[ clinical commentary ]

KEVIN E. WILK, PT, DPT, FAPTA1-3 • TODD R. HOOKS, PT, OCS, SCS, ATC, MOMT, MTC, CSCS, FAAOMPT4
LEONARD C. MACRINA, MSPT, SCS, CSCS1

The Modified Sleeper Stretch and Modified

Cross-body Stretch to Increase Shoulder
Internal Rotation Range of Motion in the
Overhead Throwing Athlete
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T
he overhead throwing athlete’s range-of-motion the increase in shoulder
(ROM) characteristics have been well described ER and the loss of IR
SUPPLEMENTAL in the overhead athlete.
in the literature as having an increase in external
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

VIDEO ONLINE
These proposed causes
rotation (ER) and a decrease in internal rotation include osseous adapta-
(IR) in the throwing shoulder compared to the nonthrowing shoul­ tions,5,6,18 posterior capsular tightness at
der.2,7,25 Wilk et al25 have described the concept of “total range of motion” the glenohumeral joint,4,17,21 musculoten-
(TROM) of the shoulder, which states that the sum of ER and IR ROM dinous tightness of the posterior portion
of the rotator cuff and posterior deltoid,19
of the throwing shoulder should be with- was noted, with the dominant shoulder and postural changes.1 The loss of shoul-
in 5° of that of the opposite, nonthrowing having an increase in ER ROM and a der IR ROM in the overhead thrower
shoulder in the overhead athlete. Wilk et resultant loss in IR ROM, no significant has been referred to as glenohumeral
Journal of Orthopaedic & Sports Physical Therapy®

al23 reported that the passive ROM of the
dominant shoulder in 369 professional
baseball pitchers, when measured at 90°
of shoulder abduction, was 132° of ER
and 52° of IR. Although a shift in motion
TTSYNOPSIS: Stretching techniques that focus on
increasing posterior shoulder soft tissue flexibility
are commonly incorporated into prevention and
treatment programs for the overhead athlete.
The cross-body and sleeper stretch exercises
have been described as stretching techniques to
improve posterior shoulder soft tissue flexibility
and to increase glenohumeral joint internal rota-
tion and horizontal adduction range of motion in
the overhead athlete. But, based on the inability
to stabilize the scapula and control glenohumeral
joint rotation with the cross-body stretch and the
potential for subacromial impingement with the
sleeper stretch, the authors recommend modi-
fications to both of these commonly performed
side-to-side difference in TROM was
noted in that population.23
Common Characteristics
There are numerous reported causes for
stretches. This clinical commentary reviews the
literature on posterior shoulder stretches, de-
scribes modifications to both of these commonly
performed stretches, and outlines a strategy to
maintain or improve posterior shoulder soft tissue
flexibility and glenohumeral joint internal rotation
range of motion in the overhead athlete.
TTLEVEL OF EVIDENCE: Therapy, level 5.
J Orthop Sports Phys Ther 2013;43(12):891-
894. Epub 30 October 2013. doi:10.2519/
jospt.2013.4990
TTKEY WORDS: GIRD, glenohumeral internal
rotation deficit, overhead athlete, posterior
shoulder tightness
internal rotation deficit (GIRD) and was
originally described by Burkhart et al.4
These authors originally described GIRD
as any loss of IR ROM in the throwing
shoulder compared to the nonthrowing
shoulder. Burkhart et al4 suggested that
GIRD may be a primary cause of shoul-
der pain and shoulder disability in the
overhead thrower and encouraged the
use of a stretching program for the pos-
terior shoulder structures, particularly
the sleeper stretch, to restore IR ROM.
Myers et al16 found a GIRD of 19.7° in
throwers with pathologic internal im-
pingement; similarly, Wilk et al24 report-
ed a GIRD of 18°, which correlated to a
1.9-fold increase in injury risk. Based on
these studies, Kibler et al9 have reported
GIRD to be a loss of 18° or greater of IR
in the throwing shoulder compared to the

