Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach
- Craig Young, MD
Craig Young, MD
- Professor of Orthopaedic Surgery and Family and Community Medicine
- Medical College of Wisconsin
- Section Editors
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Joseph Chorley, MD
Joseph Chorley, MD
- Section Editor — Pediatric Sports Medicine; Adolescent Sports Medicine
- Associate Professor of Pediatrics, Adolescent Medicine, and Sports Medicine
- Baylor College of Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Millions of people throughout the world participate in sports that involve throwing or throwing-like movements. These movements range from classic ball throwing, as performed by baseball pitchers or cricket bowlers, to throwing implements other than balls, such as a javelin, to throwing-like actions that do not involve a ball directly, such as a tennis serve or volleyball spike. All such movements involve complex biomechanics and great stresses being placed on the musculoskeletal system. Improper biomechanics, excessive stress beyond the capacity of an individual's musculoskeletal system, or cumulative trauma from throwing too frequently can cause injury. Differences in the mechanics of non-classic throwers make such athletes susceptible to other injuries not discussed in this topic.
The clinical presentation of throwing related injuries and an approach to diagnosing them are reviewed here. Throwing biomechanics, treatment of specific injuries, and physical examination of the shoulder are discussed separately. (See "Throwing injuries: Biomechanics and mechanism of injury" and "Physical examination of the shoulder".)
PRESENTATION, EXAMINATION, AND RADIOGRAPHIC FINDINGS OF SPECIFIC INJURIES
Shoulder injuries — Specific shoulder injuries incurred by the throwing athlete are described below, but the clinician should keep in mind that the structures described here are intimately related and more than one may be involved in producing shoulder pain in the throwing athlete. With repetitive throwing, a number of anatomic adaptations develop that can produce pathologic changes in movement, ultimately resulting in structural damage. Key findings for common and important throwing injuries of the shoulder and elbow are summarized in the following table (table 1).
Repetitive throwing causes increased proximal humeral retroversion that manifests as increased shoulder external rotation and decreased internal rotation. With repetitive microtrauma, beyond the athlete's ability to heal, proximal humeral epiphysiolysis (stress fracture or Little League shoulder) can develop.
Decreased internal rotation is caused by tightening of the posterior capsule and muscular tightness over time. Once the total loss of motion exceeds 20 degrees (loss of internal rotation far exceeds gains due to increased external rotation), some secondary anterior translation of the humeral head will occur during the cocking phase. The result is "Dead arm syndrome" and internal impingement involving pinching of the posterior capsule and labrum. Prolonged tension on the posterior inferior glenohumeral ligament and/or repetitive pinching of the posterior inferior labrum and glenoid can cause a Bennett lesion.
- Burkhart SS, Morgan CD, Kibler WB. Shoulder injuries in overhead athletes. The "dead arm" revisited. Clin Sports Med 2000; 19:125.
- Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics. Arthroscopy 2003; 19:404.
- Rowe CR. Recurrent transient anterior subluxation of the shoulder. The "dead arm" syndrome. Clin Orthop Relat Res 1987; :11.
- Simão MN, Nogueira-Barbosa MH, Muglia VF, Barbieri CH. Anterior shoulder instability: correlation between magnetic resonance arthrography, ultrasound arthrography and intraoperative findings. Ultrasound Med Biol 2012; 38:551.
- Magnusson L, Kälebo P, Baranto A, et al. The value of ultrasonography in the preoperative diagnostic evaluation of patients with recurrent anterior shoulder dislocation: a prospective study of 44 patients. Knee Surg Sports Traumatol Arthrosc 2007; 15:649.
- Brookham RL, McLean L, Dickerson CR. Construct validity of muscle force tests of the rotator cuff muscles: an electromyographic investigation. Phys Ther 2010; 90:572.
- Lesniak BP, Baraga MG, Jose J, et al. Glenohumeral findings on magnetic resonance imaging correlate with innings pitched in asymptomatic pitchers. Am J Sports Med 2013; 41:2022.
