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Upper Extremity Return to Play Assessments

Original Editor - Caroline Stone

Top Contributors - Caroline Stone and Vidya Acharya  

Introduction

Return to play assessments are an integral part of sports physiotherapy treatment. Standardised return to play assessments can support clinicians in assessing readiness of athletes to return to sport post-injury. Ability of patients to return to sport post-surgery for SLAP tears varies widely, from 20% to 94%, with overhead athletes having rates as low as 45% on average.[1] Functional testing, as well as strength testing, can be used to ensure readiness to return to play with the lowest possible risk for reinjury.[2][3]

Functional testing can also be used as baseline testing at the start of the season, ensuring that athletes are returning to their pre-injury level before returning to play. Functional tests that measure power and explosiveness are particularly helpful, as upper-extremity muscular power is a significant factor in performance of sports such as basketball, cheerleading, volleyball, tennis, and gymnastics. [4]

Although many upper extremity functional tests exist, they have not been studied as extensively as those for the lower extremity. Many studies contain small sample sizes or poor methodological quality, indicating a need for further research.[5] Of the upper extremity functional tests, only 3 have been recommended by a systematic review for use in clinical practice. Those are the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), the Seated Single-Arm/Unilateral Seated Shot-Put Test, and the Seated Medicine Ball Throw. [5]

Criteria to Return to Play

Many return to play criteria in the upper extremity are time based. Expected return to play post SLAP repair is approximately 6 months, although longer time periods are likely required.[1] Throwing and overhead athletes likely require longer time frames, up to 2 years, to return to sport.[6]Other important criteria to consider are ROM, strength, and upper extremity function.

Strength and ROM

Similar to other return to play assessments, such as ACL, patients should be expected to improve strength and range of motion (ROM) as close as possible to their uninvolved limb. Michener et al suggests regaining ROM of at least 90% and strength of at least 70% compared to the uninvolved limb before initiating a return to sport protocol.[1] High performance on the CKCUEST and increased shoulder IR strength have been shown to correlate to improved serve velocity in competitive tennis players, highlighting a possible benefit of return to sport criteria.[7] Isometric strength of internal rotation (IR) and external rotation (IR) is a protective factor against rotator cuff (RTC) tendinopathy, indicating a need for high levels of strength in those positions.[3]

Upper Extremity Functional Tests

Closed Kinetic Chain Upper Extremity Test (CKCUEST)

Purpose

The Closed Kinetic Chain Upper Extremity Test (CKCUEST) was developed to guide clinicians in determining readiness to return to sport by providing objective data on both muscle capacity and neuromuscular control.[8] It assesses the patient's ability to transfer forces, shift their center of mass, and recruit proximal chain musculature to stabilise the upper extremity.[8] It also measures speed, endurance, and strength.[9]

The CKCUEST also has clinical value as a preseason assessment to help reduce injury risk. A score of <21 touches indicated an increased risk for injury in American Football athletes.[9]

As the CKCUEST requires minimal equipment, it is an rapid and cost-effective tool for clinicians to help determine upper extremity function. The CKCUEST has both high reliability and validity in upper extremity conditions.[10]

Administration

Patient assumes a push up position, or modified push up position, with hands 36 inches (91.44cm) apart. The patient reaches one hand across their body to tap their opposite hand. Score is determined by how many taps the patient can perform in a 15 second period.[10] An average of three trials may be used, with a 45 second rest in between trials.[10]

Normative Data

Female Reference Values [11]

  • Number of touches: 20.5
  • Minimal Detectable Change (MDC) 3.91 touches

Male Reference Values [11]

  • Number of touches: 18.5
  • MDC 2.82 touches

[12]

Seated Single-Arm/Unilateral Seated Shot-Put Test

Purpose

The Seated Single-Arm or Unilateral Seated Shot-Put Test (SSPT) is a functional test that measures explosive power of the shoulder.[13] It is an easy, inexpensive and fast unilateral shoulder test, making it a good choice for in-clinic assessments.[3] It is particularly applicable for overhead athletes, as shoulder injuries comprise between 9-32% of injuries in this group.[3] The SSPT directly measures shoulder function at high velocity and in a more extreme range of motion, similar to many movements in throwing and overhead sports. [3]

Administration

The test begins with the patient seated on the floor with their back against the wall, knees extended and legs outstretched. Using a 3kg medicine ball, the patient starts with the ball at shoulder height, and throws the ball forward horizontally as far as possible. If the patients back comes off the wall, or the ball is thrown non-horizontally, test does not count. 3 attempts should be performed, with one minute of rest between attempts.[3]The distance thrown is then measured, and an average is taken.

