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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                         Volume 2 – Issue 2 – June 2019 
 

Regionally Interdependent Applications of Total Motion Release® and 
Active Rotational Shoulder Range of Motion in Overhead Athletes  
R Ross Dexter, MS, MKin, AT, LAT, CSCS1,3; Terylan K Loftis, MS, AT, LAT, PRT-c®2; Russell T Baker, PhD, 
DAT, AT, CMP, PRT-c®3; Timothy E Speicher, PhD, AT, LAT, CSCS, PRT-c®2  
1Grtiman Medical Center, Moscow, ID; 2Positional Release Therapy Institute, Ogden, UT; 3University of Idaho, Moscow, ID 

 

 
ABSTRACT 

Healthy athletes commonly engage in pre-participation 
warm-up strategies designed to physiologically and 
mechanically prepare the body for training and competition. 
Alterations in rotational range of motion (ROM) of the 
dominant shoulder in overhead athletes, resulting in total 
rotation ROM loss, correlate with performance deficit, injury 
risk, and lost training time. Researchers have suggested that 
interventions using Total Motion Release® (TMR®) increase 
shoulder ROM more effectively than traditional warm-up 
methods. A randomized pre-test post-test trial was used to 
explore the effects of a regionally interdependent 
application of TMR® via a forward flexed trunk twist (FFTT) 
and seated straight leg raise (SLR) compared to a 
traditionally designed athletic warm-up on active shoulder 
internal rotation (IR) and external rotation (ER) in healthy 
overhead athletes measured with the Clinometer© 
smartphone application. Participants included twenty-two 
NCAA Division I, III, Club, and Secondary School senior 
student-athletes (9 javelin, 7 volleyball, 6 baseball; 13-
females, 9-males; age= 19.3±1.1 years; height= 178±11.4 
cm; weight= 76.4±11.2 kg), randomly assigned to TMR® 
(TMRG; n=11) and traditional warm-up (TWG; n=11) 
groups. The TMRG performed 3 sets of FFTT and SLR, each 
held for 20 seconds to the side of ease. The TWG completed 
a traditionally designed athletic warm-up including running, 
athletic drills, and dynamic and static stretching. The TMRG 
experienced significantly greater increases in dominant 
shoulder IR, non-dominant shoulder IR, and non-dominant 
shoulder ER (mean change =+9.5°, +7.5o, +4.7o), than the 
TWG (+1.7°, -6.7°, -4°) respectively. Intervention time to 
completion was also different between groups (TMRG = 
7mins TWG = 25mins). This study indicates that an indirect 
TMR® application produces efficient meaningful changes in 
rotational active range of motion (AROM) of the shoulder in 
overhead athletes. 
 
Key Phrases 
Injury risk reduction, performance exercise, throwing athletes  
 
Correspondence 
R Ross Dexter, 875 Perimeter Dr, Moscow, ID 83843, 
208-885-6111. 
E-mail: dext8778@vandal.uidaho.edu  
 
 
 

Full Citation 
Dexter RR, Loftis TK, Baker RT, Speicher TE. Regionally 
interdependent application of Total Motion Release® and 
active rotational shoulder range of motion in overhead 
athletes. Clin Pract Athl Train. 2019;2(2): 20-36. 
https://doi.org/10.31622/2019/0002.4.  
Submitted: August 31, 2018 Accepted: February 18, 2019 
 

INTRODUCTION 

Dynamic, forceful, and repetitive movement of 

the shoulder among overhead athletes may 
cause osseous and soft tissue adaptations as well 
as kinematic changes within the joint and 
surrounding musculature.1-8 As a result, overhead 
athletes may present with increased external 
rotation (ER) and decreased internal rotation (IR) 
of the dominant shoulder.1,3-7 Range of motion 
(ROM) adaptations, via the reduction of total 
rotational ROM, may elevate risk of shoulder 
injury, result in lost training and competition time, 
and raise the potential for decreases in 
performance via common injury patterns.9,10 

Researchers suggest the goals of performance 
readiness be accomplished via the progressive 
sequencing of warm-up activities including low-
intensity aerobic exercise, stretching, high load 
dynamic drills, and sports specific exercises.11-13 
It is recommended that this sequence elevate the 
heart rate, increase peripheral tissue 
temperature, address specific aims such as 
increasing ROM through static or dynamic 
stretching, and then incorporate specific skill 
based drills required by the training or 
competitive environment of the participant.12,13 
Interventions to improve shoulder ROM and 
increase performance readiness are employed 

https://doi.org/10.31622/2019/0002.4


Regionally Interdependent Applications of Total Motion Release® and Active Rotational  
Shoulder Range of Motion in Overhead Athletes 

 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 - June 2019 
 

by athletes regardless of ability and health 
status. These often include static stretches that 
have traditionally focused on local 
structures.1,7,8,12,14 Though these types of 
interventions are regularly employed, 
improvements in shoulder IR are often found to 
be less than 5°.14-16 While immediate increases in 
shoulder ROM have been found, static stretching 
has often not been found to produce lasting 
changes in ROM or increase performance in 
athletic populations.12-16 Despite these findings, 
researchers have traditionally advocated that 
both healthy and at risk individuals engage in 
daily stretching programs, often as part of 
warm-up activities, in order to improve or 
maintain shoulder ROM.4,12,14-17 

