June 4, 2025 • 25 mins
Throwing athletes face unique shoulder challenges that standard medical approaches often fail to address. This deep dive into shoulder pain reveals why the timing and location of pain matters more than most practitioners realize. When throwers experience pain at layback position—that critical moment when the arm is fully rotated backward before acceleration—it requires far more than rest and ice to properly heal.
The biomechanics at play are fascinating. The biceps tendon and anterior capsule frequently become irritated from excessive forward translation of the humeral head, primarily caused by insufficient external rotation range. This limitation forces compensatory movements that stress structures not designed for such demands. While 80% of overhead athletes show some labrum involvement on imaging, most remain pain-free—highlighting the disconnect between structural findings and actual function.
Most surprising to many athletes is that GIRD (Glenohumeral Internal Rotation Deficit) isn't something that needs "fixing." This adaptive change represents a normal, even beneficial evolution for throwers, combining bony adaptations with soft tissue changes that enable high-velocity movements. Working to increase internal rotation through techniques like sleeper stretches can actually be counterproductive.
The treatment approach outlined reveals how limited shoulder mobility creates a cascade of compensatory patterns—from the characteristic "W position" at layback to increased medial elbow stress (potentially leading to Tommy John surgery) and even lumbar spine issues. Effective intervention requires understanding these interconnections and addressing the entire kinetic chain: improving subscapularis function, enhancing pure external rotation, optimizing thoracic mobility, and establishing proper scapular control.
Whether you're a baseball pitcher, volleyball player, or any overhead athlete battling shoulder pain, this comprehensive approach offers hope beyond the standard "rest and try again later" advice. Reach out to our team at 561-899-8725 or team@athleteRC.com to discover how targeted biomechanical assessment can transform your throwing performance and keep you pain-free.
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Episode Transcript
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Speaker 1 (00:00):
If you're a driven, active person who wants to reach
and pursue a higher qualitylife with some ambition, then
guess what this podcast is foryou.
This is the Driven AthletePodcast.
What's up?
Y'all?
It's your man, dr Kyle.
Welcome back to the DrivenAthlete Podcast.
Really interesting topic.
I feel like something that wehave worked a lot on is shoulder
(00:20):
pain with throwers, all right,so especially shoulder pain at
layback, and that would be likewhen the arm is all the way
rotated backwards about whenthey're about to throw, as
they're loading to throw.
So it'd be like late cocking orlayback is what that would be
termed.
And if you ever look at like apicture of a major league
(00:41):
baseball player or just a highlevel baseball player, when
they're pitching or they'rethrowing, their arm is really
far backwards, right, that'sthat full shoulder external
rotation.
It's actually really important.
So, um, anyway, a common thingis pain and that position where
it's like when I get all the wayback to lay back, that's when
(01:02):
it hurts.
And we're like when I get tolike acceleration, mid
acceleration, that's when ithurts.
And a super common uh, that's areally common thing.
And locations for that pain isoftentimes the front of the
shoulder, the medial elbow andthen sometimes the posterior
shoulder.
Right, it's just in theshoulder.
So the things that we have tolook at, that um are, uh, are
(01:24):
differentially.
Diagnosis is like where's thepain and when does it occur,
right?
So they say, hey, I'm a pitcheror I'm a volleyball player, I'm
a swimmer, an overhead athlete.
We're going to stick withthrower just for the sake of
this podcast, this topic.
And they say my arm hurts whenI throw.
It's like all right, that's acommon thing we hear.
(01:46):
Imagine going to just astandard doc's office.
They're going to say, all right, rest and just ice it down and
then take some Advil, right?
They're not even going to ask,like, when in your throat does
it hurt?
Right?
Like when, just it hurts when Ithrow?
Oh, standard rotator cuffinvolvement, right, let's start
(02:06):
some imaging.
It's like, bro, we gotta look atother stuff and maybe ask a
question of like when does itcause pain?
And then also, where it locatedin your shoulder, does it cause
pain?
That totally changes thetrajectory of our treatment
protocol.
Maybe in the, the angry tissue,that what's?
What's, what's pissed off like,what's angry, what hurts, um.
(02:27):
And then, uh, what mechanicsare causing that to be the
problem?
Uh, how chronic has it been.
What's the age of the athletelike and their skill level,
their, their development level.
