The most important aspects of caring for the throwing athlete are the history and physical exam. The presentation of excessive anterior translation in the throwing athlete is far more subtle than in that of the nonthrower who usually has traumatic instability. Throwers will often present with complaints of decreased control, decreased velocity, “dead arm,” and pain (11). A history of subluxation or dislocation is almost never the presentation. A component of night pain, while rare, may signify a significant rotator cuff involvement. The thrower can sometimes localize the timing and localization of the pain in the throwing cycle. Posterior-based pain during cocking and early acceleration may suggest internal impingement or a SLAP tear (12). Anterior pain may be associated with injury to the subscapularis, biceps tendon, or anterior capsulolabral structures. Pain noted during follow-through when the humerus is in internal rotation and stress is placed on the posterior complex often signifies posterior capsulolabral and/or posterior cuff injury.

Examination typically may begin with the patient seated. First begin with inspection of the integumentary system and the musculature of the shoulder girdle to note any scars or soft-tissue asymmetry. Though rare, atrophy of the infraspinatus signifies suprascapular neuropathy. Range of motion should be performed comparing the athlete’s dominant and nondominant shoulder, consisting of forward elevation, external rotation with the arm adducted at the side, internal rotation relative to posterior spine landmarks, external rotation, and internal rotation at 90 degrees of abduction. While throwers will have increased external rotation and decreased internal rotation versus the nondominant arm, their total rotational arc should be symmetric. Greater than a 20-degree internal rotation deficit on the throwing shoulder versus the nonthrowing shoulder is suggestive of glenohumeral internal rotation deficit. Provocative tests such as Speed’s and Yergason’s might suggest biceps pathology. Neer and Hawkins’ tests assess for impingement. O’Brien’s and labral shear are utilized to assess for a SLAP tear.

Particular attention should be paid toward an assessment of laxity and joint translation. Signs of generalized ligamentous laxity are not usually seen in throwers but nevertheless should be evaluated in cases where concern for instability exists. In the office setting, inferior, anterior, and posterior translation are assessed and graded on a scale of 1 to 3. Both shoulders are examined and the involved shoulder is compared versus the contralateral but not graded against the contralateral as is done in the knee. The goals of the examination are to determine if there is increased anterior translation, with or without reproduction of pain.

In the seated position, inferior translation is assessed via the sulcus sign. The scapula is first stabilized with one hand and with the arm in adduction traction is applied to the distal arm with the other hand. Inferior translation is graded as 0 to 3 based on the amount of inferior displacement. Grade 1 is defined as less than 1 cm, 2 is 1 to 2 cm of inferior translation, and 3 as greater than 2 cm. It is important to note that normally the humeral head sits 7 to 8 mm below the acromion. Therefore, an acromiohumeral distance of 1.2 cm implies only 4 to 5 mm of translation but is grade 2. A positive sulcus sign does not itself lead to a diagnosis and it is important to corroborate evidence of instability on exam with symptoms (13, 14, 15). Anterior and posterior translation is assessed in both the supine and seated position with the load and shift test. With the arm supported in the neutral plane of the scapula, with one hand, the examiner applies an axial load to center the humeral head in the glenoid. The humeral head is translated anteriorly and posteriorly on the glenoid. Laxity is graded from 1 to 3 as follows: one, increased translation short of the glenoid rim (0 to 1 cm); two, translation with perching onto the glenoid rim (1 to 2 cm); and three, translation over the glenoid rim (greater than 3 cm) (13, 14, 15).

The internal impingement test is performed supine at 90 degrees of abduction and maximal external rotation, recreating the position of late cocking. Pain at the posterior aspect of the glenohumeral joint is considered a positive test. The relocation test performed at 90 degrees of abduction and external rotation is used to assess for internal impingement. Relief of pain with a posteriorly directed force on the upper arm is positive, i.e. a posterior relocation test (Fig. 20-3). In the thrower, it is important to note that posterior pain that is relieved with relocation suggests internal impingement (6). The posterior force relieves the contact by preventing tissue infolding between the cuff and labrum. In the classic apprehension test for anterior instability, relocation relieves the apprehension.

As the kinetic chain and scapulothoracic mechanics play an integral role in the pathology of the throwing shoulder, a full assessment of throwing mechanics should be performed. Poor mechanics include opening up, a dropping elbow, and hyperangulation (Fig. 20-4). These are all factors in pathology of the throwing shoulder. While this is a surgical technique text, it is important to that rehabilitation is the mainstay of treatment for the thrower’s shoulder. The majority of throwers can be successfully managed with a period of rest and supervised physical therapy (16, 17, 18).

It is important to evaluate for scapular dyskinesis, posterior structure tightness, pectoralis tightness, poor joint position sense, and rotator cuff weakness or poor endurance. Scapular dyskinesis is best evaluated by testing the patient from behind. The patient repeatedly elevates both arms at a moderate pace, while the examiner looks for dyskinesis or winging. Winging is maximized by performing resisted shoulder flexion at 30 degrees of elevation or by performing a wall push-up. Posterior tightness is evaluated by decreased horizontal adduction and loss of motion on the internal rotation side of the motion arc. Pectoralis tightness is often present in those with a rounded posture and protracted scapula. At our institution, our physical therapy rehabilitation program for scapular dyskinesis and rotator cuff weakness focuses on resistance band and isotonic exercises. Band exercises for scapular dyskinesis include low and high rows, bear hugs, seated upright rows, push-up plus, and bow and arrows. Proprioception is improved with rhythmic stabilization exercises in multiple positions moving toward functional range of motion. Body blade and other perturbations are used at different positions to improve kinematic awareness and proprioception. Rotator cuff band exercises include external and internal rotation at 0 and 45 degrees, high rows,
and proprioceptive neuromuscular facilitation D2 patterns, when asymptomatic band exercises are performed at 90 degrees of abduction (Shanley, E., Thigpen, C.: Proaxis Therapy. Greenville, SC, personal communication.).

Posterior soft tissue is mobilized with cross-body and sleeper stretches and joint mobilization. Anteriorly pectoralis stretching and soft-tissue subscapularis mobilization are utilized (Shanley, E., Thigpen, C.: Proaxis Therapy. Greenville, SC, personal communication.). The pectoralis is stretched by placing a rolled towel between the shoulder blades with the patient supine and pushing posteriorly on the shoulders or by single arm on wall stretch. If someone has no improvement within 3 months of conservative rehabilitation or is unable to return to play within 6 months, we consider them as failing conservative management.

Knitve and Jobe classified anterior shoulder pain in throwers into four groups (see Table 20-1). Although perhaps helpful, this classification is largely historical. Group I patients were classified as having primary impingement without evidence of increased anterior translation. Impingement testing resulted in pain, whereas anterior translation testing, including under anesthesia, was negative. This was a small subset of patients and generally over 35 years of age. Group II includes patients with primary microanterior instability and resulting secondary impingement or secondary internal impingement. They noted that these patients often have relief of
pain with a relocation test but will not have apprehension in the ABER position. Group III was noted to have generalized ligamentous laxity with secondary impingement. Exam under anesthesia demonstrated laxity in both shoulders. Group IV were patients with pure primary instability (traumatic) without evidence of impingement (6). In this classification, the throwing athlete fits into Group II.