Normative Data

Female Reference Values[13]

  • Age 18-22
    • Dominant: mean 60.25 cm
    • Non-dominant: mean 54.83 cm
  • Age 23-27
    • Dominant: mean 85.92 cm
    • Non-dominant: mean 78.10 cm
  • Age 28-32
    • Dominant: mean 99.35 cm
    • Non-dominant: mean 91.74 cm
  • Age 33-37
    • Dominant: mean 88.98 cm
    • Non-dominant: mean 77.10 cm
  • Age 38-42
    • Dominant: mean 78.82 cm
    • Non-dominant: mean 75.08 cm

Male Reference Values[13]

  • Age 18-22
    • Dominant: mean 87.76 cm
    • Non-dominant: mean 77.58 cm
  • Age 23-27
    • Dominant: mean 115.78 cm
    • Non-dominant: mean 115.78 cm
  • Age 28-32
    • Dominant: mean 155.16 cm
    • Non-dominant: mean 144.03 cm
  • Age 33-37
    • Dominant: mean 230.80 cm
    • Non-dominant: mean 211.80 cm
  • Age 38-42
    • Dominant: mean 216.33 cm
    • Non-dominant: mean 194.33 cm

MDC: 43.18cm in the dominant limb, 45.72 cm in nondominant limb[14]

[15]

Seated Medicine Ball Throw

Purpose

The Seated Medicine Ball Throw (SMBT) is another test of explosive power in the upper extremity[16] It is another simple, easily reproducible test that requires minimal equipment. Normative reference values and standardized testing procedure have yet to be developed for this test, partially due to under utilization.[4]Nevertheless, it can be a quick, easy and useful tool to measure upper extremity function. The SMBT has been shown to be valid for the older adult population as well as younger populations and athletes.[17]

Administration

Testing position is similar to the Seated Single-Arm Shot Put Test. The patient sits on the floor with their back against the wall with their legs outstretched, or in a chair. The patient is then instructed to push the ball forward and away from the body as far as they can, in a bilateral motion akin to a chest press in basketball. [17] The distance thrown is then measured.

Conclusion

Shoulder ROM, strength, the CKCUEST, the Seated Single-Arm Shot-Put Test, and the Seated Medicine Ball Throw are a helpful testing battery to include for return to sport following upper extremity injury. [5][2]Of these tests, the CKCUEST has been shown to be predictive of injury risk, and can be used in preseason testing to help reduce injury.[2] The SSPT and CKCUEST have a strong relationship with IR and ER isokinetic strength, and can be used to help determine isokinetic strength in the absence of an isokinetic dynamometer.[3] Other tests, such as the posterior shoulder endurance test and the One-Arm Hop Test and the Upper Quarter Y Balance Test may also be used, but have poorer reliability and validity, and should be used with caution.[2]

