Arm soreness plagues far too many young athletes throughout the season and I would like to provide some information on how to prevent and address arm soreness. Any information provided here does not substitute for a comprehensive assessment performed by a qualified professional such as a doctor, physical therapist, or athletic trainer.
Throwing Mechanics
Before diving into arm care techniques, I strongly believe it is imperative to address an athlete’s throwing mechanics in the beginning of the season and when they present with elbow or shoulder soreness throughout the season. Improper throwing mechanics can not only cause accuracy issues and a decrease in velocity, but it can lead to injury very quickly. Throwing a ball, like hitting, is a sequence of transferring kinetic energy from the foot to the hand. It’s extremely important to take the time and check an athlete’s mechanics from the ground up. While the following is not an extensive list, these are key factors that can lead to arm soreness or injury:
Reduced stride length
Improper foot alignment of the front foot
Front leg knee flexion or lack of extension
Insufficient hip internal rotation of the back leg
Poor pelvis and trunk rotation or improper timing of the rotation
Excessive shoulder horizontal abduction in cocking phase
Decreased shoulder external rotation in the cocking phase
Decreased elbow flexion in cocking
Leading with elbow
Improper follow through
If a mechanical flaw is detected, it should be addressed immediately to reduce the risk of injury. Throwing mechanics of each athlete should continually be addressed throughout the entire season. Sometimes an athlete can have perfect mechanics, but still present with soreness or pain; therefore an arm care program should be followed during the season.
Shoulder Anatomy
I would like to give you a brief overview of what happens with the shoulder when an athlete throws a ball. While throwing a ball requires the whole body to do it properly, there are several upper extremity muscles that are involved in throwing. In order to get the arm in the proper cocking position, the shoulder must abduct (deltoid, supraspinatus), externally rotate (supraspinatus, infraspinatus, teres minor), and horizontally abduct (deltoid, teres minor, infraspinatus) while the scapula upwardly rotates and posteriorly tilts (serratus anterior, traps), retracts (rhomboids, mid traps) and the elbow flexes (bicep). During the cocking phase the thoracic spine is rotatingand extending to create a better lay back position and create more hip and shoulder separation. To accelerate through the throwing motion and release the ball, the shoulder must forcefully internally rotate (pectoralis major, latissimus, teres major, subscaburalis) and adduct (pec major, latissimus). The scapula must protract (serratus anterior, pec minor) while the elbow rapidly extends(triceps), at velocities up to 7000° per second at the shoulder and 2500° per second at the elbow. After ball release distraction forces up to one and a half times the athlete’s body weight can be applied to the shoulder complex.
It is imperative to have proper throwing mechanics in the upper and lower body to decrease the amount of stress put on the shoulder and elbow. The posterior rotator cuff muscles and the bicep are often eccentrically stressed during the deceleration phase of throw because they are forced to slow down up to 7000° of internal rotation. This action occurs with every throw. For some pitchers and catchers, that can be up to a hundred times in a day.
Now that you have a brief idea of whats happening in the shoulder during a throw, the rest of this post is going to address strategies to keep your arm healthy.
While arm care programs truly begin in the off season, for this post they start with a proper warmup. I cannot stress the importance of a proper warm up enough. Way to often I see kids run right out onto the field and jump right in to the throwing the ball or I see them do a couple static shoulder stretches and then throw the ball. If you don’t spend the 10 -15 minutes to warm up effectively you are going to spend a lot more time on the injured list . The warm up should not just focus on the arm but the whole body. However, for today’s post I am going to focus on the arm portion of the warm up, I will discuss the full dynamic warm up at another time.
Soft Tissue Management
Trigger points and adhesions are developed over time in the front and back of the shoulder, as well as the neck. Restrictions are often found in the internal rotators and shoulder adductors because of the forceful rotation and adduction that occur during the acceleration phase of the throw. As the season progresses, throwing athletes will see a decrease in internal rotation range of motion and an increase in external rotation because the structures of the anterior capsule of the shoulder begin to loosen. A decrease in internal rotation may be due to tightness in both pectoralis major and minor, latissimus, teres major, and subscapularis. The posterior rotator cuff muscles in most throwers tend to get fatigued and tight from having to concentrically externally rotate and eccentrically control rapid internal rotation after ball release. Trigger points may be found in these muscles because of the constant stress applied to them. The bicep, especially the long head, is sometimes forced to become an anterior stabilizer in the cocking phase and must resist the distraction forces applied to the shoulder and elbow after ball release. Added stress on the biceps may lead to SLAP tears and anterior instability related injuries. Over the course of the season the lat can become overused, stiff and develop trigger points. Lat strains from overuse and lat dominance are predominantly seen in more experienced throwers. Lat stiffness and trigger points can be seen in all ages. Lat stiffness will decrease shoulder flexion which will impair movement quality of the shoulder complex and can eventually lead to injury. Trigger points in the lats can refer pain to the medial border of shoulder blade, posterior shoulder, and medial aspect of triceps into the ring and pinky fingers. Trigger points can also create numbness and tingling as well as disrupt shoulder muscles from activating correctly which may create compensation patterns in the shoulder complex.