- Miniaci A, Mascia AT, Salonen DC, Becker EJ. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med 2002; 30:66.
- Abrams GD, Safran MR. Diagnosis and management of superior labrum anterior posterior lesions in overhead athletes. Br J Sports Med 2010; 44:311.
- Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003; 19:531.
- Raasch WG. Baseball. In: Netter’s Sports Medicine, Madden CC, Putukian M, Young CC, McCarty EC (Eds), Saunders, Philadelphia 2010. p.546.
- Moore-Reed SD, Kibler WB, Sciascia AD, Uhl T. Preliminary development of a clinical prediction rule for treatment of patients with suspected SLAP tears. Arthroscopy 2014; 30:1540.
- Tokish JM, Curtin MS, Kim YK, et al. Glenohumeral internal rotation deficit in the asymptomatic professional pitcher and its relationship to humeral retroversion. J Sports Sci Med 2008; 7:78.
- Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med 2011; 39:329.
- Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in Glenohumeral Passive Range of Motion Increase Risk of Shoulder Injury in Professional Baseball Pitchers: A Prospective Study. Am J Sports Med 2015; 43:2379.
- Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: a prospective study. Am J Sports Med 2014; 42:2075.
- Wright RW, Paletta GA Jr. Prevalence of the Bennett lesion of the shoulder in major league pitchers. Am J Sports Med 2004; 32:121.
- Yoneda M, Nakagawa S, Hayashida K, et al. Arthroscopic removal of symptomatic Bennett lesions in the shoulders of baseball players: arthroscopic Bennett-plasty. Am J Sports Med 2002; 30:728.
- Ramappa AJ, Chen PH, Hawkins RJ, et al. Anterior shoulder forces in professional and Little League pitchers. J Pediatr Orthop 2010; 30:1.
- Osbahr DC, Kim HJ, Dugas JR. Little league shoulder. Curr Opin Pediatr 2010; 22:35.
- Heyworth BE, Kramer DE, Martin DJ, et al. Trends in the Presentation, Management, and Outcomes of Little League Shoulder. Am J Sports Med 2016; 44:1431.
- Murachovsky J, Ikemoto RY, Nascimento LG, et al. Does the presence of proximal humerus growth plate changes in young baseball pitchers happen only in symptomatic athletes? An x ray evaluation of 21 young baseball pitchers. Br J Sports Med 2010; 44:90.
- Pai DR, Thapa M. Musculoskeletal ultrasound of the upper extremity in children. Pediatr Radiol 2013; 43 Suppl 1:S48.
- Burkhart SS, Morgan CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation. Arthroscopy 2003; 19:641.
- Myers JB, Oyama S, Rucinski TJ, Creighton RA. Humeral retrotorsion in collegiate baseball pitchers with throwing-related upper extremity injury history. Sports Health 2011; 3:383.
- Petty DH, Andrews JR, Fleisig GS, Cain EL. Ulnar collateral ligament reconstruction in high school baseball players: clinical results and injury risk factors. Am J Sports Med 2004; 32:1158.
- Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med 1995; 23:233.
- Aguinaldo AL, Chambers H. Correlation of throwing mechanics with elbow valgus load in adult baseball pitchers. Am J Sports Med 2009; 37:2043.
- Anz AW, Bushnell BD, Griffin LP, et al. Correlation of torque and elbow injury in professional baseball pitchers. Am J Sports Med 2010; 38:1368.
- Werner SL, Fleisig GS, Dillman CJ, Andrews JR. Biomechanics of the elbow during baseball pitching. J Orthop Sports Phys Ther 1993; 17:274.
- Sabick MB, Torry MR, Lawton RL, Hawkins RJ. Valgus torque in youth baseball pitchers: A biomechanical study. J Shoulder Elbow Surg 2004; 13:349.
- Fleisig GS, Barrentine SW, Zheng N, et al. Kinematic and kinetic comparison of baseball pitching among various levels of development. J Biomech 1999; 32:1371.
