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Arm Care and Injuries

It's a beautiful Saturday morning. The sun is out, and there's not the slightest chance of a typical afternoon thunderstorm. You and your family are at the ball fields, watching your child pitch a great game. Your child only gives up two hits, and the team wins the game.

Then, the next day, your child is back out on the mound, pitching another great game. Your child complains about a little soreness during or after pitching; however, everyone reinforces that this is "normal". This trend continues for the next several months-until one day, your child walks off the mound holding the pitching elbow after throwing one pitch too many.

In recent years, this scenario has become all too common, and in many cases, the final outcome can be prevented. Serious injuries among youth and adolescent baseball pitchers are on the rise, and many of them are caused by overuse. Youth and adolescent baseball throwers require a dedicated, informed, and altruistic team of supporters, including parents, coaches, league personnel, doctors, and other athletes, to keep them on the diamond performing at their best while maintaining proper arm care health. Below are some common shoulder and elbow injuries that may occur in youth and adolescent throwers as well as some arm care tips to help keep your youth and adolescent baseball players healthy.

Common Shoulder Injuries

Proximal Humeral Epiphysiolysis (i.e. Youth Throwing Shoulder Syndrome): In skeletally immature athletes, including youth and adolescent baseball players, the open "growth plates" at the ends of the bones can often be the weak links. When the arm is overworked and/or experiences increased stress, the growth plate at the shoulder end of the arm bone (humerus) may become painful. Rest from throwing and a guided physical therapy plan is important in these situations to allow the growth plate time to heal prior to return to throwing.

Rotator Cuff Injury: The rotator cuff is the group of coordinated muscles that keep the end of the arm bone (humeral head) in the shoulder socket (glenoid). Although full-thickness rotator cuff tears are less common in throwers, weakness, tendinitis and partial-thickness tears can present with pain and/or aching in the shoulder during and/or after throwing. In baseball throwers, rotator cuff weakness may result in increased stress upon the shoulder and elbow resulting in pain and inability to throw. Non-surgical treatment, including rest from throwing, physical therapy, and throwing mechanics evaluation, will often be beneficial in alleviating pain and allowing for return to play.

Labral Injury: The shoulder socket (glenoid) is surrounded by a soft tissue lip (labrum) that increases the depth and surface area of the socket for stability but allows for enough arm motion to throw. In baseball throwers, the top of the labrum may be injured (SLAP tear) resulting in pain and inability to throw. Non-surgical treatment, including rest from throwing, physical therapy, and throwing mechanics evaluation, will often be beneficial in alleviating pain and allowing for return to play.

Internal Impingement: With repetitive throwing, the rotator cuff and labrum may come into contact with the arm in the cocked position, resulting in progressive pathology and pain during the throwing motion. Non-surgical treatment, including rest from throwing, physical therapy, and throwing mechanics evaluation, will often be beneficial in alleviating pain and allowing for return to play.

Glenoid Osteochondritis Dissecans: Tearing of the cartilage and/or bone of the shoulder socket (glenoid) may result in pain, clicking, and inability to throw. Depending upon the size of the cartilage and/or bone injury, non-surgical or surgical treatment will be required.

Scapular Dyskinesis: The shoulder blade muscles at the back of the shoulder are extremely important in maintaining arm health. When these muscles are weak, the shoulder and elbow may experience significant stress resulting in pain and inability to throw. Although these muscles are not typically injured, a balanced physical therapy program focusing on increasing muscle activity, strength, and flexibility can restore normal support to the scapula and improve mechanics allowing for decreased stress on the shoulder and elbow during the throwing motion.

Common Elbow Injuries

Medial Epicondyle Apophyseal Injuries: The growth plate in the bone on the inside aspect of the elbow (that is, the part of the elbow near the hip when your arm is by your side) can be a significant source of pain in the baseball thrower. The growth plate injury may involve isolated pain with no fracture (epiphysiolysis) or fracture with or without displacement.

Epiphysiolysis (i.e., Youth Throwing Elbow Syndrome): When the arm is overworked and/or over-stressed, the growth plate may become painful. This pain can be a warning sign for possible future fracture. In this situation, non-surgical treatment with rest from throwing and a guided physical therapy plan can be critical in preventing more significant injury and allow for eventual return to play.

Medial Epicondyle Avulsion Fracture: When the growth plate is overworked or overstressed, the growth plate may eventually fracture. Depending upon the displacement of the fracture, non-surgical or surgical treatment will be required.

