Taking The Athlete from Rehab

to Sports Specific Training

Pathophysiology and Mechanics

of the shoulder girdle and
overuse injuries of the LE in the
athlete
Evaluation Special tests for
the shoulder and LE
Muscle Physiology- Anaerobic /
Aerobic
Keys to starting a strength
training program
Neuromuscular Training
Plyometrics- Perturbation

Robert Donatelli PhD PT OCS

Current Concepts in Shoulder

Overuse Injuries Etiology & Rx
Core rotators of Glenohumeral & Scapula
Mechanics of Overhead Activities
Instability-Impingement-Rotator cuff tears

mechanics of dysfunction
Evaluation Special Tests
Treatment Restore mobility, Increase
strength, Return to sporting activities

Core Muscles of the Shoulder

Glenohumeral Rotators
Primary: Infraspinatus and Teres Minor,
Subscapularis, Lats. Teres Major, Pect major and
minor.
Secondary: Supraspinatus, Deltoid and Biceps
Scapula Rotators
Upper, middle, lower traps
Serratus anterior
Rhomboids, levator scapulae

Mechanics of Shoulder Elevation

Humeral head needs to be centered on the
glenoid humeral head arch of rotation 3mm.
Muscle action pulls the humeral head inferior,
superior, anterior, and posterior.
Inferior Lats, subscapularis, infraspinatus
and teres minor.
Superior Deltoid, supraspinatus
Anterior- Ext rotators Posterior Int. rotators

Elevation in the POS - Research

-Greenfield, Donatelli, et al. AJSM 1990
*External rotators significantly stronger
in the POS vs. Frontal Plane
-Tata JOSPT 1993
*Better ratio of external to internal rotators
(35 degrees anterior to frontal Plane)
-Overhead throwing athlete function in Frontal Plane

Humeral & Scapula

Mechanics of Elevation
Critical Phase of elevation: Donatelli
60-140 degrees
Max shearing forces, max depressive forces
Greatest amount of scapula rotation 80-140
Greatest amount of humeral depressor activity
Rotation of the clavicle is complete 120-150
ICR of scapula rotation shifts from SC to AC joint
at 100 degrees of elevation Bagg and Forrest 1988

External Rotation Importance

*Key component to elevation
Rajendran Singapore Med 1991
Prevents Impingement
Faltow AJSM 1994
Most Important movement to restore after total
shoulder surgery
Brems JBJS 1994
Direct correlation between increase in passive
external rotation and active elevation in the
POS Donatelli et al

The relevance of moment arm of

shoulder muscles with axial rotn
Kuechle, Newman et al, Clin Biomech 2000
Motion studies included axial rotation with the
humerus elevated 90 degrees in the frontal, sagittal,
scapular planes and neutral position (add)
Results indicated most powerful ext rotator
infraspinatus, followed by the teres minor and post.
Deltoid
Most powerful int rotn subscapularis & pect major
Largest moment arms in ext. rot, infraspinatus, teres
minor and the subscapularis for int. rotn

Glenohumeral Elevation Studies

In Three Dimensions
Browne etal JBJS 1990
External rotation is necessary to allow

maximum elevation anterior to the frontal

plane. (average plane 23 deg./ 35 deg ext)
Internal rotation is necessary to allow
maximum elevation posterior to the frontal
plane. (average plane 31 deg/ further
posterior 60 deg. Int rotn. necessary)

Dynamic and Static Forces of

Subacromial Impingement
GH joint Muscles that act parallel to
the. Provide compressive forces
Subsapularis-lats-infraspinatus,
teres minor Design to counterbalance the Deltoid
Muscles acting perpendicular to the
GH joint Provide shearing forces Deltoid
The Resultant Force is from all the
muscles producing compressive
and shearing the vector direction
of the total force Payne AJSM 1997

Muscle forces and Acromial

Pressure During Elevation

Payne et al Am J Sports
Med 1997
Biceps 10% reduction in
6 of the 10 shoulders
34% reduction
RC reduces 52% without
supraspinatus simulation
Deltoid abduction force
is increased 17% and the
average pressure inc.
1240% without RC

Dynamic Stability of G-H Joint

in Overhead throwing Activities
Balance of Rotator Cuff and Scapula

rotators
Force Couple of the Scapula and Humerus
Joint compression
Short and Long head of Biceps stabilizes
the anterior capsule.
Stable Scapula Base

Role of the Biceps

The long head of the biceps at

60 & 90 degrees of abduction
and external rotation is an
important stabilizer to the
anterior capsule Itio et al
JBJS 1993
During internal and external
rotation the long head of the
biceps produces compressive
forces to the humeral head
and controls translations
Abboud Clin Ortho Rel Res
2002

Overhead Throwing Athletes

Assessment of Shoulder
Strength in Professional
Baseball Pitchers
Donatelli, Ellenbecker, et
al. JOSPT Sept 2000
Significant deficit of the
external rotators
Significant increase in
strength of the lower
traps.

