A 25-Year-Old Recreational Softball Athlete with Internal Impingement

  • Anirudh K. Gowd
  • Gregory L. Cvetanovich
  • Joseph N. Liu
  • Nikhil N. VermaEmail author


Overhead athletes are a unique and challenging patient population because their sport is so taxing on the glenohumeral joint. From performing overhead activity throughout the adolescent, teenage, and collegiate years, the athlete develops several adaptations to increase external rotation of the arm. In consequence, the thrower’s paradox results in anterior laxity and posterior contracture of the shoulder’s capsule. Often this is asymptomatic, but over time, posterior contracture can lead to internal impingement of the glenohumeral joint on to the posterosuperior aspect of the rotator cuff and posterior labrum. Resulting pathologies often require management and sometimes surgery. The following case-based review illustrates the anatomic and physiologic changes that may result in symptoms of internal impingement, techniques to evaluate and diagnose pathology, and appropriate management.


Internal impingement Overhead athlete Thrower’s shoulder Posterior labrum 


  1. 1.
    Jobe CM. Superior glenoid impingement. Orthop Clin North Am. 1997;28:137–43.CrossRefGoogle Scholar
  2. 2.
    Gelber JD, Soloff L, Schickendantz MS. The Throwerʼs shoulder. J Am Acad Orthop Surg. 2018;26:204–13.CrossRefGoogle Scholar
  3. 3.
    Reuther KE, Sheridan S, Thomas SJ. Differentiation of bony and soft-tissue adaptations of the shoulder in professional baseball pitchers. J Shoulder Elb Surg. 2018; Scholar
  4. 4.
    Meister K, Buckley B, Batts J. The posterior impingement sign: diagnosis of rotator cuff and posterior labral tears secondary to internal impingement in overhand athletes. Am J Orthop (Belle Mead NJ). 2004;33:412–5.Google Scholar
  5. 5.
    Wilk KE, Obma P, Simpson CD, Cain EL, Dugas JR, Andrews JR. Shoulder injuries in the overhead athlete. J Orthop Sports Phys Ther. 2009;39:38–54.CrossRefGoogle Scholar
  6. 6.
    Radkowski CA, Chhabra A, Baker CL 3rd, Tejwani SG, Bradley JP. Arthroscopic capsulolabral repair for posterior shoulder instability in throwing athletes compared with nonthrowing athletes. Am J Sports Med. 2008;36:693–9.CrossRefGoogle Scholar
  7. 7.
    McClincy MP, Arner JW, Bradley JP. Posterior shoulder instability in throwing athletes: a case-matched comparison of throwers and non-throwers. Arthroscopy. 2015;31:1041–51.CrossRefGoogle Scholar
  8. 8.
    Katthagen JC, Tahal DS, Montgomery SR, Horan MP, Millett PJ. Association of traumatic and atraumatic posterior shoulder instability with glenoid retroversion and outcomes after arthroscopic capsulolabral repair. Arthroscopy. 2017;33:284–90.CrossRefGoogle Scholar
  9. 9.
    Bahk MS, Karzel RP, Snyder SJ. Arthroscopic posterior stabilization and anterior capsular plication for recurrent posterior glenohumeral instability. Arthroscopy. 2010;26:1172–80.CrossRefGoogle Scholar
  10. 10.
    Kraeutler MJ, Aberle NS, Brown CC, Ptasinski JJ, McCarty EC. Clinical outcomes and return to sport after arthroscopic anterior, posterior, and combined shoulder stabilization. Orthop J Sports Med. 2018;6:2325967118763754.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med. 1995;23:233–9.CrossRefGoogle Scholar
  12. 12.