1
Champion Sports Medicine, Birmingham, AL. 2Rehabilitative Research, American Sports Medicine Institute, Birmingham, AL. 3Tampa Bay Rays, Tampa Bay, FL. 4Drayer Physical
Therapy Institute, Columbus, MS. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the
subject matter or materials discussed in the article. Address correspondence to Dr Kevin E. Wilk, Champion Sports Medicine, 805 St Vincent’s Drive, Suite G100, Birmingham,
AL 35205. E-mail: kwilkpt@hotmail.com t Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy®

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 [ clinical commentary
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Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE 1. Modified sleeper stretch. (A) The athlete
is slightly rotated posteriorly (20°-30° posterior to
the coronal plane of the body) to place the shoulder
in the scapular plane as passive internal rotation
is performed. (B) This position stabilizes the
scapula without causing subacromial impingement
complaints.
Journal of Orthopaedic & Sports Physical Therapy®
FIGURE 2. A towel is placed under the elbow to
increase the stretch at the posterior shoulder.
nonthrowing shoulder. In addition, a bi-
lateral comparison of TROM has shown
that an asymmetry of 5° is predictive of
an increased injury rate.24 Recently, Wilk
et al22,24 reported a correlation between
shoulder injuries and TROM deficits in
professional baseball pitchers.
Horizontal adduction ROM has also
been identified as a predictor of increased
injury rates.16,21 Tyler et al21 reported an
average loss in horizontal adduction of
35° in subjects with pathological internal
impingement. Myers and colleagues16 as-
892  |  december 2013  |  volume 43  |  number 12  |  journal of orthopaedic & sports physical therapy
43-12 Wilk.indd 892
FIGURE 3. (A) A traditional cross-body stretch is
performed without adequate scapular stabilization.
(B) Due to the lack of stabilization during the
traditional cross-body stretch, note the amount of
scapular abduction.
sessed changes in horizontal adduction
motion by calculating the difference in
horizontal adduction between the throw-
ing and nonthrowing arm, and reported
a decrease of 4.2 cm in throwing athletes
with internal impingement.
Stretching Techniques
Stretching techniques for the posterior
shoulder are commonly incorporated
]
into the maintenance and prevention
program of the overhead athlete to mini-
mize risk of injury.4,11,20,21,24 Burkhart et
al4 described the sleeper stretch, per-
formed with the patient in sidelying on
the throwing side to stabilize the scapula
against the table and both the shoulder
and elbow flexed to 90°. In this position,
passive IR is applied to the dominant arm
by using the opposite hand. These au-
thors4 also described the rollover sleeper
stretch, which is similarly performed, ex-
cept that the shoulder is only flexed 50°
to 60° and the patient is rolled forward
30° to 40° from vertical.
Horizontal adduction of the shoulder
is also commonly advocated, with and
without scapular stabilization, to im-
prove flexibility of the posterior shoulder
region.4,21 Tyler et al21 reported that the
cross-body stretch, or horizontal adduc-
tion stretch, also improved shoulder IR.
In addition, Manske et al12 reported that
combining horizontal adduction stretch-
ing exercises with posteriorly directed
glenohumeral joint mobilization tech-
niques increased shoulder IR. Cadaveric
studies designed to determine the best
position to stretch the posterior shoul-
der soft tissue structures have quanti-
fied the strain on the posterior cuff and
capsule in a number of positions. 3,8,15,20
These studies reported increased strain
on the posterior capsule with the arm at
60° and 90° of elevation combined with
IR.3,8 The greatest strain on the inferior
fibers of the infraspinatus was reported
to occur at 90° of shoulder elevation with
IR.15
Comparative studies have been per-
formed to determine outcomes between
