The document outlines a clinical reasoning algorithm for examining the overhead athlete for shoulder pathology. It begins by listing potential shoulder issues such as impingement, rotator cuff dysfunction, instability, SLAP lesions, scapular dyskinesis, and glenohumeral internal rotation deficit (GIRD). For each issue, it describes relevant tests and signs and symptoms. It also differentiates between primary and secondary impingement. The document provides an overview of assessment tests for various shoulder structures and conditions. It concludes by emphasizing the need for caution when relying on diagnostic tests that have only been studied once.

1. “How I examine the
overhead athlete….”
A clinical reasoning algorithm
Ann M. Cools, PT, PhD
Ghent University
Dept of Rehabilitation Sciences
& Physiotherapy
Belgium

2. Shoulder pathology?
Impingement (SA & int)
(Anderson Radiol Clin North Am 2010, Lintner Wrightington nov 2012 2008,
Ann Cools Clin Sports Med
Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

3. Shoulder impingement
Impingement of soft tissue (tendon)
between bony components
External
(Subacromial)
Impingement
(Neer 1972)
Ann Cools Wrightington nov 2012

4. Shoulder impingement
Impingement of soft tissue (tendon) between
bony components
Internal
(postero superior glenoid)
Impingement
(Walch 1990, Drakos JBJS 2009) Cools Wrightington nov 2012
Ann

5. Shoulder pathology?
Impingement
Rotator cuff dysfunction,
including suprascapular
nerve entrapment
(Anderson Radiol Clin North Am 2010, Lintner Wrightington nov 2012 2008,
Ann Cools Clin Sports Med
Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

6. Shoulder pathology?
Impingement
Rotator cuff pathology
Instability (traumatic & acquired)
(Anderson Radiol Clin North Am 2010, Lintner Wrightington nov 2012 2008,
Ann Cools Clin Sports Med
Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

7. Shoulder pathology?
Impingement
Rotator cuff pathology
Instability
SLAP lesions
(Anderson Radiol Clin North Am 2010, Lintner Wrightington nov 2012 2008,
Ann Cools Clin Sports Med
Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

8. Shoulder pathology?
Impingement
Rotator cuff pathology
Instability
SLAP lesions
Scapular dyskinesis
(Anderson Radiol Clin North Am 2010, Lintner Wrightington nov 2012 2008,
Ann Cools Clin Sports Med
Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

9. Shoulder pathology?
Impingement
Rotator cuff pathology
Instability
SLAP lesions
Scapular dyskinesis
GIRD
(Anderson Radiol Clin North Am 2010, Lintner Wrightington nov 2012 2008,
Ann Cools Clin Sports Med
Seroyer Sports Health 2009 , Reeser BJSM 2006, Briner Sports Med 1997)

10. Impingement symptoms
External Internal
Subacromial (posterior)
impingement impingement
Primary Secondary
Impingement Impingement
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
Ann Cools Wrightington nov 2012
(Cools et al. BJSM 2008)

11. Impingement tests:
Jobe, Hawkins, Neer
Ann Cools Wrightington nov 2012
(Hegedus 2008)

12. Impingement symptoms
Jobe +
Jobe –
Neer + ant
Neer + post
Hawkins +
Hawkins –
External Internal
Subacromial (posterior)
impingement impingement
Primary Secondary
Impingement Impingement
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
(Cools et al. BJSM 2008)

13. Instability tests:
Apprehension “Posterior Impingement
Sign”– Relocation - Release
Ann Cools Wrightington nov 2012
(Meister 2004)

14. Impingement symptoms
Jobe +
Jobe –
Neer + ant
Neer + post
Hawkins +
Hawkins –
Apprehension +(pain) ant
Apprehension +(pain) post
External Internal
Subacromial (posterior)
impingement impingement
Relocation -
Relocation+ Relocation+
Release +(pain) Release +(pain)
Primary Secondary
Impingement Impingement
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
(Cools et al. BJSM 2008)

15. Rotator cuff tendinopathy?:
Full can test (Reinold et al. JOSPT 2009)
Ann Cools Wrightington nov 2012

16. Impingement symptoms
Jobe +
Jobe –
Neer + ant
Neer + post
Hawkins +
Hawkins –
Apprehension +(pain) ant
Apprehension +(pain) post
External Internal
Subacromial (posterior)
impingement impingement
Relocation -
Relocation+ Relocation+
Release +(pain) Release +(pain)
Primary Secondary
Impingement Impingement
Full Can +
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
(Cools et al. BJSM 2008)

