Shoulder and elbow injuries occur frequently in the throwing athlete, particularly in baseball players from Little League to high school level. Of course, for both the short- and long- term, injury prevention is in the athlete's best interest; however, when injuries do occur, rehabilitation is critical to full recovery.

Shoulder instability is one of the most common conditions in the throwing athlete and is usually the result of an imbalance that exists when the structures in the front of the shoulder are too loose and the structures in the back of the shoulder are too tight. This imbalance often occurs in combination with weakness of the rotator cuff and scapula (shoulder blade) muscles. Players complain of pain in the front or back of the shoulder, which is the result of an unstable ball and socket joint that actually allows too much movement of the joint during the throwing motion.

Treatment of shoulder instability requires rest from throwing to allow inflammation within the shoulder to subside. The treatment also includes a series of exercises to increase the strength of the muscles that stabilize the shoulder and to increase the flexibility of tissues that are too tight. Proper strengthening of the shoulder muscles usually requires the athlete to perform a 4 to 6 week exercise program prescribed and monitored by a physical therapist. Exercises progress from basic strengthening exercises that isolate specific muscles (Fig. 1) to sport-specific exercises that require the coordination of several different muscle groups (Fig. 2). All muscle groups around the shoulder must work well together to allow the athlete to perform at his or her highest level while decreasing the risk of further injury.

Specific exercises are undertaken to strengthen the muscles that stabilize and position both the scapula and the ball and socket of the shoulder joint. Careful attention is also given to exercises that strengthen the athlete's "core" (legs and trunk) (Fig. 3), which is the source of power during the throwing motion. A strong core can take pressure off both the shoulder and elbow, thereby decreasing the risk of injury to these areas.

A gradual return to throwing is encouraged once the athlete is stronger and pain-free. Throwing begins at a distance of about 30 feet and slowly progresses to longer tosses within a 2 to 4 week period. This progress is based on how much throwing the athlete can tolerate without pain. Once a pain-free throwing program has been completed, the physician and therapist determine whether to allow the athlete to return to play. However, even after returning to sport, the athlete should continue a strengthening and flexibility program to prevent further injury.

Rehabilitation of a growth-plate injury requires the athlete to discontinue all throwing for at least 2 to 3 weeks. During this time, the athlete's arm is usually immobilized in a sling to prevent unwanted arm movement. Following this period, the athlete undergoes a therapy program focused on increasing both range of motion and strength. In the case of elbow injuries, the core and shoulder as well as the elbow are addressed during the athlete's rehabilitation. A gradual return to throwing follows, with an emphasis on both proper throwing mechanics and frequency of throwing.

The rehabilitation of throwing injuries can be difficult and requires time away from one's sport. Therefore, it is in the athlete's best interest to prevent injuries from occurring. A physician, therapist, or athletic trainer can provide additional information about the prevention and rehabilitation of common baseball injuries.

David Keese, PT
Columbus, Georgia