Shoulder Rehab Phase 4: Return to Activity or Sport

Phase 4: Return to Throwing

Phase 4 of the rehabilitation program encompasses the progression and continuation of the ITP and is designed to systemically allow the athlete to progress to unrestricted throwing activities. It is important for the clinician to continuously monitor and assess the athlete’s mechanics and intensity of effort throughout the throwing program. Position players progress throughout the throwing program to 180 feet (60 m), whereas pitchers progress to 120 feet (40 m), and upon successful completion they can begin throwing from a windup on level ground at 60 feet (20 m). Pitchers can begin phase 2 of the ITP upon successful completion of phase 1 [90]. Position players during this phase will progress with use of position-specific fielding drills and throwing drills.

The athlete is instructed to continue with all previously described exercises and drills to maintain and improve upper extremity, core, and lower extremity strength, power, and endurance during this final phase of treatment [92-94]. Additionally, the athlete should be educated regarding a year-round conditioning program, including periodization of throwing and strength training activities to help prevent overtraining and initiation of throwing when poorly conditioned and to properly prepare for the upcoming season [95]. Wooden et al [96] showed that a dynamic variable resistance exercise program significantly increased throwing velocity. Likewise, the throwing velocity in high school baseball players has been shown to increase when utilizing an exercise program that varies the type of resistance exercises and includes plyometric training and a Throwers Ten program [97,98].

Before the athlete is cleared to return to play or competition, a clinical examination is performed to establish whether specific criteria have been met. We have established specific criteria for the athlete to achieve prior to returning play (see Table 4). The criteria we use includes full nonpainful ROM, satisfactory results of a muscle strength test, a satisfactory shoulder examination, and successful completion of a throwing program without pain while exhibiting proper throwing mechanics. In addition, we ask each player/ patient to complete the Kerlan-Jobe Subjective Form for Throwers. Because of the predictive association of this measure with shoulder injuries in baseball players, we look for a score of 95 or higher prior to returning to competition [99].

Table 4

Return to play criteria

  • Full nonpainful sports-specific range of motion
  • Strength that fulfills our specific criteria
  • Excellent stability with no painful tests
  • Demonstrates proper throwing mechanics
  • Has successfully completed the rehabilitation program
  • Satisfactory subjective shoulder score


The overhead throwing athlete displays unique ROM, postural, strength, and joint laxity characteristics that occur as a result of physical adaptation to the imposed stresses and demands of repetitive throwing over numerous years. The success of the rehabilitation program for the overhead throwing athlete is dependent upon an accurate recognition of the underlying cause of the condition and all associated pathologic features. An effective rehabilitation program should focus on correcting the cause of the dysfunction and/or pain with particular focus on re-establishing full ROM and dynamic shoulder stability and implementing a progressive resistance exercise program to fully restore strength and local muscle endurance of the shoulder and scapular musculature. In addition, the rehabilitation program should incorporate exercises that link the upper and lower extremity. This program will evolve to include sport-specific drills and functional activities to allow a return to sport and activity. Additionally, proper throwing mechanics, utilization of pitch counts, appropriate rest, and proper off-season conditioning will help decrease the overall injury risk in overhead throwing athletes.

Watch the video for Kevin Wilk’s 5 Minute warm-up for throwers or overhead athletes

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