The Throwing Shoulder and Overhead Athlete
Few activities place more stress and strain on the upper extremities than overhead sports and throwing. Biomechanical analyses of throwing mechanics of pitchers have shown that the speed of rotation at the shoulder joint can exceed 7500 degrees per second. This level of force production requires the entire kinetic chain to function properly from the foot to the hand, and any dysfunction can have detrimental effects on athletic performance. Proper treatment of these athletes begins with a thorough assessment of the patient from stem to stern. While many pathologies are localized to a specific extremity, throwing is an incredibly complex motion that requires excellent lower extremity and core strength in addition to good technique and upper body strength. Any deficits in the kinetic chain could prove detrimental to both performance and health of the throwing shoulder, so a thorough evaluation is crucial to getting athletes healthy and back on the mound.
When focusing specifically on the injured extremity, it is important to rule out structural pathologies such as capsular contractures, rotator cuff tears, labral tears and suprascapular nerve entrapment among others. Once the problem is defined, treatment options can be tailored specifically to each athlete. While some cases may require surgical correction, such as Tommy John procedure or labral repair, many shoulders can be treated non-operatively using physical therapy and specialized return-to-play programs tailored specifically to each athlete. This multi-faceted, holistic approach helps to correct abnormalities throughout the entire body and ensures a shoulder joint that functions properly while enabling the athlete to return to elite levels of competition.
Glenohumeral Internal Rotation Deficit (GIRD) refers to a lack of internal rotation (turning in towards the body) that is very common in pitchers. Since pitchers externally rotate the arm while throwing, and throw hundreds of pitches, they begin to stretch their shoulder into external rotation while neglecting internal rotation. This leads to a shoulder that externally rotates much further than it internally rotates and places the pitcher and an increased risk for labral tears. While GIRD can cause many problems for the throwing shoulder and pitchers of all ages, it is very easily treatable with at home stretching programs and physical therapy. Once full, 180 degree ROM has been established, most pitchers can return to play while maintaining their strength and flexibility improvements.
While throwing is a fairly natural motion, the excessive repetition and force required in pitchers and overhead athletes today places stress on the throwing shoulder. A fairly common cause of pain called internal impingement is caused by the bony prominence on the outside of the humerus pressing against the back portion of the glenoid. This can squish or “impinge” the rotator cuff tendons and lead to pain or damage to the rotator cuff. Like GIRD discussed above, internal impingement is very manageable with non-operative treatment, and most pitchers are able to return to play after rest and physical therapy to restore normal kinematics and strengthen the shoulder.
While many people are familiar with the shoulder being a ball and socket, most tend to forget that the shoulder blade itself is actually completely separate from the ribs it sits on. Due to this, the scapula must be held in place by several muscles, and its position on the body dictates which direction the arm can move. Additionally, the scapulo-thoracic joint is responsible for a small percentage of the motion of the shoulder. If the muscles surrounding the scapula are too weak to properly maintain its position, the scapula does not move properly and the patient develops scapular dyskinesis. While this condition can have drastic implications on the motion and strength of the shoulder, it is often treatable with physical therapy and supervised, specialized return-to-play programs. Physical therapy usually focuses on ensuring the shoulder joint has a full range of motion while also focusing on a specific exercise routine known as periscapular strengthening. These exercises strengthen the muscles around the scapula and help make sure pitchers can return to throwing with a normal, healthy throwing shoulder.
SUPRASCAPULAR NERVE Compression
The suprascapular nerve originates from the neck, where it travels down to the scapula and through a small “tunnel” formed by the suprascapular notch and the suprascapular ligament in order to reach the supraspinatus and infraspinatus muscles of the rotator cuff. If this tunnel gets overly crowded, the suprascapular nerve can become compressed, inhibiting its ability to innervate the rotator cuff muscles. In these cases, patients may notice decreased strength and loss of muscle which can lead to permanent muscle atrophy if left untreated. Luckily, this condition can usually be treated arthroscopically to cut the suprascapular ligament and free up space for the nerve. See the video below for a step-by-step guide to the procedure.
UCL Reconstruction (Tommy John)
With proper coaching and limitations, throwing is no more harmful to the body than any other activity. However, young pitchers tend to see drastic increases in pitch count compared to their peers. This can cause excessive stress to several different parts of a developing musculoskeletal system, specifically the ligaments on the inside part of the elbow. These ligaments provide stability and prevent the elbow from bending side-to-side, and tears to these ligaments leave the athlete with a painful, unstable elbow.
When an athlete tears the Ulnar Collateral Ligament, procedure commonly known as a Tommy John Procedure can reconstruct the ligament and allow the athlete to return to competition. These procedures have become more common in recent years, particularly in young pitchers. During surgery, a graft is prepared most commonly from the palmaris longus tendon in the forearm and secured to the 2 bones of the elbow through small holes drilled in the bones.