Throwing Pains: Managing Shoulder & Elbow Issues in Baseball Players

Introduction

The act of overhand throwing exerts significant strain on the elbow joint. Unlike sudden injuries resulting from falls or collisions, repeated high stresses on the elbow, commonly experienced by throwing athletes like baseball pitchers, can lead to severe overuse injuries. Overuse injuries gradually develop over time. They typically occur when an athletic movement is repeated without sufficient intervals for rest and recovery between games or practices. Excessive stress on the shoulder muscles or tendons is the primary cause of shoulder pain in throwing athletes.

In some cases, the ball of the upper arm bone may dislocate from the shoulder socket, resulting in a condition known as dislocation. The muscle and tendons collection is referred to as the rotator cuff. Repeated throwing motions and improper technique can cause irritation, inflammation, and occasionally tears in the rotator cuff. Over time, this can lead to damage in the surrounding structures as well.

What is throwing pain?

Typically, experiencing pain after throwing is indicative of inflammation in the rotator cuff tendons. Essentially, the shoulder becomes inflamed or irritated following the throwing motion. One possible explanation is that the tendons are subjected to excessive stress. This often happens when individuals attempt to improve their physical condition within a short period rapidly. Overhand throwing significantly strains the elbow, resulting in extremely high stresses. Unlike acute injuries caused by falls or collisions, throwing athletes, such as baseball pitchers, can develop severe overuse injuries due to repeated stress on the elbow. Generally, when the arm has been subjected to excessive stress, recovery can be achieved through conventional treatments. However, when the pain is caused by overuse, the recovery process is never as quick as desired, which can be challenging for both the athlete and coaches to remain patient.

Elbow anatomy

The elbow joint serves as the meeting point for three bones in the arm:

• The humerus (upper arm bone) 
• The radius 
• The ulna (two bones in the forearm). 

This joint functions as a combination hinge, permitting the arm to bend and straighten and a pivot, enabling the lower arm to twist and rotate. The olecranon is located at the upper end of the ulna, which is the bony prominence of the elbow. 

Thicker ligaments, known as collateral ligaments, are present on the outer and inner sides of the elbow to maintain joint stability and prevent dislocation. The ulnar collateral ligament (UCL) runs explicitly from the inner side of the humerus to the inner side of the ulna, enduring significant stress while stabilizing the elbow during overhand throwing. 

Additionally, various muscles, nerves, and tendons intersect at the elbow. The pronator/flexor muscles of the forearm and wrist originate from the elbow and contribute to elbow stability during throwing motions. The ulnar nerve passes behind the elbow and controls the hand muscles.

Elbow issues in baseball players

1. Extension Overload: During the throwing motion, the olecranon and humerus bones twist and exert pressure on each other. Eventually, this can lead to valgus extension overload (VEO). In this condition, the protective cartilage on the olecranon wears away, and abnormal bone growth called bone spurs or osteophytes develops. Athletes with VEO will have swelling and pain at maximum contact between the bones in the posterior part of the elbow.

2. Ulnar Collateral Ligament Injury: The ulnar collateral ligament (UCL) is the most regularly injured among throwers. Injuries to the UCL can range from inflammation and minor damage to a complete ligament tear. Athletes experience pain on the inward side of the elbow and often notice decreased throwing velocity. Valgus 

3. Ulnar Neuritis: When the elbow is flexed, the ulnar nerve stretches around the bony protrusion at the inner end of the humerus. In throwing athletes, the ulnar nerve undergoes repeated stretching. It may even dislocate, causing painful snapping—this stretching or snapping leads to nerve irritation, a condition referred to as ulnar neuritis. Throwers with ulnar neuritis will experience pain resembling electric shocks originating from the inner elbow (commonly known as the “funny bone”) and radiating along the nerve as it extends into the forearm. They may also have numbness, tingling, or pain in the tiny and ring fingers during or immediately after throwing, and these symptoms may persist even during rest periods. Ulnar neuritis can also occur in individuals not engaging in throwing activities. These individuals often notice the same symptoms upon waking up or when keeping the elbow flexed for extended periods.

