A practical guide to shoulder injuries in the throwing athlete

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Applied Evidence

A practical guide to shoulder injuries in the throwing athlete

J Fam Pract. 2013 April;62(4):175-180

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References

1. Altcheck DW, Dines DM. Shoulder injuries in the throwing athlete. J Am Acad Orthop Surg. 1995;3:159-165.

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5. Riand N, Boulahia A, Walch G. Posterosuperior impingement of the shoulder in the athlete: results of arthroscopic debridement in 75 patients. Rev Chir Orthop Reparatrice Appar Mot. 2002;88:19-27.

6. Bottoni CR, Smith EL, Berkowitz MJ, et al. Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized controlled trial. Am J Sports Med. 2006;34:1730-1737.

7. Burkhart SS, Morgan CD. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy. 1998;14:637-640.

8. Glascow SG, Bruce RA, Yacobucci GN, et al. Arthroscopic resection of glenoid labral tears in the athlete: a report of 29 cases. Arthroscopy. 1992;8:48-54.

9. Altcheck DW, Warren RF, Wickiewicz TL, et al. Arthroscopic labral debridement: a three-year follow-up study. Am J Sports Med. 1992;20:702-706.

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Rotator cuff tears
What you’ll see. Partial-thickness, articular-sided tears of the supraspinatus, infraspinatus, or both—found posterosuperiorly at the posterior rotator interval—are common in throwing athletes. The patient may complain of weakness when trying to do overhead tasks or movements requiring shoulder abduction. The supraspinatus is usually the muscle affected, and so testing of this muscle with the “empty can test” will show pain with weakness if there is a tear. However, full-thickness rotator cuff tears are rare;³ consider a diagnosis of instability or a partial tear in such cases. An MRI can reveal a rotator cuff tear. In fact, the imaging may be necessary for any suspicion of a tear in an athlete.

FAST TRACK

Full-thickness rotator cuff tears are rare; consider a diagnosis of instability or a partial tear instead.

Treatment. Recommend strengthening exercises to patients before considering surgery. Nonoperative treatment is preferred, and should be given a fair trial before surgery; studies have not consistently supported the operative approach to rotator cuff tears.^5,15 However, if conservative management fails, arthroscopic debridement of torn tissues is recommended over open procedures.³

Scapular dyskinesis and “SICK syndrome”
What you’ll see. Poor development of, or fatigue in, the scapular stabilizers leads to scapular dyskinesis (poor scapular control and motion). Scapulothoracic dyskinesis can progress to an overuse muscular fatigue syndrome called the “SICK syndrome” (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement).¹⁶ The most common symptoms include anterior shoulder pain, posterior/superior scapular pain with or without radiation,¹⁶ and a “dead arm” sensation. If not treated, this can result in rotator cuff lesions, impingement, and labral pathology.

Treatment. Both treatment and prevention are dependent on the proper biomechanics to retract and rotate the scapula correctly during throwing.¹ Strengthening the scapular stabilizers and stretching tight posterior structures help to promote proper biomechanics, and enable a successful return to throwing.¹⁴

Help patients prevent injuries in the first place

To reduce the risk of shoulder injuries, athletes need to maintain an appropriate “thrower’s motion” at the glenohumeral joint.¹⁷ Overhead throwing athletes often exhibit excessive external rotation in their dominant shoulders,¹⁸ while internal rotation is reduced.¹⁹

Frequent gentle stretching may help maintain equal total motion in both the throwing shoulder and the nondominant shoulder. However, warn patients to avoid overaggressive stretching to gain mobility; the goal should be to maintain mobility.¹⁷

FAST TRACK

Warn patients to avoid overaggressive stretching to gain mobility.

Strengthening of the entire upper extremity (shoulder, scapula, elbow, and wrist) is essential. While the individual needs of each athlete must be addressed, electromyographic studies of the throwing motion suggest that stretching, strengthening, and retraining of the muscles that allow the shoulders to rotate upwards and backwards help the shoulder blade keep close to the rib cage at the back. These are the most important initial steps in rehabilitating shoulder injuries in a throwing athlete.

Prevention and treatment programs for the throwing athlete should always incorporate dynamic stabilization and neuromuscular control.¹⁷ Additionally, the transfer of kinetic energy, as well as proximal stability with distal mobility of the upper extremity, are enhanced by core stabilization drills, including planks and side planks, as well as lower body training. As such, core strengthening is a very important component of injury prevention exercise regimens for throwing athletes.

FAST TRACK

Core strengthening is a very important component of injury prevention exercise regimens for throwing athletes.

Lastly, throwing programs incorporating maximum pitch counts per day, rest days, and gentle throwing are key to injury prevention. Direct young throwing athletes and their parents to resources such as http://pediatrics.aappublications.org/content/129/3/e842.full.pdf+html. (Tell them to see the recommendations at the end of the document.) Keep in mind, however, that there are no clear recommendations for college and professional pitching.

Young athletes. It is important to note that athletes with immature skeletons are at particular risk of injury due to the relative weakness of the open growth plate and the development of muscle imbalance. It is essential to appropriately apply the principles discussed here to young athletes to prevent injury.

CORRESPONDENCE
George Guntur A. Pujalte, MD, Penn State Milton S. Hershey Medical Center, 500 Hershey Center Drive, Hershey, PA 17033; gpujalte@hmc.psu.edu