various stretching techniques to improve
posterior shoulder soft tissue flexibility.
Laudner et al10 examined the immediate
effects of the sleeper stretch, performed
3 times for 30 seconds, and found an in-
crease in both horizontal adduction and
IR ROM following the stretches. McClure
et al13 reported a significantly greater in-
crease in IR using the cross-body stretch
as compared to the sleeper stretch. Man-
ske et al12 reported that subjects treated
11/18/2013 3:22:14 PM
 with posteriorly directed glenohumeral
joint mobilizations combined with hori-
zontal adduction stretches had greater
increases in IR ROM compared to sub-
jects who performed horizontal adduc-
tion stretches only, and this increase in
motion was maintained to a greater ex-
tent at 4 weeks postintervention.
Proposed Modifications to Stretches
The authors of this clinical commentary
have utilized both the sleeper stretch
and the cross-body stretch for the treat-
ment of posterior shoulder tightness,
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with modifications to each. The modi-
fied sleeper stretch is performed with
the athlete in a sidelying position, trunk
rolled posteriorly 20° to 30°, and shoul-
der elevated to 90°. In this position, pas-
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
sive IR is performed using the opposite
arm (FIGURE 1, ONLINE VIDEO). This modified
sleeper stretch is designed to minimize
symptoms of pain that can occur with
the shoulder in a 90° flexed position.13
This trunk position also orients the hu-
merus in the scapular plane, which has
been shown to place increased strain on
the posterior capsule.3,8 To better assist
Journal of Orthopaedic & Sports Physical Therapy®
the patient in proper body positioning, a
clinician may prefer to place a hand on
the patient’s scapula to assist the patient
into the quarter-turn. However, to better
isolate the stretch to the infraspinatus,
the clinician may increase the amount of
horizontal adduction by placing a towel
under the athlete’s humerus, which is be-
lieved to better isolate the target tissues
(FIGURE 2).15 Although the incorporation
of the horizontal adduction via the use of
a towel roll essentially places the shoul-
der in a 90° flexed position, as with the
sleeper stretch, instructing the athlete to
lie with the trunk rolled posteriorly 20°
to 30° and avoiding the direct sidelying
position may minimize the complaints of
shoulder irritation frequently reported
clinically as a result of the athlete lying
directly on the shoulder. The authors
have found that patients tolerate the
placement of the towel roll much bet-
ter than the sleeper stretch with rollover
position.
journal of orthopaedic & sports physical therapy  |  volume 43  |  number 12  |  december 2013  |  893
43-12 Wilk.indd 893
FIGURE 4. Modified cross-body stretch. (A and B)
The athlete stabilizes the scapula against the table as
the shoulder is horizontally adducted, while external
rotation is restricted via counterpressure of the
opposite forearm.
The cross-body stretch is often per-
formed with the athlete in an upright
standing position (FIGURE 3), using the
opposite hand to horizontally adduct the
targeted shoulder. This method has the
disadvantage of not providing scapula
stabilization while the humerus is hori-
zontally adducted. Consequently, acces-
sory abduction of the scapula occurs,
which prevents isolating the intended
stretch to the posterior aspect of the gle-
nohumeral joint. In addition, it allows the
humerus to externally rotate as the shoul-
der moves into the outer ranges of motion
and tension is generated in the external
rotators of the shoulder posteriorly. The
authors believe that by not stabilizing the
scapula and allowing excessive ER of the
humerus to occur, optimal stretch of the
posterior shoulder is not achieved. In ad-
dition, it creates scapular abduction and
IR, which are not desired. Therefore, to
restrict scapular abduction, we suggest
