Shoulder pain and injuries are common in sports that require repetitive overhead motions, including baseball, swimming, volleyball, water polo, and tennis.1 Altered mobility patterns, including both hyper- and hypo-mobility, are used to describe the movements of the overhead athlete. These altered movement patterns can lead to structural or functional changes in the shoulder complex, including acquired hyperlaxity, posterior shoulder immobility, and scapular dyskinesis.1 Changes in structure or function can lead to shoulder injuries such as rotator cuff tendinitis, subacromial and internal2 impingement, labral injuries, and instability. Commonly, nontraumatic manifestations of shoulder injuries in overhead athletes can be correlated to instability and impingement. Repeated activity will lead to weakness and fatigue of the rotator cuff, causing overload of the passive restraints to motion. Repeated overload of passive restraints will create laxity in the noncontractile tissues of the shoulder complex.

In many cases, a small degree of hypermobility is advantageous and can be related to factors that lead to increased performance.3,4 Sport-specific movement patterns require a balance of hypermobility and stability.1,5 However, without proper stability, some degree of pathological instability will likely be present in the overhead athlete. The existence of primary instability via repetitive microtrauma can lead to subluxation of the glenohumeral joint. This may instigate internal impingement of the posterior rotator cuff with the glenoid or eccentric overload of the rotator cuff musculature, causing subacromial impingement. Multiple other impairments can occur secondary to this breakdown, which results from the loss of the required dynamic stabilization. Rehabilitation of shoulder and upper-extremity injuries associated with sports participation requires that the rehabilitation specialist is able to identify the impairments causing the pathology as well as develop a plan of care that mimics the demands of the sport.


Development of an initial treatment plan is dependent on the athlete’s presenting acuity and symptoms. Based on the acuity of the presenting injury, a model of “staging” for the patient is useful. The foundation of this model revolves around the idea that acuity is more accurately determined by symptom severity rather than a specific time frame. This staging model can easily be applied to movement dysfunctions to assist the clinician to better develop an individualized treatment regimen.6

Following the physical therapy examination, the athlete is categorized into one of three stages, with the goals of each stage differing. Stage I is often correlated with an acute symptomatic presentation. Characteristic impairments of this stage may include pain, inflammation, muscle guarding, decreased range of motion (ROM), and loss of function. Rehabilitation goals of stage I are to decrease the symptom severity of the athlete and allow progression to stage II. Stage I treatment options to control pain and inflammation include modalities such as ice, electrical stimulation, ultrasound, iontophoresis, along with activity modification. Most of these modalities are employed to reduce or control an active inflammatory process. Therefore, it is important to recognize the signs of an active inflammatory process to properly prescribe such modalities. Removal or correction of the primary activity causing the pathology must occur early in the rehabilitation process to allow apposite healing without further irritation to take place.

Progression from stage I to II, determined by a decrease in symptom volatility, will shift the focus and goals of the rehab to address specific impairments of the body segments involved. These specific impairments are determined by the examination and often include decreased internal rotation ROM, restricted accessory motion of the posterior joint capsule, and weakness of the rotator cuff (RTC) and scapulothoracic (ST) musculature. Additionally, general findings may include poor postural awareness, decreased flexibility, and altered neuromuscular control. It is useful to address any restrictions in the joint capsule with graded joint mobilization techniques followed by ROM and flexibility exercises to increase the accessory motion of the joint and the overall ROM. Placing the body segment in the positions that closely relate to the actions of the sport helps to stress the appropriate tissues. For the throwing athlete, this often implies using the 90º/90º position of the shoulder and elbow, where a posterior mobilization force into the joint capsule can be applied, followed by flexibility exercises into internal rotation. Flexibility of internal rotation in this position can be assisted by the physical therapist or by having the athlete perform a “sleeper stretch,” in which the athlete lies on the involved side with the arm in the 90º/90º position and applies a force through the forearm to stretch the shoulder into internal rotation.

As the patient progresses through the initial portions of stage II of the rehabilitation process, and the impairments of pain, restricted ROM, and stiffness are corrected, a strengthening program focusing on common deficits should be implemented. A proper strengthening program should aim at specifically improving the function of both RTC and ST musculature along with the trunk and lower extremities. Rehabilitation programs should first achieve improved isolated muscle performance of the specific RTC and ST musculature, progressing the training to include functional movement patterns, and finally to integration into sport-specific activities.

