Blog article: The Shoulder and Elbow in the Overhead Athlete Part II: Common Shoulder and Elbow Injuries and How To Avoid Them

The Shoulder and Elbow in the Overhead Athlete

Part II: Common Shoulder and Elbow Injuries and How To Avoid Them

In part 1, the biomechanics of each phase of the baseball pitch were reviewed along with forces placed on the shoulder and elbow. It is clear that throwing a baseball is an extremely aggressive and violent act in which extreme forces and ranges of motion are placed on the shoulder and elbow. In part 2 I will review the characteristics of a pitcher, common injuries in these athletes and how you can avoid them.

Physical Characteristics of a pitcher’s dominant arm vs non-dominant arm:

Range of motion disparity

  • dominant shoulder has excessive external rotation and limited internal rotation



  • excessive glenohumeral capsule laxity, which is an acquired laxity from repetitive strain


Osseous adaptations

  • Increase shoulder retroversion (rotated backwards)



  • weak external rotators, strong internal rotators
  • strong scapular protractors and elevators



  • scapula protracted, anteriorly rotated at rest
  • increased scapular upward rotation during abduction of the shoulder


Glenohumeral Internal Rotation Deficit (GIRD)



This develops throughout a season or over years of repeated throwing and is characterized by a significant loss of internal rotation of the shoulder. Many pitchers have a natural loss of internal rotation which is usually off-set by an increase in external rotation range of motion. GIRD becomes an issue when there is a larger loss of internal rotation than there is a gain in external rotation. If not addressed, this puts the athlete at increased risk of developing some of the shoulder injuries that will be discussed below. Also, most pitchers maintain a very similar total range of motion in the dominant and non-dominant shoulders but at times an uncompensated GIRD can lead to differences of 10-15 degrees or more.

As discussed in the previous article, most injuries occur during the late cocking, acceleration and the deceleration phases of the pitch.  To get a better understanding of why these injuries occur during specific phases, review part I to get an idea of the stresses at the shoulder and elbow during each phase.


Late Cocking Phase Injuries

Anterior Glenohumeral Instability. This is an umbrella diagnosis that can include the following:


SLAP Lesions:  Injury to the upper labrum of the shoulder. There are 4 common types. Types II and IV involve the origin of the long head of the biceps. When the biceps anchor is involved there tends to be an increase in shoulder instability. Type II is most commonly seen in the overhead athlete in which the “peel back” forces on the biceps tear the labrum and the biceps anchor.




Bankart Lesion: Injury to the anterior-inferior (front-bottom) part of the labrum. The head of the humerus will translate forward in the shoulder socket due to this injury.



Biceps Long Head Instability: When the shoulder is in the cocked position (90 degrees of abduction and external rotation) the long head of the biceps is placed anteriorly to the head of the humerus. With repetition of this movement and if the athlete has GIRD or a labrum lesion, the biceps tendon takes one excessive strain due to anterior movement of the humeral head. This leads to further instability. It can initially present as tendonitis and develop into tears, ruptures.




Internal Impingement, Subacromial Impingement: Anterior instability leads to compression of the posterior and/or superior rotator cuff tendons. It can also include compression of the superior labrum.




Acceleration Phase Injuries

UCL Injury: Sprain or tear of the ulnar collateral ligament of the elbow due to violent extension, valgus force, pronation and a traction force on the elbow. Athletes usually feel a pop followed by immediate intense pain.




Valgus Extension Overload:  This injury is exclusive to overhead athletes and is caused by repeated forceful hyperextension and valgus stress of the elbow. There is compression of the lateral part and distraction of the medial elbow. This injury is characterized by soft tissue swelling, development of osteophytes (bony overgrowth) in the elbow and at times fractures of the elbow can occur.




Little League Elbow:  This is characterized by the same forces on the elbow seen in valgus extension overload but occurs in preadolescents. It can lead to changes in the growth of the medial epicondyle of the humerus, tears of the wrist flexor tendons or even stress fractures of the humerus growth plates.




Deceleration Phase Injuries: These include all of the acceleration phase injuries along with rotator cuff tendonitis and tears.


So now you know all of the bad things that can happen to your shoulder or elbow with repeated pitching. Did it make you want to do everything that you can to prevent these from happening?…. I hope so.