Focusing on specific tissues and localized areas 
of the body, while ignoring the complexity of the 
neuromuscular system, may reduce the efficacy 
of traditional warm-up protocols.18-21 Instead, 
heeding the interconnected nature of the 
neuromuscular and fascial systems may be the 
key to producing meaningful injury prevention 
and performance enhancement strategies. 
Researchers have established that alterations in 
one region of the body affect not only local 
outcomes, such as positional changes in joints, 
tension dynamic changes across soft tissues, and 
alterations in stability,22-24 mobility,25-27 and 
motor control,28,29 but invariably produce 
adjustments in other, interdependent, body 
regions.26,27,30-32 The term regional 
interdependence (RI) is used to describe this 
phenomenon.32 While the RI model is primarily 
concerned with musculoskeletal factors, it may 
also involve neurophysiological effects.31,32 
Therefore, neuromuscular adaptation is of 
particular interest when movement is the primary 
driver of intervention, as is the case during 
therapeutic exercise or warm-up programs prior 
to training or competition.  

Total Motion Release® (TMR®), a movement 
based orthopedic intervention, utilizes RI, 
potentially via cross education,22-25 neural 
coupling,28 and the common core hypothesis,29 as 
well as the fascial interconnectedness of the trunk 
and upper limbs,33-35 to produce changes in 
ROM, pain, and dysfunction, through targeted 
pain-free movement.30 The TMR® system is 
based on the theory that pain alters motor 
control, movement patterns adapt to dysfunction 
created by pain, and that the body seeks 
symmetry and will correct dysfunctional 
movement patterns in the absence of pain.30 
Participants using TMR® are asked to perform 
movements bilaterally and then self-rate to 
compare the motions on a scale of 0-100.30 On 
this scale, 0 represents an absence of pain, 
dysfunction, or strength deficit, and equal quality 
and quantity of ROM. In contrast, a score of 100 
represents extreme pain, complete dysfunction or 
unilateral strength deficit, or substantial loss of 
quality or quantity of ROM.30 Once these self-
determined ratings have been established, the 
motion with the highest rating (i.e., the most 
‘dysfunctional’ movement or ‘bad side’) is 
addressed by performing the same motion to the 
side of ease (i.e., ‘good side’) through set and 
repetition schemes determined by the clinician or 
based on patient comfort.30 The movement is 
completed so long as the motion is not bilaterally 
painful or dysfunctional, which would be a 
contraindication to use that movement within the 
TMR® system.30 The use of TMR® may have 
benefits as a performance readiness and injury 
prevention strategy due to the proposed effects 
regarding increased ROM,26,27 and may help 
patients/athletes achieve symmetry in paired 
movement patterns.26  

Although TMR® research is scarce, its use has 
been found to quickly increase shoulder ROM in 
baseball players when using arm raise and trunk 
twisting motions.26,27 However, TMR® as an 



Regionally Interdependent Applications of Total Motion Release® and Active Rotational  
Shoulder Range of Motion in Overhead Athletes 

 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 - June 2019 
 

intervention strategy, is often applied in a 
regionally interdependent fashion.30 Therefore, 
further research is warranted to determine the 
effects of TMR® as an intervention for increasing 
shoulder ROM in overhead athletes. Specifically, 
it is necessary to assess if these positive changes 
in ROM are the result of direct application of 
TMR® movements at the upper extremity. 
Therefore, the purpose of this study was to 
explore the regionally interdependent effects of 
an indirect application of TMR® using forward 
flexed trunk twist (FFTT) and active straight leg 
raise (SLR) techniques on shoulder AROM 
compared to a traditional athletic warm-up 
among healthy overhead athletes.  

PATIENTS 

With the approval of a university Institutional 
Review Board, a non-blinded randomized control 
trial design was utilized to examine and 
compare the effects of an indirect TMR® 
intervention and a traditionally designed warm-
up. All participants were informed of the risks 
and benefits of the investigation prior to signing 
informed consent documents and were aware 
that they could withdraw their participation at 
any time. A total of 22 student-athletes were 
recruited from NCAA Division I University 
volleyball and track and field teams, a NCAA 
Division I University Club Baseball team, a NCAA 
Division III track and field team, and secondary 
school baseball and volleyball teams. Gender 
and sport differences between groups are 
presented in the CONSORT flow chart (Figure 1). 

