FAQ Category: Shoulder

A snapping or catching sensation felt along the front of the shoulder can be caused by many different problems. There could be a torn rotator cuff or a torn labrum. The labrum is a fibrous rim of extra cartilage around the otherwise shallow shoulder socket. It helps give the shoulder socket more depth and keeps the round ball at the top of the humerus (upper arm bone) in the socket.

Other possible causes of shoulder snapping include bursitis, tendon tears, bone spurs, or loose pieces of cartilage or bone inside the shoulder joint. There’s also a chance that it could be a shoulder bursitis.

In a recent case report, symptoms of shoulder snapping like yours were reported in a 23-year-old weight lifter. When the weight lifter first went to the Mayo Clinic Sports Medicine Center in Rochester, Minnesota, he had an eight-week history of painful shoulder snapping. The snapping occurred whenever he lifted his arm straight forward with the elbow straight or when he used his left arm in a rowing motion.

After a series of tests, they found a pocket of fluid over the tendon of the subscapularis muscle. The subscapularis muscle is part of the rotator cuff, so although the rotator cuff wasn’t torn or ruptured, there was evidence of a tendinopathy. Tendinopathy refers to chronic changes in the tendon without active inflammation.

Inflamed tissue was observed around the subcoracoid bursa. The subcoracoid bursa is sandwiched between the subscapularis muscle and the coracoid process. The coracoid process is a hook-shaped piece of bone that comes from the shoulder blade to help stabilize the shoulder.

It’s impossible to say what is causing your snapping shoulder without some specific tests to identify what’s going on. Make an appointment with your primary care physician or an orthopedic physician and get a proper diagnosis. Early treatment can sometimes help prevent minor problems from growing into major problems. It may be something simple that can be treated easily if diagnosed early.

Before and after measurements of pain, motion, strength, and function are a good way to track which patients improve with surgery and rate the level of success or failure for each procedure. But as you probably already know, there are over 30 different tests that can be done.

You may even recognize the names of some of the most commonly used tests: the American Shoulder and Elbow Surgeons (ASES) shoulder outcome score, the Constant Shoulder Score, Disabilities of the Arm, Shoulder, and Hand (DASH), the Western Ontario Osteoarthritis of the Shoulder Index (WOOS).

Here’s a little bit about each one. The American Shoulder and Elbow Surgeons (ASES) test has been around for the last 15 years. It was developed by a committee with the hope of using it for research. The ASES can be used with all patients no matter what’s wrong with the shoulder. And it can be used for patients treated conservatively (nonoperatively) as well as for those who end up having surgery for their shoulder problem.

The ASES assesses pain, instability, and function (activities of daily living or ADLs). The one major disadvantage of this test is the level of difficulty in calculating the score. It is widely used in the U.S. and Europe and can be used for research and for a general idea of how the shoulder is doing.

The Constant score is used to measure before and after results from surgery, but it can be used with nonsurgical cases as well. It does measure pain, activities of daily living (ADLs), shoulder motion, and strength.

But the Constant score test has not been validated for all different kinds of shoulder problems. And there are problems with examiner bias when it comes to measuring strength and motion. So, for now, this one isn’t recommended until some of these issues have been ironed out.

Everyone agrees that the Disabilities of the Arm, Shoulder, and Hand (DASH) is a good measure of disability for the arm that can stand alone (i.e., other tests aren’t needed along with it). It’s a questionnaire patients take answering questions about symptoms and physical function.

It can be completed quickly, scored with moderate ease, and used with many different shoulder problems (e.g., arthritis, tendinitis, psoariatic arthritis, rotator cuff problems and repair, shoulder joint replacement). For general assessment and worker’s compensation claims, the DASH can’t be beat.

And finally, the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) is rated the best for assessing results of total shoulder replacement and treatment for arthritis of the shoulder. The patient answers 19 questions about symptoms (including pain), sport, recreation, work, lifestyle, and emotional function.

The best thing to do is consider your setting, the type of patients you are seeing most often, and how much detail you need in the information gathered. Once you select the most appropriate tool and use it consistently, you’ll have a better idea if that is the one you want to stick with — or if your patient population should be tested using one of the other tools.

Test tools developed for shoulder outcomes measures often have a specific focus such as severity of motion loss or change in pain intensity. Some are designed to be used in research, while others assess shoulder instability in all forms of rotator cuff pathology.

