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Overhead Athlete Shoulder Assessment and Treatment

Original Editor - Ari Kaplan

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

Overhead sports, such as baseball, volleyball and handball, place high mechanical demands on the shoulder, increasing injury risk.[1][2] Athletes participating in these sports can develop distinct shoulder adaptations as a result of repetitive sporting demands.

This article explores shoulder assessment and treatment considerations for overhead athletes, including the total arc concept, the external-to-internal rotation strength ratio, and treatment recommendations.

Specific Considerations in Overhead Athletes

In the general population, shoulder range of motion tends to be symmetrical. However, because of the repetitive demands of their sport, overhead athletes develop adaptive changes in their shoulders, which alter their range of motion.[3]

Treatment success depends on using consistent measurement techniques, understanding normal adaptations, identifying underlying impairments early, and implementing appropriate prevention strategies where possible.[4][5]

Clinical relevance: changes that may be significant in the general population can be normal adaptations in overhead athletes. However, seemingly minor deficits can significantly increase injury risk. Proper assessment distinguishes between adaptive changes and pathological limitations and guides the overall management approach.[6]

Structural Adaptations in Overhead Athletes

When assessing shoulders, it's important to remember Wolff's Law—bones adapt to the mechanical stress or load placed on them.[7] The repetitive forced external rotation required for throwing can lead to the following adaptations during an overhead athlete's growth and development:

  • humeral retroversion, with an average gain of 10.6-15.6 degrees in the throwing shoulder[8][9]
  • structural asymmetry, with changes typically occurring before 12 years of age[10]
  • sport-specific adaptations

Clinical relevance: structural adaptations in overhead athletes provide mechanical advantages, but require modified assessment approaches.[11]

Range of Motion Assessment

Unlike the general population, shoulder range of motion in overhead athletes is not symmetrical. Therefore, overhead athletes should be assessed using their total arc of motion (TRM). The total arc of motion is the sum of a person's external and internal rotation range of motion. It should be equal between the dominant and non-dominant shoulders, even when individual measurements differ.[6][12]

"A shoulder in an overhead thrower is more likely to be injured if there is a greater than 5° difference in TRM in the throwing shoulder compared to the non-throwing shoulder."[12]

Example: a non-throwing athlete has an external rotation range of 95° and an internal rotation range of 75° in both arms. Their total arc of motion is 170° on each side. A throwing athlete also has an external rotation range of 95° and an internal rotation of 75° in their non-throwing arm. However, their external rotation range is 110° and their internal rotation range is 60° in their throwing arm. Their total arc of motion is also 170°, but they have increased external rotation range. This represents an arc shift, which is a normal adaptation in overhead athletes.[6]

Alternatively, this throwing athlete could present with an external rotation range of 110° and an internal rotation range of 40° in their throwing arm. Their total arc of motion is now 150°, due to a reduction in internal rotation range.[6]

Clinical relevance: research demonstrates that significant injury risks are associated with minimal range of motion losses:

  • an internal rotation loss of ≥5° increases injury risk by 2.5x[13]
  • an external rotation loss of ≥5° increases injury risk by 2.8x[14]
  • a shoulder flexion loss of ≥5° increases injury risk by 2.4x[14]
The images below illustrate positions to assess muscle length and range of motion of key shoulder movements for overhead athletes:
Teres major length assessment
Subscapularis length assessment
Latissimus dorsi length assessment
Horizontal adduction ROM assessment: non-dominant upper extremity
Horizontal adduction ROM assessment: dominant upper extremity
Internal rotation ROM assessment
External rotation ROM assessment


Strength Assessment

The external-to-internal rotation strength ratio is a critical measurement of shoulder strength in overhead athletes. This strength ratio should be measured in prone in neutral external/internal rotation. A 1:1 external-to-internal rotation strength ratio is ideal in this position.