But, um, that all that stufftotally changes the trajectory
of like okay, how are we goingto fix it Right, what manual
therapy stuff are we going toinvolve to intervene with?
Um, and then, uh, whatcorrective exercises are going
(02:50):
to involve?
That totally changes everything, man.
So it's just super importantthat you find a practitioner
that's going to be like oh, ithurts when you throw.
Okay, tell me more, when.
What's it feel like?
Where's it located in yourshoulder?
How long has it been going on?
That totally changes everything.
So, anyway, so what we're goingto look, we're going to ask, is
(03:10):
when and where, what's it feellike?
And they say, let's say, forthe example, it hurts at layback
, at full backwards range ofmotion, or they call that full
external rotation, and it hurtsin the front of the shoulder.
Super common, all right, one ofthe first things we're going to
look at for testing is therange of motion and pure
external rotation.
(03:31):
All right.
So we're going to bring theirarm up into their throwing angle
, right, oh, sorry.
In addition to that, we're alsogoing to ask like hey, show me
your throw, because throwingmechanics are different for
everybody and their arm angle,their arm slot is going to be
different.
So, like some people have avery low arm slot where they're
throwing more sidearm and thensome people have a very high arm
slot throwing more overhead,like a Ferris wheel versus like
(03:53):
a merry-go-round, if you canvisualize that.
So it's important to look attheir mechanics right.
Like I'm not going to changetheir mechanics or like they're
throwing if they're like a highlevel athlete and they're
college or like a late highschool, I'm not going to be like
we need to totally change yourthrowing mechanics.
I'm not a pitching coach, butbiomechanics and pain that's
what I do.
And if they have pain andthey're a younger kid and
(04:13):
they're throwing two sidearm, wemight suggest an influence.
But like it might be better foryou to raise your arm slot a
little bit, especially at thisyoung age.
You're influenceable like that.
So that's what we're going toask Show me your throwing form.
So they say you throw it andthey say it hurts at the layback
, at the very front of myshoulder.
We're going to check theirshoulder.
(04:34):
Passive range of motion and pureexternal rotation.
Oftentimes throwers are limitedin external rotation.
They have a lot right, but it'sa natural accommodation for uh
the athlete to be able to dothat high level throw at that
high level velocity in order tohave, uh, the best mechanics
(04:57):
possible and to spare their armand the structures in their
shoulder.
So it's super important thatthey have enough shoulder
external rotation.
We find ourselves interveningto get more external rotation
for them.
They're actually limited.
They need like 140 to 130 to145, 150 degrees of pure
(05:20):
external rotation in theirshoulder.
It's like to get back there tohave the right throwing
mechanics that they need andspare their arm.
A lack of pure shoulder externalrotation, it stresses other
structures to overcompensate andthat's what gets painful and
that's why we're interveningwith what we do right.
And oftentimes people ask like,okay, what hurts?
Well, with anterior frontshoulder pain with a thrower at
(05:45):
layback, it's very commonly thebiceps tendon that's just
irritated and painful.
It's getting chronicallyover-lengthened and it's
chronically required too muchstability of that structure when
that's not really what it'sdesigned to do and that causes
pain right in the front of theshoulder.
So the long head of the bicepstendon traverses up the shoulder
(06:08):
joint and attaches to thesupraglenoid tubercle of your
scapula and that is where thebiceps anchor of the superior
labrum is.
So your biceps tendon actuallyhas an attachment to the
superior labrum.
So if somebody has chronicbiceps pain seems to be an
increased risk of a slap tear intheir labrum.
(06:31):
The slap tear means superiorlabrum, anterior to posterior
SLAP slap and that's theconnection with the biceps
anchor to the labrum at the topof their shoulder joint all
right and their shoulder glenoid.
So that's what that's theinfluence of the biceps tendon
in the labrum and the slap tearAll right.
That's where that comes from.
(06:51):
Interesting fact slap tears arereally common in overhead
athletes.
Like 80% of overhead athleteshave some kind of a slap tear
labrum involvement, if it's mildto moderate, some kind of level
.
So it actually is really common.
But you don't see 80% ofthrowers having pain all the
time.
(07:11):
So the structural abnormalitiesaren't always correlated with a
lack of functionality and painand the trajectory of like,
their athletic career.
Slap tears are really common.
Just the same message as before.
