Overuse and Dead Arm Syndrome

This article will discuss overhand throwing motions in three groups of baseball players. The youth athlete, the adolescent near collegiate age athlete, and the collegiate age and professional level athlete.

We have seen many parents of youth athletes who come into our clinics with a deep medical file and deep frustration by the “lack of progress” their child is making in returning to their sport.

The important point for the pitcher to remember is that pain is your body telling you that something is wrong. The time to get treatment is not when your shoulder finally goes out, but when the pain first starts.

Shoulder problems either manifest as shoulder pain or weakness. A pitcher feeling weak requires shoulder examination. Pain and/or weakness are common signs of ligament weakness. Ligament weakness in the shoulder will almost always lead to rotator cuff tendonitis. If this is not treated, the rotator cuff muscles will give out, putting even more stress and strain on the ligaments. Eventually, shoulder instability develops.

A natural consequence of weakened or injured shoulder ligaments is chronic shoulder instability. This situation may occur as a result of previous Shoulder Dislocations, but may also occur due to congenitally loose joints or from repetitive motion injury as in pitching. Repetitive microtrauma, occurring as a direct result of these injuries, begins to take its toll on the supporting structures of the shoulder and disrupts the delicate balance between mobility and stability. Subtle signs of joint instability and laxity become evident, including pain with abduction and external rotation (called a Positive Apprehension Test), tenderness to palpation throughout the shoulder joint, and the subjective feeling of weakness in the arm (Dead Arm Syndrome).

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Preventing dead arm and overuse injuries in youth baseball players starts with preventing overuse

Research: Why do “youth pitchers remain at high risk for shoulder and elbow overuse injuries despite well-established recommendations on pitch count limits?”

Pitch count controversies in adolescent and youth baseball programs

A recent study in the Journal of Pediatric Orthopedics (Nov/Dec 2018) looked into why “youth pitchers remain at high risk for shoulder and elbow overuse injuries despite well-established recommendations on pitch count limits.”(1) What the researchers looked at was the coach’s compliance.

Sixty-one (61) youth baseball coaches in surrounding suburban areas outside 2 separate Midwestern metropolitan cities were asked to answer an anonymous 13-question survey.
The majority of coaches reported:
- coaching male athletes (89%, 54 of 61 coaches)
- primarily between the ages of 11 to 12 years (51%, 31 of 61 coaches).
A total of 56% (34 of 61 coaches) reported “always” keeping track of pitch counts
- however, 92% (56 of 61 coaches) reporting not keeping track of pitches based on established recommendations by the American Sports Medicine Institute,
- 56% were non-compliant with age-appropriate pitch count recommendations as established by the 2006 US Baseball Medical and Safety Advisory Committee.
Only 13% (8 of 61 coaches) were able to correctly identify risk factors for overuse injuries while acknowledging the necessity of off-season strengthening.
Thirty-eight percent (23 of 61 coaches) of coaches reported sitting out an athlete because of overuse injury, with the highest rates found in those coaching the youngest (8U and younger) and oldest (U17 and older) age groups.
Nine of 61 coaches, 15% were non-compliant with age-based recommendations against throwing breaking pitches.

CONCLUSIONS: “Knowledge regarding pitch count guidelines established to prevent overuse injuries to the shoulder and elbow in youth pitchers remains deficient in the group of coaches surveyed.”

“The MRI findings in asymptomatic MLB pitchers do not appear to be related to near future placement on the DL. However, there was a significant difference in numbers of innings pitched between pitchers who had an RCT (Rotator Cuff Tear) and those who did not and a moderate correlation between innings pitched and the presence of RCT as well as the presence of labral lesions. This finding supports the notion that Rotator Cuff Tear and labral injury in pitchers may result from repetitive overhead motion with subsequent strain on the rotator cuff tendons and glenoid labrum. Asymptomatic shoulder lesions in professional baseball pitchers appear to be more frequent than previously thought.”1

What the research says is that the frequency of tears in the shoulder in pitchers reporting no pain – is greater than they thought.

Rotator Cuff Tendonitis and Dead Arm Syndrome

A secondary problem to chronic shoulder instability is Rotator Cuff Tendonitis (RCT). Rotator cuff tendonitis may occur when the muscles of the rotator cuff, which include the supraspinatus, infraspinatus, teres minor, and subscapularis, are overworked causing the tendon to become inflamed and painful. The more common scenario of RCT occurs when a chronically unstable shoulder forces the muscles of the shoulder, especially the rotator cuff muscles and tendon, to work beyond their capabilities to stabilize the shoulder as it moves through its complex pitching motions. These small rotator cuff muscles were not designed to stabilize the shoulder or perform the major work in shoulder motion but instead should function to perform shoulder rotation. Chronic ligamentous instability can lead to rotator cuff tendonitis, but the treatment of Prolotherapy can treat both the instability and the secondary tendonitis that follows.

Prolotherapy treats the root cause of shoulder instability and rotator cuff tendonitis not only by strengthening the rotator cuff tendons but also by correcting the shoulder ligament weakness.

Rotator Cuff Tendonitis and Impingement Syndrome Rotator cuff tendonitis occurs when the small muscles of the rotator cuff, the supraspinatus, infraspinatus, teres minor, and subscapularis, become strained causing weakness of these structures and subsequent tendonitis. Once the balance between motion and joint stability is altered through a weakness in the static structures (ligaments) or the dynamic structures (rotator cuff muscles), pain and impaired function will invariably ensue. Pitchers are prone to rotator cuff tendonitis and impingement syndrome because of the overhead movement involved in throwing a baseball and because the rotator cuff, in this position, is at its most vulnerable.

A common treatment for rotator cuff tendonitis and impingement syndrome by traditional medical doctors includes rest, NSAIDS (nonsteroidal anti-inflammatory drugs), physical therapy, and cortisone injections. Because a cortisone injection has very strong anti-inflammatory properties, it may reduce the swelling in the tendon and bursa, relieving the symptoms. These treatments may temporarily help, but since the underlying cause has not been addressed the problem invariably returns. Degenerative fraying and tearing of the tendon may occur if constant irritation of the tendon occurs from the impingement process over time. The best way to treat this unresolved process is with Prolotherapy treatments to the ligaments and tendinous insertions of the rotator cuff and deltoid. This, combined with gradual re-strengthening of the rotator cuff muscles, give an excellent chance for a full recovery and performance.

If the rotator cuff tear has become large enough to produce profound weakness in the shoulder, shoulder surgery may be necessary and Prolotherapy can be used as a post-operative treatment to improve tissue strength and overall recovery.

1 Knapik DM, Continenza SM, Hoffman K, Gilmore A. Youth Baseball Coach Awareness of Pitch Count Guidelines and Overuse Throwing Injuries Remains Deficient. Journal of Pediatric Orthopaedics. 2018 Nov 1;38(10):e623-8. (Google Scholar)

1. Lesniak BP, Baraga MG, Jose J, Smith MK, Cunningham S, Kaplan LD. Glenohumeral Findings on Magnetic Resonance Imaging Correlate With Innings Pitched in Asymptomatic Pitchers. Am J Sports Med. 2013 Jun 17. [Epub ahead of print]

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