Why Is the Athlete in Your Office? Making the Right Diagnosis in the Disabled Throwing Shoulder

  • John M. Tokish
  • W. Ben Kibler


The athlete with the disabled throwing shoulder presents a challenge to evaluate and treat. The clinical symptoms may vary widely; there are “normal” adaptations in flexibility and strength in overhead athletes; otherwise “pathologic” findings may be part of the adaptive process, and imaging may be imprecise. Difficulty in establishing the diagnosis may result in variation in treatment and inconsistency in outcomes. The clinician must develop a comprehensive plan for making the diagnosis of all of the factors that result in the dysfunction that brings the athlete to the office. The dysfunction has components of pathoanatomy, pathophysiology, and pathomechanics and can be affected by patient-specific factors.

History considerations include the patient’s description of the dysfunction and limitations, the clinical course and degree of disability, and the past medical history. Physical exam considerations include leg/core stability and strength, evaluation of scapular position and motion, and the shoulder exam, with emphasis on glenohumeral (GH) motion and specific tests for anatomic injury. Imaging can be used as a confirmatory tool. Patient-specific factors should evaluate psychological and social aspects that affect the dysfunction. All of this information can provide “value on the front end,” a comprehensive diagnosis that can guide implementation of the content and timing of the treatment.

“Value on the back end” is the outcome or how well did the treatment allow the athlete to return to activity. Self-reported tools may help, but throwing-specific tools provide effective measures of disability and outcomes.


Physical exam Shoulder injury Overhead athlete Diagnosis 


  1. 1.
    Kibler WB, Sciascia A. Current practice for the diagnosis of a Superior Labral Anterior to Posterior (SLAP) lesion: systematic review and physician survey. Arthroscopy. 2015;31(12):2456–69.PubMedCrossRefGoogle Scholar
  2. 2.
    Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46:964–78.PubMedCrossRefGoogle Scholar
  3. 3.
    Ketola S, Lehtinen J, Rousi T, Nissinen M, Huhtala H, Konttinen YT, et al. No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome: five-year results of a randomised controlled trial. Bone Joint Res. 2013;2(7):132–9.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2012;93:229–36.PubMedCrossRefGoogle Scholar
  5. 5.
    Unruh KP, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, et al. The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears. J Shoulder Elb Surg. 2014;23(7):1052–8.CrossRefGoogle Scholar
  6. 6.
    Wylie JD, Suter T, Potter MQ, Granger EK, Tashjian RZ. Mental health has a stronger association with patient-reported shoulder pain and function than tear size in patients with full-thickness rotator cuff tears. J Bone Joint Surg Am. 2016;98:251–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Cho CH, Hwang I, Seo JS, Choi CH, Ko SH, Park HB, et al. Reliability of the classification and treatment of dislocations of the acromioclavicular joint. J Shoulder Elb Surg. 2014;23:665–70.CrossRefGoogle Scholar
  8. 8.
    Jones GL, Bishop JY, Lewis B, Pedroza AD, MOON Shoulder Group. Intraobserver and interobserver agreement in the classification and treatment of midshaft clavicle fractures. Am J Sports Med. 2014;42(5):1176–81.PubMedCrossRefGoogle Scholar
  9. 9.
    Kuhn JE. A new classification system for shoulder instability. Br J Sports Med. 2010;44:341–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Balogh EP, Miller BT, Ball JR. Improving diagnosis in healthcare. Washington: National Academies Press; 2015.CrossRefGoogle Scholar
  11. 11.
    Smith-Forbes EV, Moore-Reed SD, Westgate PM, Kibler WB, Uhl TL. Descriptive analysis of common functional limitations identified by patients with shoulder pain. J Sport Rehabil. 2015;24:179–88.PubMedCrossRefGoogle Scholar
  12. 12.
    Pavlin JD, Sullivan MJL, Freund P, Roesen K. Catastrophizing: a risk factor for postsurgical pain. Clin J Pain. 2005;21(1):83–90.PubMedCrossRefGoogle Scholar
  13. 13.
    Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745–58.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Das De S, Vranceanu AM, Ring DC. Contribution of kinesophobia and catastrophic thinking to upper-extremity-specific disability. J Bone Joint Surg Am. 2013;95(1):76–81.PubMedCrossRefGoogle Scholar
  15. 15.
    Moradi A, Mellema JJ, Oflazoglu K, Isakov A, Ring D, Vranceanu AM. The relationship between catastrophic thinking and hand diagram areas. J Hand Surg Am. 2015;40(12):2440–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Baranoff J, Hanrahan SJ, Connor JP. The roles of acceptance and catastrophizing in rehabilitation following anterior cruciate ligament reconstruction. J Sci Med Sport. 2015;18:250–4.PubMedCrossRefGoogle Scholar
  17. 17.
    Menendez ME, Baker DK, Oladeji LO, Fryberger CT, McGwin G, Ponce BA. Psychological distress is associated with greater perceived disability and pain in patients presenting to a shoulder clinic. J Bone Joint Surg Am. 2015;97:1999–2003.PubMedCrossRefGoogle Scholar
  18. 18.
    Cho CH, Jung SW, Park JY, Song KS, Yu KI. Is shoulder pain for three months or longer correlated with depression, anxiety, and sleep disturbance? J Shoulder Elb Surg. 2013;22:222–8.CrossRefGoogle Scholar
  19. 19.
    Sullivan MJL, Bishop S, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7:524–32.CrossRefGoogle Scholar
  20. 20.
    Walton DM, Wideman TH, Sullivan MJL. A Rasch analysis of the pain catastrophizing scale supports its use as an interval-level measure. Clin J Pain. 2013;29:499–506.PubMedCrossRefGoogle Scholar
  21. 21.
    Ivarsson A, Tranaeus U, Johnson U, Stenling A. Negative psychological responses of injury and rehabilitation adherence effects on return to play in competitive athletes: a systematic review and meta-analysis. Open Access J Sports Med. 2017;8:27–32.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Freynhagen R, Baron R, Gockel U, Tolle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006;22(10):1911–20.PubMedCrossRefGoogle Scholar
  23. 23.
    Weber SC, Martin DF, Seiler JG III, Harrast JJ. Incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery part II candidates. Am J Sports Med. 2012;40:1538.PubMedCrossRefGoogle Scholar
  24. 24.
    Kibler WB. Value on the front end: making the effective diagnosis for optimal treatment. Arthroscopy. 2017;33(2):493–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Kibler WB. Biomechanical analysis of the shoulder during tennis activities. Clin Sports Med. 1995;14:79–85.PubMedGoogle Scholar
  26. 26.
    Putnam CA. Sequential motions of body segments in striking and throwing skills: description and explanations. J Biomech. 1993;26:125–35.PubMedCrossRefGoogle Scholar
  27. 27.
    Kibler WB, Kuhn JE, Wilk KE, Sciascia AD, Moore SD, Laudner KG, et al. The disabled throwing shoulder - Spectrum of pathology: 10 year update. Arthroscopy. 2013;29(1):141–61.PubMedCrossRefGoogle Scholar
  28. 28.
    Davids K, Glazier PS, Araujo D, Bartlett R. Movement systems as dynamical systems: the functional role of variability and its implications for sports medicine. Sports Med. 2003;33(4):245–60.PubMedCrossRefGoogle Scholar
  29. 29.
    Linter DM, Noonan T, Kibler WB. Injury patterns and biomechanics of the athlete’s shoulder. Clin Sports Med. 2008;27(4):527–51.CrossRefGoogle Scholar
  30. 30.
    Toyoshima S, Miyashita M. Force-velocity relation in throwing. Res Q. 1973;44(1):86–95.PubMedGoogle Scholar
  31. 31.