Ulnar Collateral Ligament Tear (i.e. Tommy John Ligament): The ulnar collateral ligament is one of the primary stabilizers of the elbow during the throwing motion. In youth or adolescent baseball throwers, the medial epicondyle growth plate (previously discussed) or ligament will experience stress resulting in possible injury. Growth plate injuries are usually in pitchers who haven't finished growing, while ligament injuries usually occur in pitchers at their adult height. When the ulnar collateral ligament has a sprain or tear, non-surgical treatment with rest from throwing and a guided physical therapy program will be first implemented to enable the athlete to return to play. If appropriate non-surgical treatment is unsuccessful, then surgical management may be considered involving ulnar collateral ligament repair and/or reconstruction. While Tommy John surgery may often provide a successful return to sport, there are no guarantees after surgery - especially for young pitchers. Therefore, injury prevention is always the best treatment!

Olecranon Stress Fracture: The pointy bone on the back of the elbow can often experience increased stress, especially when overuse is encountered, resulting in stress reaction or fracture. In youth and adolescent throwers, this stress can be imparted to the bone or growth plate (if still open). Non-surgical treatment will typically be first-line treatment with rest from throwing and a guided physical therapy program. If appropriate non-surgical treatment is unsuccessful, surgical management with screw fixation is typically considered.

Capitellum Osteochondritis Dissecans; The joint on the outside of the elbow (radial head and capitellum joint) can sometimes be injured. Young patients may have cartilage or bone that is susceptible to injury and/or increased stress from throwing can result in injury. The cartilage and bone at the capitellum may sometimes fragment resulting in pain, clicking, and inability to throw. Depending upon the size of the cartilage injury, non-surgical or surgical treatment will be required.

Elbow Tendinitis: The muscle and tendon structures inserting around the elbow can sometime be overworked and/or overstressed in the throwing athlete. These tendons may include the flexor-pronator tendon (inside part of the elbow), biceps tendon (front of the elbow near the crease), extensor tendons (outside part of the elbow), and the triceps tendon (back of the elbow). Although tendon tears are rare in youth and adolescent throwers, tendinitis may result in pain and inability to throw. Non-surgical treatment, including rest from throwing, physical therapy, and throwing mechanics evaluation, will often be beneficial in alleviating pain and allowing the athlete to return to play.

Ulnar Neuritis: During the throwing motion, the nerve on the inside aspect of the elbow may experience compression, pain, and tingling in the ring and pinky fingers of the hand. Although significant compression or traction is rare in youth and adolescent baseball throwers, nerve issues must still be considered during any evaluation. Non-surgical management, including rest from throwing, physical therapy, and throwing mechanics evaluation, will typically be successful in alleviating pain and allowing for return to play; however, surgical decompression or transposition (moving the nerve to the front of the elbow) of the nerve may be necessary in rare cases.

Arm Care Tips

  1. Pre-season Preparation: Consider a pre-season throwing program designed to gradually prepare the arm for throwing activities. This program should include a physical therapy component (i.e. thrower's ten program) and an interval throwing program.
  2. Warm-up: Throwing "cold" is not advisable as muscles, tendons, ligaments, and bones must have time to warm-up. Proper stretching and long tossing prior to throwing are advised.
  3. Prevent Overuse: Please don't just know the Throwing Guidelines… Please follow them. The baseball community is fortunate to have a multitude of youth and adolescent guidelines for the prevention of injuries as based upon years of research.
  4. Warm-down: Proper icing, stretching, and activities after throwing can help the thrower prevent inflammation and soreness.
  5. Rest: Proper rest periods between pitching appearances, during the season, and over the course of an entire year are critical to maintaining optimal performance and health. The thrower should follow proper pitch count and rest period guidelines.
  6. Throwing mechanics: Improper throwing form may place your arm in a more "at risk" position. It may be beneficial to have an experienced baseball throwing coach evaluate your throwing motion to make sure that your throwing motion is optimized for long-term performance and health.
  7. Listen to your body: Although many throwers may occasionally feel arm soreness, this can also be your body's warning sign that you may be overworked and/or overstressed. Don't throw through pain!

This summary of common injuries and arm care tips are not meant to provide a means for diagnosis or treatment of your child or athlete. If your child or athlete is feeling arm soreness or pain, have him evaluated by a medical provider with experience treating baseball players. If in doubt, have your doctor check it out!

Proper arm care in youth and adolescent baseball players is extremely important in maintaining long-term performance and health with the goal of keeping our kids arms healthy. Help keep our kids' baseball dreams alive! Join the Play Ball Arm Care Team… Help prevent youth and adolescent arm injuries!

 

Courtesy of Daryl C. Osbahr, M.D., Member of the USA Baseball Medical & Safety Advisory Committee, Fellowship Director and Chief of Sports Medicine at Orlando Health Orthopedic Institute, and Orthopedic Consultant for the Washington Nationals.