Shoulder Flexion and External Rotation
Decreased shoulder flexion and external rotation have shown to be independent risk factors for developing elbow injuries during a season. Over the course of a season throwers tend to lose flexion and extension of the shoulder due to adaptation from the repetitive stress of throwing. Elbow injuries increased 7% for each degree of external rotation lost and 9% for each degree of external rotation that is lost! This repetitive stress has shown to cause changes in the joint capsule of the shoulder, and increase stiffness in the rotator cuff muscles and the lat muscle. This loss of range of motion is likely from reactive formation of scar tissue. To address these impairments that occur of the course of the season it is best to get ahead of them early in the rehab process. Some good advice to take care of these issues are quality manual therapy to help mobilize the posterior portion of the shoulder joint, mobilize the soft tissue of the lat and rotator cuff and create increased ranges of motion. Maybe the most important part of increasing the range of motion is to next perform active exercises in the newly gained range of motion. Once we have regained this range of motion and are able to build strength and control the end ranges we must continue to perform soft tissue and strengthening arm care exercises.
An extreme loss of elbow extension is not uncommon in adolescent throwers and is often common in older throwers as well. The repetitive force of throwing causes stress on the inner part of the elbow and increased compressive forces on the outer of the elbow. Therefore, throwing with this loss of elbow extension can present as pain on either side of the elbow and can be predictive of little league elbow, which is a condition that can encompass anything from irritation of the forearm muscles at the elbow to those muscles completely detaching a part of the bone. Restoring this elbow range of motion is imperative for throwers of all ages. The best way to restore this range is through instrumented assisted soft tissue work, dry needling and other manual therapy, as well as with passive stretching, and, as always, performing active exercises in the newly acquired range.
As throwers move through the phases of throwing to ball release the forearm forcefully moves from a position of supination (palm facing up) to a position of pronation (palm facing down). The more the pronators of the forearm arm used the stiffer they tend to become which will limit supination. The problem with limiting supination is that it basically limits the starting position of the forearm while in the layback position. The ability to supinate facilitates the ability to drive pronation through the ball and drive arm speed and spine rate. Along with good manual therapy, a good way to restore full supination of the forearm is to stretch the wrist flexors and pronators with the elbow flexed and extended and combine that with slow eccentric supination exercises into the full range of motion.