Soft tissue Restrictions

Overhead Throwing Athletes
Subscapularis tightness restricted ext. rotation at
neutral
Capsular restrictions
Rotator cuff Imbalances External rotator weakness
Scapula asymmetry
Scapula rotator weakness: Serratus, Mid and lower
traps
* Stress to the arm (wrist, elbow, humeral shaft,
peripheral nerves)

Subscapularis Syndrome
Signs

Limited passive external rotation in the

adducted position (neutral)
-Lack of disassociation of the scapula
from the humerus during elevation
-Impingement signs Positive
-Asymmetry of the scapula poor length
tension of supraspinatus, infraspinatus

Stabilizing Mechanics of the

G-H Joint

Turkel JBJS 1981

Passive external rotation in
neutral subscapularis
muscle is the most
stabilizing tissue
At 45 degrees of abduction
subscapularis and
superior/anterior capsule
At 90 degrees of abduction
inferior glenohumeral
ligamentous complex

Rotator Cuff - Imbalances

Shoulder Strength and ROM in Symptomatic &
Pain-free Elite Swimmers Bak & Magnusson AJSM
1997
Painful shoulders have inc. ER:IR ratios of
concentric and eccentric strength implications
strengthen internal rotators
Normal and Painful shoulders during breaststroke
AJSM 1994 Jobe, Pink, Perry
Painful shoulders inc. activity of internal rotators
dec. teres minor, supraspinatus

Role of G-H Ligaments and Capsule in

Overhead Throwing Athletes

OBrien Am J Sports Med

1990 Capsule is shortened
with Rotation
Ext. Rotation at 90E abd.
Is supported by the
anterior band of the
inferior G-H lig. Posterior
band of the inferior G-H is
under the humeral head
resisting inferior
displacement

Translations of Humeral head

Harryman JBJS 1990

Translations of the
humeral head occurs
because the capsule is
asymmetrically tight
Surgically tightened
posterior capsule and
found inc. anterior
humeral head
translation with
add,flexion, int. rotn

3-Dimensional StudiesScapula Movement analysis

Ludewig et al. JOSPT 1996
Lakasiewicz et al JOSPT 1999.
During POS elevation shown general

pattern of:
1. increased posterior-tilt angle
2. increased upward-rotation angle
3.increased external-rotation angle
Serratus - progressive inc. activity 90-140

Scapula Movement

Retraction of the scapula with

horizontal extension = Middle
Trapezius & Rhomboids
Protraction of the scapula =
upward rotation and lateral
movement - Middle traps and
rhomboids eccentric, Lower,
upper traps and serratus rotate
(concentric) serratus stabilizes
scapula to chest wall
Elevation of the scapula =
upper traps & elevator

Scapula Rotators
Inferior angle of scapula

Overuse of Impingement

Ludewig JOSPT, 1996Impingement group

Inferior angle protrudes
more posterior then the
spine of the scapula.
Higher scapula elevation
Ludewig & Cook Phy.
Therapy 2000
Uupward rotation
decreased 4 degrees Inc.
activity of upper traps Dec.
anterior serratus activity

Scapula Rotators Effect on G-H

Serratus anterior and trapezius weakness

will reduce upward rotation of the scapula

and increase risk of the RC and bicipital
impingement Devita et al Phy Therapy 1990
Weakness of the scapula retractors will
result in excessive protraction and narrow
the subacromial space McQuade et al Clin
Biomech 1995 and Kibler Am J Sports Med 1998

Scapular Dysfunction

Kebaetse et al Arch Phys Med

Rehab 1999 Thoracic posture
effects position of scapula and
ROM of the shoulder girdle
Warner et al Clin Orth Rel Res
1992 Asymmetry of the scapula
in 32-57% of shoulder instability
and impingement groups.
Wadsworth & Bullock-Saxton
Int J Sports Med 97
Impingement shoulder - serratus
recruitment delayed
McMahon et al J Sh & Elbow
Surg supraspinatus/ serratus
delayed activity-instability

Scapula Rotators - Exercises

EMG analysis of Scapula

Stabilizing Synergists
during push-up
progression
Decker et al AJSM 1999
Dynamic Hug greatest
EMG activity
Lear and Gross JOSPT
1998 Inc. EMG for
serratus and upper traps
with push-up with a plus
and elevation of feet

Stretching and Strengthening

exercises: Scapular kinematics
Wang CH, et al, Arch Phys Med Reh 1999
20 asymptomatic subjects with forward shoulder
posture
Stretching for pects and resisted strengthening
exercises for the scapular retractors were performed
3x week 6wks
Strength of horizontal abduction and internal /ext
rotator increased (p<.01)
Scapula showed less upward rotation and less superior
translation after the exercise prog. (p<.01)