As we talk about with likelumbar disc herniations or
cervical disc herniations,there's plenty of people that
have herniated discs and theyhave no pain and they're totally
(07:32):
fine, right?
So there's a disconnect betweenimaging abnormalities,
structural abnormalities foundin the image and the actual pain
and functionality andtrajectory project prognosis for
somebody.
But anyway, so that's theinvolvement and the correlation
between the biceps tendon andthe top part of the labrum.
(07:55):
So as somebody goes back intolayback there's a lot of torque
and rotation involved in theshoulder and tensile tension
against the biceps tendon,against the biceps anchor labrum
.
So if somebody's lacking pureshoulder external rotation at
layback, there's going to bemore anterior translation of the
(08:17):
humeral head.
All right, the humeral head isgoing to slide forward
excessively and there's only onemajor structure, one structure
that's active, that preventsthat on the anterior side and
that's the subscapularis muscle.
All right, the biceps tendontraverses the front part and it
contributes a little bit toanterior stability but that's
(08:39):
not its main job and with therotation component added into it
, that just caused a lot ofstretch strain and it can cause
a lot of irritation to thebiceps tendon.
So anyway, that's why it getslit up.
It's hanging on for dear lifeand it's not supposed to be
doing that kind of stabilityrequirements for the anterior
part of the shoulder, the frontpart of the shoulder at layback,
the anterior capsule, the jointcapsule also, is what gets
(09:01):
irritated.
There's a ton of nerve endingsin the joint capsule also is
what gets irritated.
There's a ton of nerve endingsin the joint capsule of the
shoulder.
They're all joint capsules, allright, no-transcript.
And all those nerve endings aresuper sensitive and they get
irritated.
So if the anterior capsule isgetting chronically stretched
and overly stretched andstrained and it's overly
stressed with that excessiveanterior translation of the
(09:23):
humeral head, the biceps tendonis going to get lit up and the
anterior capsule is going to getlit up and that's why the front
of the shoulder gets reallytender and hurts.
That's where the pain comesfrom.
All right, but we're thinkinglike okay, why the biceps tendon
is lit up, the anterior capsuleis lit up.
I wouldn't be surprised if thesupraspinatus, like part of the
rotator cuff, is lit up too,because it's just overworking
(09:44):
and overwhelmed.
That's a super common thing,it's almost understood.
I guess the rotator cuff isprobably going to be involved in
some capacity a little bit.
But anyway, the question we askis why?
Why?
What is this thrower doingdifferently that's causing the
biceps tendon and the anteriorcapsule get lit up?
We know what the angry tissueis.
It's not that hard to figureout.
But the question is like why,and as a biomechanics and pain
(10:05):
experts, that we do withathletes.
That's what we're trying tofigure out, because that's what
we're going to fix.
What's the cause of the cause?
All right, so the anteriorbiceps, the biceps tendon, gets
lit up, the anterior capsulegets lit up and it's from
excessive anterior translationof the humeral head in the
shoulder joint, in the shouldergirdle, in relation to the
glenoid fossa, that's where itarticulates with the scapula or
(10:27):
the shoulder blade.
So that excessive anteriortranslation, we will call that
anterior instability or anteriorhypermobility.
Excessive anterior translation,we would call that anterior
instability or anteriorhypermobility.
So shoulder hypermobility,that's a standard, that's a
common thing.
The shoulder joint is superhypermobile, it's very unstable,
all right.
So that excessive anteriortranslation, that also can
(10:49):
create posterior impingement,all right.
So if the front part of theshoulder joint is, somebody goes
into layback like this and theshoulder joint glides
excessively forward toovercompensate for a lack of
shoulder pure external rotationrange of motion, the posterior
contents are going to abutagainst each other early or
(11:10):
excessively.
And that abutment of theposterior rim, of the glenoid
part, of the bone, of thescapula and the humeral head,
that causes posteriorimpingement and that's why the
posterior shoulder pain occurscommonly with this at layback.
When I go all the way back, ithurts in the back of my shoulder
.
It's excessive anteriortranslation and anterior
(11:31):
instability.
Hypermobility of the shoulderjoint and the posterior contents
are getting abutted into eachother.
Andmobility of the shoulderjoint, okay, and the posterior
contents are getting abuttedinto each other, and that would
be posterior impingement and thestructures that get posterly
impinged would be theinfraspinatus and teres minor
and the posterior capsule.