Three main tools used with patients who have rotator cuff disease include the Rotator Cuff Quality of Life and Western Ontario Rotator Cuff Index. For patients who have had surgery for rotator cuff disease, there are a few additional tests such as the Rowe Rating Sheet for Bankart Repair, the Western Ontario Rotator Cuff index (WORC), and the Wolfgang criteria.

Here are a few details about each of these rotator cuff disease outcomes measures. The Rotator Cuff Quality of Life assesses five different areas including pain, physical complaints (and other symptoms), sports and recreation, work concerns, lifestyle issues, and social and emotional issues. So you can see that it offers information on a wide range of outcomes, not just pain.

The Western Ontarior Rotator Cuff Index also asks patients to rate their pain and physical symptoms, sports and recreation participation, work function, social and emotional function. It was designed to be used with surgical and nonsurgical care including partial and full-thickness rotator cuff tears.

The Wolfgang criteria rates results of rotator cuff surgical repair, so it’s limited to that particular group of patients. Some experts suggest that to obtain the highest level of outcome assessment, a test of general health outcome should be done. Along with that, the clinician or researcher should also measure activity and administer a disease- or condition-specific questionnaire. Combined together these outcome measures will give a broad assessment of each patient — even those who have a specific diagnosis of rotator cuff pathology.

Subluxation is usually defined as an incomplete instability event that did not require manual assistance to reduce it. Manual assistance refers to a doctor or emergency medical technician using a hands-on technique (or surgery) to put the joint back in place. A shoulder that pops out of the joint but goes back in on its own is technically still a subluxation.

Dislocation is a complete disruption of the joint that requires some means of relocation (either the manual technique or surgery). The joint was forced out of the socket and didn’t go back in without help.

But there is technically a third classification that falls somewhere in-between. Orthopedic surgeons from West Point have proposed using the term transient luxation. Transient means temporary. Luxation refers to a separation of the two joint surfaces with enough force to cause damage to the joint or surrounding tissue.

They came up with this idea after investigating the kind of damage that occurs within the joint of first-time (acute) shoulder subluxations. Because these injuries normally spontaneously reduce (head of the humerus goes back into the socket by itself), X-rays and MRIs aren’t routinely taken. But in this study, they were able to look at imaging studies taken within two weeks of the initial injury and see significant changes.

Most had both a Bankart and a Hill-Sachs lesion. A Bankart lesion indicates damage to the cartilage around the rim of the shoulder socket. The Hill-Sachs lesion appears as a dent in the bone of the head of the humerus (round ball at the top of the upper arm bone). It’s an indication that the head of the humerus hit the edge of the socket on its way out of (or back in) the socket.

What you describe sounds like a subluxation but more specifically, you may have had a transient luxation.

A Bankart lesion occurs when a shoulder dislocation has caused a tear in the labrum. The labrum is a tough rim of fibrous cartilage around the shoulder acetabulum (socket). It is designed to help hold the shoulder in the otherwise shallow socket. Loss of the integrity of the labrum increases the risk of shoulder instability.

What do we mean by shoulder instability? Without an intact labrum, you are at increased risk for recurrent shoulder dislocations. It is possible to rehab the shoulder and recover strength and stability needed to maintain its natural position inside the socket. The odds of doing so with both shoulders involved is not something that has been reported on.

In a recent study of military cadets, about 25 per cent who opted for conservative care of one shoulder with a Bankart lesion ended up having surgery after all. That means 75 per cent were able to recover without surgery. It should be noted that they were required to complete the rehab program and continue with the daily physical training that is part of military life.

Your surgeon is the best one to advise you on this. Treatment (conservative or nonoperative care versus surgery) is usually based on your age, the mechanism of injury, and extent of damage. Usually, there’s no reason not to try rehab. It will give you a better chance of recovery and certainly benefit you should surgery be required.

There are many factors that go into the decision to repair or replace a broken shoulder. Patient age, general health, mental status, and ability to survive surgery head up the list. But type of fracture and condition of the bones are important, too.

The fracture pattern is another important considerations — especially when the surgeon is forming the plan of care. X-rays and CT scans help show the extent of damage. Surgeons use the results of these imaging studies to classify fractures.

There are two commonly used classification systems. The Neer classification looks at the number of broken pieces of bone that have shifted away by more than one centimeter or that angle more than 45 degrees from their normal location. The AO-ASIF classification looks at how much of the shoulder joint surface is involved.

