1. Introduction

Basketball is a team contact sport that involves sprinting, cutting, pivoting, and jumping, along with a significant amount of overhead activity (Li et al., 2019, Lian et al., 2022, Wellm, Jäger and Zentgraf, 2024). Each team consists of five players; power forwards play near the basket, while small forwards move around the court. Both can score from long and close shots (NBA, 2025), the throwing mechanics of which are broadly similar: During the acceleration phase of the throw the shoulder flexes to bring the arm overhead, the elbow extends, and the shoulder internally rotates at the point of release (Morikawa et al., 2023, Matsunaga and Oshikawa, 2022). During the deceleration phase shoulder flexion decreases, and the wrist moves into flexion. Eccentric control of the biceps brachii is essential to decelerate elbow extension, while infraspinatus works eccentrically to control internal rotation and decelerate the arm (Cools et al., 2021, Matsunaga and Oshikawa, 2022, Borms et al., 2017). These mechanics put basketball players at increased risk of biceps-related shoulder injuries such as the superior labrum anterior-to-posterior (SLAP) tear (Borms et al., 2017, Lian et al., 2022, Hester et al., 2018).

The glenoid labrum is a band of fibrocartilaginous tissue that surrounds the glenoid fossa of the scapula, increasing its surface area, and providing stability to the glenohumeral joint. It is also the attachment point for the tendon of the long head of the biceps brachii and glenohumeral ligaments (Hester et al., 2018, Hill et al., 2008). While its inferior portion is firmly attached to the glenoid rim, the superior portion is more mobile in structure, making it vulnerable to damage such as in a Type II SLAP tear, where the biceps-labral complex detaches from the superior portion of the glenoid fossa (Hester et al., 2018, Park et al., 2004, Wilk et al., 2005). While SLAP tears can result from trauma, they often present chronically (Morikawa et al., 2023). The ‘peel-back’ phenomenon, in which forces generated during abduction and external rotation pull the biceps tendon away from the labrum, is thought to be the main contributing factor in throwing in sports such as baseball, American football, and cricket (Borms et al., 2017). However, this is less likely to factor in basketball where the throwing arm is kept mostly in the sagittal plane. Instead, compression of the tendon-labral complex in the subacromial space, along with traction from eccentric loading of the biceps cause irritation and dysfunction that can ultimately lead to failure of the tissue (Cools et al., 2014, Borms et al., 2017, Michener et al., 2018).

Labrum tears have been documented at an incidence of 0.04 per 1000 game exposures in the National Basketball Association, as compared to 1.9 per 1000 person years in the general population (Morikawa et al., 2023, Varacallo, Tapscott and Mair, 2025). While surgery for Type II SLAP tears is often necessary, clinical guidelines recommend conservative rehabilitation where possible, with primary goals of restoring strength to the biceps-labral complex and enhancing the dynamic stability of the glenohumeral joint (Manske and Prohaska, 2010, Wilk et al., 2005, Michener et al., 2018). This review will justify the exercises prescribed in this early-to-intermediate rehabilitation package in relation to how they achieve these goals.

2. Evidence Review

2.1 Strengthening of the biceps-labral complex
The principles of mechanotransduction describe how the body responds to loading by creating lasting structural change. During loading, cells are subject to mechanical deformation and respond by releasing signalling proteins into the extracellular matrix, stimulating widespread synthesis of collagen fibres. In rehabilitation science these principles are applied in the form of ‘mechanotherapy’ whereby specific exercises are used to stimulate the repair and remodelling of damaged tissue (Khan and Scott, 2009). When applying these principles, increases in loading should be gradual and allow sufficient time for the stressed tissues to adapt, otherwise further damage may occur (Docking and Cook, 2019). The type of tissue being rehabilitated should also be accounted for. Tendons are dynamic in nature and composed of longitudinally aligned Type I collagen fibres that respond well to eccentric loading, particularly during the remodelling stage of healing (Galloway, Lalley and Shearn, 2013, Khan and Scott, 2009, Langberg et al., 2007). The glenoid labrum in contrast, is fibrocartilaginous in structure and composed of randomly aligned fibres. Debate exists over the extent to which the labrum is mechanosensitive, however, there is evidence that it adapts to its mechanical environment to some degree (Hill et al., 2008, Khan and Scott, 2009).
According to these principles, the long head of the biceps brachii must be progressively loaded to stimulate repair and remodelling of collagen fibres in the tendon-labral complex. Indeed, guidelines recommend beginning with submaximal isometric contractions, before increasing contraction strength, and then progressing onto concentric loading, ensuring good control is achieved before beginning eccentric loading (Manske and Prohaska, 2010, Wilk et al., 2005). There are also suggestions that exercises using active elbow flexion with a fixed degree of shoulder flexion will load the biceps brachii with minimal stress to the site of injury, making them more appropriate during early stages of rehabilitation (Park et al., 2004).