    Toyoshima S, Hoshikawa T, Miyashita M. Contributions of body parts to throwing performance. In: Nelson RC, Morehouse CA, editors. Biomechanics IV. Baltimore: University Park Press; 1974. p. 169–74.CrossRefGoogle Scholar
  32. 32.
    Hirashima M, Kadota H, Sakurai S, Kudo K, Ohtsuki T. Sequential muscle activity and its functional role in the upper extremity and trunk during overarm throwing. J Sports Sci. 2002;20:301–10.PubMedCrossRefGoogle Scholar
  33. 33.
    Hirashima M, Kudo K, Watarai K, Ohtsuki T. Control of 3D limb dynamics in unconstrained overarm throws of different speeds performed by skilled baseball players. J Neurophysiol. 2007;97(1):680–91.PubMedCrossRefGoogle Scholar
  34. 34.
    Hirashima M, Yamane K, Nakamura Y, Ohtsuki T. Kinetic chain of overarm throwing in terms of joint rotations revealed by induced acceleration analysis. J Biomech. 2008;41:2874–83.PubMedCrossRefGoogle Scholar
  35. 35.
    Hirashima M, Ohtsuki T. Exploring the mechanism of skilled overarm throwing. Exerc Sport Sci Rev. 2008;36(4):205–11.PubMedCrossRefGoogle Scholar
  36. 36.
    Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med. 1995;23(2):233–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Fleisig GS, Barrentine SW, Escamilla RF, Andrews JR. Biomechanics of overhand throwing with implications for injuries. Sports Med. 1996;21:421–37.PubMedCrossRefGoogle Scholar
  38. 38.
    Elliott B, Fleisig G, Nicholls R, Escamillia R. Technique effects on upper limb loading in the tennis serve. J Sci Med Sport. 2003;6(1):76–87.PubMedCrossRefGoogle Scholar
  39. 39.
    Robb AJ, Fleisig GS, Wilk KE, Macrina L, Bolt B, Pajaczkowski J. Passive ranges of motion of the hips and their relationship with pitching biomechanics and ball velocity in professional baseball pitchers. Am J Sports Med. 2010;38(12):2487–93.PubMedCrossRefGoogle Scholar
  40. 40.
    Myers NL, Kibler WB, Lamborn L, Smith BJ, English T, Jacobs C, et al. Reliability and validity of a biomechanically based analysis method for the tennis serve. Int J Sports Phys Ther. Jun. 2017;12(3):437–49.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Bottros MM, AuBuchon JD, McLaughlin LN, Altchek DW, Illig KA, Thompson RW. Exercise-enhanced, ultrasound-guided anterior scalene muscle/pectoralis minor muscle blocks can facilitate the diagnosis of neurogenic thoracic outlet syndrome in the high-performance overhead athlete. Am J Sports Med. 2017;45(1):189–94.PubMedCrossRefGoogle Scholar
  42. 42.
    Ciampi P, Agnoletto M, Scotti C, Ballis R, Gerevini S, Peretti GM, et al. Thoracic outlet syndrome in the overhead athlete: a report of 2 cases of subclavius posticus muscle. Clin J Sports Med. 2017;27(3):e29–31.CrossRefGoogle Scholar
  43. 43.
    Shutze W, Richardson B, Shutze R, Tran K, Dao A, Ogola GO, et al. Midterm and long-term follow-up in competitive athletes undergoing thoracic outlet decompression for neurogenic thoracic outlet syndrome. J Vasc Surg. 2017;66(6):1798–805.PubMedCrossRefGoogle Scholar
  44. 44.
    Beckett M, Hannon M, Ropiak C, Gerona C, Mohr K, Limpisvasti O. Clinical assessment of scapula and hip joint function in preadolescent and adolescent baseball players. Am J Sports Med. 2014;42(10):2502–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Laudner K, Wong R, Onuki T, Lynall R, Meister K. The relationship between clinically measured hip rotational motion and shoulder biomechanics during the pitching motion. J Sci Med Sport. 2015;18(5):581–4.PubMedCrossRefGoogle Scholar
  46. 46.