Both systems help predict the risk of osteonecrosis (bone death) from lack of blood supply. If the risk is too great, then surgery to replace the bone is done instead of trying to save it. Shoulder replacement may be complete (both sides of the joint removed and replaced) or a hemiarthroplasty (just one side is replaced).

The decision to replace part or all of the shoulder isn’t easy. The patient must have good enough bone to support the implant. They must be strong enough to have major surgery and then go through rehab. Talk to the surgeon to understand more about why your family member ended up with a shoulder replacement. There was probably more than one reason the natural joint couldn’t be saved.

Shoulder fractures in older adults are definitely on the rise. The upper arm bone your mother broke is called the humerus. A sudden fall from bed or even from a standing position can generate enough force to break the humeral shaft away from the humeral head. Sometimes the humeral head splits into multiple parts at the same time.

Surgery is often needed to repair or replace the shoulder. Younger patients in good health and active are more likely to have salvage surgery (save rather than replace the joint). Older patients (70 years old and older) are more likely to need a joint replacement.

The use of a reverse arthroplasty has been the implant of choice for inactive patients aged 70 or older with severe osteoporosis and now a severe fracture. In this type of implant, the ball portion of the shoulder is put where the socket used to be and the socket now goes where the ball or humeral head was located.

Patients with fracture and poor muscle function (often caused by an old unrepaired rotator cuff tear) are also good candidates for the reverse arthroplasty. The design of the reverse arthroplasty creates a much more stable shoulder joint that can function without a rotator cuff.

Certain types of fractures that aren’t likely to heal seem to do well with a reverse shoulder arthroplasty. Sometimes a hemiarthroplasty is done but fails. Then it is replaced with a reverse shoulder arthroplasty. A hemiarthroplasty is the replacement of just one side of the joint — either the head of the humerus or the cup that forms the socket).

Patients receiving a total shoulder replacement must be alert and able to participate in an active rehab program after surgery. Older adults who are inactive and perhaps who have some cognitive (thinking, memory) problems are good candidates for the reverse replacement.

Don’t stop wearing your brace without first discussing the decision with your surgeon. Each patient has his or her own unique injury and repair procedure that dictates post-operative protocol.

For example, patients with small tears are often able to take the arm out of the abduction brace after only four weeks. This compares with five weeks of immobilization for patients with medium tears and six weeks for large tears. Likewise, patients with smaller tears may be allowed to move the arm sooner than patients with large or massive tears.

Sometimes there’s more damage done to the joint than just the rotator cuff tear. There can be a torn labrum (rim of fibrous cartilage around the shoulder socket), other tendons frayed, or tendon tears. Any soft tissue injury of the rotator cuff can be partial or full (complete).

Extensive repairs to several injuries present at the same time can delay healing and extend recovery time. That can mean a longer period of time in an immobilizer such as the abduction brace.

Shoulder surgery to repair a rotator cuff tear is designed to reduce pain, restore power (strength), and improve motion. Patients report that pain relief is by far the most important and best result of this procedure. Is it possible to know before surgery how much improvement in pain might be expected?

According to orthopedic surgeons from Seoul, Korea, it is possible to predict pain reduction after rotator cuff repair. And they say this is the first study of its kind! How is it done? A simple injection of a numbing agent called lidocaine is inserted into the subacromial space.

The subacromial space is the area just above the head of the humerus (upper arm bone) and below the acromion. The acromion is a curved piece of bone that comes around from the back of the shoulder blade over the humeral head.

Muscles of the rotator cuff pass underneath this arch of bone. As the arm lifts up, the damaged (torn) or weak rotator cuff can get pinched between the head of the humerus and the acromion. This condition is called impingement. It’s the pinching of the tendon that causes pain and loss of motion and function.

Injecting a numbing agent into this space would provide substantial pain relief when impingement is the real problem. The authors called this test the modified impingement test. It’s modified because instead of just assessing pain while the arm is lifted, there’s been the injection of lidocaine as well.

The modified impingement test is simple, safe, and easy to do. It provides a fairly accurate estimate of how much pain relief patients can expect with rotator cuff repair surgery. It’s not a good predictor of how much change in motion or function might be expected from before to after surgery. But since pain is the primary symptom of concern, knowing pain will be relieved may be enough to satisfy patients and help them when making the decision to have surgery.