having the athlete in a sidelying position,
and, to restrict ER of the humerus, we
suggest aligning the forearms together
with the opposite forearm on top. These
modifications may best isolate the target-
ed tissues of the posterior shoulder region
as the shoulder is brought into horizontal
adduction (FIGURE 4, ONLINE VIDEO).
Clinical Suggestions
In overhead athletes without shoulder
pain, these stretches are performed for
30 seconds for at least 4 repetitions with
each stretch.10,14 The stretches are per-
formed before and at the end of the exer-
cise program to improve shoulder ROM
and flexibility. The authors prefer dy-
namic flexibility drills, such as plyomet-
rics and quick movements, directly prior
to throwing activities. But, based on our
clinical experience, in overhead athletes
with shoulder pain and posterior shoul-
der tightness, the stretches should be
performed for 30 seconds and repeated at
least 8 to 10 times for each stretch. Moore
et al14 have reported utilizing a muscle
energy technique to enhance the effects
of the stretch. We frequently incorporate
muscle energy techniques to augment
the manual stretch of the athlete into
horizontal adduction, as this stretch has
been shown to increase both horizontal
adduction and IR.14 However, the authors
do not commonly perform muscle energy
techniques for the external rotators, as
the authors agree that, clinically, similar
to the findings by Moore and colleagues,14
this technique does not seem to increase
IR ROM.
SUMMARY
M
aintaining optimal soft tissue
flexibility of the posterior shoulder
in the throwing athlete is critical
to reduce the risk of injury. Because the
exact tissue that causes the pathophysi-
ological loss in shoulder mobility in this
population varies between osseous ad-
aptations, posterior capsular tightness,
musculotendinous tightness, and pos-
tural (scapular) adaptations, it is impor-
tant that the clinician continually assess
and adjust the treatment strategies as
deemed appropriate.9 The goal of this
11/18/2013 3:22:15 PM
 [ clinical commentary
commentary is to provide the treatment Exerc. 2002;34:2052-2056. http://dx.doi.
strategies and rationale for maintaining org/10.1249/01.MSS.0000039301.69917.0C
optimal shoulder mobility in the over- 8. Izumi T, Aoki M, Muraki T, Hidaka E, Miyamoto
S. Stretching positions for the posterior capsule
head athlete. Clinically, the authors have
of the glenohumeral joint: strain measure-
found these stretching techniques to be ment using cadaver specimens. Am J Sports
extremely beneficial to improving IR Med. 2008;36:2014-2022. http://dx.doi.
of the shoulder in the overhead throw- org/10.1177/0363546508318196
9. Kibler WB, Kuhn JE, Wilk K, et al. The disabled
ing athlete, without increasing shoulder
throwing shoulder: spectrum of pathology—10-
symptoms. Systematic research is nec- year update. Arthroscopy. 2013;29:141-161.e26.
essary to document the efficacy of these http://dx.doi.org/10.1016/j.arthro.2012.10.009
stretches. t 10. Laudner KG, Sipes RC, Wilson JT. The acute ef-
fects of sleeper stretches on shoulder range of
motion. J Athl Train. 2008;43:359-363. http://
dx.doi.org/10.4085/1062-6050-43.4.359
REFERENCES
Downloaded from www.jospt.org at on February 5, 2014. For personal use only. No other uses without permission.
]
Sports Med. 2006;34:385-391. http://dx.doi.
org/10.1177/0363546505281804
17. Pappas AM, Zawacki RM, McCarthy CF. Reha-
bilitation of the pitching shoulder. Am J Sports
Med. 1985;13:223-235.
18. Reagan KM, Meister K, Horodyski MB, Werner
DW, Carruthers C, Wilk K. Humeral retroversion
and its relationship to glenohumeral rotation in
the shoulder of college baseball players. Am J
Sports Med. 2002;30:354-360.
19. Reinold MM, Wilk KE, Macrina LC, et al. Changes
in shoulder and elbow passive range of motion
after pitching in professional baseball players.
Am J Sports Med. 2008;36:523-527. http://
dx.doi.org/10.1177/0363546507308935
20. Terry GC, Hammon D, France P, Norwood LA.

