Depending on the level of participation and time of season, among other factors, diagnosis may need to be established “yesterday.” In some circumstances, there is time enough for “Mother Nature” to take her course, allowing the diagnosis to evolve and become clear on its own. At the professional level, however, we are quick to establish a diagnosis, exposing the athlete immediately to x-ray studies, magnetic resonance imaging (MRI), and whatever else is needed to aid in establishing the diagnosis, so that appropriate, effective, and efficient treatment can be instituted quickly. At the Little League level, however, we often allow some time for these diagnoses to become evident. In the Little Leaguer, the approach is less aggressive with regard to using diagnostic testing toward establishing an immediate diagnosis, so as to avoid compromising the health of the patient.

After a fracture, acromioclavicular dislocation, or acute dislocation of the glenohumeral joint, the clinical examination is fairly straightforward. Patients present with a painful shoulder with limited range of motion. In many overhead athletes who present with shoulder pain due to overuse, the physical findings vary, but frequently consist of limitation of internal rotation and crossed-arm adduction, scapular dysfunction, weakness in certain ranges (e.g., external rotation), and instability findings (e.g., excess translation, positive relocation testing, and often signs of impingement). Many overhead athletes, such as throwers, have excess external rotation. This constellation of physical examination signs is frequently found in the high-profile overhead athlete, such as the professional baseball pitcher, but it is rarely found in the general population (1).

In the overhead athlete’s shoulder, it is critical to understand the relationship between translational measurements and instability. Instability is a loss of control of the ball in the socket that produces symptoms. These symptoms are usually of “looseness” or “coming out” and those described as instability-related. The difficulty occurs when pain is the only symptom occurring in a shoulder that has excess translation, which may or may not be interpreted as translation or be labeled as “instability.” It is common for overhead athletes to have excess translation, and recent appreciation of different pathologies such as internal impingement and SLAP lesions may bear some relationship to this excess translation. These patients may have no symptoms or signs of instability other than this excess translation, complicating the diagnosis. Many patients have considerable physiologic translation of the ball in the socket and yet have no symptoms of instability. It remains unknown whether excess translation can create a tendinosis problem through stretching of the joint capsule and tendons, or whether excess work of these same structures will cause pain. When performing translational testing on patients who complain of instability, particularly when they are awake, it is important to ask them if the testing reproduces the instability complex by reinforcing the symptoms and direction of displacement of the unstable shoulder. In assessing for translation in a patient who has perceived instability, we translate the shoulder posteriorly and describe how far it goes. For example, it may just move up the face of the glenoid, it may perch on the glenoid rim, or it may go over the rim. We then go through the following sequence of questions with the patient:

If these questions are all answered in the affirmative, the diagnosis, or at least partial diagnosis, of posterior instability would be established.

Recent literature suggests that throwers with excess translation may not function biomechanically at their maximum capacity. In the presence of a SLAP lesion or internal impingement, a stabilizing procedure may be performed, more to address the excess translation than to address the possibility of instability. This may directly address the goal of making the shoulder more sound biomechanically.

There is a fine line between diagnosing excess translation and instability, particularly in patients with pain. Under these circumstances, it may be conjecture, at best, to say these patients have instability. Research work, particularly by Harryman and Matsen, has shown that translation does not equal instability (2). Certain symptoms more clearly represent instability, such as when a patient complains of the “shoulder coming out,” “shoulder is loose” or there is “catching and clunking.” The shoulder can, in the face of excess translation particularly with reproduction of those symptoms, clearly represent instability. It is common in patients who have a tendency toward multidirectional or posterior instability to reflect equal translational findings in both shoulders. Yet one is symptomatic, and the other is not.

Over the past 10 years, many new physical examination signs have been described that aid in the diagnosis of shoulder problems in the athlete (1). Many signs suggest a SLAP lesion (3). These include the active compression test or O’Brien’s test, the moving valgus test of O’Driscoll, Kibler’s anterior slide test, Andrews’ clunk test, and the biceps load test, among others. Bicipital signs are often present with SLAP lesions, as are impingement signs. These overlapping signs often make the accuracy of the tests unpredictable. Gerber described the lift-off test, demonstrating subscapularis insufficiency (4). Recent publications have demonstrated the belly-press test as indicative of upper subscapularis problems and the lift-off test as more indicative of lower or entire subscapularis insufficiency (5). These are just a few of the newer tests that have evolved and are described in later chapters.