthening of the rotator cuff in abduction (pushing out against the wall). B, Isometric strengthening of the rotator cuff in external rotation.

Figure 3-13 Wall clock exercise.

Figure 3-14 Wall clock exercise with manual resistance.

Isometric exercises can also be performed in various ranges of shoulder elevation. It is easiest to do this with the patient in supine. The “balance position” is that of 90 to 100 degrees of forward flexion of the shoulder while supine (Fig. 3-15). This position requires little activation of the deltoid so that the rotator cuff can be worked without provoking a painful shoulder response. In this position a contraction from the deltoid will result in joint compression, helping to enhance joint stability. Rhythmic stabilization or alternating isometric exercises can be performed very comfortably in the supine position and can be done for both rotator cuff and shoulder muscles.

Figure 3-15 The “balance position” is that of 90 to 100 degrees of forward flexion of the shoulder while supine.

Strengthening of scapular stabilizers is important early on in the rehabilitation program. Scapular strengthening can begin in side lying with isometrics or isotonics or closed chain (Fig. 3-16) and progress to open-kinetic-chain exercises (Fig. 3-17).

Figure 3-16 Closed chain strengthening exercises of the scapula stabilizers. A, Scapular protraction. B and C, Scapular retraction.

Figure 3-17 Open chain strengthening exercises of the scapula stabilizers without (A–D) and with (E–H) lightweight dumbbells.

Recovery can be enhanced by utilizing proprioceptive neuromuscular facilitation (PNF) exercises. The therapist can apply specific sensory inputs to facilitate a specific activity or movement pattern. One example of this is the D2 flexion–extension pattern for the upper extremity. During this maneuver, the therapist applies resistance as the patient moves the arm through predetermined patterns. These exercises can be done in various levels of shoulder elevation including 30, 60, 90, and 120 degrees of elevation. These exercises are to enhance the stability of the glenohumeral joint through a given active range of motion (AROM).

As the patient progresses, more aggressive strengthening can be instituted by moving from isometric and closed-chain exercises to those that are more isotonic and open chain in nature (Fig. 3-18). Open chain exercises are done with the distal end of the extremity no longer stabilized against a fixed object. This results in the potential for increased shear forces across the glenohumeral joint. Shoulder internal and external rotation exercises are done initially standing or seated with the shoulder in the scapular plane. The scapular plane position is recreated with the shoulder between 30 degrees and 60 degrees anterior to the frontal plane of the thorax, or halfway between directly in front (sagittal plane) and directly to the side (frontal plane). The scapular plane is a much more comfortable plane to exercise in because it puts less stress on the joint capsule and orients the shoulder in a position that more closely represents functional movement patterns. Rotational exercises should begin with the arm comfortably at the patient’s side and advance to 90 degrees based on the patient’s injury, level of discomfort, and stage of soft tissue healing. The variation in position positively stresses the dynamic stabilizers by altering the stability of the GH joint from maximum stability with the arm at the side to minimum stability with the arm in 90 degrees of abduction.

Figure 3-18 Open chain isotonic strengthening of the rotator cuff (internal rotation) using Theraband tubing (A), lightweight dumbbells (B), and external rotation strengthening (C).

For those who participate in either competitive or recreational overhead sporting activities, the most functional of all open-chain exercises are plyometric exercises. Plyometric activities are defined by a stretch-shortening cycle of the muscle tendon unit. This is a component of almost all athletic activities. Initially the muscle is eccentrically stretched and loaded. Following the stretched position the shoulder/arm quickly performs a concentric contraction. These forms of exercises are higher level exercises that should only be included once the patient has developed an adequate strength base and achieved full ROM. Not all patients require plyometric training, and this should be discussed before their incorporation. Plyometric exercises are successful in development of strength and power. Theraband tubing, medicine ball training, or free weights are all acceptable plyometric devices for the shoulder (Fig. 3-19).

Figure 3-19 Plyometric shoulder strengthening exercises using Theraband tubing (A) and an exercise ball (B).

Nothing is more important when rehabilitating the shoulder than remembering the musculature of the upper extremity and core. Total arm strengthening is a must when rehabilitating the shoulder because injuries to the shoulder that limit normal functional movement patterns and use will result in strength deficits of other upper extremity muscles. Overall conditioning including stretching, strengthening, and endurance training of the other components of the kinematic chain should be performed simultaneously with shoulder rehabilitation.

Patient motivation is a critical component of the rehabilitation program. Without self-motivation, any treatment plan is destined to fail. For complete recovery, most rehabilitation protocols will require the patient to perform some of the exercises on his or her own at home. This requires not only an understanding of the maneuvers, but also the discipline for the patient to execute them on a regular basis. Patient self-motivation is even more crucial in the present medical environment with increased attention and scrutiny directed at cost containment. Many insurance carriers limit coverage for rehabilitation at the patient’s expense. As a result, a comprehensive home exercise program should be outlined for the patient early in the rehabilitation process. This allows patients to augment their rehabilitation exercises at home and gives them a feeling of responsibility for their own recovery.

Anatomy and Biomechanics

The rotator cuff is composed of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. These four muscles take origin on the body of the scapula and insert on the tuberosities of the proximal humerus. The rotator cuff serves several functions in glenohumeral joint motion and stability. It provides joint compression, resistance to glenohumeral translation, and some rotation in all planes of motion. It is intricately involved in powering movement of the shoulder.

