Interpreting a Positive Special Test in a Thrower With Shoulder Pain
A 22-year-old collegiate javelin thrower reports 6 weeks of anterior shoulder pain that worsens with cocking and acceleration phases. Pain is 4/10 at rest and 7/10 with throwing. He has no night pain, no numbness, and no history of dislocation. On exam: painful arc 90-120 degrees abduction, positive Neer and Hawkins-Kennedy, negative Speed's and O'Brien's, and full passive ROM. Resisted external rotation is painless; resisted internal rotation reproduces pain. Scapular dyskinesis is present (type III). He wants to compete in 5 weeks. He has been doing general strengthening without improvement.
1. How do you interpret the cluster of positive impingement signs in this athlete, and what is your working diagnosis and differential?
Read the worked answer
The positive Neer and Hawkins-Kennedy tests plus painful arc and pain with resisted internal rotation in a throwing athlete suggest subacromial pain syndrome / external impingement as the leading hypothesis, but these tests have limited specificity and should not be treated as diagnostic alone.
Differential to consider:
- Rotator cuff tendinopathy / partial-thickness tear (especially supraspinatus and infraspinatus).
- Internal impingement / labral pathology - common in throwers; would expect pain in late cocking, positive relocation or dynamic tests.
- SLAP lesion - negative Speed's and O'Brien's reduce but do not exclude.
- Scapular dyskinesis contributing to secondary impingement - type III is a plausible contributor.
- Glenohumeral internal rotation deficit (GIRD) - must measure; throwers commonly have it and it alters mechanics.
Next steps: measure GIRD and total arc of motion, assess cuff strength and endurance, and consider imaging only if it would change management. The clinical picture is most consistent with a movement/load problem rather than an acute structural tear.
2. Design a 5-week plan that balances return to throwing with tissue protection, and state the criteria you will use to progress him.
Read the worked answer
The plan should be criteria-based, not calendar-based, even though he has a 5-week target.
Weeks 1-2 - Reduce irritant load, restore capacity:
- Relative rest from throwing; avoid provocative positions.
- Scapular stabilization (serratus anterior, lower trapezius), cuff endurance (external rotation at 0 and 90 degrees abduction), and posterior capsule stretching if GIRD present.
- Pain monitoring: keep throwing-related pain ≤2/10 and resolving within 24 hours.
Weeks 2-3 - Reintroduce throwing:
- Short-toss program at low intensity, focusing on mechanics and scapular control.
- Progress distance and intensity only if pain remains ≤2/10 and does not increase the next day.
Weeks 4-5 - Interval throwing and sport-specific loading:
- Advance to mound/approach throwing, then full-intensity throws if criteria met.
Progression criteria: pain-free resisted internal rotation, pain-free Hawkins-Kennedy or markedly improved, normalized scapular mechanics on observation, and a symptom-free interval throwing session before advancing intensity.
Realistic expectation: full competition in 5 weeks is possible but not guaranteed; set review points at weeks 2 and 4 and communicate the conditional nature of the timeline.