With the start of the baseball season, every year I see an influx of upper extremity throwing injuries in my office. Some of these injuries may have been lingering before the season and resurface when athletes resume throwing activities. The COVID pandemic has resulted in shortened seasons with compressed schedules, which places more burdens on throwing arms. My goal is to discuss the different injuries, the warning signs and prevention tips in hopes to prevent athletes from getting injured.
The throwing athlete’s injuries are shared by other overhead athletes, such as football quarterbacks, softball players, javelin throwers and other non-throwing athletes like swimmers and volleyball players. However, baseball throwing injuries are most common. They do not only happen in pitchers. Position players can be susceptible as well. The worst combination is a player that plays pitcher AND catcher, which significantly increases the volume of throws. The injuries primarily involve the shoulder and elbow. Shoulder injuries include rotator cuff tendonitis, tendon tears, bursitis, biceps injuries, including the biceps anchor, we call the “labrum.” Shoulder instability can also develop. Elbow injuries range from muscle strains, loose bodies, tendonitis, and ligament injuries, including the ulnar collateral ligament, well known for “Tommy John” surgery. Stress fractures can occur in the shoulder, arm and elbow, as well as in the rib cage. Skeletally immature athletes also can injure their growth plates and cartilage, commonly referred to as “Little Leaguer’s shoulder and Little Leaguer’s elbow”.
Growth plate fracture in young baseball player, fixed with screw.
Was able to return to baseball.
As you can see, there is a wide range of problems that can occur in the throwing and overhead athlete. Early recognition and early management are critical to prevent injuries from becoming a bigger problem. The consequence of some of these injuries may result in decreased performance, loss of playing time, prolonged recovery, lasting joint damage, and potentially surgery.
The player may not only experience pain while throwing. Lingering pain after throwing is also a concern. Frequently, a player’s performance starts to decrease, throwing velocity decreases, and ball control decreases. The player can be seen shaking their arm, rubbing their arm or making attempts at stretching it out between throws or even in the dugout, so those are signs to be aware.
What are the risk factors to avoid and hopefully lessen the chance for an injury? The vast majority of throwing injuries are simply a result of overuse. These injuries may present suddenly or as a result of cumulative and gradual onset. Too many pitches and not enough rest between throwing days are huge contributors to the overuse and abuse of the throwing arm. It has been said, “You only have so many pitches in you.” One of the biggest risk that can lead to injury is throwing with fatigue, which can take away the protective effect of full muscle performance. Faster throwers are at higher risk than slower throwers. Athletes that play year-round baseball, especially on multiple teams as well as those that attend showcases are at particular risk. Deconditioned, unprepared athletes or athletes that do not warm up appropriately before practice or a game are also at risk. Muscle imbalance, muscle weakness, and loss of shoulder motion are well documented risk factors. Finally, poor throwing form and faulty throwing mechanics add stress to the throwing arm and represent additional risk.
Clearly, prevention is key to avoid throwing injuries. The shoulder and arm are only a part of the link which includes the torso, core and legs. One of the quotes I use with patients is that “throwing begins with the legs.” Strengthening and conditioning of not only the upper extremity, but core and legs is an important part of injury avoidance. Proper warm up, stretching and cool down are important before and after games. Pitch count limits and days of rest have helped decrease throwing injuries and are now mandatory in most baseball programs and are used to a large extent in professional baseball. Proper mechanics should be monitored and fine-tuned by knowledgeable coaches and instructors. Participation in other sports not only helps develop other skills and strengthens other areas of the thrower’s chain, but it also provides rest to the throwing arm.
The treatment of shoulder and elbow injuries in throwers starts with a thorough evaluation and identification of the problem as well as contributing factors. Early diagnosis will usually lead to quicker recovery and avoidance of further damage. Athletes must communicate when they feel shoulder, arm and elbow soreness as soon as possible. The first step to treatment is commonly involves refraining from throwing for a period of time. Changing playing positions can provide relative rest to the throwing arm. Anti-inflammatory medication and rehabilitation are very important. Rehabilitation aims to target the deficient areas, including weaknesses, poor muscle coordination and inflexibility. Treatment of the upper extremity often requires addressing deficiencies along the rest of the chain, including torso, core and legs. Mechanical flaws need to be identified once a player is permitted to gradually return to throwing. Although most throwing injuries can be managed conservatively, some will not resolve and may require surgery. Unfortunately, surgery may take many months of recovery and affects participation in other activities.
In my world of influence in baseball over many years, I have been dedicated to educating players, coaches and parents in the hope to preventing and identifying clues before they become bigger problems. I have had a broad range of experience with baseball, with care of professional players, experience coaching the game, and experience as a parent! So I have seen the different perspectives when it comes to evaluating and caring for baseball injuries. It is best to avoid the risk factors outlined above if everyone involved takes part in prevention. My hope is that by raising awareness of throwing injuries, players can enjoy the game of baseball and avoid getting hurt. Best of luck this season!