Debridement of Partial-Thickness
Tears RC without Acromioplasty
Budoff, Nirschl et al, JBJS May 1998
Supraspinatus is small and relatively weak
susceptible to overuse and trauma
Eccentric overload weakens musculotendinous
rotator cuff unit.
Unable to oppose the superior pull of the
Deltoid-inappropriate superior migration
Continued superior migration causes secondary
impingement RC & Grt Tuberosity abuts

Pathological Changes Of
Overuse
Deltoid retains strength longer than RC loss of
depressor effect on humeral head during elevation
Reactive and degenerative osseous changes eg.
Osteophytic spurring causing a weakened cuff to
rupture resulting from impingement
Chronic tendinopathy or angiofibroblastic
hyperplasia degenerative tissue tendinosis, no
inflammatory cells-degenerative tearing or
avascularity, aging or overuse.
Outlet stenosis or G-H instability extrinsic factors

Pathology of RC tears

Ozaki et al, JBJS 1988

Most tears of RC is a
degenerative process that
predates the formation of
osteophytes and acromial
changes, result from
reactive osseous changes
secondary to superior
migration and humeral
impingement rather than
primary acromial
variants.

Rotator Cuff Pathology

Uhhtoff et al Internat Orthop 1988
Ozaki et al, JBJS 1988
Cadaveric shoulders most partial thickness tears
articular side supraspinatus near insertion
hypovascular critical zone
72% of RC tears are painless degeneration
occurs at a rate the body can absorb it, leaving
a full thickness tear of RC

Function of the Arch

Harryman believes the function

of the shoulder may eventually
become dependent on the arch
for functional stability. Contemp
Orthop 1995
Williams stated patients with a
marginally functional torn cuff
need the coracoacromial arch. If
removed shoulder may become
completely non-functional.
Franklin states the arch
provides restraint to anterior
and anterosuperior migration of
humerus

Internal Impingement

Impingement of deep surface of the subscap tendon and

the reflection pulley on the ant/sup glenoid rim: Gerber
et al J sh/elbow surgery 2000

Increased internal rotation with 100 deg. Flexion

the lesser tuberosity and biceps tendon are brought
closer to the ant/sup glenoid rim and the superior
G-H lig. Becomes lax
At 90 deg flexion and internal rotation the deep
surface of the subscap tendon is impinging against
glenoid rim

Posterior G-H pain in Overhead

Throwing athletes
Superior Glenoid Impingement Jobe Clin Orth 1996

Ext. rotn 90 deg abduction and horizontal extension

(early part of acceleration)
Impingement of inner fibers of the RC & post. Sup
labrum between the grt tub and post superior
glenoid. Secondary to lack of resistance from
subscapularis muscle causing angulation of the
humeral head instead of translation
Walker ext. rotation necessary for the grt tub to clear
the glenoid - more cartilage contact for elevation.

SLAP Lesion in Overhead

Throwing Athletes
Morgan and Burkhart Arthroscopy 1998
Mechanism of injury in overhead throwing
athletes is a torsional force the peels back the
biceps and posterior labrum from the neck of
the glenoid.
External rotation and abduction twisting force
is produced at the base of the biceps and this
transmits a torsional force to the posterior
superior labrum

SLAP Lesion

Normal anatomy

OBriens test

SLAP II

Rehabilitation of Shoulder Girdle

-Strength the Core Rotators
of the glenohumeral and
scapulothoracic
-Manual Therapy Static
progressive stretch
-Scapula mobility Dynamic
Stability
-Restore Rotation Sleeper
stretch Int. Rotn
-Explosive weight training
and plyometrics
-Medicine ball exercises

New Research EMG analysis

muscle function during exercises

Richard Ekstrom Dissertation

RMUofHP
Lower and Middle traps
Kendall position for manual
muscle test Prone 90
horizontal abd thumb up
Upper traps and serratus not
isolated well from other muscles
Synergistic unit for elevation
test position 125 POS serratus
Upper traps-shoulder shrug
Lower traps- horizontal abd
with ext. rotation and prone
horizontal abd 145 deg

Impingement Syndrome

Bang Md & Deyle GD Comparison of supervised

exercise with & without manual PT for patients with
shoulder impingement syndrome JOSPT 2000

N=52 2x/wk 3 weeks

Both groups same exercise regime
Manual therapy group Maitland superior to
exercise group only
Manual therapy group significant inc. strength,
ROM, function and decreased pain

Case Presentations
Baseball Player
RC tear/repair
Scapula asymmetry
Scapula muscle weakness
Pain with overhead movements
Restricted ext. rotation in Add.
Lack of disassociation of scapula/humerus

Asymmetry of the Scapula

Before
After

Tight Subscapularis

External Rotation WNL

Treatment RC, Serratus, LLPS

Baseball player-Elbow Pain

Before
After

Strength Training

Strength Training

Strength Training

Plyometrics

Advanced Trunk and

Shoulder Strength / Stability

Football player Impingement

Before
After

Strengthening exercises

Strengthening Exercises