    Chimera NJ, Smith CA, Warren M. Injury history, sex, and performance on the functional movement screen and Y balance test. J Ath Train. 2015;50(5):475–85.CrossRefGoogle Scholar
  47. 47.
    Kibler WB, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the “scapula summit”. Br J Sports Med. 2013;47:877–85.PubMedCrossRefGoogle Scholar
  48. 48.
    McClure PW, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for identifying scapular dyskinesis: Part 1: Reliability. J Athl Train. 2009;44(2):160–4.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Tate AR, McClure PW, Kareha S, Irwin D, Barbe MF. A clinical method for identifying scapular dyskinesis: Part 2: Validity. J Athl Train. 2009;44(2):165–73.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Borstad JD, Ludewig PM. The effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. J Orthop Sports Phys Ther. 2005;35(4):227–38.PubMedCrossRefGoogle Scholar
  51. 51.
    Kibler WB, Sciascia AD, Thomas SJ. Glenohumeral internal rotation deficit: pathogenesis and response to acute throwing. Sports Med Arthrosc Rev. 2012;20(1):34–8.PubMedCrossRefGoogle Scholar
  52. 52.
    Kibler WB. The role of the scapula in athletic function. Am J Sports Med. 1998;26:325–37.PubMedCrossRefGoogle Scholar
  53. 53.
    Kibler WB, Sciascia AD, Dome DC. Evaluation of apparent and absolute supraspinatus strength in patients with shoulder injury using the scapular retraction test. Am J Sports Med. 2006;34(10):1643–7.PubMedCrossRefGoogle Scholar
  54. 54.
    Tate AR, McClure P, Kareha S, Irwin D. Effect of the scapula reposition test on shoulder impingement symptoms and elevation strength in overhead athletes. J Orthop Sports Phys Ther. 2008;38(1):4–11.PubMedCrossRefGoogle Scholar
  55. 55.
    Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy. 2003;19(6):641–61.PubMedCrossRefGoogle Scholar
  56. 56.
    Madsen PH, Bak K, Jensen S, Welters U. Training induces scapular dyskinesis in pain-free competitive swimmers: a reliability and observational study. Clin J Sport Med. 2011;21(2):109–13.PubMedCrossRefGoogle Scholar
  57. 57.
    Plummer HA, Sum JC, Pozzi F, Varghese R, Michener LA. Observational scapular dyskinesis: known-groups validity in patients with and without shoulder pain. J Orthop Sports Phys Ther. 2017;47(8):530–7.PubMedCrossRefGoogle Scholar
  58. 58.
    Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: Pathoanatomy and biomechanics. Arthroscopy. 2003;19(4):404–20.PubMedCrossRefGoogle Scholar
  59. 59.
    Tokish JM, Curtin MS, Kim YK, Hawkins RJ, Torry MR. Glenohumeral internal rotation deficit in the asymptomatic professional pitcher and its relationship to humeral retroversion. J Sports Sci Med. 2008;7(1):78–83.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Osbahr DC, Cannon DL, Speer KP. Retroversion of the humerus in the throwing shoulder of college baseball pitchers. Am J Sports Med. 2002;30:347–53.PubMedCrossRefGoogle Scholar
  61. 61.
    Reagan KM, Meister K, Horodyski M, Werner DW, Carruthers C, Wilk KE. Humeral retroversion and its relationship to glenohumeral rotation in the shoulder of college baseball players. Am J Sports Med. 2002;30(3):354–60.PubMedCrossRefGoogle Scholar
  62. 62.
    Kibler WB, Sciascia AD, Moore SD. An acute throwing episode decreases shoulder internal rotation. Clin Orthop Relat Res. 2012;470:1545–51.PubMedCrossRefGoogle Scholar
  63. 63.
    Wilk KE, Macrina LC, Fleisig GS, Aune KT, Porterfield RA, Harker P, et al. Deficits in glenohumeral passive range of motion increase risk of shoulder injury in professional baseball pitchers: a prospective study. Am J Sports Med. 2015;43(10):2379–85.PubMedCrossRefGoogle Scholar
  64. 64.