4. Olecranon Stress Fracture: Stress fractures arise when muscles become exhausted and cannot absorb additional shock. Eventually, the fatigued muscle transfers the excessive stress to the bone, resulting in a minute crack known as a stress fracture. Among throwers, stress fractures in the olecranon are the most common. Athletes will experience aching pain on the surface of the olecranon, located on the underside of the elbow. This pain is most severe during throwing or other strenuous activities and may occasionally occur during rest periods. 

5. Flexor Tendinitis: Repetitive throwing can cause irritation and inflammation of the flexor/pronator tendons, which connect to the humerus bone on the inner side of the elbow. When athletes throw, they will feel pain on the inner side of the elbow, and if the tendinitis is severe, they may also experience pain even when at rest. 

Causes 

Elbow injuries are frequently observed in pitchers, but they can also affect athletes engaged in repetitive overhand throwing regardless of their sport. The repetitive stresses caused by high-speed throwing can result in various overuse injuries. The inside of the elbow is particularly susceptible to problems as significant force is concentrated in that area during the throwing motion. In most instances, the pain subsides when the athlete ceases throwing, and it is rare for these injuries to occur in individuals who do not engage in throwing activities.

Treatment for elbow issues

In most cases, elbow-throwing injuries can be effectively treated without surgery. Non-surgical methods, such as a short rest period, physical therapy, adjustments to throwing mechanics, and anti-inflammatory medications like ibuprofen, are often sufficient to alleviate painful symptoms.

However, surgical treatment may be necessary if these methods fail to provide relief and an athlete wishes to continue throwing. 

There are two main surgical options available: 

1. Arthroscopy: This procedure involves the removal of bone spurs on the olecranon and any loose fragments of bone or cartilage within the elbow joint. A small camera guides miniature surgical instruments and is inserted into the joint. 

2. UCL reconstruction: Athletes with an unstable or torn UCL may undergo this procedure, commonly known as “Tommy John surgery.” A tissue graft is replaced in place of the torn ligament, which serves as a scaffold for the growth of a new ligament. 

In most cases, the patient’s tendons can be used for the reconstruction. 

Please note that surgical intervention should only be considered if non-surgical methods have proven ineffective and the athlete is determined to continue their throwing activities.

Shoulder issues in baseball players

1. Scapular Rotation Dysfunction (SICK Scapula) 

This condition affects the proper movement and rotation of the scapula during the throwing motion. The scapula, also known as the shoulder blade, is connected to the clavicle and relies on various muscles in the upper back to maintain its position and support healthy shoulder movement. Repetitive use of the scapular muscles during throwing can lead to changes in these muscles, affecting the position of the scapula and increasing the risk of shoulder injury. One of the main characteristics of scapular rotation dysfunction is the drooping of the affected shoulder. This condition is often accompanied by pain near the collarbone in front of the shoulder. In many throwing athletes with this condition, the chest muscles tend to tighten in response to the changes occurring in the upper back muscles. It is important to note that lifting weights and performing chest strengthening exercises can worsen this condition.

2. SLAP Tears (Superior Labrum Anterior to Posterior) 

In a SLAP injury, the superior portion of the labrum is damaged. This specific area is where the long head of the biceps tendon connects to the labrum. A SLAP tear occurs in this attachment point’s anterior and posterior regions. Common symptoms include a sensation of catching or locking and pain during specific shoulder movements. Pain deep within the shoulder or discomfort with particular arm positions, such as late cocking, is also frequently experienced. 

3. Rotator Cuff Tendinitis and Tears 

When a muscle or tendon is overused, it can become inflamed, leading to tendinitis. The rotator cuff is frequently irritated in individuals who engage in throwing activities. The initial indications of rotator cuff tendinitis encompass pain that extends from the shoulder’s anterior part to the arm’s lateral side. This pain can manifest during activities such as throwing or other movements and may persist while at rest.