Participants were included if they were between 
the age of 18 and 25, could complete all warm-
up activities and ROM testing procedures, were 
a member of a Secondary School,  
Junior/Community College, NAIA, NCAA I, II, III, 
club baseball, baseball, volleyball, or track and 
field team, and had been competitive in their 

discipline for at least 3 years. Participants were 
excluded from this study if they had had any 
orthopedic surgery three months prior to data 
collection at the hip, knee, ankle, spine, shoulder, 
or elbow. Individuals with orthopedic injuries 
older than three months that remained 
symptomatic were also excluded. Participants 
were also excluded from this study if they were 
found to be unable to complete shoulder ROM 
testing or had painful motion with both left and 
right trunk rotation or left and right straight leg 
raise as these are contraindication within the 
TMR® system.30 All participants were also able to 
complete a full traditionally designed athletic 
warm-up. If the participant was being advised 
by their medical or coaching staff not to take 
part in such activity, was unable to complete any 
portion of the traditional warm-up, or wished for 
their ROM or demographic information to not be 
utilized, withdrawal from participation was 
accepted. All volunteers met the pre-screened 
inclusion criteria with no participants dropping or 
being excluded once data collection had begun. 

INTERVENTIONS 

The study was conducted in a single session for 
each participant. All interventions were 
performed before any sport-specific or warm-up 
activities had occurred for the day. 
Randomization was accomplished by using a first 
generator by randomization.com, participants 
randomly assigned to either the TMR® group 
(TMRG; n=11) or the traditional warm-up group 
(TWG; n=11). A Certified Strength and 
Conditioning Specialist (CSCS) collected all 
measurements and data in their second year 
studying in a masters of science in athletic training 
program. All measurements and interventions 
were conducted indoors in athletic training 
facilities and gymnasiums. Pretest measurements  



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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                         Volume 2 – Issue 2 – June 2019 
 

Figure 1. CONSORT diagram showing the breakdown of participants by intervention, gender, and sport.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
    
  

Assessed for eligibility 

(n = 22) 

Excluded (n = 0) 

Included (n = 22) 

Male (n = 9) Female (n = 13) 

 Sport Breakdown: 

   Baseball (n = 6) 

       

       

     

     

 

 

 

Randomized (n = 22) 

Allocated to TMRG 

(n = 11) 

 

Received allocated 
intervention (n = 11) 

 

    
    

 

A
llo

ca
tio

n 

 

Allocated to TWG 

(n = 11) 

 

Received allocated 
intervention (n = 11) 

 

    
     

 

Br
ea

kd
ow

n 
 

Male (n = 6) Female (n = 5) 

Sport Breakdown: 

   Baseball (n = 4) 

   Volleyball (n = 4) 

       

     

     

 

Male (n = 3) Female (n = 8) 

Sport Breakdown: 

   Baseball (n = 2) 

   Volleyball (n = 3) 

       

     

     

  

Analyzed (n = 11) 

 

Excluded from analysis 

     

Analyzed (n = 11) 

 

Excluded from analysis 

    

A
na

ly
si

s 



Range of Motion Changes in Female Elite Swimmers Throughout a Competitive Season 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                         Volume 2 – Issue 2 – June 2019 
 

of active shoulder IR and ER were measured on 
the dominant and non-dominant sides before 
performing either intervention. Following baseline 
AROM measurements, the participants in the 
TMRG performed one seated straight leg raise 
(SLR) (Figure 2) with each leg and one FFTT 
(Figure 3) with the arms across the chest placing 
the palmar surface of the hand at the anterior 
axilla, the hips slightly flexed as if performing a 
dead lift, and the torso at an angle which caused 
no discomfort in the lumbar region to each side. 
Hip angle, depth, and postural control were not 
controlled for as the TMR® system asks for the 
participant to reach their perceived end range 
requiring changes in joint angles during 
intervention.30 The participant then determined 
which side or motion provided the most ROM, best 
quality of motion, was pain free, or free of 
restriction.30 

Figure 2. Seated straight leg raise starting 
position and ending position.  

Figure 3. Forward flexed trunk twist movement. 

Total Motion Release® Group (TMRG Intervention) 

Participants in the TMRG established a side of 
ease for both the seated TMR® SLR and FFTT 
through self-determination. After the easier side 
had been determined, participants performed the 
seated SLR (3 sets of 20-second static holds at end 
range) and the FFTT (3 sets of 20-second static 
holds) in the direction of the side of ease 
beginning with the most dysfunctional of the two 
patterns. After each set, there was a 30-second 
rest interval. Static holds of 20 seconds at end 
range were chosen to mitigate the fatigue 
associated with completing multiple high-volume 
repetition and set schemes as part of this 
intervention.36 Participants in the TMRG were 
given instruction by a level 3 TMR™ trained 
investigator and were cued to ‘sit back, rotate, 
and breathe’ throughout the FFTT and ‘to lift the 
foot up and breathe’ during the SLR. Following the 
intervention, AROM measurements were 
reassessed. Each participant accomplished the 
TMRG intervention, including testing on the side of 
ease, in approximately 7 minutes. 

