Shoulder and Elbow Problems
Experience indicates a direct relationship between the number of pitches thrown or time spent swimming a week and shoulder or elbow pain. The amount of stress that is applied to a given area is cumulative. For any of us the risk of injury increases with an increased workload. This is especially true for children. Specific recommendations regarding age and number of pitches thrown or frequency and duration of swimming have been developed (Tables 1 and 2) and should be followed precisely. All pitches or meters count, whether in games or competition, in practice, playing with friends, or in private lessons.
Pitching recommendations for
young baseball players91 +/- 16
Progressive development of the swimmer
wk of 20-60 min
and technique
wk of 45-60 min
wk of 60-90 min
strokes over various distances
wk of 90-120 min
Because the throwing motion involves both the shoulder and elbow, there may be elbow problems in shoulder injuries and shoulder problems in elbow injuries. Remember that shoulder and elbow pain are not limited to pitchers. Other high-volume throwing positions include catcher and shortstop. Be extremely suspicious of injury in a pitcher who plays these other positions when not on the mound.
The goal of exercise is to apply repetitive submaximal loads to connective tissue, muscle, and bone to build strength and endurance. Because the beneficial aspects of exercise actually take place during the recovery phase, adequate rest is essential to allow tissue to adapt and undergo further activity without injury. Patients should have at least two full rest days a week, with a minimum of two rest days immediately after a pitching performance. This advice may be contrary to participation in weekend tournaments-staples of youth sports in which athletes are often required to perform several times in a two- or three-day period.
Excessive demand and insufficient recovery result in tissue microtrauma with release of vasoactive substances, inflammatory cells, and enzymes that create clinical symptoms of pain, weakness, and diminished range of motion.3 In overhead sports, too much activity leads to fatigue of the supporting rotator cuff muscles, allowing for increased movement of the humeral head within the shoulder joint.
In early phases of overuse, pain is vague and noted only with activity. Further progression leads to more sharp, localized pain during activity and at rest (Table 3). Besides pain, signs of shoulder or elbow weakness include decreased accuracy, endurance, and throwing velocity. Technical errors such as "dropping the elbow" during the acceleration phase of throwing or the out-of-water recovery and catch phases of freestyle swimming can also lead to fatigue of rotator cuff muscles.
Functional classification of pain
not restricting performance
restricting performance
Because of the valgus stresses placed on the elbow in throwing motion, athletes under 14 years of age, who have immature ligament and tendon attachments to the medial epicondyle apophysis, are at greater risk of injury than older athletes. Growth of the longitudinal bone occurs sooner than that of ligament, muscle, or tendon, creating an imbalance that places undue stress on the immature cartilage of these apophyseal attachment sites.In summary, for all athletes, especially the young, skeletally immature, it is important to be aware of the potential for the sports that favor shoulder movement to cause overuse problems and to customize each exercise or sport program to the individual participant.