Trigger points or adhesions can restrict movement, increase risk of injury and refer pain throughout the arm. Applying soft tissue management strategies can help decrease the frequency of trigger points, make the arm feel better and reduce the risk of injury. Soft tissue work should be incorporated into a warm up and used as a recovery strategy after an athlete throws.
The gold standard of soft tissue care is treatment by a manual therapist, but most youth and high school athletes do not have access to a manual therapist every day. Learning how to manage your soft tissue quality on your own can be very beneficial in keeping your arm healthy throughout the season. Soft tissue management can be done with a variety of tools, the most effective being a lacrosse ball and foam roller. If you don’t have access to a lacrosse ball or roller, you can use a baseball, softball, or even a bat.
When soft tissue techniques are used in a warm up, the focus should be on releasing neural tone, increasing blood flow to the muscles, and releasing trigger points. In the warm up we are not trying smash our muscles or give ourselves a deep tissue massage. We are just trying to prepare the muscles to function properly. I like to tell athletes they should be able to breathe comfortably when performing pregame or pre workout soft tissue work, you should not be in so much pain that the rest of your body tenses. Overhead athletes should address, if time allows, the pectoralis muscles, subclavious, latissimus, teres major, subscapularis, bicep, rhomboids, and the posterior rotator cuff. Pre- game rolling should be a 5- 7 minute process. As stated previously we are just trying to warm up the muscles and release tension. Below are a few examples of how address several shoulder and scapula muscles.
Teres Major
Rhomboids
Stretching (Only If Necessary)
After applying soft tissue techniques, the next step in the warm up should be static stretching but only for the athletes that actually need to stretch. Most, not all, throwing athletes do not need to stretch their shoulders and they definitely do not need to stretch their shoulders into excessive external rotation, horizontal abduction, or extension (softball pitchers). A common stretch I see athletes performing is a pectoralis stretch against the wall or having someone pull their arm back into extension. This just drives the shoulder into anterior humeral glide (the ball of shoulder slides forward in the socket), which causes the anterior capsule to stretch and it irritates nerves, the bicep tendon, and rotator cuff tendons. As I referred to before, throwers gain more external rotation as the season progresses, which can cause anterior shoulder instability. Therefore athletes should avoid any stretches that puts the shoulder into this position. Another stretch I would like throwing athletes to avoid is the classic cross body shoulder stretch. As mentioned above the posterior rotator cuff muscles get fatigued from deceleration forces and trigger points are formed. The posterior rotator cuff muscles are designed to stabilize the humeral head on the glenoid fossa. Stretching them across the body will not make them stronger or better stabilizers. This cross body stretch also stretches the posterior capsule of the shoulder and can cause compression to anterior muscles of the shoulder, such as the bicep tendon. A better way to improve the posterior rotator cuff before throwing is through manual soft tissue work, and activation. However, if you feel the need to stretch prior to throwing a few stretches that are safe to perform lightly for a short amount of time are the Genie Stretch and a latissimus stretch. These stretches can be held for 1-2 sets of 8 breaths. I like to count in breaths because it helps the athlete relax and focus on their breathing.
A note on breathing: I will add one or two breathing exercises prior to manual soft tissue work. Breathing exercises help set the diaphragm and rib cage. The rib cage should be slightly convex so the concave shoulder blade can move smoothly along it. If the rib cage is flat, the scapula won’t move appropriately and can lead to injury of the throwing arm.
Lat Stretch with Band
Deep Squat Lat Stretch
Genie Stretch
Mobility
Before we throw, we want the shoulder to be moving properly and the correct muscles engaging at the correct times. Mobility exercises should be completed for the whole body, however for the purpose of this article I am not going to include lower body mobility exercises. I noted previously that it was important for the rib cage to be somewhat convex (rounded) so the shoulder blade could move correctly along it. If the thoracic spine is not mobile, proper rib cage position cannot be acquired. The thoracic spine or upper back needs to be the most mobile portion of our spine; the lumbar and cervical spine are meant to stable and not mobile. Thoracic mobility helps with rib cage positioning and increasing hip and shoulder separation in rotational athletes. The thoracic spine must be able to rotate in order for throwing athletes to get back into a proper lay back position. If an athlete has limited thoracic rotation, they will compensate through the shoulder to get back into a proper lay back position. This can cause an increase of stress on the anterior capsule of the shoulder and medial elbow structures, which leads to anterior shoulder instability. Instability can lead to many other injuries and medial elbow injuries. It is important for athletes to work on the thoracic spine mobility throughout the season and I have provided a few examples of the most beneficial ways to work on thoracic rotation during the season. It is best to avoid thoracic rotation exercises that call for shoulder external rotation.