Traditional Warm-Up Group (TWG Intervention) 

Researchers suggest that a pre-training or pre-
competition warm-up should include sequential 
phases designed with the specific goals of 
elevating the heart rate and increasing peripheral 
tissue temperature, addressing mobility and ROM 
through static or dynamic stretching, and 
incorporating specific skill based or sport specific 
drills.11,13 The TWG in this study followed a 
protocol fashioned after these recommendations 
using static stretches shown in the literature to 
increase IR and decrease posterior capsular 
tightness at the shoulder.14,15 Static stretching was 
done in the terminal phase, as increases in 
rotational ROM was the end goal of the TWG.37 
The TWG completed the warm-up protocol (Table 
1) after baseline AROM measurements were 
assessed. Following the intervention, AROM 
measurements were reassessed. Each participant 
completed the TWG intervention in 
approximately 25 minutes. To complete the  



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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                         Volume 2 – Issue 2 – June 2019 
 

Table 1. Traditional Warm-Up Protocol 
Warm-up Exercise Repetitions 

Phase I  
Jog 3min at 25%  

Phase II  
Walking Knee Hug 10m 

Alternating Forward Lunge w/ Rotation 10m 
Alternating Reverse Lunge w/ Rotation 10m 

Alternating Walking Quadriceps Stretch 10m 
Power Skips 10m 

Alternating Lateral Lunges 10m 
Walking dynamic forward overhead arm circles 10m 
Walking dynamic reverse overhead arm circles 10m 

Walking horizontal cross body arm swings 10m 
Phase III  

Sprint (50%) 2 x 30m 
Sprint (75%) 2 x 30m 
Sprint (90%) 2 x 30m 

Phase IV  
Alternating seated cross body stretch 3 x 30s each 

Alternating seated upper trapezius stretch 3 x 30sec each 
Alternating side lying sleeper stretch 3 x 30sec each 

protocol, each participant in the TWG completed 
a 4-phase warm-up. Phase I consisted of a 3-
minute steady state jog.11 Phase II was comprised 
of a series of dynamic full body warm up drills 
with upper and lower extremity dynamic stretches, 
dynamic movements in all three planes of motion, 
and a focus on full range shoulder motion.11,12 
Phase II was completed in three continuous rounds 
with a 30-second rest interval. Phase III included 
two rounds of 30 meter runs at 50%, 75%, and 
90% of perceived max intensity, each done with 
a 30-second rest interval.11 Phase IV was 
comprised of 3 rounds of 30-second alternating 
static stretches for the shoulder done to produce a 
30-second rest interval on the uninvolved side 
while the involved side was stretched.11-14 Static 
stretches included a seated cross body stretch, a 
seated upper trapezius stretch, and a side lying 
sleeper stretch with the arm at 90 degrees of 
adduction, 90 degrees of shoulder flexion, and 
90 degrees of elbow flexion.14,15  

 

OUTCOMES MEASURES 

Active shoulder IR and ER were measured using 
the Clinometer© digital smartphone application 
(Plaincode Software Solutions, Stephanskirchen, 
Germany) which is accurate to 0.1°.  A 
smartphone was affixed to the participant's 
forearm just proximal to the wrist, utilizing an 
Ailkin Running Sports Armband for Droid Turbo™ 
Android Smartphone by Motorola© to make use 
of the Clinometer© digital application (Figure 4). 
Shin et al 38 demonstrated the Clinometer© app to 
have high intra-rater reliability when measuring 
active shoulder ER (ICC=0.98, 95% Confidence 
Interval [CI]=0.95-0.99 and IR (ICC=0.96, 95% 
CI=0.96-0.99) among evaluators. Significantly 
correlation with goniometer measurement have 
also been shown through Pearson Correlation 
Coefficient (PCC) evaluation for both active 
shoulder ER (PCC=.95) and IR (PCC=.92).38 Inter-
observer reliability was comparable to 
goniometry as well for both active ER (ICC= 0.87, 
95% CI=0.79-0.92) and active IR (ICC=0.67, 
95% CI=(0.43-0.82).38 



Regionally Interdependent Applications of Total Motion Release® and Active Rotational  
Shoulder Range of Motion in Overhead Athletes 

 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188    Volume 2- Issue 2 - June 2019 
 

 

Figure 4. Ailkin Running Sports Armband for Droid 
Turbo™ Android Smartphone by Motorola© 
 
The examiner stood opposite the desired 
movement, near the head during active IR and at 
the torso during active ER to allow the examiner 
access to the functional use of the smartphone 
Clinometer©.38 Each participant was asked which 
arm they primarily used during their competitive 
activity to determine dominance. For ER and IR 
measurements, the participant was instructed to lie 
supine on a table. An adjustable belt was placed 
across each participant’s chest at the level of the 
sternoclavicular joint to limit trunk compensation 
into extension, rotation, or flexion during ROM 
testing (Figure 5).39 Participants were positioned 
with the shoulder abducted to 90°, the elbow 
flexed to 90°, and the forearm supinated with 
support from the table along the proximal 50% 
of the humerus (Figures 6 & Figure 7). Once 

positioned, the participant was instructed to either 
internally or externally rotate the arm, making 
sure to minimize excessive scapular and trunk 
motion by maintaining contact with the table at the 
humerus and posterior trunk. The measurement 
was recorded when the participant verbally 
confirmed reaching perceived end range.38 All 
measurements occurred in the same order, 
beginning with dominant shoulder IR, dominant ER, 
non-dominant IR, and finally non-dominant ER.  
 
