Shoulder RTS Index

Test Administration Guide

Standardized setup, measurement, and interpretation notes for the tests used in the proposed Shoulder Return-to-Sport Index.

In-service presentation resource by Benjamin Blackstone

General Standardization

  • Use the same tester, device, setup, and warm-up when serially retesting whenever possible.
  • Record pain, symptoms, and compensations rather than treating the numeric score in isolation.
  • Use the athlete’s preinjury baseline when available; otherwise use contralateral and population-reference data appropriately.
  • For LSI: involved ÷ uninvolved × 100.
  • For dominant overhead athletes, interpret asymmetry in context; sport adaptation is not automatically pathology.
  • The composite scoring rules on this site are proposed and have not been prospectively validated.
01

Mobility

Restore the athlete’s functional motion without erasing normal overhead-sport adaptation.

Shoulder Elevation AROM

Setup

  • Standing or supine; keep testing position consistent.
  • Measure active shoulder elevation with goniometer or inclinometer.
  • Compare involved with uninvolved side.

Record

  • Degrees of elevation.
  • LSI or side-to-side difference.
  • Presence of pain or obvious compensatory shrug.

ER / IR Total Rotational Arc & GIRD

Setup

  • Supine with shoulder at 90° abduction and elbow at 90°.
  • Stabilize the scapula to limit anterior tilt/protraction.
  • Measure passive ER and IR bilaterally using the same endpoint criteria.

Calculate

  • Total arc = ER + IR.
  • Arc deficit = uninvolved total arc − involved total arc.
  • GIRD = uninvolved IR − involved IR.

Overhead-thrower adaptation: the dominant arm commonly demonstrates more ER and less IR. Interpret total arc and humeral retrotorsion before labeling this pattern abnormal. Henry et al. (2026) and Vasquez et al. (2025) both show how HRT can materially change interpretation of measured rotational deficits.

02

Strength

Quantify isolated rotator strength and long-lever overhead force capacity.

ER / IR Isometric Strength

Setup

  • Use an HHD or fixed dynamometer with consistent stabilization.
  • Test the same shoulder position bilaterally; document whether testing is at side or 90° abduction.
  • Perform 2–3 maximal trials after familiarization; use best or mean consistently.

Calculate

  • ER LSI and IR LSI.
  • ER:IR ratio = ER force ÷ IR force.
  • Record absolute force and body-mass-normalized values when useful.

Evidence anchor: isometric ER:IR ratios around 0.75 have been used in overhead-athlete research; interpret ratios alongside absolute force, side-to-side values, sport, and testing position. Intelangelo et al., 2025.

Prone I / Y / T Lift-Off — Modified Long-Lever Test

Important: This index uses a prone lift-off / isometric I-Y-T variation. It is not the original ASH push-down test performed into a force plate.

Setup

  • Prone, elbow extended, long lever maintained.
  • Test standardized I (180°), Y (135°), and T (90°) arm positions.
  • Use fixed HHD/Tindeq or another reproducible setup that resists the athlete’s attempted lift-off.
  • Prevent trunk rotation and excessive upper-trapezius substitution.

Record

  • Peak or mean force for I, Y, and T on both sides.
  • Calculate LSI for each position or a pre-specified composite LSI.
  • Document the exact device and setup for repeat testing.

Because this is a modified lift-off variation, do not assume published cutoffs from the original ASH push-down protocol transfer directly. The original ASH has excellent reliability, and a 2025 meta-analysis reported promising pooled reliability/validity for the test construct.

03

Power

Assess unilateral and global upper-extremity explosive performance.

Single-Arm Shot Put (SASP)

Setup

  • Seated with back supported to minimize lower-extremity contribution.
  • Use the same ball mass and standardized starting position each session.
  • Perform practice trials, then 2–3 maximal throws per arm.

Record

  • Best throw distance for each arm.
  • LSI = involved ÷ uninvolved × 100.
  • Keep ball mass and measuring method identical at retest.

Seated Medicine-Ball Throw (SMBT)

Setup

  • Seated with trunk/back supported; chest-pass the medicine ball horizontally.
  • Prevent trunk momentum and leg contribution.
  • Keep ball mass, seat/back support, start position, and measuring method identical across sessions.
  • Record the best valid throw after familiarization/practice trials.

How this index handles SMBT

  • Prior baseline available: compare current distance with the athlete’s own baseline.
  • Well-matched published reference available: compare with that reference using the same protocol.
  • Neither available: record the distance descriptively and exclude SMBT from the Power score.
  • When SMBT is excluded, the remaining scored Power test is automatically reweighted to 100% of that domain.

