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What the Sports Medicine Specialist Must Know About Throwing Athletes

You've probably seen the speed of some animals on TV shows. The smooth, sleek cheetah has been clocked at 60 to 70 miles per hour. The large, sturdy bison can run 40 miles per hour -- and get up to that speed in a matter of minutes. But do you know what's the fastest recorded human movement? The throwing arm of athletes like quarterbacks, softball players, and tennis players. It's true!

And guess what comes with throwing a ball forward 70 to 90 miles per hour over and over and over? Stress on the shoulder, microtrauma of the soft tissues, and changes in alignment and position of the entire shoulder complex. Specialists in the world of sports medicine must be on their toes to recognize problems early and intervene to prevent injuries.

In this article, the clinical examination for the overhead throwing athlete is reviewed. Details of the athlete's history, shoulder and arm range of motion, and condition of the joint movement are presented. Changes in the position of the scapula (shoulder blade) that come about after 100s and even 1000s of throws are discussed. These are normal adaptive changes, not necessarily pathologic changes but they do affect how the shoulder moves and functions.

The authors provide tests to assess joint laxity (looseness), scapular position, muscle strength, and proprioception (joint sense of position). Photos showing the examiner performing each test are provided. A special section on testing for rotator cuff injuries and labral tears is also offered.

This review is designed to help sports specialists working with overhead throwing athletes recognize variations from normal movement and function that naturally occur after months of training and competition. Recognizing acute (short-term) and chronic (long-term) changes and adaptations that occur help the examiner narrow down what puts the athlete at risk for injury and what's protective. We'll talk more about this in a little bit.

Pain while throwing is the most common physical complaint reported by athletes when something is wrong. The pain may have started with a specific throw but it's most likely the result of a problem that has progressed and gotten worse over time. Often the athlete isn't even fully aware that something is happening until a major problem develops.

The careful examiner takes into consideration everything the athlete says about how he or she thinks the injury occurred. But asking questions like, What phase of the throw brings on the most symptoms? can help isolate the soft tissue structures involved. For sports medicine specialists, seeing an athlete lose speed of pitch, serve, or throw is a yellow (caution) flag. Hearing athletes say they can't get loosened up or it takes much longer to warm up are additional red (warning) flags.

At that point, it's time to take a look at the athlete's range-of-motion and throwing pattern. The clinician will look for strength imbalances, loss of soft tissue flexibility and/or loss of motion, muscle weakness, and changes in joint stability. Assessment of movement may reveal alterations in throwing mechanics that could translate into injury.

Most overhead throwing athletes end up with too much shoulder motion in external (outward) shoulder rotation and a loss of flexibility in internal (inward) rotation. Joint laxity (excess motion) can be a big problem, especially for the athlete who started out with pretty loose joints to begin with. But joint laxity is one problem that may be prevented with the proper stretching and strengthening program.

More recently, attention has been brought to the importance of scapular position and movement. Even a small amount of abnormal tilt of the shoulder blade can affect how the shoulder muscles contract to move the arm. Studies have documented a loss in shoulder muscle strength linked with a scapula that is forward-tilted and protracted (slid forward over the trunk). A special tool called an inclinometer can be used to test the position of the scapula and measure its rotation.

Once an injury has occurred, the sports specialist conducts special tests to find out what's going on. Is it a bursitis? Rotator cuff tear? Impingement (pinching) of a tendon? Certain positions of the shoulder/arm relax some soft tissues while tightening others. Finding positions of comfort and discomfort help identify what might be affected.

Tests to detect a rotator cuff tear include the relocation test and internal impingement tests such as the Neer test or the Hawkins impingement test. Superior labral injuries are more difficult to diagnose because the athlete often has a rotator cuff tear (partial or full) along with a superior labral tear from anterior to posterior (SLAP). A SLAP injury is a front to back tear of the labrum, a rim of cartilage around the shoulder joint.

There are many tests used to identify a SLAP lesion. Most are familiar to sports medicine experts but two new tests including the pronated load test and the resisted supination external rotation test may be less familiar. These two tests use positioning of the shoulder and forearm along with muscle contraction to place tension on the labrum and reproduce the patient's symptoms. The tests are described with photos of an examiner performing the tests on an athlete.

Orthopedic surgeons, physical therapists, athletic trainers, and other sports medicine specialists will find this article informative and helpful when examining and training overhead throwing athletes. There's plenty of good information to help these specialists evaluate athletes in an effort to prevent injuries and then recognize and treat them when they do occur. These athletes can present a very complex challenge to the best of sports medicine's experts!

References: Michael M. Reinold, PT, DPT, ATC, CSCS, and Thomas J. Gill, MD. Current Concepts in the Evaluation and Treatment of the Shoulder in Overhead Throwing Athletes: Part 1: Physical Characteristics and Clinical Examination. In Sports Health. January-February 2010. Vol. 2. No. 1. Pp. 39-50.

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