So those guys, those softtissues, is what's getting angry
and irritated and pinched orimpinged upon with a lack with
(11:54):
upon, with excessive anteriortranslation at the layback.
But why?
Again, it's because they'relacking pure external rotation.
We can always work on strengthand stability, so we would call
this it's an anterior shoulderstability problem.
All right, and there's onemuscle that really stabilizes
against this excessivetranslation anteriorly as they
(12:15):
go back and lay back, and thatmuscle is one of the rotator
cuff muscles and that's calledyour subscapularis.
The subscapularis rotator cuffmuscle is located on the ventral
side of the scapula and itspans across the anterior part
of the shoulder joint, of thehumeral head, and that's the
only active tissue that's mainjob is to prevent excessive
(12:36):
anterior translation.
So very commonly that thing'sgoing to be tight and weak, it's
going to be bound down or it'sjust not going to be active as
best it could be and it's goingto be inhibited.
It's not going to be superstrong and recruitable.
So we have to activate thatmuscle more, get it stronger,
get it more activated withfunctional movement overhead,
especially external rotation, toallow the shoulder to rotate
(12:57):
backwards and external rotationwithout excessively just
shifting forward at the sametime.
That takes just some time towork on right.
We also have to improve itspliability.
All right, we have to lengthenthe muscle pliability.
We have to improve itspliability.
So we have to do asubscapularis release too.
(13:18):
That doesn't feel good.
Maybe even dry needle it aswell, if someone's cool with
that.
So we're going to dry needle,we're going to release and work
on the pliability, extension,extension, pliability of the
subscapularis with theflexibility, dry needle it and
then also work on posteriorcapsule mobs of the humeral head
(13:39):
to reseat it in a betterposition and re-educate it to
rotate in a more establishedcenter of rotation.
We call that PICR path ofinstantaneous center of rotation
and then also work on someposterior rotator cuff soft
tissue work and then the subscapMET and then subscap exercises
(14:02):
on the gym floor that we'regoing to do corrective exercises
with overhead movement and withexternal rotation.
So anyway, that's where ourhead's at with that.
That's what our brains arethinking.
If somebody comes in withanterior shoulder pain as a
thrower, one of the first thingswe're looking at is do they
have enough pure externalrotation?
Having enough pure externalrotation is going to solve all
(14:22):
those problems.
It's going to prevent a lot ofthose problems.
That's the best recipe.
So an interesting thing withthat is GERD.
If y'all have ever heard ofGERD, g-i-r-d glenohumeral
internal rotation deficit.
So the shoulder joint rotatesright like this, okay, and if it
(14:42):
has excessive amounts ofexternal rotation, the thought
is they're lacking internalrotation because the shoulder
joint has developed andproliferated into accommodating
more pure external rotation.
So the thought would be likethey're lacking internal
rotation.
Well, that's accepted, that isunderstood to be the case.
(15:02):
That's that's going to betotally understood, expected,
right.
But I'm not going to work onmore internal rotation.
All right, gerd is actually agood thing for shoulder overhead
throwers like baseball players.
All right, gerd is a good thing.
It's an accommodation that theyneed to throw well and have the
(15:26):
best mechanics possible withthat high velocity, high torque,
rotation, throwing motion.
It's an adaptation of threethings.
It's a bony adaptation wherethe humeral head actually
develops more in a retrovertedposition.
So that's going to be a comment.
Imagine like a young kid whothrows and plays baseball a lot.
(15:49):
I mean all the thousands andthousands of throws they've done
.
That influence.
And torque influences thegrowth of the bone over through
adolescence.
So I imagine something likegoes through adolescence years
and puberty, like as they learnhow to throw Like a 10, like
maybe it's like aneight-year-old who then throws
for their whole life.
And now that they're in collegeat 22, right, that's a long
(16:11):
time.
Right, that's what.
14 years, right, that's a longtime.
Right, that's what 14 years.
So, so bony changes getinfluenced in that direction.
Is to accommodate all the stressthey've been going through, all
right, um.
The other one is soft tissuedevelopment.
So like the joint capsuleitself, um develops to get more
lax and and the uh, the anteriordirection, and that bounds gets
(16:33):
bounded down in the anteriordirection.
