Shoulder Instability & Return to Throwing
Shoulder Instability & Return to Throwing
Advanced · 12 chapters · 144 MCQs · 144 flashcards · Illustrated
Shoulder Instability & Return to Throwing - complete clinical course for physiotherapy students and clinicians.
What you'll learn
Chapter 1: Foundations: Glenohumeral Anatomy and Stabilizing Mechanisms in the Throwing Shoulder
Chapter 2: Pathomechanics of Instability: Static Restraints, Dynamic Control, and the Kinetic Chain
The glenohumeral joint is inherently mobile, with a shallow glenoid that presents roughly one-third of the humeral head surface. Stability therefore depends on a combination of static restraints and dynamic control.
Chapter 3: Subjective Assessment: History-Taking, Mechanism of Injury, and Symptom Behaviour Profiling
Chapter 4: Clinical Testing: Orthopaedic Special Tests for Laxity, Apprehension, and Labral Pathology
Chapter 5: Imaging Interpretation and Red Flags: Knowing When to Refer, Investigate, or Escalate
By the end of this chapter you should be able to: - Relate glenohumeral and capsulolabral anatomy to the injury patterns seen in throwing athletes.
Chapter 6: Staged Management I: Acute Phase, Pain Modulation, and Restoration of Range and Control
Chapter 7: Staged Management II: Strength, Neuromuscular Training, and Load Progression
Chapter 8: Progressions and Criteria: Advancing Through Throwing Phases with Objective Benchmarks
The glenohumeral joint relies on a shallow glenoid and a large humeral head, so stability depends on static and dynamic restraints.
Chapter 9: Special Considerations: Adolescent Throwers, Multidirectional Instability, and Post-Operative Care
This chapter addresses three populations that differ from the adult overhead athlete in ways that change assessment and management: skeletally immature adolescent throwers, patients with multidirectional instability (MDI), and patients…
Chapter 10: Outcomes and Return Criteria: Validated Measures, Return-to-Sport Decision Making, and Re-Injury Risk
Glenohumeral stability depends on static restraints (the glenoid labrum, capsule, and glenohumeral ligaments) and dynamic restraints (the rotator cuff and scapulothoracic musculature).
Chapter 11: Clinical Pearls: Common Pitfalls, Communication with Coaches and Surgeons, and Practice Efficiency
The throwing shoulder is a high-demand kinetic chain. During the cocking and acceleration phases, the glenohumeral joint undergoes extreme external rotation (often beyond 170°) and horizontal abduction, placing the anterior-inferior…
Chapter 12: Case-Based Reasoning and Summary: Integrated Clinical Scenarios, Synthesis, and Key References
Glenohumeral stability depends on static and dynamic restraints. The static restraints are the glenoid labrum, which deepens the socket by roughly 50%, the glenohumeral ligaments (superior, middle, and inferior), and the negative…
Practice questions
5 sample MCQs from this course. Tap a question to see the answer.
A 19-year-old male javelin thrower sustained an anterior shoulder dislocation during a fall 3 months ago and reports apprehension when his arm is placed in 90° abduction and external rotation. He has no neurological symptoms, and his throwing has been limited to light, short-distance drills. Clinical testing reveals increased anterior translation of the humeral head in the apprehension position.
1. Which structure provides the primary static restraint to anterior translation of the humeral head in this position?
- A. Subscapularis tendon fibres of the rotator cuff
- B. Anterior inferior glenohumeral ligament complex
- C. Coracoacromial ligament
- D. Long head of biceps tendon
Show answer
Answer: B. The anterior inferior glenohumeral ligament complex is the main static restraint to anterior translation when the arm is abducted and externally rotated, and it is typically injured in anterior dislocation. Dynamic structures such as the subscapularis contribute, but they are not the primary static restraint. The coracoacromial ligament limits superior migration, not anterior translation.
A 24-year-old male rugby player fell onto an outstretched, abducted arm 2 hours ago and reports an audible 'clunk' followed by immediate shoulder pain. He cannot lift the arm and holds it in slight abduction and external rotation, with a squared-off anterior contour. He reports numbness over the lateral deltoid.
2. Which immediate action takes priority for this presentation?
- A. Urgent medical referral for reduction and assessment of axillary nerve and vascular status
- B. Commencement of a supervised progressive rotator cuff strengthening programme
- C. Two weeks of activity modification with NSAIDs and review
- D. Grade III glenohumeral mobilisations to restore range of motion
Show answer
Answer: A. A traumatic anterior dislocation with lateral deltoid numbness suggests possible axillary nerve injury and requires emergency reduction and neurovascular assessment. Physiotherapy loading or mobilisation is contraindicated until the joint is reduced and medically cleared.