    Dillman CJ, Fleisig GS, Andrews JR. Biomechanics of pitching with emphasis upon shoulder kinematics. J Orthop Sports Phys Ther. 1993;18:402–8.CrossRefGoogle Scholar
  13. 13.
    Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002;30:463–8.CrossRefGoogle Scholar
  14. 14.
    Anz AW, Bushnell BD, Griffin LP, Noonan TJ, Torry MR, Hawkins RJ. Correlation of torque and elbow injury in professional baseball pitchers. Am J Sports Med. 2010;38:1368–74.CrossRefGoogle Scholar
  15. 15.
    Albright JA, Jokl P, Shaw R, Albright JP. Clinical study of baseball pitchers: correlation of injury to the throwing arm with method of delivery. Am J Sports Med. 1978;6:15–21.CrossRefGoogle Scholar
  16. 16.
    Liu JN, Garcia GH, Gowd AK, Cabarcas BC, Charles MD, Romeo AA, Verma NN. Treatment of partial thickness rotator cuff tears in overhead athletes. Curr Rev Musculoskelet Med. 2018;11:55–62.CrossRefGoogle Scholar
  17. 17.
    AF DP, Callery G, Bennett G. Variational anatomy in degenerative lesions of the shoulder joint. Instr Course Lect. 1949;6:255–81.Google Scholar
  18. 18.
    Fortenbaugh D, Fleisig GS, Andrews JR. Baseball pitching biomechanics in relation to injury risk and performance. Sports Health. 2009;1:314–20.CrossRefGoogle Scholar
  19. 19.
    Crockett HC, Gross LB, Wilk KE, et al. Osseous adaptation and range of motion at the glenohumeral joint in professional baseball pitchers. Am J Sports Med. 2002;30:20–6.CrossRefGoogle Scholar
  20. 20.
    Edelson G. The development of humeral head retroversion. J Shoulder Elb Surg. 2000;9:316–8.CrossRefGoogle Scholar
  21. 21.
    Altchek DW, Hobbs WR. Evaluation and management of shoulder instability in the elite overhead thrower. Orthop Clin North Am. 2001;32:423–30, viii.CrossRefGoogle Scholar
  22. 22.
    Walch G, Boileau P, Noel E, Donell ST. Impingement of the deep surface of the supraspinatus tendon on the posterosuperior glenoid rim: an arthroscopic study. J Shoulder Elb Surg. 1992;1:238–45.CrossRefGoogle Scholar
  23. 23.
    Conway JE. Arthroscopic repair of partial-thickness rotator cuff tears and SLAP lesions in professional baseball players. Orthop Clin North Am. 2001;32:443–56.CrossRefGoogle Scholar
  24. 24.
    Fukuda H, Hamada K, Nakajima T, Tomonaga A. Pathology and pathogenesis of the intratendinous tearing of the rotator cuff viewed from en bloc histologic sections. Clin Orthop Relat Res. 1994;304:60–7.Google Scholar
  25. 25.
    Thorsness RJ, Romeo AA. Diagnosis and management of the biceps-labral complex. Instr Course Lect. 2017;66:65–77.PubMedGoogle Scholar
  26. 26.
    Itoigawa Y, Itoi E. Anatomy of the capsulolabral complex and rotator interval related to glenohumeral instability. Knee Surg Sports Traumatol Arthrosc. 2016;24:343–9.CrossRefGoogle Scholar
  27. 27.
    Burkhart SS, Morgan CD, Ben Kibler W. The disabled throwing shoulder: spectrum of pathology Part I: Pathoanatomy and biomechanics. Arthroscopy. 2003;19:404–20.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Anirudh K. Gowd
    • 1
  • Gregory L. Cvetanovich
    • 2
  • Joseph N. Liu
    • 3
  • Nikhil N. Verma
    • 1
    Email author
  1. 1.Department of Orthopedic SurgeryRush University Medical CenterChicagoUSA
  2. 2.Department of Orthopedic SurgeryThe Ohio State University Wexner Medical CenterColumbusUSA
  3. 3.Department of Orthopedic SurgeryLoma Linda University Medical CenterLoma LindaUSA

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