There have been many studies done on shoulder and elbow injuries among overhead throwing athletes. Arm injuries are the most common in this group of players. We do know that pitchers often have one group of muscles that are weak compared to another. For example there may be an imbalance between the external rotator muscles used to cock the arm back and the internal rotator muscles used to throw the ball forward.

In a recent study the effect of preseason shoulder strength was evaluated on the risk of in-season throwing-related injuries. As part of the study, they also looked to see if previous shoulder surgery put the players at increased risk for future injuries.

They measured the shoulder range-of-motion of 144 baseball pitchers. Baseball pitchers from both major and minor leagues were included. All measurements were taken before the season began for five years in a row (2001-2005). Then they compared strength data with in-season injuries to see if there was a link between the two.

As it turns out, a history of shoulder surgery did not mean the pitcher was more likely to reinjure that arm. But preseason muscle weakness in any player does point to the potential for increased risk of in-play shoulder injuries. Players who have surgery and complete a rehab program are usually only released to return-to-play when testing shows they are ready to compete again safely.

As you already know, a shoulder or elbow injury (the two most common types of injuries in overhead throwing) can put a pitcher out of the game. Sports orthopedic surgeons have investigated the effect of preseason shoulder strength on the risk of in-season throwing-related injuries.

After looking over what’s already known about shoulder (throwing or pitching) injuries, they decided to see if weak shoulder muscles during preseason are linked with in-season problems. To test their ideas out, they measured the shoulder range-of-motion of 144 baseball pitchers. These were major and minor league baseball pitchers but their findings might still be what you are looking for.

All measurements were taken before the season began for five years in a row (2001-2005). Then they compared strength data with in-season injuries to see if there was a link between the two. They found that shoulder injuries were more likely to occur when muscles used to externally rotate the shoulder (cock the arm back to throw) were weak. An imbalance between internal and external rotator muscle strength (one group stronger or weaker than the other) was a red flag that weakness could lead to injury. This finding has been reported in many other studies as well.

Professional baseball pitchers also end up in surgery when the supraspinatus muscle is weak. The supraspinatus muscle is one of the four muscles of the rotator cuff. Its major function is to abduct the arm. Abduct means the arm moves away from the body.

Preseason strengthening of the rotator cuff and muscles of the elbow/forearm may be the answer. Strong muscles help reduce the force and load placed on the joints during overhead throwing activities. A strengthening and conditioning program is a good place to start. You may want to enlist the aid of a sports trainer, physical therapist, or other knowledgeable fitness instructor.

The most common cause of collarbone or clavicle fracture for teens is a sports injury. This could be from playing organized sports and being injured during a play, or by falling or having an accident while riding a bike, climbing, and so on.

Joint laxity (even hyperlaxity) is a common shoulder problem among overhead pitchers. Hyperlaxity means the soft tissues around the joint that usually hold it in place are extra long and very elastic.

Some people are born with joint hyperlaxity. Their joints can slide and glide all over the place. They can move and rotate joints in all directions without dislocation. This condition is called multidirectional hyperlaxity.

Athletes like yourself who use their shoulder(s) over and over cause the soft tissues to stretch out too much. Overuse or overtraining often only affects one direction of shoulder motion making this a problem of unilateral hyperlaxity. Conservative care may be helpful but surgery at the end of a long career is often the best answer.

If you decide to pursue nonoperative care, you will see a physical therapist who will help you modify your activities. Essentially you’ll learn how to do things that don’t stress your shoulder.

The therapist can provide a program of exercises to help strengthen the muscles around the joint. Strong muscles help stabilize loose joints. The patient with multidirectional shoulder hyperlaxity must follow the prescribed program for at least a full year with a maintenance program that should be carried out for the rest of life.

If rehab doesn’t help and surgery is indeed advised, then the techniques used most often include the capsular shift, capsular plication, and thermal capsulorraphy. The procedures are usually done arthroscopically at a special shoulder unit by a surgeon who has advanced training in this type of treatment.

The capsular shift procedure is a bit like a tummy tuck. Incisions are made so that the excess tissue can be pulled up and tightened. Different types of incisions and incision patterns can be used depending on where the greatest laxity is located.

With the plication procedure, excess capsular material is pinched and tucked to form pleats. It’s like taking in the waistband on a pair of pants or a skirt that is just too big. The surgeon attaches the pinched pleat to the stiff labrum (fibrous rim around the shoulder joint). This procedure must be done in such a way that the folds of extra tissue don’t get pinched during shoulder motion.