A 24-year-old male handball player is 8 weeks after arthroscopic anterior stabilisation and is progressing through a structured throwing programme. He reports that pain during the last session peaked at 2/10 and had settled completely by the following morning. His therapist is deciding whether to maintain the current throwing volume.
3. Which pain response is the most acceptable indicator that the current throwing load can be maintained?
- A. Peak pain of 2/10 during throwing that resolves by the next morning
- B. Pain of 5/10 that persists for 24 hours after throwing
- C. New sharp pain at the point of ball release
- D. Night pain that wakes the athlete from sleep
Show answer
Answer: A. Low-level pain that settles within 24 hours is generally accepted as a tolerable response to loading, whereas persistent or escalating pain signals overload. New sharp pain at release or night pain suggests a structural or irritative problem that requires load reduction and review.
A 14-year-old male pitcher reports lateral proximal arm pain that has gradually worsened over six weeks, with no specific trauma. He has lost velocity and can no longer complete full innings. Examination reveals tenderness over the proximal humerus, and his growth plates remain open.
4. Which radiographic feature most strongly supports a diagnosis of proximal humeral physeal injury rather than a soft-tissue strain?
- A. Widening or irregularity of the proximal humeral growth plate compared with the contralateral side
- B. Narrowing of the glenohumeral joint space
- C. Sclerosis of the glenoid rim
- D. Anterior displacement of the humeral head on the AP view
Show answer
Answer: A. In skeletally immature throwers, repetitive rotational and distraction forces can injure the proximal humeral physis, which may appear as widening or irregularity compared with the uninjured side. Comparing with the contralateral shoulder helps distinguish normal physeal appearance from pathology.
A 24-year-old male rugby player has had three anterior shoulder dislocations over 18 months and is 4 months post arthroscopic Bankart repair. He has full range and good strength. The physiotherapist wants a patient-reported outcome that captures his instability-related symptoms, sport and recreation function, lifestyle and emotions, and that can be repeated at each review.
5. Which patient-reported measure is most appropriate for tracking instability-specific quality of life in this athlete?
- A. Western Ontario Shoulder Instability Index (WOSI)
- B. Numeric pain rating scale alone
- C. Constant-Murley score as the only outcome
- D. Single-item global rating of return to work
Show answer
Answer: A. The WOSI is a validated, disease-specific questionnaire for shoulder instability. It covers physical symptoms, sport/recreation/work, lifestyle and emotional domains, so it suits serial monitoring. A pain scale alone or a general score misses the instability-specific content.
Flashcards
Roughly how much does the glenoid labrum increase glenoid depth, and why does this matter for stability?
The labrum increases glenoid depth by roughly 50%, deepening the socket and enlarging the contact area for the humeral head. It also creates a suction-seal effect and acts as a fibrocartilaginous bumper that resists translation. Labral injury therefore reduces both bony concavity and this dynamic seal.
Describe the sulcus sign test and how inferior glenohumeral laxity is graded.
With the patient seated and the arm relaxed at the side, the examiner pulls the humerus inferiorly and watches for a depression below the acromion. Laxity is graded by the distance of the sulcus: under 1 cm is grade 1 (mild), 1 to 2 cm is grade 2 (moderate), and over 2 cm is grade 3 (marked), often with a sulcus that does not resolve quickly.
By approximately what percentage does the glenoid labrum deepen the glenoid socket, and why does this add to stability?
The labrum increases glenoid depth by roughly 50%, deepening the socket and enlarging its surface area. This raises the concavity-compression effect, so the humeral head is held more securely in the glenoid. Loss of labral integrity therefore reduces passive stability, especially at end-range positions.
By roughly what percentage does the glenoid labrum deepen the glenoid socket, and why does this matter for stability?
The labrum increases glenoid depth by roughly 50%, though estimates vary across studies. This deepening gives the humeral head a larger contact area and a stronger concavity, so it resists translation. Labral tears or resection reduce this depth and can contribute to instability.
By roughly what percentage does the glenoid labrum deepen the glenoid socket, and why does this matter for shoulder stability?
The labrum deepens the glenoid by approximately 50%, creating a larger concave surface that holds the humeral head. This increases joint congruency and the bony-soft tissue buttress against translation. Labral tears or resection therefore reduce the socket's effective depth and can contribute to instability.
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