Before completing this study, intra-rater reliability 
pilot testing was conducted using the Clinometer© 
application, armband, and chest strap. The 
examiner measured shoulder IR and ER five times 
with the smartphone application and averaged 
the values. The examiner placed the smartphone 
in the correct position for measurement and 
positioned the participants for proper 
measurement. Measurements were conducted on 
each participant (n=10) twice over a 5-day 
period. A two-way mixed effects model Intraclass 
Correlation (ICC) was used to assess intra-rater 
reliability for the investigating clinician 
responsible for data collection using the 
Clinometer© application. The standard error of the 
mean (SEM) values were calculated for shoulder 
IR and ER using the formula (SEM = SD√1- ICC).  
where SD is the standard deviation from the test.40 
Minimal Detectable Change (MDC) was 
calculated using the formula (MDC=SEM×1.96× 
√2).2, 22 The ICC, SEM and MDC values were 
excellent for both measurements, and comparable 

Table 2. Intra-rater reliability for shoulder Internal & External Rotation using the 
Clinometer application (N = 10). 

Active Range of 
Motion (AROM) 

Intraclass 
Coefficient 

(ICC) 

Standard Error 
Measurement Value 

(SEM) 

Minimal Detectable 
Change Value 

(MDC) 

Shoulder Internal 
Rotation 0.99 0.32 0.87 

Shoulder External 
Rotation 0.96 0.80 2.22 



Regionally Interdependent Applications of Total Motion Release® and Active Rotational  
Shoulder Range of Motion in Overhead Athletes 

 

 

 
 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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to previously research by Shin et al. for active ER  
(SEM=3.01, MDC=2) and active IR (SEM=1.86, 
MDC=3) (Table 2).38,40,39  
 
Statistical Analysis 
 
All data were analyzed using the Statistical 
Package SPSS version 21 (IBM Corp. Armonk, NY, 
USA). Normality was confirmed using the Shapiro-
Wilk test. Levene's test for homogeneity of 
variances was non-significant for dominant IR 
(p=.504), non-dominant IR (p=.376), and non-
dominant ER (p=.696). A one-way ANOVA was 
used to determine the difference between groups 
for change in shoulder IR and ER from pre-to post-
intervention, to calculate effect size and observed 
power, and to assess group means comparisons. A 
priori α level of p ≤ .05 was utilized for all 
statistical analyses. Effect size calculations were 
completed using partial Eta-squared. Partial eta 
squared values lower than 0.0099 were 
considered small, while 0.0588 was the 
benchmark for medium, and values greater than 
0.1379 were considered large effect sizes.42 

 
RESULTS 
 
All of the 22 participants recruited for the study 
met inclusion criteria and completed the study in 
its entirety. Analyses of variables at baseline 
testing did not reveal any significant differences 
between groups in age (p=.349), weight 
(p=.188) (Table 3), pre-intervention dominant 
shoulder IR (Table 4), non-dominant shoulder IR 
(Table 5), pre-intervention dominant shoulder ER 
(Table 4), or non-dominant shoulder ER (Table 5). 
However, there was a significant difference 
between the mean height of participants in both 
groups ( p=0.003) (Table 3). Table 6 shows the 
differences in shoulder IR and ER pre-intervention. 
On average female participants had greater IR  

Figure 5. Adjustable Belt Used to Stabilize 
Patient. 

Figure 6. Internal Rotation Measurement Starting 
and Ending Position.  

Figure 7. External Rotation Measurement Starting 
and Ending Position. 



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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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Table 4. Dominant Shoulder Range of Motion by Group 

Active ROM IR Pre IR Post ER  Pre ER Post 

TMRG 96°±16.2° 106.4°±17.2° 117.7°±6.5° 120.1°±8.7° 

TWG 101.8°±14.3° 103.5°±12.9° 114.5°±15.8° 117.1°±8.7° 

p value p=0.384 p=0.169 p=0.012 p=0.935 

(IR) internal rotation, (ER) external rotation, (TMRG) total motion release group, (TWG) 
traditional warm-up group 

Table 5. Non-Dominant Shoulder ROM by Group 

Active ROM IR Pre IR Post ER Pre ER Post 

TMRG 101.5°±16.1° 108°±14.7° 107.63°±13.2° 112.5°±12.4° 

TWG 108.8°±9.5° 103°±11.9° 110.9°±10.4° 106.8°±13.2° 

p value p=0.068 p=0.176 p=0.773 p =0.824 

(IR) internal rotation, (ER) external rotation, (TMRG) total motion release group, (TWG) 
traditional warm-up group 

Table 6. Range of Motion Differences by Gender  

Gender DOM IR Pre DOM ER  Pre NON DOM IR Pre NON DOM ER Pre 

Male 88.6°±16.09° 110.5°±9.26° 96.1°±14.45° 101.7°±10.91° 

Female 105.7°±9.02° 119.4°±12.91° 111.6°±9.3° 115°±12.08° 

(DOM) dominant shoulder, (NON DOM) non-dominant shoulder, (IR) internal rotation, (ER) 
external rotation 

Table 3. Descriptive Statistics  

 Height (cm) Age (years) Weight (kg) 

Participants 178±11.4 19.3±1.1 76.2±10.9 

TMRG 184.7±10.4 19.5±1.3 79.3±10.8 

TWG 171.6± 7.6 19±0.9 73.1±10.7 

(TMRG) total motion release group, (TWG) traditional 
warm-up group 



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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                         Volume 2 – Issue 2 – June 2019 
 

and ER for both dominant and non-dominant 
shoulders.  