A primary function of the RTC and the ST musculature is to maintain proper arthrokinematics of the glenohumeral and ST joints during movement. The actions of the overhead athlete place extreme demands on the RTC and ST musculature in attempting to maintain the proper position of the arm and scapula throughout the movement. Thus, the RTC and ST musculature is required to perform the actions throughout the motion of the overhead activity; it is important to train the muscles in positions that mimic their demands.

Left: Co-authors Adam Popchak, PT, DPT, CSCS (left), and Jason Han, PT, DPT, CSCS, demonstrate an upper-extremity strengthening exercise.

Particular attention should be paid to the posterior RTC musculature consisting of the infraspinatus and teres minor muscles. These muscles reduce the strain on the anterior soft tissue structures, which often become injured with the overhead throw. Strengthening of posterior RTC should be performed at angles specific to the overhead throw. Matching the type of muscular contraction utilized and performing the exercises specific to the patient’s demands should be applied to the entire RTC and shoulder musculature. The serratus anterior and upper, middle, and lower trapezius muscles are important in providing proper scapular stability, which if not achieved places increased stress on the glenohumeral joint. Also, the ST musculature acts to elevate and facilitate upward rotation of the scapula, allowing the humeral head to clear the acromion process of the scapula without impinging. Often the middle and lower trapezius muscles are trained in the prone position and with horizontal abduction of the glenohumeral joint at an angle of 90º and 120º, respectively. As the rehabilitation specialist, it is important to emphasize that these movements facilitate scapular movement instead of just glenohumeral movement, and that the athlete is able to recruit the appropriate muscles when performing the exercise. Traditionally, the serratus anterior muscle has been trained with a push-up plus, supine punch-up, and/or wall slide. Additionally, the serratus anterior can be activated and trained by performing end range elevation, 150º to 180º, with the scapula protracted. Once appropriate levels of ROM, strength, and stabilization have been achieved, and the athlete is no longer experiencing pain, progression to “stage III” can occur. The focus of stage III of the rehabilitation process for an athlete is sport-specific activity and return to competition.


Sport-specific exercises should be graded throughout the rehabilitation process, and constant attention must be paid to the athlete’s immediate and delayed response to the activities. Sport-specific activities can vary greatly; however, the activities should relate to or mimic actual demands of the sport of interest. Medicine ball exercises can be used to improve eccentric and concentric strength of the RTC and the shoulder complex. Weighted ball exercises can include an eccentric ball catch where a weighted ball is tossed to patients over their shoulder, while standing behind them. The patient should maintain the 90°/90° to start the motion. As the patient catches the ball, the arm is controlled through the typical motion of the followthrough, imitating the eccentric action of the deceleration phase of throwing. Particular attention should be paid to performing the action with control of the shoulder and trunk. Then the ball is tossed back to the therapist by athletes over their shoulder via a concentric toss, representing the cocking phase.

Plyometric exercises can also be used, in which a concentric toss, utilizing shoulder internal rotation and adduction, is performed causing the ball to bounce back and be caught and controlled, via eccentric action of the muscles, and repeated. Elastic resistance can also be useful to condition the acceleration and deceleration phases of the overhead action. Elastic resistance applied from behind the athlete would address the acceleration portion, while elastic resistance pulled in front would attend to the follow-through or the deceleration portion. Thus, proper resistance can be applied throughout the positions each athlete’s sport will demand.

Resistance can consist of elastic bands, free weight, weighted balls, manual resistance, or, in some cases, no weight at all to instill proper movement patterns. When resistance is used, it is important to select an amount of resistance that corresponds to the goals of the exercise (ie, power, strength, or endurance). Proper rest periods are also important to allow sufficient recovery between exercises. Varying the amount of resistance and repetitions used between different exercises allows the athlete to train all phases of the strength-endurance continuum in the athlete’s rehabilitation program.

Although we have primarily focused on strengthening of the shoulder complex, it is important to improve the performance of the trunk and lower extremity muscles as well. Proper conditioning of the entire kinetic chain is essential in sports performance, and along with individualized interventions, will aid the athlete in achieving a successful return to competition.

Adam Popchak, PT, DPT, CSCS, and Jason Han, PT, DPT, CSCS, are physical therapists and sports physical therapy residents at Centers for Rehab Services, UPMC Center for Sports Medicine, Pittsburgh; Valerie J. Williams, PT, DPT, is a physical therapist and orthopedic physical therapy resident at Centers for Rehab Services, UPMC South Hills and Center for Sports Medicine; Chad L. Crossley, PT, DPT, ATC, is a physical therapist and orthopedic physical therapy resident at Centers for Rehab Services, UPMC Center for Sports Medicine. For more information, contact .


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