And it gets bounded down in theposterior direction, I'm sorry,
yeah, in the opposite direction, the posterior structures.
That's to accommodate moreexternal rotation, again, all
right.
And then the other one is justmuscular.
So the muscles get moredeveloped and tight with the
posterior structures and thenalso in the anterior ones they
(16:54):
get more pliable and lax.
But over time compensationpatterns happen and maybe
throwing mechanics change andover over, overly doing, uh
overtraining can happen, like Itotally.
At some point you gotta, yougotta, modify training right.
Overtraining is uh always goingto be a concern.
Um, but at some point got toback it down a little bit right,
even point got to back it downa little bit right.
(17:15):
Even the pro athletes will backit down a little bit to allow
things to settle down.
It wouldn't be smart to justtrain through, but anyway.
So GERD, glenohumeral internalrotation deficit is actually an
expected good thing for throwers.
We're not going to work on moreinternal rotation.
So, as an example, I'm notgoing to do sleeper stretch with
with athletes, I'm not going todo the behind the back rope
pull with athletes or the elbowforward stretch with athletes or
(17:38):
with these throwers.
We're going to work on moreexternal rotation actually, and
that's going to prevent a lot offuture issues and resolve their
pain right.
That's what the ultimate goalis.
So what happens if somebodylacks a periaxial rotation?
Well, they have more anteriortranslation or anterior shifting
of the shoulder joint.
(17:59):
They have more hyperangulationat layback.
So that'd be like the W posture, the W throwing position, so
like if somebody throws andtheir arms out, like this,
they're going to retract theirscapulas more and they're going
to horizontally abduct All right, they're going to horizontally
abduct their shoulder and thatjust creates even more anterior
(18:21):
shift of their shoulder jointand that's no bueno.
Steven Strasburg was reallyhe's a, he was a pro pitcher and
he was really known to havethat W posture.
The thought would be like thathyperangulation position.
It just creates more anteriorshift and more stress and strain
on the anterior structures ofthe shoulder joint.
(18:41):
That has been also correlatedwith medial elbow stress.
So medial elbow stress, as anexample, like Tommy John issues,
that's the anterior band of theUCL ligament in the elbow, so
the owner collateral ligamentand there's an anterior band of
the owner collateral ligamentand that guy gets overly
stretched and strained with alot of valgus forces, which
(19:03):
would be this position herewhere imagine, like shifting
your arm inwards all the timeand your elbow goes forward.
Where imagine, like shiftingyour arm inwards all the time
and your elbow goes forward,that valgus stress on the elbow
stretches and stresses theanterior band of the UCL.
And imagine doing that athousand, thousands and
thousands of times at highvelocity.
But it's gonna cause somechanges and maybe some issues
(19:24):
and then it can cause a ligamentinjury at the UCL and that
surgical repair is called TommyJohn surgery.
All right, so a lack of pureexternal rotation seems to be
just a foundation for a lot ofthese issues to develop Biceps
tendon pain, anterior capsulepain, an excessive anterior
(19:45):
shift of the shoulder joint.
Anterior translation is what wewould call that Hyperangulation
at the shoulder, with throw atlayback with that W position,
creates even more anterior shiftand then more medial elbow
stress.
And the last one is oftentimesathletes will hyperextend their
low back.
So like lumbar hyperextensionand hyperextension rotation.
(20:06):
So another common thing forathletes is with throwers is
they get back pain right.
They excessively hyperextensionrotation.
So another common thing forathletes with throwers is they
get back pain right.
They excessively hyperextendtheir lumbar spine and
hyperextend, rotate their lumbarspine with the throw motion.
It's because they'reovercompensating to get back far
enough as they need to.
And the thing we're going tocheck out if an athlete is their
(20:28):
shoulder rotation, their pureexternal rotation range of
motion, even for an athletecoming in with back pain.
If a pitcher comes in with backpain, we're checking out their
shoulder for sure.
That's what they do, right,their shoulder is their main
driver and the torque that theydo with their throw.
And if their back hurts withthrowing, we're definitely
(20:48):
checking out pure externalrotation range of motion for
their back pain.
So it's just a compensation.
It's interesting how these likethese compensation patterns
lead to manifestations of painelsewhere.
So that's just where ourbrain's at and looking at that
stuff.
So the other things thatinclude.
Here's the last thing I wasgoing to talk about.