And the last procedure thermal capsulorraphy uses heat to shrink the shoulder capsule. Results from this technique have not been very good, so the method is not recommended much anymore.

You’ll need to see an orthopedic surgeon to find out what’s the best approach for your problem. Tests for ligamentous laxity, directional instability, and motion will be done. The strength and condition of other joints and soft tissues around the shoulder are also tested. Surgery for patients with structural abnormalities of the shoulder will address those imbalances.

Most rotator cuff tears are the result of sports-related injuries. But there are other mechanisms of injury such as a fall (from a height or from a standing position), lifting heavy items, car accidents, or other accidents.

Is it possible that you have experienced one of these injuries in the past but just didn’t link it with the damage to your shoulder? If not, it is entirely possible to have an atraumatic (without trauma) cause of rotator cuff and labral tears.

Sometimes age related changes combined with imbalances in and around the shoulder and repetitive motions can lead to similar injuries. Most often, these apparent atraumatic tears are really related to a remote event several years ago. But because there weren’t any immediate symptoms, it’s easy to miss the connection.

According to surgeon observation and reported studies, stiffness after shoulder surgery is more common in older adults (40 years old or older). This is especially true when concomitant (combined) procedures such as a rotator cuff repair and a SLAP repair are done at the same time.

SLAP refers to the labral tear you have. It stands for superior labral anterior-posterior. The structure that is torn is the labrum, a fibrous rim of cartilage around the shoulder socket. It is designed to help hold the round head of the humerus (upper arm bone) in the joint thus increasing the joint stability. Superior anterior-posterior tells us the location of the damage: top of the shoulder socket from front to back.

The reason for the stiffness isn’t entirely clear. It may be due to age-related changes as collagen tissue dries out and loses its pliability (flexibility). But there’s some evidence that it might be related to the type of rehab program used after surgery.

A recent study from Harvard University compared patients having isolated rotator cuff repairs with those who had the combined rotator cuff repair with SLAP repair. The patients in both groups were over age 40. In fact, the average age was 58 years old, which is older than most other studies of this type.

The patients in both groups followed a very intensive rehab program right from the start. Early range of motion was part of the protocol. This type of rehab isn’t always used for fear of re-tears in the healing tissue. But they found no stiffness in the patients. Normally, patients are told not to stretch the arm overhead for the first six weeks to avoid damaging the repair.

There may be some other explanation for your postoperative stiffness. The best thing to do is make a follow-up appointment with your surgeon and let him or her examine your shoulder. It’s possible the problem could be cleared up easily with some additional therapy.

Conservative (nonoperative) care for shoulder osteoarthritis is often recommended before patients consider surgery. Often a short-course of antiinflammatories, pain relievers, and/or physical therapy provide short-term relief from painful and disabling symptoms.

It’s amazing how a little pain relief can go a long way to improving function and therefore quality of life. But questions have been raised as to how long pain relief lasts with these conservative approaches. Is the money well-spent if the pain comes back and/or disability continues to progress?

Studies to support (or refute) nonoperative care are lacking. In fact, clinical practice guidelines recently published by the American Adademy of Orthopaedic Surgeons (AAOS) couldn’t support the use of any of these nonoperative methods of treatment.

That’s not to say you can’t get relief from your painful symptoms with antiiflammatories or physical therapy. It just means there haven’t been enough studies done to say one way or the other what works best and what doesn’t work at all.

Until we have firm evidence from high-quality studies, it’s up to each patient to discuss the particulars of his or her problem with the physician and chart a course of action. It may take a while to find the right treatment or combination of treatments that work best for you.

Orthopedic surgeons continue to seek evidence to guide all aspects of patient care. In a newly released document, the American Academy of Orthopaedic Surgeons (AAOS) offers 16 guidelines for clinical practice in the care of patients with shoulder osteoarthritis.

There is a wide range of issues related to shoulder arthritis. The fact that the shoulder joint can be replaced with a joint replacement (implant) has changed the way patients are treated. Younger patients with shoulder arthritis has helped push the envelop so-to-speak, meaning the search is on for the right treatment for all ages.

Every day surgeons around the world weigh the pros and cons for the treatment of their patients’ painful shoulder arthritis. Patient factors such as age, occupation, severity of symptoms, general health, and education level are taken into consideration when choosing a treatment path. The surgeon’s examination and X-ray findings also provide important information when forming the plan of care.

