Guest Post by:
Shane K. Woolf, M.D.
Associate Professor of Orthopaedics and
Chief of Sports Medicine
MUSC

After a busy Friday in the operating room treating rotator cuff tears, among other orthopaedic injuries, I had a welcome opportunity for a fun and relaxing evening out with family. My wife and I took our daughter to her very first baseball game! We sat along the third base line watching our local minor league ball club, the Charleston Riverdogs, earn a win, and throughout the evening we enjoyed boiled peanuts, pretzels, and brats. Despite her tender young age, our baby girl seemed to really enjoy the sights, sounds, and action of the game, both on and off the field.

Yet, for me, the thrill of an exciting ballgame on a comfortable and breezy evening was punctuated by other thoughts. While I observed the players in action, I could not help but to consider the types of injuries and problems that I see every day in my orthopaedic clinic. As my family sat there taking in the ballpark experience together, I pointed out the relief pitcher warming up directly in front of us. The windup and throwing mechanism is a fascinating athletic accomplishment. Rotation of the pitcher’s shoulder during a pitch is considered the fastest motion of any human joint in sports. Remarkable! And also stressful to the bones, cartilage and tissues of the shoulder. While, certain sports can be prone to injuries of one joint or another, baseball, in particular, is known for issues with the shoulder. While injury can happen during lower velocity and distance throws, sliding into base, getting hit by a pitch, or colliding with another player, it is the repetitive action of throwing that places the majority of the high velocity throwers, like the relief pitcher we were observing, at risk for shoulder problems. This is due, in part, to the fact that the soft tissues of the shoulder have a biologic limit to the degree of force and stress they can tolerate before damage, or even rupture, occurs. Here are some important principles for the aspiring high-velocity thrower to consider:

Conditioning First:
Keeping the joint limber and muscles strong are essential to achieving optimal athletic performance. Just like a car transmission, plane engine or other high-performance device, these tissues require maintenance, proper tuning, and occasional repair. During the off-season, spring training and throughout the year, high level throwers work hard to maintain the health of their throwing mechanics. This includes focus on strengthening the core and back, hips, and shoulder musculature. The rotator cuff, a sleeve of 4 tendons responsible for actively stabilizing the shoulder joint during motion as well as initiating rotational motion of the joint, is especially important. Poor rotator cuff performance can slow velocity, but also can place the shoulder labrum, basically a gasket around the socket, at risk for injury. The biceps can be at risk as well. The muscles of the upper back that stabilize the shoulder blade also have a key role in facilitating a fast, accurate pitch. The hips and back, if neglected, can derail a pitchers mechanics. Strength training, therabands, and core exercises form the foundation for a strong pitch. Warming up before games/practice is an important part of the high level thrower’s routine as well.

Flexibility:
Most, if not all, trainers with professional and college level teams teach shoulder specific stretches and exercises meant to maintain a limber joint and to allow the humeral head (ball) to rotate freely without constraint on the glenoid cavity (socket). The ‘sleeper stretch’ and cross body stretch are thought to help maintain a compliant and forgiving posterior shoulder joint capsule. Without some flexibility of the shoulder joint, range of motion is subtly limited, and higher stresses on the rotator cuff and labrum are seen. Stretching is prophylactic – meant to decrease the chances of injury during the season.

Optimize Technique:
Arm position, body angle during the throw, and orientation of the lead foot are each important factors in preventing injury. Failure of throwing mechanics can place significantly great stresses on the tissues around the shoulder and lead to higher risk for pain or injury. For younger athletes, another important consideration is to avoid pitches like the slider, forkball, and knuckleball until mid to late teen years given the additional stresses on growing bones and developing muscles that these complicated pitches can induce.

Respect the Value of Rest:
As you might imagine, such high stresses on the shoulder can lead to micro-tears and small areas of muscle or tendon injury. For the most part, a well-conditioned athlete can heal quickly and recover to throw at a high level again in just a short period of time. But, proper rest is the key to allowing the body a chance to mend between outings. Thus, 1-3 days of rest from throwing is recommended depending upon pitch counts. And on that topic, youth throwers need to be mindful of the number of pitches thrown, which directly correlates with injury risk. As the young body matures, an increasingly higher number of pitches can be tolerated, but still needs to be monitored. Off-season rest from throwing, and in-season limits on showcase/all-star pitching, are also considered vital to maintaining healthy shoulders. Not uncommonly, I see young pitchers with shoulder pain who enthusiastically talk about pitching in multiple leagues, playing all year, pitching showcase games, and throwing way more than the recommended number of pitches per outing. Sadly, given a higher risk of injury or burnout, it is less likely that these aspiring, over-pushed athletes will ever get a chance to warm up in front of a family like mine or take the mound at a professional ballpark.