Example: an athlete's shoulder external rotation strength is 20kg when measured in prone and in neutral. Their internal rotation strength is also 20kg in this position. Thus, their external-internal strength ratio is 100% (1:1).[6]

Injury risk is increased in athletes with strength deficits.[15] For example, when a person's external-to-internal rotation strength ratio is less than 80%, their injury risk increases by 4.5.[16]

Clinical relevance: an external-to-internal rotation strength ratio of less than 90% warrants intervention. It's also important to take note of reduced strength in the dominant (throwing) arm compared to the non-dominant arm.[6]

Team approach in the pyramid of corrections

Treatment Principles

When treating overhead athletes, there are several key principles to consider, and the pyramid of corrections can be a useful guide when planning rehabilitation.[6]

It is essential to address the root causes of a person's issue (i.e., the impairment). Do not treat symptoms in isolation. External rotation "weakness" may be caused by scapular position rather than a true strength deficit.[17]

We must always respect tissue healing. It is recommended to allow four days between high-intensity throwing sessions for tissue recovery and adaptation.[18]

It is also important to reassess immediately after providing manual therapy interventions. Effective interventions should produce immediate improvements (i.e., within minutes). If no change occurs, reconsider the diagnosis or technique.[6]

Incorporate progressive loading into a rehabilitation plan and follow the treatment hierarchy or pyramid. Attempting high-level interventions without addressing lower-level issues can affect outcomes.[6]

Finally, it's essential to work with other members of the rehabilitation/sport medicine team. Rehabilitation requires coordination between physiotherapists, strength coaches, pitching coaches, etc.[19]

Treatment Strategies for Range of Motion Limitations

Effective rehabilitation should follow a systematic approach (see pyramid above):[6]

  1. Address pain inhibition first
  2. Restore range of motion deficits
  3. Establish proper movement patterns
  4. Build foundational strength
  5. Progress to sport-specific demands
  6. Integrate movement patterns

Clinical relevance: addressing higher-level deficits without correcting foundational issues first will limit treatment success. For example, attempting to progress to sport-specific demands in a person with significant pain inhibition will produce minimal gains.[6]

External Rotation Limitations

External rotation deficits in overhead athletes may result from issues, such as subscapularis restriction, teres major/latissimus dorsi tightness, scapular malpositioning,[20] and thoracic spine dysfunction.[21]

The following techniques might be useful for patients with external rotation deficits.[6]

Latissimus dorsi and teres major soft tissue techniques, such as foam rolling along the lateral scapula (avoiding the axilla) or using a lacrosse ball to massage tender points, specifically targeting the lateral rib area posteriorly.[6]

Latissimus dorsi and teres major stretching techniques, such as floor-based stretches and foam roller-assisted stretches. Rotation components can be added for increased effectiveness, but it's important to make sure there is no impingement pain at the top of the shoulder.[6]

Subscapularis self-treatment techniques, such as massaging the subscapularis with the opposite hand or a TheraCane. It is also possible to use a massage gun (with extreme caution near the axilla).[6]

Critical relevance: it's important not to simply provide external rotation stretches for all overhead athletes with restricted external rotation range. Always identify the underlying cause first![6]

Internal Rotation Limitations

Internal rotation deficits are commonly caused by infraspinatus, teres minor and posterior deltoid deficits and issues with scapular and thoracic positioning.[6]

Treatment options for internal rotation deficits include infraspinatus soft tissue release (e.g., using a lacrosse ball to massage the posterior scapula) and the sleeper stretch.[22][6]

Clinical relevance: a loss of internal rotation increases injury risk by 2.5 times. Remember that overhead athletes may experience a reduction in internal range of motion immediately post-throwing, but recovery can be accelerated if appropriately managed (e.g., sleeper stretch programme).[23]

Flexion Limitations

Flexion restrictions in overhead athletes are commonly caused by latissimus dorsi and triceps deficits, scapular malpositioning, and thoracic spine mobility limitations. The treatment techniques for latissimus dorsi described above may also be beneficial for shoulder flexion restrictions.[6]

Treatment Strategies for Strength Deficits

Strength deficits in overhead athletes are not always just a sign of weakness. They can also be caused by pain inhibition, poor positioning and/or altered length-tension relationships.