As the condition progresses, pain may occur at night, and the individual may experience a loss of strength and range of motion. Rotator cuff tears often begin with fraying. As the condition worsens, the tendon has the potential to rupture. If one or more of the tendons in the rotator cuff tear, they lose their complete attachment to the head of the humerus. Most tears experienced by athletes who engage in throwing activities occur in the supraspinatus tendon. Issues with the rotator cuff frequently result in shoulder bursitis. Positioned between the rotator cuff and the acromion (the bone located on the top of the shoulder) is a lubricating sac known as a bursa. This bursa facilitates smooth movement of the rotator cuff tendons when the arm is in motion. However, when the rotator cuff tendons sustain injury or damage, the bursa can also become inflamed, leading to pain.

4. Biceps Tendinitis and Tendon Tears 

Repetitive throwing can cause inflammation and irritation in the upper biceps tendon, known as biceps tendinitis. Symptoms of biceps tendinitis often include pain in the front of the shoulder and weakness. In some instances, the damage to the tendon caused by tendinitis can lead to a tear. A torn biceps tendon may result in a sudden, sharp pain in the upper arm. Some individuals may also hear a popping or snapping sound when the tendon tears. 

5. Internal Impingement 

Internal impingement is seen when the tendons of the rotator cuff in the back of the shoulder are pinched between the humeral head and the glenoid during the cocking phase of an overhand throw. This can cause a partial tearing of the rotator cuff tendon and damage to the labrum, resulting in it peeling off from the glenoid. The cause of internal impingement may be attributed to some looseness in the structures at the front of the joint and tightness in the back of the shoulder. 

6. Glenohumeral Internal Rotation Deficit (GIRD) 

GIRD occurs when the extreme external rotation required for high-speed throwing causes the ligaments at the front of the shoulder to stretch and loosen. As a result, the soft tissues in the back of the shoulder tighten, leading to a loss of internal rotation. This loss of internal rotation increases the risk of labral and rotator cuff tears for throwers.

7. Shoulder instability 

This refers to the head of the humerus slipping out of the shoulder socket (dislocation). It is known as chronic shoulder instability when the shoulder is loose and repeatedly moves out of place. In throwers, instability develops gradually over time due to repetitive throwing, stretching the ligaments and increasing laxity. If the rotator cuff structures cannot control this laxity, the shoulder may slightly slip off-centre (subluxation) during the throwing motion. Initial symptoms of instability include pain and a loss of throwing velocity rather than a sensation of the shoulder slipping out of place. Occasionally, the thrower may experience a feeling of the arm going numb. In the past, instability was commonly referred to as dead arm syndrome. 

Causes 

Pain experienced during the act of throwing can be attributed to several factors. These include the shoulder blade, the shoulder joint (specifically the cartilage and labrum), the rotator cuff muscles and tendons, and the nerves responsible for controlling muscle function. 

The shoulder blade is connected to the chest wall through ligaments, muscles, and tendons. The coordinated movement of these muscles and tendons is crucial in shoulder blade movement, affecting throwing motions. 

Any abnormalities within this intricate network can result in shoulder dysfunction and ultimately lead to pain while throwing. One common abnormality is the posterior shoulder capsule’s tightness, which restricts the shoulder’s regular internal rotation. If this tightness is the cause of your pain, you may observe that you cannot reach as high on the side of the painful shoulder when reaching behind your back.

Treatment for shoulder issues

The majority of individuals who encounter sudden pain while throwing can enhance their condition through non-surgical interventions. The initial stage of treatment involves resting the affected joint and minimizing inflammation. 

Potential treatments include anti-inflammatory medications and cortisone injections. 

After the acute symptoms of inflammation have diminished, it becomes essential to identify and address the root cause of the discomfort. Targeted treatment can be administered to take care of the underlying issue specifically. 

Typically, a physical therapist can assist in restoring complete mobility and strength to the shoulder.

Conclusion

The shoulder becomes inflamed or irritated after throwing. One potential cause is excessive stress on the tendons. This typically happens when individuals attempt to get fit too quickly within a limited timeframe. Overhand throwing significantly strains the elbow, resulting in extremely high stresses. Unlike sudden injuries caused by falls or collisions, throwing athletes, like baseball pitchers, can develop severe overuse injuries due to repeated stress on the elbow.

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