Among the TMRG, a statistically significant 
increase in dominant shoulder IR (F(1,21)=6.623, 
p=0.044), non-dominant shoulder IR 
(F(1,21)=20.52, p<0.001), and non-dominant 
shoulder ER ((F(1,21)=9.108, p= 007) was 
observed after the intervention compared to the 
TWG (Table 7). A significant group difference 
was not observed for dominant shoulder ER 
(F(1,21)<0.001, p=0.982) and the variable did 
not meet the assumption for homogeneity of 
variance. The differences between groups 
represented a large effect size (η2 >0.138) for 
the increases found in dominant shoulder IR, non-
dominant shoulder ER, and non-dominant shoulder 
IR.42 

DISCUSSION 

While examining the effects of a regionally 
interdependent application of TMR® in healthy 
overhead athletes, members of the TMRG 
experienced significant increases in dominant 
shoulder IR when compared to participants who 
completed a traditional warm-up. The dominant 
shoulder IR and ER improvements found in the 
current study were not as large as those produced 
in previous TMR® shoulder ROM investigations.26,27 
However, in the current study, 9 out of the 11 
members of the TMR® group experienced an 

increase in IR greater than 5° on the dominant 
shoulder without performing any upper extremity 
activity or warm-up. Interestingly, non-dominant 
shoulder IR and ER AROM increased significantly 
in the TMRG compared to the TWG, a result not 
identified in previous research utilizing TMR®.26,27    
 
The improvements in dominant and non-dominant 
shoulder IR following the TMR® intervention used 
in this study exceeded shoulder ROM gains 
reported in much of the stretching literature, while 
the traditional warm-up protocol achieved similar 
ROM alterations cited in previous 
research.14,16,26,27,43 Participants in the TWG of 
the current study experienced similar changes in 
dominant shoulder IR (mean=1.7°± 7°) to Laudner 
et al.14 (3.1°), Oyama et al.43 (3.8°), and Gamma 
et al.'s 26 findings (2.2°). In contrast, Gamma et 
al.’s 27 follow-up study found greater gains in the 
warm-up group (6.2°) than previous research, but 
this increase was still below the improvement 
experienced by the TMR® group for both 
dominant shoulder IR (mean=9.5°) and non-
dominant shoulder IR (mean=7.5°) in the current 
study. The Faul’s stretching routine,16 which 
incorporates 3-7 second static stretches of 
shoulder flexion, extension, and ER, has produced 
gains in dominant shoulder ROM more similar to 
our TMR® findings. Sauers et al.16 reported the 
Faul’s stretching routine increased baseball 
players’ ER by an average of 7.6° and IR 9.2°, 

Table 7. Change in Shoulder Internal and External Rotation from Pre to Post-intervention Between 
Groups 

Change from 
Baseline TMRG TWG p value Effect Size (η2) Observed 

Power 

DOM IR +9.5°±9.6° +1.7° ± 7° p = .044 η2 = .188 .534 

DOM ER + 2.5° ± 5.3° +2.5° ± 11.9° p = .982 η2 = .000 .05 

NON DOM IR +7.5° ± 5.7° -6.7° ± 9.7 p < .001 η2 = .468 .99 

NON DOM ER +4.7° ± 6.2° -4° ± 7.5° p = .007 η2 = .313 .819 

(DOM) dominant shoulder, (NON DOM) non-dominant shoulder, (IR) internal rotation, (ER) external 
rotation, (TMRG) total motion release group, (TWG) traditional warm-up group 



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but we do not know if this protocol results in ROM 
improvements in the non-dominant arm as was 
found with the application of TMR® in the current 
study. While non-dominant ER improvement was 
found, the result do not suggest that this 
application of TMR® will significantly increase 
dominant shoulder ER in overhead athletes. 
Methodological differences between studies may 
explain differences in the magnitude of ROM 
change when compared to previous research on 
TMR® and shoulder ROM.26,27 While the length of 
time to complete the TMR® or traditional warm-up 
interventions was similar to previous research 26 (7 
vs. 25 min), the application of TMR® was 
different.26,27 In previous studies 26,27 examining 
the effect of TMR® on shoulder ROM, researchers 
combined a trunk twist motion with the arm raise, 
while the seated straight leg raise replaced the 
arm raise in the current study. It is possible that the 
use of the TMR® arm raise, even when performed 
on the non-dominant side, is more effective than 
the leg raise in producing changes in shoulder 
ROM. The arm raise may have either a 
contralateral or direct effect on shoulder motion 
and may be more effective than the SLR for 
increasing shoulder IR or ER due to the cross-
education effect, or in the case of dominant side 
of ease, direct shoulder neuromuscular training 
paired with the indirect effects of the FFTT.  
 