17. Scapular involvement?
Scap Ass Test – Scap Retr Test
(Rabin et al. JOSPT 2006, Kibler et al. AJSM 2006, Tate et al. AJSM 2008)
Ann Cools Wrightington nov 2012

18. Impingement symptoms
Jobe +
Jobe –
Neer + ant
Neer + post
Hawkins +
Hawkins –
Apprehension +(pain) ant
Apprehension +(pain) post
External Internal
Subacromial (posterior)
impingement impingement
Relocation -
Relocation+ Relocation+
Release +(pain) Release +(pain)
Primary Secondary
Impingement Impingement
SAT +
Full Can +
SRT +
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
(Cools et al. BJSM 2008)

19. Glenohumeral laxity?
Load&shift, Sulcus, posterior subluxation test
Ann Cools Wrightington nov 2012

20. Glenohumeral laxity?
Load&shift, Sulcus, posterior subluxation test
Ann Cools Wrightington nov 2012

21. Impingement symptoms
Jobe +
Jobe –
Neer + ant
Neer + post
Hawkins +
Hawkins –
Apprehension +(pain) ant
Apprehension +(pain) post
External Internal
Subacromial (posterior)
impingement impingement
Relocation -
Relocation+ Relocation+
Release +(pain) Release +(pain)
Primary Secondary
Impingement Impingement
SAT + Laxity tests +
Full Can + Appr + (appr)
SRT +
Relocation + (appr)
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
(Cools et al. BJSM 2008)

22. Biceps pathology or SLAP?
O’ Brien, Speed’s, Biceps Load II
Ann Cools Wrightington nov 2012
(Hegedus et al. BJSM 2008, Oh et al. AJSM 2008)

23. Impingement symptoms
Jobe +
Jobe –
Neer + ant
Neer + post
Hawkins +
Hawkins –
Apprehension +(pain) ant
Apprehension +(pain) post
External Internal
Subacromial (posterior)
impingement impingement
Relocation -
Relocation+ Relocation+
Release +(pain) Release +(pain)
Primary Secondary
Impingement Impingement
O’Brien+
SAT + Laxity tests + Speeds+
Full Can + Appr + (appr) Biceps load II+
SRT +
Relocation + (appr)
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
(Cools et al. BJSM 2008)

24. GIRD?
Internal Rotation ROM in 90° abduction
Ann Cools Wrightington nov 2012
(Trakis et al. AJSM 2008, Cools BJSM 2010, Borstad JOSPT 2011)

25. Impingement symptoms
Jobe +
Jobe –
Neer + ant
Neer + post
Hawkins +
Hawkins –
Apprehension +(pain) ant
Apprehension +(pain) post
External Internal
Subacromial (posterior)
impingement impingement
Relocation -
Relocation+ Relocation+
Release +(pain) Release +(pain)
Primary Secondary
Impingement Impingement
O’Brien+
SAT + Laxity tests + Speeds+ IR
Full Can + Appr + (appr) Biceps load II+ ROM↓
SRT +
Relocation + (appr)
Rotator cuff Biceps
Scapular dyskinesis instability G.I.R.D.
pathology SLAP
(Cools et al. BJSM 2008)

26. Measurement of GH ROM
Digital inclinometer (Acumar) (Cools et al.
Submitted JAT 2012)
Ann Cools Wrightington nov 2012

27. Measurement of GH and
ST strength
HHD (compuFET, Biometrics)
(Cools et al. BJSM 2010; Cools et al. Submitted JAT 2012)
Ann Cools Wrightington nov 2012

28. More information?
In general: “ we urge caution if a diagnostic test is
only been studied once, and if the originator of the
test is the author of the paper” (Hegedus et al. BJSM
2008)
www.standaarduitgeverij.be
Ann.cools@ugent.be
Ann Cools Wrightington nov 2012

29. 29

30. Future congress:
EUSSER is proud to announce, in collaboration
with Ghent University and the Flemish Society of
Shoulder and Elbow Surgeons:
THE SHOULDER IN THE OVERHEAD ATHLETE:
CHALLENGES FOR SCAPULAR REHABILITATION
AND RETURN TO PLAY AFTER INJURY
FRIDAY 29th MARCH 2013
Invited international speakers:
Kajsa Johansson (Sweden)
Klaus Bak (Denmark)
Jo Gibson (UK)
Het Pand, Gent, Belgium

31. (Gent- Belgium)
Thank you!!
Ann Cools Wrightington nov 2012