(21:09):
The other thing that isimportant to investigate is,
with a lack of pure externalrotation, they're getting
rotation somewhere.
If they're getting back there,the thoracic spine also needs to
rotate and their scapula needsto retract in order to get up
(21:31):
into full layback and their armslot.
So their scapula retracts andtheir thoracic spine rotates and
their shoulder joint externallyrotates.
We would call that the MERM-E-R, the max external rotation
.
So when you see the poster orthe picture of a pitcher in
baseball when they're at theirfull stride and they're at full
layback or late cocking positionfor the throw, they're like way
(21:54):
back there.
Their shoulder isn't the onlything rotating.
Their thoracic spine needs toextend and rotate and their
lumbar spine needs to extend androtate.
But it's mainly we're going tolook at the thoracic spine and
then their scapula.
Their shoulder blade needs toretract and upwardly rotate.
So all those factors, thosethings need to be functioning
well in order to get to a fulllayback position as best they
(22:16):
can and as efficiently as theycan and not have pain.
So we're also going to look atthe scapula for sure and we also
need to work at the thoracicspine rotation for sure.
It's not always T-spineextension rotation, sometimes
it's flexion rotation, but forlayback we need to look at the
rotation range of motion for thethoracic spine and that would
(22:36):
be the MER All right.
So exercises that we work on weneed to work on their scapula,
upward rotation and retraction,which is a tricky thing to work
on.
It's not that it's justsomething that people don't
consider which is a tricky thingto work on.
It's not that it's justsomething that people don't
consider, but we've had reallygood results with athletes when
we work on upward rotation andretraction at the same time and
(22:57):
then also thoracic spine, and wecan't neglect that.
Part of that is core stability,all right.
So it's just interesting to lookat all these factors to help an
athlete that has anteriorshoulder pain, all these pieces
to the puzzle that contribute,and we don't want to leave any
stones unturned as to like whythis athlete that developed
shoulder pain like this, whenthe answer of just overtraining,
(23:19):
that can be effective, for sure, but if that's just, it's just
too much, take a break, you'reworking too much, just rest.
That's a that's a cop-outanswer.
The reason is because all ofhis teammates pitcher teammates
they're throwing at the samevolume.
They don't have the sameshoulder pain that this other
athlete does.
So what is this athlete doingdifferent?
Right?
They're all throwing the sameamount.
(23:40):
Why don't they have shoulderpain?
The same way that this personhas shoulder pain?
It's because this guy's doingsomething different and we have
those compensation patterns weneed to figure out and we need
to work on.
Intervene that appropriatelywith a recipe of the purposeful
manual therapy, some soft tissuework, muscle activation and
recruitment, and then stabilitycorrective exercises out in the
(24:00):
gym, right, all those things.
That's the best recipe and thatshould translate to their
functional throwing motion thatwe're going to, later stages,
work on too, but that's the bestrecipe to actually fix shoulder
pain at layback and that's whatwe have to investigate and
differentially diagnose and it'sgoing to totally change the
trajectory for different peoplebased on their shoulder pain and
(24:21):
all the stuff I mentioned inthe beginning.
So those are just things thatwe got to consider.
So that's just a little sneakpeek and snapshot and like
what's going on in ourevaluative process differential
diagnosis where our brains arethinking if somebody comes in
with shoulder pain as a thrower.
So if any questions, don'thesitate to reach out.
We're always open tosuggestions, comments, questions
(24:42):
, concerns, conflicting opinionsand if you have any questions
yourself or you're battling pain, don't hesitate to give us a
call.
Reach out on our website.
You can DM us on Instagram.
Our phone number is561-899-8725.
Don't hesitate to reach out tous on our email.
The best email to reach us isteam T-E-A-M team at
(25:02):
athleteRCcom and we're alwaysexcited and optimistic to help
people and open to havingconversations.
So feel free to reach out andwe'll catch you all next time.
If you're a driven, active person who wants to reach
and pursue a higher qualitylife with some ambition, then
guess what this podcast is foryou.
This is the Driven AthletePodcast.
What's up?
Y'all?
It's your man, dr Kyle.
Welcome back to the DrivenAthlete Podcast.
Really interesting topic.
I feel like something that wehave worked a lot on is shoulder
(00:20):
pain with throwers, all right,so especially shoulder pain at
layback, and that would be likewhen the arm is all the way
rotated backwards about whenthey're about to throw, as
they're loading to throw.