2.1.1 Exercise prescription
With the above in mind, the following open-chain exercises have been prescribed: Progressive biceps brachii isometrics, followed by isotonic elbow and then shoulder flexion to safely initiate mechanical loading of the tissues (Manske and Prohaska, 2010, Wilk et al., 2005, Cools et al., 2014), followed by eccentric elbow flexion and then shoulder flexion, to promote optimal alignment and remodelling of collagen fibres at the site of injury (Cools et al., 2014, Galloway, Lalley and Shearn, 2013). These exercises were selected in line with electromyographic evidence that they generate appropriate levels of muscle activation for this stage of rehabilitation (Cools et al., 2014). Movements involving a more functional component of biceps activation have been included in the movement re-education section below.

2.2 Movement re-education
In the case of overhead athletes, mechanical stresses on the tendon-labral complex are frequently exacerbated by pathological biomechanics, often in the form of scapular dyskinesis and glenohumeral internal rotation deficit (GIRD). Much of the rehabilitation literature therefore focuses on the need to re-train correct shoulder mechanics by addressing these deficits (Steinmetz et al., 2022, Michener et al., 2018, Manske and Prohaska, 2010).

2.2.1 Scapular dyskinesis
Scapulohumeral rhythm describes the coordinated movement of the glenohumeral joint, whereby the scapula lifts out of the way during elevation of the humerus to prevent compression of the soft tissues surrounding the humeral head. Scapular dyskinesis, in contrast, refers to the loss of this rhythm due to improper movement of the scapula (Scibek and Carcia, 2012, Panagiotopoulos and Crowther, 2019). Evidence suggests that in overhead athletes the scapula of the dominant shoulder tends to be protracted and anteriorly tilted (Wilk et al., 2009, Steinmetz et al., 2022). This interferes with scapulohumeral rhythm, causing compression of the biceps-labral complex in the subacromial space, resulting in irritation and degeneration of the tissues (Mathew and Lintner, 2018). In most athletes this posture is associated with weakness of serratus anterior and the lower trapezius (which maintain scapular depression during the acceleration and deceleration phases of throwing, respectively), and tightness of pectoralis minor (which draws the coracoid process anteriorly), and has been identified as a negative prognostic factor for recovery from SLAP tears (Steinmetz et al., 2022, Reinold, Escamilla and Wilk, 2009, Wilk et al., 2009).

Activation and strengthening of serratus anterior and the lower trapezius, along with stretching of pectoralis minor are therefore key for most rehabilitation programmes (Lefèvre-Colau et al., 2018, Wilk et al., 2009). Guidelines suggest beginning with scapular retraction and isometrics (Manske and Prohaska, 2010, Hester et al., 2018). Active motion of the shoulder can then be introduced and progressed, with scapular retraction being maintained throughout (Hester et al., 2018). Once sufficient control has been achieved, diagonal patterns of movement through multiple planes can be introduced to facilitate neuromuscular recruitment (Witt, Talbott and Kotowski, 2011).

2.2.2 GIRD and the rotator cuff
GIRD describes a postural and biomechanical deviation in which an athlete’s throwing arm has increased external and decreased internal rotation compared to the non-throwing arm (Hester et al., 2018). As with scapular dyskinesis, this leads to compression of the biceps-labral complex in the subacromial space and has been implicated as a causative factor in labral pathologies of the sporting shoulder (Cools et al., 2021). Rehabilitation for GIRD primarily focuses on restoring symmetry in internal rotation flexibility, with some authors proposing that stretching the posterior shoulder can alleviate symptoms (Manske and Prohaska, 2010, Michener et al., 2018, Hester et al., 2018). However, there is controversy over this, as rotation deficits may be accompanied by bony adaptations, capsule laxity, or damage to the external rotators, which will either not respond to or may be worsened by stretching (Cools et al., 2021, Wilk et al., 2009, Hester et al., 2018). This programme therefore does not include any posterior shoulder stretches.