- Fleisig GS, Weber A, Hassell N, Andrews JR. Prevention of elbow injuries in youth baseball pitchers. Curr Sports Med Rep 2009; 8:250.
- Safran MR, McGarry MH, Shin S, et al. Effects of elbow flexion and forearm rotation on valgus laxity of the elbow. J Bone Joint Surg Am 2005; 87:2065.
- O'Driscoll SW, Lawton RL, Smith AM. The "moving valgus stress test" for medial collateral ligament tears of the elbow. Am J Sports Med 2005; 33:231.
- Ciccotti MG, Atanda A Jr, Nazarian LN, et al. Stress sonography of the ulnar collateral ligament of the elbow in professional baseball pitchers: a 10-year study. Am J Sports Med 2014; 42:544.
- Smith W, Hackel JG, Goitz HT, et al. Utilization of sonography and a stress device in the assessment of partial tears of the ulnar collateral ligament in throwers. Int J Sports Phys Ther 2011; 6:45.
- Ahmad CS, Park MC, Elattrache NS. Elbow medial ulnar collateral ligament insufficiency alters posteromedial olecranon contact. Am J Sports Med 2004; 32:1607.
- Osbahr DC, Dines JS, Breazeale NM, et al. Ulnohumeral chondral and ligamentous overload: biomechanical correlation for posteromedial chondromalacia of the elbow in throwing athletes. Am J Sports Med 2010; 38:2535.
- Dugas JR. Valgus extension overload: diagnosis and treatment. Clin Sports Med 2010; 29:645.
- Ahmad CS, ElAttrache NS. Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med 2004; 23:665.
- Furushima K, Itoh Y, Iwabu S, et al. Classification of Olecranon Stress Fractures in Baseball Players. Am J Sports Med 2014; 42:1343.
- Radunovic G, Vlad V, Micu MC, et al. Ultrasound assessment of the elbow. Med Ultrason 2012; 14:141.
- Benjamin HJ, Briner WW Jr. Little league elbow. Clin J Sport Med 2005; 15:37.
- Wei AS, Khana S, Limpisvasti O, et al. Clinical and magnetic resonance imaging findings associated with Little League elbow. J Pediatr Orthop 2010; 30:715.
- Alla VM, Natarajan N, Kaushik M, et al. Paget-schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med 2010; 11:358.
- Kibler WB, Wilkes T, Sciascia A. Mechanics and pathomechanics in the overhead athlete. Clin Sports Med 2013; 32:637.
- Kibler WB, Press J, Sciascia A. The role of core stability in athletic function. Sports Med 2006; 36:189.
- PRESENTATION, EXAMINATION, AND RADIOGRAPHIC FINDINGS OF SPECIFIC INJURIES
- Shoulder injuries
- - Transient subluxation ("Dead arm syndrome")
- - Rotator cuff injuries
- - Labral tears
- - Glenohumeral internal rotation deficiency (GIRD)
- - Bennett lesion
- - Proximal humeral epiphysiolysis (Little League shoulder)
- - SICK scapula syndrome and scapular dyskinesis
- Elbow injuries
- - Ulnar collateral ligament (UCL) injury
- - Common flexor tendon sprain
- - Valgus extension overload (VEO) syndrome
- - Olecranon stress fracture
- - Triceps tendinopathy
- - Ulnar neuropathy
- - Osteochondrosis of elbow (panners disease)
- - Osteochondral defect of the elbow
- - Little League elbow
- Axillary-subclavian vein thrombosis
- Summary of key findings for major throwing injuries
- DIAGNOSTIC IMAGING
- Additional ultrasound resources
- INDICATIONS FOR ORTHOPEDIC CONSULT OR REFERRAL
- PHYSICAL EXAMINATION
- STEPWISE CLINICAL APPROACH
- Shoulder problems
- Elbow problems
- SUMMARY AND RECOMMENDATIONS