I am going to go over some things that I do with my patients in therapy, along with our clients at SPI to help decrease their risk of developing one of these shoulder or elbow injuries.


Posterior Shoulder Mobility

As described above, anterior instability leads to many shoulder injuries. That’s why it is extremely important to maintain good mobility and soft tissue quality of the posterior shoulder to prevent excessive anterior movement of the humeral head.


Modified Sleeper Stretch

This works on improving internal rotation and stretching the posterior cuff muscles. The traditional sleeper stretch involves the body and arm being at a 90 degree angle, this however reinforces the compression of the tendons in the shoulder. The modified stretch has the body rotated back at 20-30 degrees to avoid this.


Modified Cross Body Stretch: The athlete stabilizes the scapula on their side and restricts external rotation at the elbow.


Posterior Cuff Mobilization: Using a lacrosse ball the athlete mobilizes the posterior rotator cuff. They can perform circles using their trunk to move while maintaining pressure, they can also perform active shoulder movements.



Thrower’s Ten / Advanced Thrower’s Ten: We utilize these shoulder strengthening programs developed by Kevin Wilk; a sports physical therapist who works with Dr. James Andrews and many MLB players to develop shoulder strength, stability and prevent injury. These exercises strengthen the shoulder while challenging the core by performing most on a stability ball.

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These are just a few examples of what we do. There’s a lot of ways we work on the shoulder and elbow using techniques proven through sports medicine research. I can’t give away all of the goods. I can give you an idea of what else we work on….. CORE AND POSTERIOR CHAIN.

Some tips for decreasing injury risk while training:

1. don’t do overhead presses – they reinforce the shoulder impingement mechanism

2. limit back squats – or if you do back squats, use a safety bar to prevent anterior shoulder strain. I prefer front squats or hip thrusts.

3. limit bench pressing – it “locks down” your shoulder blades. Do pushups instead, there’s a ton of ways to progress pushups to make them more challenging.


What else can you do to help prevent injury?….. don’t throw year round. Nowadays we see athletes playing in leagues for almost the entire year!  This continues to be the number one risk factor for developing injuries.

If you would like to learn more on how you can prevent shoulder and elbow injuries, properly strengthen and stabilize your shoulders and train like the pros then contact

Blog Post – Has Human Performance Passed Human Evolution?

Has Human Performance Passed Human Evolution?


This past weekend I had the opportunity to work along side an Orthopedic Surgeon who specializes in Sports Medicine with more years of experience than he would like me to mention in this blog post. I always look forward to these times as he is a great teacher and I get 3+ hours to pick his brain.

One topic that we spoke of was the rise in shoulder and elbow injuries for baseball players, specifically pitchers. I told him my hypothesis (and not mine alone) that the increase in the velocity of the fast-ball over the past decade and the rise in injuries is a correlation that cannot be ignored. Even with the advancement in injury prevention and pitch count etc. we usually will not see a significant change until the younger generations become of age to sustain a possible injury.

With the emergence of concussions being a significant problem in the media and the rise in shoulder and elbow injuries for major league baseball, one injury that has taken a back seat in recent years are ACL tears.

ACL tears have become a common theme in athletics and specifically female athletics. Female athletes have a 4-6x greater chance of tearing an ACL then their male counterparts and about 1 in 20 female collegiate athletes will undergo an ACL injury.

So why is there not a huge out-cry to stop female athletics like there is to institute pitch count rules or remove hitting in football? Surely these numbers are indicative of an epidemic. One thing is that we have gotten really good at fixing ACL’s and they are not career ending like they were 20 years ago.

fig-3What do we know?

  1. We know that like the ulnar collateral ligament of the elbow there has been a rise in ACL injuries over the past ten years.
  2. We have many theories as to why there is an increase in ACL injury in the male and female athlete but not one thing is certain.
  3. 70% of ACL injuries are non-contact.

Lets take a look at that last statistic. 70% of the injuries are non-contact. Doesn’t that seem a little funny? 30% of the injuries are relatively unpreventable with contact sports being the way they are but 70% come from performing normal athletic activities such as running, cutting and jumping.