References

  1. ↑ 1.0 1.1 1.2 Michener LA, Abrams JS, Huxel KC, Falsone S, Laudner KG, McFarland EG, Tibone JE, Thigpen CA, Uhl TL. National Athletic Trainers’ Association position statement: evaluation, management, and outcomes of and Return-to-Play criteria for overhead athletes with superior labral anterior-posterior injuries. J Athl Train 2018;53(3):209–229 doi: 10.4085/1062-6050-59-16
  2. ↑ 2.0 2.1 2.2 2.3 Pontillo M, Bellm E, Barber P, Gauthier M, Unverzagt C, Davies G. Upper extremity return to sport functional testing: a systematic review. Sports Med Open. 2026 Feb 23;12(1):13.doi: 10.1186/s40798-026-00984-4.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Tagliarini, G.O., de S Junior, J.R., Glauber, M., Barbosa, P. and Secchi, L.L., 2023. Performance, test-retest reliability, and measurement error of the upper limb seated shot put test according to different positions of execution. International Journal of Sports Physical Therapy, 18(3), p.698.
  4. ↑ 4.0 4.1 Biggar C, Larson A, DeBeliso M, Establishing normative reference values for the Utah seated medicine ball throw protocol in adolescents. The Sport Journal. 2022. Available from: https://thesportjournal.org/article/establishing-normative-reference-values-for-the-utah-seated-medicine-ball-throw-protocol-in-adolescents/
  5. ↑ 5.0 5.1 5.2 Barbosa GM, Calixtre LB, Fonseca Fialho HR, Locks F, Kamonseki DH. Measurement properties of upper extremity physical performance tests in athletes: a systematic review. Braz J Phys Ther [Internet]. 2024 Jan 1;28(1):100575. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1413355523000965
  6. ↑ Mastroiannai MA, Dillon MR, Muscat J, Obana KK, Kim DJ, Luzzi AJ, Alexander FJ, Levine WN, Ahmad CS. Return to play and performance After shoulder labral repair in major league baseball players. Orthop J Sports Med, 14(2), 23259671261415844 doi: 10.1177/23259671261415844
  7. ↑ Stubbe J, Borms D, Vandenbosch D, Cools AM. Validation of an upper extremity physical performance test battery in competitive adult tennis players. Sports Health. 2026 Jan-Feb;18(1):57-66 DOI: 10.1177/19417381251381305
  8. ↑ 8.0 8.1 Torabi TP, Bencke J, van den Tillaar R. The closed kinetic chain upper extremity stability test (CKCUEST) performance in elite team handball players playing with shoulder pain, previous pain, or no pain. Int J Sports Phys Ther. 2024 Feb 1;19(2):189–198. doi: [1]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10837824/
  9. ↑ 9.0 9.1 Pontillo M, Spinelli BA, Sennett BJ. Prediction of in-season shoulder injury from preseason testing in division I collegiate football players. Sports health. 2014 Nov;6(6):497-503.n I collegiate football players. Sports Health. 2014 Nov;6(6):497–503. doi:
  10. ↑ 10.0 10.1 10.2 Lee DR, Kim LJ. Reliability and validity of the closed kinetic chain upper extremity stability test. J Phys Ther Sci. 2015 Apr;27(4):1071-3. doi:10.1589/jpts.27.107
  11. ↑ 11.0 11.1 Tucci HT, Martins J, Sposito GD, Camarini PM, De Oliveira AS. Closed Kinetic Chain Upper Extremity Stability test (CKCUES test): a reliability study in persons with and without shoulder impingement syndrome. BMC musculoskeletal disorders. 2014 Jan 3;15(1):1.
  12. ↑ Pollen T. Fitness Pollenator – Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) [video on the Internet]. [place unknown]: Travis Pollen; 2018 April 12 [cited 2026 May 29]. Available from: https://www.youtube.com/watch?v=tUAlb6diMM4
  13. ↑ 13.0 13.1 13.2 Negrete RJ, Hanney WJ, Kolber MJ, Davies GJ, Ansley MK, McBride AB, et al. Reliability, minimal detectable change, and normative values for tests of upper extremity function and power. J Strength Cond Res [Internet]. 2010 Dec;24(12):3318–25. doi:10.1519/JSC.0b013e3181e7259c
  14. ↑ Pinheiro JS, Monteiro OLS, Pinheiro CAB, Penha LMB, Almeida MQG, Bassi-Dibai D, et al. Seated Single-Arm Shot-Put Test to Measure the Functional Performance of the Upper Limbs in Exercise Practitioners With Chronic Shoulder Pain: A Reliability Study. J Chiropr Med 2020 Sep;19(3):153-158. doi:10.1016/j.jcm.2020.01.001.
  15. ↑ Schwabe B. Seated Shot Put Test (Upper Body Power). [video on the Internet]. [place unknown]. Brian Schwabe DPT 2018 October 2021 [cited 2026 May 29]. Available from https://www.youtube.com/watch?v=shRntjYS-I4
  16. ↑ Beckham G, Lish S, Keebler L, Longaker C, Disney C, DeBeliso M, et al. The reliability of the seated medicine ball throw for distance. J Phys Act Res. 2019 Sep 25;4(2):131–6.doi: 10.12691/jpar-4-2-9.
  17. ↑ 17.0 17.1 Harris C, Wattles AP, DeBeliso M, Adams KJ, Berning JM. The seated medicine ball throw as a test of upper body power in older adults. J Strength Cond Res. 2011 Aug;25(8):2344-8. doi:10.1519/JSC.0b013e3181ecd27b.
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