Consider the following progressions to retrain external rotation strength deficits.[6]

  • Phase 1: isometric exercises (e.g., wall-based isometrics with a towel roll)
  • Phase 2: basic strengthening (e.g., side-lying external rotation)
  • Phase 3: functional progressions (e.g., row to external rotation)
  • Phase 4: ballistic training (e.g., rapid-fire external rotation movements)
  • Phase 5: functional integration (e.g., D2 PNF patterns for deceleration training)

The Thrower's Ten includes a range of ideas for strengthening progressions. This exercise programme, which was developed specifically for overhead athletes, targets the major muscles necessary for throwing.[24][25]

Various manual techniques might also be considered, such as joint mobilisations, including glenohumeral posterior glide, anterior capsule mobilisation (rare in non-operative cases), scapulothoracic mobilisation, and thoracic spine manipulation.[26] Other advanced soft tissue techniques,[25] including dry needling for trigger point release, instrument-assisted soft tissue mobilisation (IASTM), myofascial release,[27] and cupping therapy for fascial restrictions[27] may also be useful.[6]

Conclusion

Treating overhead athletes requires clinicians to understand the unique biomechanical demands of overhead activities and shoulder adaptations that can develop in response to repetitive overloading. Accurate assessment of the underlying causes, a systematic progression through the treatment hierarchy, and integration of multiple therapeutic approaches help to optimise outcomes.