Hemiarthroplasty (replacement of part of the joint) has good results but total shoulder replacement still seems to work better for the diagnosis of shoulder osteoarthritis. Many patients who receive a hemiarthroplasty end up having a second surgery to convert to a complete joint replacement.

There is general agreement that patients who have a torn rotator cuff are not good candidates for shoulder replacement. Other factors that must be taken into consideration when choosing the best plan of care for yourself include age, occupation, severity of symptoms, general health, and education level.

The surgeon’s examination and X-ray findings also provide important information when forming the plan of care. These are not quick and easy decisions. Getting a second opinion is a good idea. When the two opinions don’t match, a third opinion might help.

The rotator cuff is a group of four muscles and their tendons that surround the shoulder and give it both stability (keeps the shoulder in the socket) and mobility (allows the shoulder to rotate and move in so many directions.

The two most commonly injured or torn tendons are the infraspinatus and supraspinatus. Both of these muscles and tendons come from the back of the shoulder to attach in different places.

A recent study done at the Washington University at St. Louis Department of Orthopedic Surgery showed that the majority of degenerative rotator cuff tears seem to start where the two tendons meet.This might help explain why some people seem to have an infraspinatus tear but their supraspinatus tendon is the one that looks worn out and vice versa.

One of the current theories to explain why the tendons tear in this pattern is called the rotator crescent concept. The rotator crescent is a crescent-shaped area from the biceps tendon to the bottom border of the infraspinatus tendon. Along the edge of this area is a thick arch-shaped bundle of fibers called the rotator cable.

The cable protects the crescent from stress by its shape and design, which is much like a suspension bridge. With aging, the crescent loses blood supply and starts to thin out. The shoulder mechanics start to rely more and more on the cable. The area that starts to tear is right in the middle of that aging, thinning crescent.

That’s just a theory right now. With more research and study, the full details of rotator cuff pathology will eventually come to light. Understanding the how and why of these tears (where they start and how they progress over time) will be helpful for surgeons. The goal is to direct prevention and treatment, especially guiding surgical strategies.

You may have what’s called a degenerative rotator cuff tear. Thinning and tearing of the rotator cuff associated with aging is fairly common. Then with only a minor amount of trauma, a fall, or eve no trauma at all (just daily use of the arm), a tiny tear progresses from small to large or from a partial to full-thickness tear.

Efforts are underway to study rotator cuff tears more thoroughly in the senior population. Finding out where the tears start might help surgeons design prevention programs — or change the way surgery is done. There’s some speculation that instead of waiting for the tears to progress, surgery to repair the tiny defects might be a better approach.

It’s possible that seniors who do not engage in strength training of the rotator cuff are at increased risk of tears. Loss of muscle bulk to protect the tendons could lead to fat infiltrating the muscle. The lack of specific exercises to tone and strengthen the shoulder might actually be a risk factor in this case.

The Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure is a 30-item, self-report questionnaire designed to measure physical function and symptoms in people with any of several musculoskeletal disorders of the upper limb. The tool gives clinicians and researchers the advantage of having a single, reliable instrument that can be used to assess any or all joints in the upper extremity.

A shorter version called the QuickDASH is also available. Both tools are valid, reliable and responsive and can be used for clinical and/or research purposes. The full DASH Outcome Measure provides greater precision, so it may be the best choice for clinicians who wish to monitor arm pain and function in individual patients.

There is a new tool available called the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score (KJOC). It was developed by and named for (in part) the well-known orthopedic surgeon, Frank Jobe, MD. The KJOC has been pilot tested and then revised and retested on a larger group of overhead throwing athletes.

There are 10 questions about pain, missed games/practices, flexibility, weakness, stability, change in throwing patterns, and throwing velocity (speed) and power. A few questions also address level of competition, history of injury, and effects of arm problems on relationships with others (e.g., coaches, team players, agents, team managers).

The KJOC is designed to make sure the questions aren’t just directed toward baseball pitchers but can be used with tennis players, volleyball players, swimmers, golfers, and others with upper extremity problems.

The KJOC will be tested further on many more athletes in order to confirm the results reported from this study. Reliability testing on a larger sample size is the next step. Follow-up of all athletes involved in these studies may also provide some additional useful information.