Tspine extension with roller
Tspine Bench Mobility
Quadriped Rock, Quadriped Rock back with rotation, Qaudriped Rock With OH Reach, and Adductor Rock
Floor slides
Back to wall Shoulder flexion
Activation
Activation exercises are very important for preparing the arm to throw. With activation exercises, we are not just turning on the correct muscles, but prepping the central nervous system as well. Baseball and softball are technique and skill based sports and extremely demanding on the central nervous system. It is very important that the musculoskeletal system and central nervous system are working congruently throughout a practice or game. Activation exercises should be completed for the glutes, core, posterior rotator cuff, and scapular movers.
Some examples of activation exercises are:
SL Hip Lifts with Hip Flexion
RKC Planks
Deadbugs
Half Kneel 90 90 External Rotation (no resistance)
Half Kneel 90 90 External Rotation Isometric Holds
Half Kneel 90 90 External Rotation with Band
Serratus Wall slides
Yoga push up
Ws press overhead
Recovery
After a pitching outing, game, or practice, recovery strategies should be implemented to promote healing. A game or practice is both physically and mentally demanding on athletes. Not only does it stress the throwing arm by creating micro-traumas with each throw, but games and practices can fatigue the central nervous system as well. Key components of recovery are a whole body cool down, soft tissue management, gentle static stretching, proper nutrition and adequate sleep. A whole body cool down can be accomplished by completing a full body dynamic warm up. We want to provide the inflamed muscles with the necessary anti-inflammatory chemicals that the body produces to initiate healing. Increasing blood flow and oxygen uptake in the whole body may aid in this process. Soft tissue management will help in decreasing Delayed Onset Muscle Soreness(DOMS) and prevent trigger points and adhesions from forming. Gentle static stretching to the upper body should only be applied by athletes that absolutely need to stretch and only in the areas that are tight. Lower body stretches should be completed by most athletes. Special attention should be given to hip flexors, hip rotators, and groin. Proper nutrition and adequate sleep are probably the two most forgotten components of recovery. Proper nutrition is imperative to decrease soreness, maintain muscle mass, prevent injury, decrease fatigue, and decrease inflammation. Athletes should consume 20 -30 grams of protein and 40-60 grams of carbohydrates immediately following a game or practice and then consume a well-balanced meal 2-3 hours later. A high quality protein shake mixed in chocolate milk is a great option for youth athletes to get the necessary amount of macronutrients in after physical activity. Sleep is taken for granted by way too many athletes. Sleep is when our body recovers; if we don’t get enough sleep our bodies will never fully recover.
I bet you are probably wondering why ice is not mentioned for recovery. Ice has its place in sports medicine, but not as a post-game modality to promote healing. In a few weeks, I will follow up on my thoughts on ice and the research to support my opinions.
In Season Strength and Conditioning
Throwing athletes should engage in in-season strength and conditioning at least 2-3 x a week. In season, lifting programs are not just for maintaining strength, but can be used as a recovery tool as well. In season strength and conditioning programs should include soft tissue management, mobility exercises for the whole body, light power exercises, a full body strength training routine, and sport specific conditioning. Arm care specific exercises should be incorporated into the training routine, and should focus on maintaining strength in the posterior rotator cuff, serratus anterior, and mid/low traps. Arm care exercises should never be done to failure, 2 to 3 arm care exercises for 2 sets of 8 should be performed each training day. The goal is not over work those muscles but to keep them functioning properly. As for strength training the intensity and volume should be very low, again we use in season training to maintain strength, athleticism, and keep the body functioning properly. You do not want to engage in training that is going to make you sore, so it is best to avoid new exercises and training muscles eccentrically. In season training sessions should not go more than an hour, stress levels are already high throughout the season, training longer than an hour in the weight room will increase cortisol levels and make recovery even harder. In season training should be taken serious, it is a key factor in staying healthy throughout the softball/baseball season.
Wrap Up
- Arm care truly begins in the off season, but during the season it begins with a quality warm up
- A comprehensive warmup should include soft tissue work, very little static stretching, mobility exercises, shoulder, core, and lower body activation exercises, and a full body dynamic warm up.
- Recovery strategies should include soft tissue work, full body mobility work and dynamic stretching. Compression can be applied if needed.
- Maintaining strength and function of the posterior rotator cuff, serratus anterior, and mid and low traps should be incorporated into an in-season strength and conditioning program.
If you’d like to learn more about how to manage the overhead athlete throughout the season attend our Injury Prevention and In-Season Training for the Throwing Athlete on Sunday April 15th.
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