Resources

References

  1. ↑ Lenart M, Kozinc Ž, Čeklić U. Sport-Specific Shoulder Rotator Adaptations: Strength, Range of Motion, and Asymmetries in Female Volleyball and Handball Athletes. Symmetry. 2025 Jul 30;17(8):1211.
  2. ↑ Ramasamy Y, Usman J, Razman R, Wei YM, Towler H, King M. A Systematic Review of the Biomechanical Studies on Shoulder Kinematics in Overhead Sporting Motions: Types of Analysis and Approaches. Applied Sciences. 2023; 13(16):9463.
  3. ↑ Viera HL, Leite-Nunes TD, Gidiel-Machado L, Laporta LI, Royes LF, Forgiarini Saccol M, Lanferdini FJ. Assessment of shoulder joint and muscle characteristics side asymmetry in professional padel players. Sports Biomechanics. 2025 Feb 24:1-7.
  4. ↑ Steele MC, Lavorgna TR, Ierulli VK, Mulcahey MK. Risk factors for shoulder injuries in female athletes playing overhead sports: a systematic review. Sports Health. 2025 May;17(3):512-22.
  5. ↑ Hoppe MW, Brochhagen J, Tischer T, Beitzel K, Seil R, Grim C. Risk factors and prevention strategies for shoulder injuries in overhead sports: an updated systematic review. J Exp Orthop. 2022 Aug 16;9(1):78.
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 6.15 6.16 6.17 6.18 6.19 6.20 Kaplan A. Shoulder Assessment and Treatment Principles in Overhead Athletes Course. Plus, 2025.
  7. ↑ Allena R, Scerrato D, Bersani AM, Giorgio I. Functional adaptation of bone mechanical properties using a diffusive stimulus originated by dynamic loads in bone remodelling. Zeitschrift für angewandte Mathematik und Physik. 2024 Jun;75(3):85.
  8. ↑ Chant CB, Litchfield R, Griffin S, Thain LM. Humeral head retroversion in competitive baseball players and its relationship to glenohumeral rotation range of motion. J Orthop Sports Phys Ther. 2007 Sep;37(9):514-20.
  9. ↑ Thomas SJ, Swanik CB, Kaminski TW, Higginson JS, Swanik KA, Bartolozzi AR, Nazarian LN. Humeral retroversion and its association with posterior capsule thickness in collegiate baseball players. J Shoulder Elbow Surg. 2012 Jul;21(7):910-6.
  10. ↑ Edelson G. The development of humeral head retroversion. J Shoulder Elbow Surg. 2000 Jul-Aug;9(4):316-8.
  11. ↑ Makaruk H, Starzak M, Tarkowski P, Sadowski J, Winchester J. The effects of resistance training on sport-specific performance of elite athletes: a systematic review with meta-analysis. Journal of Human Kinetics. 2024 Apr 15;91(Spec Issue):135.
  12. ↑ 12.0 12.1 De Luigi AJ, Raum G, King BW, Bowers RL. Osteopathic approach to injuries of the overhead thrower’s shoulder. Journal of Osteopathic Medicine. 2025 May 22;125(6):285-98.
  13. ↑ Wilk KE, Macrina LC, Fleisig GS, Porterfield R, Simpson CD 2nd, Harker P, Paparesta N, Andrews JR. Glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers are correlated. Am J Sports Med. 2011 Feb;39(2):329-35.
  14. ↑ 14.0 14.1 Camp CL, Zajac JM, Pearson DB, Sinatro AM, Spiker AM, Werner BC, Altchek DW, Coleman SH, Dines JS. Decreased Shoulder External Rotation and Flexion Are Greater Predictors of Injury Than Internal Rotation Deficits: Analysis of 132 Pitcher-Seasons in Professional Baseball. Arthroscopy. 2017 Sep;33(9):1629-1636.
  15. ↑ Kline D, Fischer SK, Bullock GS, Kissenberth MJ, Shanley E, Thigpen CA. Risk Factors and Injury Prevention in the Throwing Athlete. Arthrosc Sports Med Rehabil. 2024 Nov 6;7(2):101037.
  16. ↑ Byram IR, Bushnell BD, Dugger K, Charron K, Harrell FE Jr, Noonan TJ. Preseason shoulder strength measurements in professional baseball pitchers: identifying players at risk for injury. Am J Sports Med. 2010 Jul;38(7):1375-82.
  17. ↑ Greiwe RM, Ahmad CS. Management of the throwing shoulder: cuff, labrum and internal impingement. Orthop Clin North Am. 2010 Jul;41(3):309-23.
  18. ↑ Hintz C, Colón D, Honnette D, Denning N, Porras E, Willard J, Diamond A. Individualizing the Throwing Progression Following Injury in Baseball Pitchers: the Past, Present, and Future. Curr Rev Musculoskelet Med. 2022 Dec;15(6):561-569.
  19. ↑ Armstrong A. Clarifying the role of the strength and conditioning coach in athlete rehabilitation. (Unpublished document submitted in partial fulfilment of the requirements for the degree of Master of Applied Science). Otago Polytechnic 2021, New Zealand.
  20. ↑ Smith J, Dietrich CT, Kotajarvi BR, Kaufman KR. The effect of scapular protraction on isometric shoulder rotation strength in normal subjects. J Shoulder Elbow Surg. 2006 May-Jun;15(3):339-43.
  21. ↑ Manoso-Hernando D, Bailón-Cerezo J, Elizagaray-García I, Achútegui-García-Matres P, Suárez-Díez G, Gil-Martínez A. Cervical and Thoracic Spine Mobility in Rotator Cuff Related Shoulder Pain: A Comparative Analysis with Asymptomatic Controls. J Funct Morphol Kinesiol. 2024 Jul 24;9(3):128.
  22. ↑ Gharisia O, Lohman E, Daher N, Eldridge A, Shallan A, Jaber H. Effect of a novel stretching technique on shoulder range of motion in overhead athletes with glenohumeral internal rotation deficits: a randomized controlled trial. BMC Musculoskelet Disord. 2021 Apr 30;22(1):402.
  23. ↑ Reuther KE, Larsen R, Kuhn PD, Kelly JD 4th, Thomas SJ. Sleeper stretch accelerates recovery of glenohumeral internal rotation after pitching. J Shoulder Elbow Surg. 2016 Dec;25(12):1925-1929.
  24. ↑ Asal B, Özünlü Pekyavas N. Assessing Thrower's Ten program's effect on shoulder flexibility, stability, and strength in water polo athletes. Shoulder & Elbow. 2025 Apr 28:17585732251335933.
  25. ↑ 25.0 25.1 Wilk KE, Arrigo CA, Ivey M. Rehabilitation of the Shoulder and Elbow in the Throwing Athlete. Clinics in Sports Medicine. 2025 Apr 1;44(2):249-72.
  26. ↑ Khandaloo A, Taghizadeh Delkhoush C, Paknazar F, Ehsani F, Shokrian Z. A comparison of two mobilisation approaches on the acromiohumeral distance in overhead athletes with primary subacromial impingement syndrome: a randomised clinical study. Journal of Manual & Manipulative Therapy. 2025 Aug 8:1-4.
  27. ↑ 27.0 27.1 Richey B. The Effectiveness of Myofascial Release on Overhead Athletes with Posterior Shoulder Tightness. Illinois State University; 2022.
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