    Freehill MT, Ebel BG, Archer KR, Bancells RL, Wilckens JH, McFarland EG, et al. Glenohumeral range of motion in major league pitchers: changes over the playing season. Sports Health. 2011;3(1):97–104.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Thomas SJ, Swanik KA, Swanik CB, Huxel KC. Glenohumeral rotation and scapular position adaptations after a single high school female sports season. J Athl Train. 2009;44(3):230–7.PubMedPubMedCentralCrossRefGoogle Scholar
  66. 66.
    Lin DJ, Wong TT, Kazam JK. Shoulder injuries in the overhead-throwing athlete: epidemiology, mechanisms of injury, and imaging findings. Radiology. 2018;286(2):370–87.PubMedCrossRefGoogle Scholar
  67. 67.
    Miniaci A, Mascia AT, Salonen DC, Becker EJ. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball players. Am J Sports Med. 2002;30(1):66–73.PubMedCrossRefGoogle Scholar
  68. 68.
    Pennock AT, Dwek J, Levy E, Stearns P, Manning J, Dennis MM, et al. Shoulder MRI abnormalities in asymptomatic little league baseball players. Orthop J Sports Med. 2018;6(2):232596711875682.CrossRefGoogle Scholar
  69. 69.
    Tibone J, Jobe FW, Kerlan RK, Carter VS, Shields CL, Lombardo SJ, et al. Shoulder impingement syndrome in athletes treated by an anterior acromioplasty. Clin Orthop Relat Res. 1985;198:134–40.Google Scholar
  70. 70.
    Franz JO, McCulloch PC, Kneip CJ, Noble PC, Linter DM. The utility of the KJOC score in professional baseball in the United States. Am J Sports Med. 2013;41(9):2167–73.PubMedCrossRefGoogle Scholar
  71. 71.
    Alberta FG, ElAttrache NS, Bissell S, Mohr K, Browdy J, Yocum LA, et al. The development and validation of a functional assessment tool for the upper extremity in the overhead athlete. Am J Sports Med. 2010;38(5):903–11.PubMedCrossRefGoogle Scholar
  72. 72.
    Domb BG, Davis JT, Alberta FG, Mohr KJ, Brooks AG, ElAttrache NS, et al. Clinical follow-up of professional baseball players undergoing ulnar collateral ligament reconstruction using the new Kerlan-Jobe Orthopaedic Clinic overhead athlete shoulder and elbow score (KJOC Score). Am J Sports Med. 2010;38(8):1558–63.PubMedCrossRefGoogle Scholar
  73. 73.
    Neuman BJ, Boisvert CB, Reiter B, Lawson K, Ciccotti MG, Cohen SB. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. Am J Sports Med. 2011;39(9):1883–8.PubMedCrossRefGoogle Scholar
  74. 74.
    Sauers EL, Bay RC, Snyder Valier AR, Ellery T, Huxel Bliven KC. The Functional Arm Scale for Throwers (FAST)-Part I: The design and development of an upper extremity region-specific and population-specific patient-reported outcome scale for throwing athletes. Orthop J Sports Med. 2017;5(3):2325967117698455.PubMedPubMedCentralCrossRefGoogle Scholar
  75. 75.
    Huxel Bliven KC, Snyder Valier AR, Bay RC, Sauers EL. The functional arm scale for throwers (FAST)-part II: reliability and validity of an upper extremity region-specific and population-specific patient-reported outcome scale for throwing athletes. Orthop J Sports Med. 2017;5(4):232596711770001.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • John M. Tokish
    • 1
  • W. Ben Kibler
    • 2
  1. 1.Mayo Clinic, Department of Orthopedic SurgeryPhoenixUSA
  2. 2.Shoulder Center of KentuckyLexington ClinicLexingtonUSA

Personalised recommendations