by Raphael S. F. Longobardi, MD, FAAOS
University Orthopedic Center, PA – Hackensack, NJ
Spring time typically marks the return of America’s favorite pastime- baseball. All over the country, baseball (and softball) teams have been gearing up to start play. In years past, baseball had remained a single-season sport. Now, teams and clubs remain active nearly year round. The results of those schedule demands has resulted in the rise of typical over-use injuries related to throwing. Injuries once isolated to older, seasoned players are now being seen in younger, even high school age throwers at a significantly higher frequency.
One of the unique aspects of baseball is the injuries its’ play manifests. The action of overhand throwing is biomechanically more difficult and taxing on the shoulder and upper extremity. Years of intensive research have established the “norms” for throwing, with respect to muscle contraction, arm position and stresses (both dynamic and static).
The act of throwing places extreme demands on the shoulder. Over a short period of time, the shoulder must maximally rotate, accelerate, and then decelerate the arm, all of this while maintaining precise control over the direction and speed of the ball. The muscles of the thigh, hip, abdomen, back and shoulder form a “kinetic chain” which generates the high loads which are necessary to propel the baseball. With each throw, these forces place considerable stress and strain on the soft tissue structures surrounding the shoulder. Repetitive throwing results in “micro-traumatic” tears of the stabilizing structures of the shoulder, such as the labrum, the capsule and the rotator cuff tendons. Eventually, this microscopic disruption of tissues leads to the development of pain, altered shoulder mechanics, and potentially worsening injuries.
There is a spectrum of over-use shoulder injuries that vary greatly with an athlete’s age. In children and adolescents, (the skeletally immature person), repetitive throwing can lead to both soft-tissue and bony injuries. Stress-fractures or reactions in the areas of growth (“growth-plates”) around the shoulder (and elbow) are commonly identified with concomitant soft tissue contractures or scar tissue.
In athletes of any ages, throwing produces abnormal laxity or looseness in the ligaments that support and stabilize the front of the ball and socket (called glenohumeral) joint. The same force that propels the baseball actually distracts the ball (humeral head) from the socket (glenoid) and causes tearing and loosening of these ligaments in the front of the shoulder. There is an extensive list of injuries to the shoulder related to throwing that is beyond the scope of this article. To suffice, they include injuries to the rotator cuff and biceps tendons (tears, tendinitis and impingement), the labrum (cartilage rim/ring around the glenoid ,) as well as, injuries to the artery and nerves to the shoulder.
Any and all of these structures can be damaged by throwing. Although it may seem obvious, the occurrence of pain with throwing indicates an abnormality in one or more structures in the shoulder and shoulder girdle. By understanding the exact mechanics of throwing, physicians can diagnosis the problem depending on when in the act of throwing a patient may experience pain.
The throwing motion is broken down into distinct phases, which coincide with specific arm, shoulder and body positions. These phases include (in order): “wind-up”, “stride”, “arm cocking”, “arm acceleration”, “arm deceleration” and “follow through”. Pain experienced when the player has his arm back, right before it begins to move forward, would be described as “a pain in the “ arm cocking phase”. Common causes for pain with this motion include SLAP tears (a specific type of labral tear) or internal impingement of the rotator cuff. Another example of concern with throwing is pain experienced during the “arm deceleration” phase. This phase is noted by the moment the ball is released from the hand. During this phase, the shoulder joint (glenohumeral joint) undergoes the maximal distractive force, as well as, the maximal anterior translative force. To better describe these forces, the ball moves forward and away from the socket at the greatest force during throwing in this phase. Pain during this phase of throwing may occur along with a feeling of numbness and tingling down the arm; both of these symptoms are related to instability of the ligaments controlling the motion of the humeral head within the glenoid socket.
Recognition of these specific types of problems, along with the accurate diagnosis of the condition can greatly assist in the development of a management plan for recovery and return to pain-free play. Sometimes, sophisticated diagnostic tests, such as MRI arthrograms, are necessary to aid in the diagnosis of these conditions, but more frequently, the clinician will be able to diagnosis these problems solely via a comprehensive and detailed patient history and physical examination. Tests that reproduce pain, reveal weakness, or identify restricted motions, are often the most diagnostically effective and accurate; the tests will often confirm the diagnosis found on MRI’s or other sophisticated scans.
Once the injury has been diagnosed, a treatment plan will be outlined by the evaluation physician. The vast majority of painful throwing conditions can be successfully treated with rehabilitation programs that restore mobility and strength to the shoulder and shoulder girdle musculature. There is also a required period of rest in order to allow for the tissue to recover and to heal; thus the necessity of the “disable list” for professionals. Yet, more importantly, even the amateur needs a time to recover and get well. The common thought is that professionals play through pain and injuries. The truth is that when professionals have significant injuries, they are required to rest and to recover for a period of time. When these more conservative measures do not improve or alleviate the painful symptoms, then surgical interventions may be necessary.
The advent and revolutionizing of arthroscopic, minimally invasive surgery on the shoulder has allowed for the correction of these injuries, with the restoration of the normal mechanical functioning of the shoulder. Arthroscopic procedures are now used routinely to repair rotator cuff tears, torn labrums, and to correct instability. Following these procedures, the thrower embarks on an intensive course of rehabilitation to improve shoulder mobility, strength and function. Throwers will participate in a regulated throwing program which progressively increases their throwing workloads, while being supervised for painfree throwing. Once fully healed and rehabilitated, the player is ready to return to game, and ready to resume throwing.
Baseball is a terrific game for all ages to participate and compete. It is a game that has been shared between generations of fathers and sons, parents and children. It is a wonderful piece of American ingenuity and pride, which helps to define us as uniquely American. It is a sport that should be enjoyed for many years, by all ages. Unfortunately, it is a sport where shoulder pain looms as part of its very essence. Fortunately though this pain does not have to persist as long as it is properly identified and managed by the specially trained group of professionals who are dedicated to preserving its’ players long-term health, well being and performance.
Dr. Longobardi is a board-certified orthopedic surgeon specializing in sports medicine and athletic injuries. He is Chairman of the Orthopedics Department at Holy Name Medical Center and a consultant/team physician at Berkeley College and Bergen Catholic High School. He has authored various articles and presentations related to the shoulder. Dr. Longobardi endorses the American Academy of Orthopedic Surgeons, “STOP Sports Injuries” program.
If you wish to contact Dr. Longobardi, he can be reached at his private practice located at University Orthopaedic Center, PA, Continental Plaza, 433 Hackensack Avenue, 2nd Floor, Hackensack, NJ 07601 or by calling (201) 343-1717 or visiting his website at www.universityorthopaedic.com
Apex Orthopedic Rehabilitation in Paramus, NJ provides orthopedic, spine and sports physical therapy for the greater Ridgewood, Paramus, and Bergen County region. This blog is intended for informational purposes only and should not be used for diagnostic or prescriptive purposes. The views expressed here are the author’s views and should be taken as suggestions. Always consult your doctor or healthcare practitioner before engaging in a physical therapy or rehabilitative program.
by Raphael S. F. Longobardi, MD, FAAOS