In addition to differences in TMR® application, 
other methodological differences were present in 
participant inclusion criteria. In the first Gamma et 
al.26 study, participants presented with less 
baseline dominant IR (66°±12.06°) and dominant 
ER (82.4°±11.33°) than was found in the present 
study (baseline=96°±16.2°of IR and 
117.7°±6.5° of ER). The current results could also 
be affected by gender and sport differences as 
the previous studies included only male baseball 
players,26,27 while the current study included both 
male and female participants and participants 

who competed in a variety of overhead sports. It 
is important to note that our methods for shoulder 
IR and ER measurement did not call for the control 
of scapular motion via pinning of the scapula or 
visual inspection (i.e. stopping the measurement 
when the scapula begins to rotate and tilt 
anteriorly).46-48 Measurement of this type accounts 
for scapulothoracic function and glenohumeral 
ROM providing a more integrated and 
performance driven active measure. Thus, 
shoulder complex ROM was measured in place of 
strict glenohumeral ROM. Researchers have 
compared passive ROM measurements with 
humeral head stabilization, scapular stabilization, 
visual inspection, and without stabilization and 
found that measurement without stabilization 
increased shoulder IR means by 8-30°.46,47 As a 
result, when stabilization methods are accounted 
for, our IR measurements fall closer to normative 
values. Additionally, our study features 13 female 
participants while previous shoulder IR research 
has been largely conducted in male participant 
populations.14,16,26,27,43,46 Multiple studies support 
our findings suggesting that females have greater 
IR and ER on average than males regardless of 
the measuring method (Table 6).47,48 Furthermore, 
passive measurements of shoulder IR and ER ROM 
often produce values greater than active by 
approximately 4 degrees for males and 
females.48 Despite the different methodology, the 
low MDC values for our measurement methods 
indicate that changes in ROM are unlikely due to 
measurement error. 
 
Generalization of this study is limited due to the 
sample size (n=22) and use of collegiate and 
secondary school athletes. Additionally, neither 
the examiner nor the participants were blinded to 
the intervention or measurements. The 
investigating clinician, while trained in TMR®, was 
a relative novice using the intervention. A more 
experienced TMR® clinician may have achieved 



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different alterations in ROM. Additionally, no 
follow-up measures were recorded, so it is 
unknown how long the ROM gains in either group 
remained. In spite of such limitations, the 
significant improvement in bilateral shoulder IR 
and non-dominant shoulder ER, and strong effect 
sizes, suggests the results of this study are clinically 
and practically meaningful. Thus, future research 
on TMR® is warranted. The time to completion 
differences between our intervention groups 
merits exploring interventions that are of a similar 
duration. Additionally, the duration of ROM 
improvement following TMR® intervention, along 
with assessing if multiple interventions produce 
more meaningful results, should be established. 
Further research efforts should also focus on single 
method interventions within the TMR® system and 
explore the TMR® intervention principle of 
addressing the side of ease versus the side of 
restriction. Finally, electromyographic study of 
activation patterns during trunk rotation may yield 
information regarding neuromuscular changes 
following TMR® intervention. 
 
Considerations Regarding TMR® Mechanisms  
 
Our findings, when compared with those in the 
current literature, 14,16,26,27,43 suggest that indirect 
RI interventions produce superior increases in ROM 
for overhead athletes bilaterally compared to a 
traditional direct methods, and require less time 
for completion. The findings, when combined with 
previous work, 26,27 support a hypothesis that 
increases in shoulder rotational ROM may be able 
to be driven by interventions directed at the core, 
which may be related to reducing ROM 
asymmetries of the trunk. The use of a trunk twist 
to improve shoulder ROM supports RI research 
linking the relationship between thoracic spine 
function and trunk stabilization to shoulder pain, 
mobility, and motor control.5,31,32,49 Weakening of 
muscles that attach to the thoracolumbar fascia 

may have profound effects on the spine as the 
fascial structures provide for spinal integrity and 
mechanical function.49 Loss of stiffness and 
mechanical function at the spine places greater 
stress upon the glenohumeral joint and rotator cuff 
in throwing athletes as the force needed to 
accelerate and decelerate the limb is initiated 
and increasingly dispersed through the 
glenohumeral joint during forceful overhead 
power production and deceleration.49 Insufficient 
core stability also correlates with a higher 
incidence of scapular dyskinesis, which is a risk 
factor for shoulder injuries in volleyball players.5  
 