So this leads us to the title of this article: Has Human Performance Passed Human Evolution. If a possible reason for the increase in UCL injuries of the elbow is due to the increase in velocity of throwing, is it reasonable to assume that in sports such as football, basketball and soccer where the athletes are getting bigger, faster and stronger has our muscular strength increased so much that our ligaments cannot withstand the stress put on them with athletic activity? And I’m not speaking of a muscular imbalance here. I have some highly skilled and significantly strong athletes who still manage to tear their ACL.

Where do we go from here? Fortunately there is a significant amount of research out there on what works and what doesn’t as far as ACL injury prevention. Our goal at SPI is to implement these specific exercises and training techniques into our programming for our male and female athletes. To find out more information about our ACL injury prevention programs contact us at for us to speak to your organization and show you how to implement these exercises to reduce risk of injury.

Blog Article – The Shoulder and Elbow in the Overhead Athlete: Part I

The Shoulder and Elbow in the Overhead Athlete

Part I: Basic Anatomy and Biomechanics of Throwing

The world series might be coming to an end but now is the time where high school and college baseball players can make big impacts on their upcoming season. Doing the right things now for your shoulder, arm and body can help make or break your season. As they say, “championships are won in the off-season”. But that is something I will talk about in my next post “Part II: Common shoulder and elbow injuries and how to avoid them”.

In part 1, I want to talk about the biomechanics of the throwing motion, most specifically in the pitcher. Throwing a baseball has been described as “one of the most violent maneuvers to which any joint in the body is subjected”. Throwing a baseball requires flexibility, muscular strength, coordination, synchronicity and neuromuscular control.

Here’s examples of the incredible stress and forces that are placed on your shoulder and elbow while pitching.

Angular velocity:                  Forces:
Shoulder – up to 7250º/s              Shoulder – 1/2 to 1-1/2 body weight
Elbow – up to 2300º/s                   Elbow – 300 N to 900 N


Before we go into the biomechanics of throwing let’s briefly review the shoulder or as us fancy medical people call it, the glenohumeral joint:



The shoulder is the most mobile joint in the body and therefore is inherently unstable. It has static and active stabilizers. Static Stabilizers – ligaments, labrum, capsule. Active stabilizers – rotator cuff, large muscles (deltoid, serratus anterior, biceps, pectorals).



UnknownStabilizers throughout the pitching cycle:

Mid range – rotator cuff

End range – large muscles, ligaments and capsule

Extreme ranges – ligaments, capsule




The elbow:

Made upd1d21e74605b7e0a2e2c9e26e0cce941 of bony, ligamentous and muscular stabilizers. The most famous ligament stabilizer is the ulnar collateral ligament or the UCL. This is the ligament that we are seeing more injuries in, resulting in Tommy John surgery. Some muscular stabilizers are the triceps and wrist flexors.

The UCL31216tn



Phases of Throwing a Baseball:




        Windup and Early Cocking:img_1247

  •    Ball leaves glove, arm moves into abduction/external rotation
  • Pre-loading for stretch-shortening cycle of shoulder internal rotators
  • Leg drive, trail leg loading, trunk rotation



Late Cocking Phase:wagner-300x199

  • Maximal external rotation, abduction
  • Initial trail leg hip extension
  • Extreme forces at shoulder
  • Minimal forces at elbow
  • Onset of large shoulder muscle activation
  • High rotator cuff activation attempting to stabilize the shoulder


Acceleration Phase:


  • Explosive forward motionimages
  • 0 – up to 100 mph in 0.03 seconds
  • Loading of lead leg
  • Abrupt, vigorous extension and pronation at elbow
  • High activation of rotator cuff and all scapular muscles
  • High activity of pectorals and lats for ball velocity
  • High forces at elbow
  • Low forces at shoulder



Deceleration Phase:

  • Release off ball, forward motion ceasespitching-arm-strength-drills-01
  • Most violent phase
  • High injury risk
  • Highest forces at shoulder, up to 1000N
  • High forces at elbow up to 900N
  • Very high muscle activity



As you now can see, throwing a baseball is a very aggressive action that can put you at high risk of injury if you don’t do the right things to care for your shoulder and body as a whole. In my next post I will cover some characteristics of the baseball pitcher, common injuries and how we help our athletes decrease their risk of injury during the season (hint: it’s not stretching your already hyper-mobile shoulder).

If you want to learn more about the shoulder, elbow, how to make them stronger and decrease your risk of injury email