Armed with uncertainty: Understanding baseball’s shoulder and elbow injuries

Baseball is more about precision than brute strength. It’s how a 5-foot-6 second baseman wins a Most Valuable Player award or a 170-pound pitcher with a mid-80s fastball and an insurance salesman’s countenance becomes a near unanimous Hall of Famer.

It’s also why baseball players often are overlooked in the conversation about premier athleticism. For every Greek god in a collegiate or professional baseball uniform there’s another who looks like he should be manning the counter at the neighborhood convenience store.

Baseball attracts all kinds, shapes and sizes, but requires a special brand of athlete. The sprints may be only 90 feet and physical collisions are at a minimum, but the ability to effectively accelerate and decelerate with the legs, hips and hands constitutes elite athleticism. So does the craft of reaching above the head and throwing with thunderous velocity and pinpoint accuracy.

With these skills come inherent risks, such as knee-ligament tears, muscle pulls and the bane of baseball players everywhere: Arm injuries.

Since another baseball season is underway, from Little League to the big leagues, let’s take a look at the basics of pitching injuries in the sport – with some guidance from an expert in the field. What happens, what’s the best treatment for recovery and what, if anything, can prevent serious ones from occurring?

A baseball evolvement that isn’t positive

There’s a need for speed in throwing a baseball. The harder you throw the more intimidating it is, increasing the likelihood of a strikeout – assuming your pitches are near the plate. 

Athletes are bigger, stronger and faster now than ever before. Yet the baseball throwing motion is basically the same. And the number of times that delivery is repeated by today’s pitchers in competitive environments has multiplied exponentially, and often is executed with improper throwing mechanics.

Many amateur athletes choose a singular sport much earlier nowadays, sometimes by age 10 or 12. Consequently, many sports have become year-round, even in cold-weather environments, and players and parents often envision more exposure as a promise of future dollar signs. 

Pitch for your school team in the spring and your travel club in the spring and summer. Attend fall-ball tournaments and winter sessions with personal coaches. You also could play for multiple travel clubs in the same season – all potentially contributing factors why arm injuries caused by overuse continue to skyrocket.

What’s the best remedy for curtailing arm ailments? Most experts will say: Common sense. 

Shoulders and elbows need resting periods, especially from high-intensity pitching, whether that means taking weeks off with only light throwing or choosing a different sport for a couple months at a time. Major leaguers don’t pitch 12 months a year; high school kids shouldn’t either. 

Even the most cautious overhead athlete, however, can develop arm issues; it’s the nature of the repetitiveness and ferocity of the overhead throwing process.

The dreaded UCL injury

The arm’s most common overuse injury is now widely considered an inevitability for those who throw repeatedly and competitively.

Swing your arm down hard enough and for an extended period of time and you’ll be in danger of partially or completely tearing your ulnar collateral ligament (UCL), a band of tissues on the inside part of the elbow that provides joint stability.

Anyone who has pitched for multiple years likely has at least a partial UCL tear – the ligament just isn’t strong enough to support extended overhead use.

With proper treatment from athletic trainers and physical therapists, an athlete with a partially torn UCL can continue to pitch and play. That usually involves rest and personalized care to strengthen areas around the elbow in hopes of minimizing pain and avoiding surgery.

If the UCL is fully torn, however, surgery is recommended – specifically elbow-ligament-reconstruction or Tommy John surgery, named after the former all-star lefty who underwent the procedure in 1974 and pitched an additional 14 seasons in the majors. Typically, a tendon is harvested from another part of the body – often from the forearm or near the hamstring – and surgically attached to the unstable elbow. 

The procedure takes between one and two hours and the recovery ranges from 10 to 18 months depending on various factors. One of every three major league pitchers have had at least one elbow reconstruction surgery. Alarmingly, more than 50% of Tommy John recipients are ages 15-19; some are as young as 12, with one report suggesting the youngest was 10. 

The surgery is considered highly successful, with roughly 90% of patients returning to throwing competitively within 18 months. In many cases, pitchers actually threw harder after recovering from surgery, partially because they have a new elbow ligament but also because they spent six months not throwing while building strength elsewhere. 

Follow the well-documented blueprint of recovery, without jumping ahead due to boredom or impatience, and there’s hope that a return to previous form is within reach. 

The caveat here is there are no guarantees. Sometimes, the graft doesn’t hold and a second surgery is required. Sometimes, past performance can’t be replicated due to age or other circumstances. 

There are also increasing variations to Tommy John surgery, including inserting an internal brace to support the injured ligament, which is less invasive and can expedite a return by several months. Another method increasing in use is a combination of Tommy John reconstruction and internal-brace insertion, which provides more stability and an elevated chance of avoiding future issues.

The good news is elbow surgery is no longer a career death sentence like it was 50 years ago, when Tommy John was given a 1% chance of resuming his career. It remains a significant surgery, but there is a defined recipe for success.

The double whammy of shoulder injuries

Compared to an elbow surgery, a shoulder injury that leads to surgery is more likely to derail a baseball career.

If a small tear is discovered in the rotator cuff – the tendons and muscles surrounding the shoulder joint – or in the labrum – the cartilage ringing the shoulder socket – a pitcher should be able to get back to the mound relatively quickly. With initial rest and subsequent work with a physical therapist or athletic trainer to rebuild strength and mobility, a return is possible within six weeks.  

Similar to the UCL, if athletes throw aggressively for years, they probably have incurred shoulder damage that will appear in imaging, like an MRI, as well as through evaluations. 

Trained clinicians can examine a player, compare the injured shoulder’s strength and range of motion to the non-throwing shoulder or to other athletes in similar demographics and obtain a nuanced sense of the ailment before creating an individualized care plan. 

If there is a significant tear in either the labrum or rotator cuff and surgery is needed, the recovery likely will be nine months or longer. Oftentimes, if one is damaged, the other might be as well. Both the labrum and rotator cuff stabilize the shoulder, and an injury to one can lead to an overcompensation or change in mechanics that affects the other.

Return to sport for a shoulder can be more precarious than for an elbow, which adds to the fear that a pitcher returning from shoulder surgery won’t regain top form. 

There’s a psychological component to this, too. Since the shoulder’s recovery isn’t as easy to predict as the elbow, confidence can wane even more. Additionally, those rebounding from a labrum tear, for instance, may not have the same sense of where their arms are moving during delivery, which can affect pitchers’ control. 

Physical therapists and athletic trainers may focus on exercises that pinpoint stability and isolated rotational movements to help pitchers regain their “feel” after shoulder surgery.

The bottom line

If you suffer an arm injury due to overuse, know you aren’t alone. It is extremely common for an overhead athlete to deal with some level of arm ailments in a career.

Also, understand that with hard work and the proper treatment, there is no reason you can’t put your injuries in the rear view.

The most integral component is finding the right clinicians who understand how to treat athletic injuries, from surgeons who routinely operate on athletes’ arms to experienced athletic trainers and physical therapists who know what it takes, physically and mentally, to return to the mound.

A powerful arm can lift athletes to impressive heights. Therefore, it’s important to take care of it, rest it, build a solid core of strength around it and employ the best clinicians for training and recovery.

Clinical contribution to this blog provided by Physical Therapist Tommy Hockenjos.