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Throwing injuries of the upper extremity: Clinical presentation and diagnostic approach

Craig Young, MD
Section Editors
Karl B Fields, MD
Joseph Chorley, MD
Deputy Editor
Jonathan Grayzel, MD, FAAEM


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".)


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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Literature review current through: Dec 2017. | This topic last updated: Jun 28, 2016.
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