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
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.
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- 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