During overhead sports, extreme forces are placed on the rotator cuff. It is continuously challenged to keep the humeral head centered in the glenoid, preventing subluxations of the joint. If proper conditioning and sound mechanics are not used, the rotator cuff and posterior joint capsule can become inflamed and irritated. Chronic inflammation can become pathologic and lead to dysfunction of the rotator cuff. When the four cuff muscles fail to act in synchrony to keep the humeral head centered in the glenoid, dynamic stability can be compromised. Repeated microtrauma to the posterior rotator cuff and capsule leads to posterior capsule contracture. Posterior capsular tightness and loss of dynamic stability lead to increased subluxation and anterior–posterior (AP) translation of the humeral head on the glenoid, further contributing to irritation of the rotator cuff. Over time, this repetitive insult can cause tears of the rotator cuff and superior labrum.

The Throwing Cycle

The baseball pitch serves as the biomechanical model for many overhead throwing motions. The throwing cycle is a kinetic chain that derives energy from the lower extremities, transfers it through the pelvis and trunk rotation, and releases that energy through the upper extremity. The arm positions and motions of the throwing cycle serve as a good model for examination of rotator cuff function in overhead athletes. The throwing motion and its biomechanics have been divided into six stages: wind-up, early-cocking, late-cocking, acceleration, deceleration, and follow-through (Fig. 3-20).

Figure 3-20 The six phases of the throwing cycle.

(Adapted with permission from DiGiovine NM, Jobe FW, Pink M, Perry J. An electromyographic analysis of the upper extremity in pitching. J Shoulder Elbow Surg 1:15-25, 1992.)

Pathogenesis

Injury to the shoulder during the throwing cycle is thought to occur during the late-cocking phase, when the shoulder is in extreme external rotation and horizontal abduction. Abnormal motion of the humeral head relative to the glenoid can injure the superior and posterosuperior labrum and glenoid and the undersurface of the rotator cuff. This phenomenon has been called internal impingement of the shoulder or posterior superior glenoid impingement (Burkhart et al. 2003, Fleising et al. 1995, Jobe 1995, Kelly and Leggin 1999). Several factors have been implicated in the development of internal impingement, including traction on the biceps tendon, laxity of the anterior band of the inferior glenohumeral ligament caused by excessive external rotation, posterior capsular tightness, and scapular dyskinesia.

Muscle imbalance and capsular tightness contribute to rotator cuff pathology by allowing excess translation at the glenohumeral joint. Weakness of the supraspinatus or subscapularis can compromise compression of the glenohumeral joint during active shoulder motion. This, in turn, leads to increased translation across the joint.

Grossman et al. (2005) quantified glenohumeral motion following external rotation capsular stretch and subsequent posterior capsular shift to simulate a posterior capsular contracture in the thrower’s shoulder. In maximal external rotation in intact specimens, the humeral head moved in a posterior and inferior direction. A posterior capsular shift was performed to simulate posterior capsular contracture. Following posterior capsular shift, there was a trend toward a more superior position of the humeral head in maximal external rotation. Posterior capsular contracture causes a similar result as the head is pushed anterior–superior into the coracoacromial arch during flexion. Superior translation allows the head to migrate closer to the acromion, and an increase in the force transmitted to the rotator cuff results as the cuff is pressed between the humeral head and the overlying coracoacromial arch. The increased pressure on the cuff can lead to degradation and damage over time.

History and Physical Examination

Evaluation of overhead athletes, particularly at higher levels, should begin prior to the season and continue intermittently throughout the season. Subjective complaints regarding performance often precede complaints of pain in the shoulder or elbow. Common complaints include loss of command or control of the pitch, loss of pitching velocity, a subtle change in pitching mechanics, or even discomfort distant to the throwing arm. Early identification of these problems requires open communication among players, coaches, physicians, and athletic trainers.

Physical examination of the overhead athlete requires a global evaluation.

The physical examination of the shoulder and upper extremity should always begin with inspection.

Active and passive range of motion (PROM) should be assessed and compared to the contralateral side. The American Shoulder and Elbow Surgeons have recommended four functional ranges of motion that should be measured (Richards et al. 1994): forward elevation, internal rotation, and external rotation at the side and at 90 degrees of abduction are measured. Loss of the total arc of rotation, specifically with internal rotation, is a common finding in the glenohumeral joint of the injured pitcher (Burkhart et al. 2003). This loss is likely secondary to tightness of the posterior soft tissues, including the posterior rotator cuff and capsule.

Complete assessment of the shoulder should also include careful assessment of rotator cuff strength and glenohumeral joint laxity and provocative tests to identify intra-articular, subacromial, and acromioclavicular pathology.

Imaging

Management

Frequently, rotator cuff tendinitis in the overhead athlete can be successfully treated with a well-structured and carefully implemented nonoperative rehabilitation program (Rehabilitation Protocol 3-1). Rehabilitation follows a multiphase approach with emphasis on controlling inflammation, restoring muscle balance, improving soft tissue flexibility, enhancing proprioception and neuromuscular control, and efficiently returning the athlete to competitive throwing (Wilk et al. 2002). Treatment should focus on restoration of sound mechanics during the throwing cycle, core muscle strengthening of the trunk and lower extremities, and strengthening of periscapular stabilizers.