The literature supports evidence of the importance 
of activation sequencing of the deep core 
musculature and trunk stabilization through the 
thoracic cage in counter rotation prior to 
movement at the upper extremity in overhead 
athletes.5,26,27,32,49 Extremity function during 
forceful counter rotation, acceleration, and 
deceleration is dependent on the sequential and 
reciprocal relationship between core stiffness and 
rotatory control, providing a stable platform at 
the trunk.5,18-21,32,49 The FFTT may have had a 
greater effect on ROM changes than the SLR in 
the TMRG due to the principle of proximal trunk 
stability predicating distal limb mobility. 
Neurological activity through the interconnected 
tissues of the posterior fascial chain and deep arm 
fascial chain during the FFTT also likely 
contributed to significant alterations in shoulder 
AROM.33 Trunk twist motions can be performed in 
a variety of positions including seated, standing, 
and with the hips hinged or the trunk flexed when 
utilizing TMR®. Placing the spine in a position of 
angular shear force during the hip hinge portion 
of the FFTT utilized in this study forces the trunk to 
stabilize and protect the spine reflexively. As the 
trunk stabilizes the spine, a more rigid platform is 
created throughout the lumbopelvic and 
thoracolumbar regions, potentially resolving 



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stability and motor control dysfunctions at the 
core, glenohumeral joint, and scapulothoracic 
articulation.18-21  
 
When considering RI interventions like TMR® as 
neurophysiological processes, RI may be a 
combined function of three interrelated 
neuromotor principles: cross education,22-25 neural 
coupling,28 and the common core hypothesis.29 
Currently, it is understood that neuromuscular 
control and strength production relies on stimuli 
received and communicated throughout the whole 
body for optimal function during complex 
integrated movements.22,23,28,29  Short term 
strength gains are due to increased neurological 
activity, not muscular hypertrophy, and are not 
dependent on local training effects in tissues.22-28 

Additionally, contralateral strength gains are due 
to increased motor neuron output rather than 
muscular fiber adaptations as ipsilateral motor 
neurons and branched spinal fibers project 
bilaterally.22,25 Therefore, repeated or sustained 
contractions can induce adaptations in the 
untrained limb.23,24,28 Such contralateral 
enhancement of motor control may serve as the 
fundamental basis of TMR®. Instead of reinforcing 
the painful, restricted, or dysfunctional movement, 
TMR® use may allow participants to adapt motor 
neurons of the spinal cord to the motor pattern 
perceived as non-threatening, which then ‘spills 
over’ to the other side of the body.22 
 
CLINICAL APPLICATION 
 
The use of TMR® in our study led to significant 
improvements in bilateral shoulder IR and non-
dominant shoulder ER in overhead athletes. These 
findings are significant as IR deficit of the 
dominant shoulder is often associated with 
reduced performance and injury risk in overhead 
athletes. Based on the results of this study, the 
TMR® FFTT and SLR are more effective at 

immediately increasing bilateral shoulder IR, as 
well as non-dominant shoulder IR and ER, in 
overhead athletes than a traditionally designed 
athletic warm-up protocol. Several factors may 
contribute to a lack of increase in dominant 
shoulder ER. Commonly, adaptations in the 
dominant shoulder of overhead athletes include 
reductions in IR accompanied by increased 
ER.6,44,45 Such paired adaptations in ROM of the 
shoulder in overhead athletes often contribute to 
asymmetries correlated with patterns of increased 
injury risk, performance deficit, and potentially to 
pathological circumstances such as Glenohumeral 
Internal Rotation Deficit (GIRD) in overhead 
athletes.1-10,44,45 As such, it is plausible that 
increasing IR without paired increases in ER, 
moving ROM toward a state of symmetry, is a 
beneficial adaptation in healthy populations for 
injury prevention. For overhead athletes, this 
means that TMR® may potentially prepare the 
shoulder for throwing, spiking, and serving far 
better than static and dynamic stretching through 
rapid increase of shoulder IR through motor 
neuron adaptation, via increases in trunk stability, 
rotatory control, and RI alterations throughout the 
shoulder girdle.  
 
The TMR® protocol was completed in less than one 
third of the time of the traditional warm-up 
indicating that the incorporation of the TMR® FFTT 
and SLR can increase shoulder AROM to a larger 
degree in a shorter amount of time than the 
common warm-up methods utilized in our TWG. 
Utilizing TMR® in place of traditional local 
stretching techniques, as part of a warm-up 
program, may result in decreased injury risk and 
increased performance in overhead athletes via 
increased AROM in crucial areas such as shoulder 
IR. 
 
 



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Regionally Interdependent Applications of Total Motion Release® and Active Rotational  
Shoulder Range of Motion in Overhead Athletes 

 

 

 
 

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https://doi.org/10.3109/09593985.2010.481011
https://doi.org/10.3109/09593985.2010.481011
https://doi.org/10.1177/001316447303300111
https://doi.org/10.1177/001316447303300111
https://doi.org/10.3928/19425864-20100524-01
https://doi.org/10.3928/19425864-20100524-01
https://doi.org/10.1177/0363546510384223
https://doi.org/10.1177/0363546510384223
https://doi.org/10.1177/03635465020300011701
https://doi.org/10.1177/03635465020300011701
https://doi.org/10.1177/1941738108331201
https://doi.org/10.1177/1941738108331201
https://doi.org/10.1053/apmr.2002.34815
https://doi.org/10.1186/1758-2555-4-33
https://doi.org/10.3233/BMR-1996-7103

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