Comparison calculation: current distance ÷ baseline/reference distance × 100. Published SMBT reference values can help contextualize performance, but sex, age, sport, and protocol differences make one universal cutoff inappropriate. Borms & Cools, 2018.

04

Dynamic Stability

A deliberately binary clinical rating of scapular neuromuscular control.

Qualitative Scapular Neuromuscular Control

Suggested observation task

  • Observe repeated active elevation/scaption and a clinically appropriate loaded or sport-relevant overhead task.
  • View from posterior and posterolateral positions.
  • Use light tactile palpation of the medial border/inferior angle when visual findings are uncertain.

Standardize the rating

  • Use the same task, load, pace, and number of repetitions between raters.
  • Look for smooth scapulohumeral rhythm and controlled upward rotation during elevation and lowering.
  • Note clear, repeatable winging/prominence, early shrug, dysrhythmia, or deterioration with repetition.
  • Do not fail the athlete for small or inconsistent asymmetries alone.
Appropriate = 100Not appropriate = 0

This binary rule is a proposed scoring convention intended to make the clinical observation explicit; it is not a validated diagnostic threshold. The Bern Consensus supports principle-based, performance-focused shoulder rehabilitation and use of clinical reasoning alongside objective measures.

05

Endurance

Combine a locally developed posterior-shoulder endurance challenge with repeated closed-chain upper-extremity loading.

Modified Prone T Endurance Test — Local Clinical Protocol

What it is: a locally developed pass/fail screen created by clinician educators. It borrows the prone-T/posterior-shoulder loading concept from published endurance testing, then adds repeated full-range raises, short-range pulses, and a terminal isometric hold. The exact 10 + 10 + 10 sequence has not been independently validated.

Setup

  • Prone with the chest supported on a Swiss ball or bench.
  • Arms in a T position: approximately 90° shoulder abduction/horizontal abduction with elbows extended.
  • Men: hold 5% of body weight in each hand.
  • Women: hold 3% of body weight in each hand.
  • Use the same support surface, load calculation, and coaching cues for serial testing.

Protocol & scoring

  1. 10 controlled full-range T raises.
  2. 10 short-range T-raise pulses near the top position.
  3. Maintain the T position for a 10-second isometric hold.
  • Pass: completes the entire sequence at the prescribed load with acceptable technique and without stopping.
  • Fail: cannot complete any component at the prescribed load or loses clinically acceptable technique.

Evidence anchor: Moore et al. (2013) and Powell et al. (2021) support prone posterior-shoulder endurance testing as a clinically measurable construct. This local protocol intentionally extends that concept; its exact loading and 10 + 10 + 10 pass/fail rule remain proposed rather than validated.

Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST)

Setup

  • Full plank with hands placed 36 in (91.4 cm) apart on marked lines.
  • Alternately touch the opposite hand as many times as possible in 15 seconds.
  • Use standardized practice and testing trials; maintain plank position throughout.

Record

  • Number of valid touches in 15 seconds.
  • Use published reference values to contextualize performance.
  • This index uses touch count as graded endurance scoring; it does not treat one touch number as a universal RTS pass/fail threshold.

Evidence anchor: CKCUEST is one of the most consistently supported upper-extremity performance tests for reliability and construct validity in the 2026 systematic review by Pontillo et al. Use touch counts as context, not a universal shoulder RTS cutoff.

Key Evidence Anchors

Schwank A, et al. 2022. 2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport. PubMed

Pontillo M, et al. 2026. Upper Extremity Return to Sport Functional Testing: A Systematic Review. Open access

Henry KM, et al. 2026. Influence of Humeral Retrotorsion on Glenohumeral Range of Motion in Healthy Collegiate Softball Players. Open article

Vasquez JE, et al. 2025/2026. Humeral retrotorsion-corrected glenohumeral external rotation deficits in college baseball players. PubMed

Ashworth B, et al. 2018. The Athletic Shoulder (ASH) test: reliability of a novel upper body isometric strength test in elite rugby players. Open access

Ulupınar S, et al. 2025. Validity and Reliability of the Athletic Shoulder Test: A Brief Systematic Review and Meta-Analysis. Open access

Intelangelo L, et al. 2025. Is Strength the Main Risk Factor of Overuse Shoulder Injuries? A cohort of 296 overhead athletes. PubMed

Powell A, et al. 2021. Reliability and minimal detectable change of the Posterior Shoulder Endurance Test in elite athletes. PubMed

Borms D, Cools A. 2018. Upper-Extremity Functional Performance Tests: Reference Values for Overhead Athletes. DOI

Protocol note: Where the index uses a modified test (particularly the prone I/Y/T lift-off), keep the protocol consistent and interpret it as a local clinical measure rather than applying cutoffs validated for a different device or test variation.

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