A secondary focus of rehabilitation for GIRD is addressing the ratio of internal to external rotational strength (Michener et al., 2018, Cools et al., 2021). Many overhead athletes show weakness of the external rotator muscles which can be accompanied by fraying and partial tearing of the infraspinatus muscle or tendon (Hester et al., 2018, Wilk et al., 2009). While the rotational demands of basketball are less than in many other throwing sports, good eccentric control of infraspinatus is required during the deceleration phase of the throw (Cools et al., 2021). Further to this, infraspinatus is also a key stabiliser of the glenohumeral joint during overhead activity, as it resists distraction and anterior translation of the humerus (Ha et al., 2013, Williams, Sinkler and Obremskey, 2023). Guidelines therefore suggest developing eccentric control of infraspinatus to improve shoulder stability and throwing mechanics (Cools et al., 2021). Caution is advised, however, with initiating this in the very early stages of rehabilitation, not only because damaged tissues need time to repair, but because dynamic control of the scapula should be restored first, to avoid reinforcing poor kinematics (Steinmetz et al., 2022, Ludewig and Reynolds, 2009, Hester et al., 2018). 

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2.2.3 Throwing motion
Finally, once scapulohumeral rhythm and dynamic stability have been restored, the athlete will be ready to return to throwing (Manske and Prohaska, 2010). Guidelines recommend this begins with a chest pass; overhead and single arm throws follow in later stages of rehabilitation (Manske and Prohaska, 2010, Wilk et al., 2005).

2.2.4 Exercise prescription
With the above in mind, the following exercises have been prescribed: The ‘low row’ and supine scapular punch to train correct scapular placement, with minimal loading of the biceps brachii and infraspinatus (Kibler et al., 2008, Intelangelo et al., 2022, Ludewig and Reynolds, 2009). Eccentric side-lying external rotation, to promote infraspinatus repair and eccentric control (Manske and Prohaska, 2010, Ludewig and Reynolds, 2009, Cools et al., 2007). The ‘lawnmower’ to introduce dynamic scapular control and facilitate recruitment throughout the kinetic chain (Berckmans et al., 2020), progressing to an eccentric ‘reverse punch’ to train eccentric control of elbow extension (Borms et al., 2017). Finally, sequential chest passes re-introduce the throwing motion (Wilk et al., 2005, Manske and Prohaska, 2010). All exercises have been prescribed in line with electromyographic evidence that they create a favourable profile of serratus anterior and low trapezius vs pec minor activation.
While other sections of this programme are not being reviewed in detail, it is relevant to note that the ‘corner stretch’ has been included to stretch pectoralis minor (Ludewig and Reynolds, 2009), and the open- and closed-chain exercises for the biceps brachii have all been selected because they have favourable periscapular muscle activation profiles (Cools et al., 2014, Reinold, Escamilla and Wilk, 2009, Mendez-Rebolledo et al., 2021). In addition to achieving their primary goals these exercises should therefore help reinforce healthy movement patterns.

3. Conclusion

Basketball involves a significant amount of overhead activity which, combined with faulty biomechanics and traction from eccentric loading, can cause irritation of the biceps-labral complex, ultimately leading to a SLAP tear. The primary goals of this rehabilitation programme were to restore strength to the biceps-labral complex and improve the kinematics and stability of the glenohumeral joint.

To address these goals, the principles of mechanotherapy were applied to progressively strengthen the biceps brachii tendon, stimulating collagen synthesis and promoting longitudinal alignment of fibres. Exercises were also prescribed to restore balance to the periscapular muscles, minimising compression of the tendon-labral complex, and preventing further damage.

This review has several limitations. Firstly, guidelines recommend a thorough assessment of the athlete’s shoulder kinematics before prescribing corrective exercises, which was not possible here. Secondly, publications on rehabilitation of the throwing shoulder focus almost exclusively on throwing from an abducted and externally rotated position, with limited application to the demands of basketball. Finally, all but one of the electromyographic studies reviewed described muscle activation during rehabilitation exercises, with limited application to functional movement. Future research should focus on patterns of muscle activation throughout the kinetic chain as they relate to the throwing mechanics of basketball. Investigations into the effectiveness of specific movement re-education programmes on rates of re-injury are also warranted.