1. B orich MR, Bright JM, Lorello DJ, Cieminski CJ,
Buisman T, Ludewig PM. Scapular angular posi-
tioning at end range internal rotation in cases of
glenohumeral internal rotation deficit. J Orthop
Sports Phys Ther. 2006;36:926-934. http://
Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
11. Laudner KG, Stanek JM, Meister K. Assess-
ing posterior shoulder contracture: the
reliability and validity of measuring glenohu-
meral joint horizontal adduction. J Athl Train.
2006;41:375-380.
12. Manske RC, Meschke M, Porter A, Smith B, Rei-
man M. A randomized controlled single-blinded
The stabilizing function of passive shoulder
restraints. Am J Sports Med. 1991;19:26-34.
21. Tyler TF, Nicholas SJ, Lee SJ, Mullaney M,
McHugh MP. Correction of posterior shoulder
tightness is associated with symptom resolu-
tion in patients with internal impingement. Am
J Sports Med. 2010;38:114-119. http://dx.doi.

dx.doi.org/10.2519/jospt.2006.2241 comparison of stretching versus stretching and org/10.1177/0363546509346050

2. Borsa PA, Dover GC, Wilk KE, Reinold MM.
Glenohumeral range of motion and stiffness in
professional baseball pitchers. Med Sci Sports
Exerc. 2006;38:21-26.
3. Borstad JD, Dashottar A. Quantifying strain
on posterior shoulder tissues during 5 simu-
lated clinical tests: a cadaver study. J Orthop
Sports Phys Ther. 2011;41:90-99. http://dx.doi.
org/10.2519/jospt.2011.3357
4. Burkhart SS, Morgan CD, Kibler WB. The dis-
abled throwing shoulder: spectrum of pathol-
Journal of Orthopaedic & Sports Physical Therapy®
joint mobilization for posterior shoulder tight-
ness measured by internal rotation motion loss.
Sports Health. 2010;2:94-100. http://dx.doi.
org/10.1177/1941738109347775
13. McClure P, Balaicuis J, Heiland D, Broersma
ME, Thorndike CK, Wood A. A randomized con-
trolled comparison of stretching procedures for
posterior shoulder tightness. J Orthop Sports
Phys Ther. 2007;37:108-114. http://dx.doi.
org/10.2519/jospt.2007.2337
14. Moore SD, Laudner KG, McLoda TA, Shaffer
22. Wilk KE, Macrina L, Fleisig GS, et al. Glenohu-
meral passive range of motion and the correla-
tion to shoulder injuries in professional baseball
pitchers. American Orthopaedic Society for
Sports Medicine Annual Meeting; July 11-14,
2013; Chicago, IL.
23. Wilk KE, Macrina LC, Arrigo C. Passive range of
motion characteristics in the overhead baseball
pitcher and their implications for rehabilitation.
Clin Orthop Relat Res. 2012;470:1586-1594.

ogy part I: pathoanatomy and biomechanics.
Arthroscopy. 2003;19:404-420. http://dx.doi.
org/10.1053/jars.2003.50128
5. Crockett HC, Gross LB, Wilk KE, et al. Osseous
adaptation and range of motion at the glenohu-
meral joint in professional baseball pitchers. Am
J Sports Med. 2002;30:20-26.
6. Drakos MC, Barker JU, Osbahr DC, et al. Ef-
fective glenoid version in professional base-
ball players. Am J Orthop (Belle Mead NJ).
2010;39:340-344.
7. Ellenbecker TS, Roetert EP, Bailie DS, Da-
MA. The immediate effects of muscle energy
technique on posterior shoulder tightness: a
randomized controlled trial. J Orthop Sports
Phys Ther. 2011;41:400-407. http://dx.doi.
org/10.2519/jospt.2011.3292
15. Muraki T, Yamamoto N, Zhao KD, et al. Ef-
fect of posteroinferior capsule tightness on
contact pressure and area beneath the cora-
coacromial arch during pitching motion. Am J
Sports Med. 2010;38:600-607. http://dx.doi.
org/10.1177/0363546509350074
16. Myers JB, Laudner KG, Pasquale MR, Bradley JP,
http://dx.doi.org/10.1007/s11999-012-2265-z
24. Wilk KE, Macrina LC, Fleisig GS, et al. Cor-
relation of glenohumeral internal rotation
deficit and total rotational motion to shoulder
injuries in professional baseball pitchers. Am
J Sports Med. 2011;39:329-335. http://dx.doi.
org/10.1177/0363546510384223
25. Wilk KE, Meister K, Andrews JR. Current
concepts in the rehabilitation of the over-
head throwing athlete. Am J Sports Med.
2002;30:136-151.

@ MORE INFORMATION
vies GJ, Brown SW. Glenohumeral joint total Lephart SM. Glenohumeral range of motion defi-
rotation range of motion in elite tennis play- cits and posterior shoulder tightness in throwers
ers and baseball pitchers. Med Sci Sports with pathologic internal impingement. Am J WWW.JOSPT.ORG

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