Testing to Begin Return to Throwing Program

by Matt Messner, PT, DPT, CSCS

When returning to throwing following a shoulder injury or surgery, it’s important to have criteria in place to ensure that the shoulder is robust enough to handle the forces that are associated with throwing and reduce the risk of re-injury. These tests are designed to assess various constructs that are important for throwing, as well as shoulder stability in general. Some commonly cited tests include rotator cuff strength testing, the athletic shoulder (ASH) test, prone shoulder endurance test (PSET), unilateral seated shot put test, and the closed kinetic chain upper extremity stability test (CKCUEST) which will be described below!

  • Rotator cuff strength testing: Whether performed isometrically or isokinetically, this test is utilized to determine the maximal strength of the rotator cuff muscles. We are looking for the following values when using this test:
    • ER/IR ratio of dominant arm: 72-76%
    • ER LSI: 95-100%
    • IR LSI: 100-115%

  • ER torque to body weight ratio: 18-23%
  • IR torque to body weight ratio: 26-32% 
  • ASH Test: This test is used to assess peak force in a closed kinetic chain environment. The patient lays prone and pushes their hand into a dynamometer at 180, 135, and 90 degrees respectively. Suggested values are the following:
    •  Limb symmetry index within 10%
    • Mean peak force of 11-15% when normalized to body weight
  • PSET: The PSET is used to assess muscular endurance of the rotator cuff as well as periscapular musculature. There are traditional, isotonic to a metronome set at 30 bpm, as well as modified, isometric hold at 90 degrees abduction until failure, versions of this test.
    • Limb symmetry index of 10%
  • Unilateral Seated Shot Put Test: In order to measure open kinetic chain upper extremity power, the unilateral seated shot put test is utilized.
    • Expected asymmetry of 3-13% in the dominant (stronger/able to throw the ball further) compared to the non-dominant arm
  • CKCUEST: The CKCUEST evaluates a plethora of movement qualities such as closed kinetic chain shoulder stability, trunk stability, and trunk coordination. The test is performed with the arms 3 feet apart and for 30 seconds.
    • Generally speaking, 21 reps or greater are reflective of decreased injury risk. Some articles state 28-33 reps are preferable. 
  • Other tests such as the single arm hop test and upper limb rotation test are also available to be tested, however, the above-listed tests are excellent when making decisions about when it is appropriate to begin a return to throwing program!
  • Check out one of our previous articles on the appropriate progression of throwing once cleared to begin a throwing regimen!

Alderink, G J, and D J Kuck. “lsokinetic Shoulder Strength of High School and College-Aged Pitchers*.” The Journal of orthopaedic and sports physical therapy vol. 7,4 (1986): 163-72. doi:10.2519/jospt.1986.7.4.163

Ashworth B, Hogben P, Singh N, et alThe Athletic Shoulder (ASH) test: reliability of a novel upper body isometric strength test in elite rugby playersBMJ Open Sport & Exercise Medicine 2018;4:e000365. doi: 10.1136/bmjsem-2018-000365

Chmielewski, Terese L et al. “Normalization considerations for using the unilateral seated shot put test in rehabilitation.” The Journal of orthopaedic and sports physical therapy vol. 44,7 (2014): 518-24. doi:10.2519/jospt.2014.5004

Cools, Ann M J et al. “Eccentric and isometric shoulder rotator cuff strength testing using a hand-held dynamometer: reference values for overhead athletes.” Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA vol. 24,12 (2016): 3838-3847. doi:10.1007/s00167-015-3755-9

Otley, Thomas et al. “Return to Sport After Shoulder Stabilization Procedures: A Criteria-Based Testing Continuum to Guide Rehabilitation and Inform Return-to-Play Decision Making.” Arthroscopy, sports medicine, and rehabilitation vol. 4,1 e237-e246. 28 Jan. 2022, doi:10.1016/j.asmr.2021.09.039

Tucci, H. T., et al. “Closed Kinetic Chain Upper Extremity Stability Test (CKCUES Test): A Reliability Study in Persons with and without Shoulder Impingement Syndrome.” BMC Musculoskeletal Disorders, vol. 15, no. 1, 2014. SCOPUS, www.scopus.com, doi:10.1186/1471-2474-15-1.

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