PRACTICE RECOMMENDATIONS
• Manage most throwing injuries with relative rest and physical therapy. A
• Evaluate patients for total loss of range of motion, which is a predictor of increased injury. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Baseball players and other athletes who spend much of their time throwing a ball risk a variety of shoulder injuries because the repetitive motion causes repeated microtraumatic stress in the area. Injuries result from overuse of the muscles involved, improper technique—or both.
The review that follows will help you zero in on the correct diagnosis and identify the treatment that’s best for your patient.
First step: Cover these points in the history
In order to gather a detailed history of a patient with shoulder pain, you’ll want to do the following:
Ask about the location of the pain. Anterior shoulder pain is associated with subluxation, multidirectional instability, subacromial bursitis, and injury to the biceps, supraspinatus or subscapularis.1 Posterior shoulder pain has been linked to infraspinatus injuries.
Assess the severity of the pain. Ask patients: “On a scale of one to 10, where 10 is the worst pain you have ever felt, how would you rate the pain you are feeling?”
Pinpoint the timing of the pain. Determine the phase of the throwing process that reproduces the primary symptoms. The 6 phases are wind up, early cocking, late cocking, acceleration, deceleration, and follow-through (FIGURE 1). So if, for instance, the patient tells you that his arm “went dead” during the late cocking, or early acceleration phase, it should prompt you to suspect subluxation.2
Videos
See how the Neer’s and Hawkin’s tests are done
Christopher Faubel, MD, Thepainsource.com
Neer’s Impingement test
Hawkins test
FIGURE 1
The 6 phases of throwing
Ascertain the nature of the patient’s pain after activity. Does the patient experience the pain at night? If he answers Yes, you’ll want to consider the possibility of a rotator cuff tear.
Ask these targeted questions:
- When you raise your arm, do you feel a pinching pain in your shoulder? This may suggest the presence of impingement.
- Is your shoulder “catching” or “locking up”? If so, consider a labral tear or loose body, eg, a piece of cartilage or bone floating around in the joint.
- Does your shoulder feel like it is coming out of its socket—either partially or completely? This suggests shoulder instability.
- Is it difficult for you to reach behind your back, or do you have shoulder pain when you try to do this? This may indicate glenohumeral internal rotation deficit.
- Do you feel like you are throwing the ball slower, or with less accuracy? This may be an indication that there is something wrong with the rotator cuff muscles, the innervation around the shoulders, or the labrum that partly holds the shoulder together. Sometimes, a tear of the labrum presents simply as a “loss of power” in throwing, as defined by the athlete who is used to throwing the ball faster or farther.
Diagnoses to consider
Based on the patient’s history and responses to your questions, you’ll likely consider one of the following diagnoses as part of the differential.
External or internal impingement syndromes
What you’ll see. External or “subacromial” impingement syndrome results from compression of the rotator cuff between the coracoacromial arch and the humeral head. A sloping or hooked acromion or osteophyte may contribute to the syndrome.3 Neer’s and Hawkin’s tests are often positive, and there may be pain with the arc of motion. (For more on these and the other tests mentioned here, see “Athlete has shoulder problems? Consider these tests”.)
Athlete has shoulder problems? Consider these tests1,3,16,18
While a full review of provocative shoulder testing is beyond the scope of this article, specific tests for impingement, labral tears, instability, and rotator cuff tears should be included when examining the throwing athlete.
Impingement
Neer’s test. The clinician uses one hand to passively flex the arm of a patient whose thumb is pointing down, as the clinician’s other hand stabilizes the patient’s scapula. The test is positive for impingement if the patient feels pain in the shoulder with this maneuver.
Hawkin’s test. This test involves stabilizing the scapula, passively abducting the shoulder to 90°, flexing the shoulder to 30°, flexing the elbow to 90°, and internally rotating the shoulder. Pain with this maneuver suggests rotator cuff impingement.
Labral tears
O’Brien’s test. The physician asks the patient to adduct his arm across the midline of his body while keeping his shoulder flexed at 90° and his thumb down. As he does this, the physician pushes downward to resist the patient’s shoulder flexion and to see if the patient feels pain. Then, the same motion is done by the patient, but this time with the thumb up. If the pain is not present—or diminishes—with the thumb up, the test is considered positive for a labral tear.
Instability
Load and shift test. The physician uses force to push the humeral head centrally onto the glenoid fossa and then attempts to move the humeral head backward and forward, while keeping the scapula stable, to see how far it can go. Displacement <1 cm is mild; 1 to 2 cm is moderate; and >2 cm is severe.
Sulcus sign. With the patient’s arm in a relaxed position at his side, the physician pulls it downward. If a gap more than 1 cm wide develops between the humeral head and the acromion, the test is positive for inferior glenohumeral instability.
Apprehension-relocation test. The physician asks the patient to lie down on his back and abduct his shoulder at 90°. The physician then externally rotates the patient’s arm and places stress on the glenohumeral joint. A patient with shoulder instability will often stop the physician and say that he feels as if his shoulder is going to “pop out.”
The relocation part of the test is done by the physician applying a posteriorly directed force on the front of the shoulder. If the patient says that the almost popping out feeling of his shoulder has disappeared (and experiences a sense of relief), the test is considered positive.
Rotator cuff tears
Drop arm test. The shoulder is passively abducted to 90° and flexed to 30° while the thumb is pointing down. The test is considered positive for a supraspinatus muscle tear if the patient is unable to keep the arm elevated after the physician releases the arm.
Empty can test (Jobe test). The shoulder is passively abducted to 90° and flexed to 30° while the thumb is pointing down. In this position, resistance is provided as the patient tries to lift the arm upward. Pain with weakness suggests a tear of the supraspinatus muscle.
Push-off test. The clinician asks the patient to adduct and internally rotate his arm behind the back. The examiner provides resistance as the patient tries to push the arm away from the body. Pain with weakness suggests a tear of the subscapularis muscle.