Common Conditions in the Overhead Athlete



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Am Fam Physician. 2014 Apr 1;89(7):537-541.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See related handout on shoulder pain, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

The overhead athlete is at unique risk for injury because of the mechanics associated with rapid shoulder elevation, abduction, and external rotation. Angulation of the humeral head against the posterosuperior glenoid can cause rotator cuff tendon and labral impingement. The throwing or striking motion of baseball, softball, water polo, tennis, racquetball, and volleyball may result in scapular dyskinesis, partial articular-sided supraspinatus avulsions, and posterosuperior labral tears. The SICK scapula syndrome (scapular malposition, inferior medial border prominence, coracoid pain and malposition, and dyskinesis of scapular movement) is thought to increase the risk of injury in the overhead athlete. Special physical examination maneuvers and magnetic resonance imaging may be helpful in diagnosing intra-articular pathology. Rehabilitation of injuries associated with internal impingement of the shoulder should include three basic components: strengthening, stretching, and sport-specific exercises. Arthroscopic surgery may be considered if symptoms do not improve after three months of conservative management.

Shoulder pain in the overhead athlete may result from fractures, nerve-related pathology, overuse, or articular, muscular, or tendon injuries. In sports such as baseball, softball, water polo, tennis, racquetball, and volleyball, the overhead throwing motion requires coordination from the feet to the hand in a single kinetic chain.1 This kinetic chain requires a coordinated delivery of muscle power to generate and transmit energy to throw or strike a ball. A break in this coordinated effort (even in the trunk or legs) can result in altered mechanics that may injure the shoulder2 via internal impingement and associated partial articular-sided supraspinatus avulsions and posterosuperior labral tears3  (Table 1). Athletes who routinely assume the overhead arm position (i.e., maximal external rotation of the humerus with shoulder abduction and elevation) are vulnerable to internal impingement from microinstability of the glenohumeral joint, overuse, or fatigue of the shoulder girdle muscles.4,5

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

Scapular motion and position should be evaluated in overhead athletes with shoulder pain, and physical therapy should be initiated if dyskinesis is present.

C

610

Physical examination maneuvers and magnetic resonance arthrography accurately identify intra-articular shoulder injuries, but their diagnostic effectiveness is limited for partial-thickness rotator cuff tears.

C

18, 20

The Jobe relocation and O'Brien tests are the most reliable for identifying labral pathology.

C

22

The primary treatment for internal impingement of the shoulder is rehabilitation and physiotherapy consisting of stretching, strengthening, and sport-specific exercises.

C

9, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingReferences

Scapular motion and position should be evaluated in overhead athletes with shoulder pain, and physical therapy should be initiated if dyskinesis is present.

C

610

Physical examination maneuvers and magnetic resonance arthrography accurately identify intra-articular shoulder injuries, but their diagnostic effectiveness is limited for partial-thickness rotator cuff tears.

C

18, 20

The Jobe relocation and O'Brien tests are the most reliable for identifying labral pathology.

C

22

The primary treatment for internal impingement of the shoulder is rehabilitation and physiotherapy consisting of stretching, strengthening, and sport-specific exercises.

C

9, 21


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1.

Major Conditions of the Overhead Athlete

ConditionMechanismPresentationDiagnosisTreatment

Labral tear (posterosuperior)

Internal impingement of the shoulder

Pain during cocking phase of throwing or ball striking

Abnormal results on O'Brien test or other preferred test for superior labrum anteroposterior tears

Physical therapy and activity modification; may require surgery

PASTA injury (partial articular-sided supraspinatus tendon avulsion)

Internal impingement of the shoulder

Pain during cocking phase of throwing or ball striking

Abnormal results on empty-can test

Physical therapy and activity modifi

The Authors

ERIC W. EDMONDS, MD, is director of orthopedic research and codirector of the sports medicine program at the Orthopedic and Scoliosis Center at Rady Children's Hospital in San Diego, Calif., and an assistant professor of orthopedic surgery at the University of California, San Diego, in La Jolla.

DOUGLAS D. DENGERINK, DO, is a sports medicine fellow at San Diego Sports Medicine and Family Health Center.

The authors thank James D. Bomar, MPH, for assistance with Figure 1.

Address correspondence to Eric W. Edmonds, MD, Rady Children's Hospital, 3030 Children's Way, Suite 410, San Diego, CA 92123 (e-mail: ewedmonds@rchsd.org). Reprints are not available from the authors.

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