SYNOPSIS: The overhead throwing motion is an extremely skillful and intricate movement. When pitching, the overhead throwing athlete places extraordinary demands on the shoulder complex subsequent to the tremendous forces that are generated. The thrower’s shoulder must be lax enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability. We refer to this as the "thrower’s paradox." This balance is frequently compromised and believed to lead to various types of injuries to the surrounding tissues. Frequently, injuries can be successfully treated with a well-structured and carefully implemented nonoperative rehabilitation program. The key to successful nonoperative treatment is a thorough clinical examination and accurate diagnosis. Rehabilitation follows a structured, multiphase approach, with emphasis on controlling inflammation, restoring muscles’ balance, improving soft tissue flexibility, enhancing proprioception and neuromuscular control, and efficiently returning the athlete to competitive throwing. Athletes often exhibit numerous adaptive changes that develop from the repetitive microtraumatic stresses occurring during overhead throwing. Treatment should include the restoration of these adaptations. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther. 2009;39(2):38-54. doi:10.2519/jospt.2009.2929

KEYWORDS: baseball, glenohumeral joint, labral lesions, pitching, rotator cuff

SYNOPSIS: Superior labral tears (SLAP lesions) can pose a significant challenge to orthopaedic surgeons and rehabilitation specialists alike. Although advancement in arthroscopic techniques has enhanced arthroscopic repair of SLAP lesions, the clinical diagnosis of SLAP lesions can still be difficult. There is a variety of etiologic factors associated with SLAP lesions and a thorough clinical evaluation is crucial to make the diagnosis. Concomitant injury to the capsular-labral complex or rotator cuff is not uncommon and can further confuse the clinical presentation. The purpose of this paper is to review the pathomechanics, diagnosis, and treatment of SLAP lesions. We will specifically review some of the physical examination tests that are used to diagnose SLAP lesions and report on our technique of arthroscopic repair. Additionally, we will discuss the operative management of associated intra-articular pathology and, finally, we will briefly discuss our postoperative rehabilitation guidelines. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther. 2009;39(2):71-80, Epub 11 August 2008. doi:10.2519/jospt.2009.2850

KEY WORDS: instability, rotator cuff tears, shoulder

SYNOPSIS: There is a growing body of literature associating abnormal scapular positions and motions, and, to a lesser degree, clavicular kinematics with a variety of shoulder pathologies. The purpose of this manuscript is to (1) review the normal kinematics of the scapula and clavicle during arm elevation, (2) review the evidence for abnormal scapular and clavicular kinematics in glenohumeral joint pathologies, (3) review potential biomechanical implications and mechanisms of these kinematic alterations, and (4) relate these biomechanical factors to considerations in the patient management process for these disorders. There is evidence of scapular kinematic alterations associated with shoulder impingement, rotator cuff tendinopathy, rotator cuff tears, glenohumeral instability, adhesive capsulitis, and stiff shoulders. There is also evidence for altered muscle activation in these patient populations, particularly, reduced serratus anterior and increased upper trapezius activation. Scapular kinematic alterations similar to those found in patient populations have been identified in subjects with a short rest length of the pectoralis minor, tight soft-tissue structures in the posterior shoulder region, excessive thoracic kyphosis, or with flexed thoracic postures. This suggests that attention to these factors is warranted in the clinical evaluation and treatment of these patients. The available evidence in clinical trials supports the use of therapeutic exercise in rehabilitating these patients, while further gains in effectiveness should continue to be pursued. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther. 2009;39(2):90-104. doi:10.2519/jospt.2009.2808

KEYWORDS: acromioclavicular joint, biomechanics, rotator cuff, scapula, shoulder

SYNOPSIS: Anterior shoulder dislocation occurs in the general population; however, the incidence is doubled in the young athletic population. Over 90% of shoulder dislocations are in the anterior direction. For the first-time dislocation, a systematic approach to evaluating the patient and prompt reduction are critical. This injury is frequently witnessed on the field or later in the emergency department. On the field, closed reductions, without prereduction radiographs, is controversial. If the athlete is encountered in the emergency department, radiographs should be obtained prior to a closed reduction. After a closed reduction is achieved, several factors, such as timing in the season, type of sport, position, and patient goals, must be considered when deciding whether further surgical intervention is required. Conservative management will usually consist of a brief period of immobilization in a sling, followed by rehabilitation. Surgical treatment consists of an arthroscopic Bankart repair. LEVEL OF EVIDENCE: Therapy, level 5.

J Orthop Sports Phys Ther. 2009;39(2):118-123, Epub 11 August 2008. doi:10.2519/jospt.2009.2804

KEY WORDS: apprehension, Bankart, glenohumeral joint, instability, physical therapy

SYNOPSIS: Frozen shoulder or adhesive capsulitis describes the common shoulder condition characterized by painful and limited active and passive range of motion. The etiology of frozen shoulder remains unclear; however, patients typically demonstrate a characteristic history, clinical presentation, and recovery. A classification schema is described, in which primary frozen shoulder and idiopathic adhesive capsulitis are considered identical and not associated with a systemic condition or history of injury. Secondary frozen shoulder is defined by 3 subcategories: systemic, extrinsic, and intrinsic. We also propose another classification system based on the patient’s irritability level (low, moderate, and high), that we believe is helpful when making clinical decisions regarding rehabilitation intervention. Nonoperative interventions include patient education, modalities, stretching exercises, joint mobilization, and corticosteroid injections. Glenohumeral intra-articular corticosteroid injections, exercise, and joint mobilization all result in improved short- and long-term outcomes. However, there is strong evidence that glenohumeral intra-articular corticosteroid injections have a significantly greater 4- to 6-week beneficial effect compared to other forms of treatment. A rehabilitation model based on evidence and intervention strategies matched with irritability levels is proposed. Exercise and manual techniques are progressed as the patient’s irritability reduces. Response to treatment is based on significant pain relief, improved satisfaction, and return of functional motion. Patients who do not respond or worsen should be referred for an intra-articular corticosteroid injection. Patients who have recalcitrant symptoms and disabling pain may respond to either standard or translational manipulation under anesthesia or arthroscopic release. LEVEL OF EVIDENCE: Level 5.

J Orthop Sports Phys Ther. 2009;39(2):135-148. doi: 10.2519/jospt.2009.2916

KEY WORDS: adhesive capsulitis, corticosteroid injection, glenohumeral joint, joint mobilization

A selection of important abstracts of articles published in other journals.

J Orthop Sports Phys Ther. 2009;39(2):150-157.