So it'd be like late cocking orlayback is what that would be
termed.
And if you ever look at like apicture of a major league
(00:41):
baseball player or just a highlevel baseball player, when
they're pitching or they'rethrowing, their arm is really
far backwards, right, that'sthat full shoulder external
rotation.
It's actually really important.
So, um, anyway, a common thingis pain and that position where
it's like when I get all the wayback to lay back, that's when
(01:02):
it hurts.
And we're like when I get tolike acceleration, mid
acceleration, that's when ithurts.
And a super common uh, that's areally common thing.
And locations for that pain isoftentimes the front of the
shoulder, the medial elbow andthen sometimes the posterior
shoulder.
Right, it's just in theshoulder.
So the things that we have tolook at, that um are, uh, are
(01:24):
differentially.
Diagnosis is like where's thepain and when does it occur,
right?
So they say, hey, I'm a pitcheror I'm a volleyball player, I'm
a swimmer, an overhead athlete.
We're going to stick withthrower just for the sake of
this podcast, this topic.
And they say my arm hurts whenI throw.
It's like all right, that's acommon thing we hear.
(01:46):
Imagine going to just astandard doc's office.
They're going to say, all right, rest and just ice it down and
then take some Advil, right?
They're not even going to ask,like, when in your throat does
it hurt?
Right?
Like when, just it hurts when Ithrow?
Oh, standard rotator cuffinvolvement, right, let's start
(02:06):
some imaging.
It's like, bro, we gotta look atother stuff and maybe ask a
question of like when does itcause pain?
And then also, where it locatedin your shoulder, does it cause
pain?
That totally changes thetrajectory of our treatment
protocol.
Maybe in the, the angry tissue,that what's?
What's, what's pissed off like,what's angry, what hurts, um.
(02:27):
And then, uh, what mechanicsare causing that to be the
problem?
Uh, how chronic has it been.
What's the age of the athletelike and their skill level,
their, their development level.
But, um, that all that stufftotally changes the trajectory
of like okay, how are we goingto fix it Right, what manual
therapy stuff are we going toinvolve to intervene with?
Um, and then, uh, whatcorrective exercises are going
(02:50):
to involve?
That totally changes everything, man.
So it's just super importantthat you find a practitioner
that's going to be like oh, ithurts when you throw.
Okay, tell me more, when.
What's it feel like?
Where's it located in yourshoulder?
How long has it been going on?
That totally changes everything.
So, anyway, so what we're goingto look, we're going to ask, is
(03:10):
when and where, what's it feellike?
And they say, let's say, forthe example, it hurts at layback
, at full backwards range ofmotion, or they call that full
external rotation, and it hurtsin the front of the shoulder.
Super common, all right, one ofthe first things we're going to
look at for testing is therange of motion and pure
external rotation.
(03:31):
All right.
So we're going to bring theirarm up into their throwing angle
, right, oh, sorry.
In addition to that, we're alsogoing to ask like hey, show me
your throw, because throwingmechanics are different for
everybody and their arm angle,their arm slot is going to be
different.
So, like some people have avery low arm slot where they're
throwing more sidearm and thensome people have a very high arm
slot throwing more overhead,like a Ferris wheel versus like
(03:53):
a merry-go-round, if you canvisualize that.
So it's important to look attheir mechanics right.
Like I'm not going to changetheir mechanics or like they're
throwing if they're like a highlevel athlete and they're
college or like a late highschool, I'm not going to be like
we need to totally change yourthrowing mechanics.
I'm not a pitching coach, butbiomechanics and pain that's
what I do.
And if they have pain andthey're a younger kid and
(04:13):
they're throwing two sidearm, wemight suggest an influence.
But like it might be better foryou to raise your arm slot a
little bit, especially at thisyoung age.
You're influenceable like that.
So that's what we're going toask Show me your throwing form.
So they say you throw it andthey say it hurts at the layback
, at the very front of myshoulder.
We're going to check theirshoulder.
(04:34):
Passive range of motion and pureexternal rotation.
Oftentimes throwers are limitedin external rotation.
They have a lot right, but it'sa natural accommodation for uh
the athlete to be able to dothat high level throw at that
high level velocity in order tohave, uh, the best mechanics
(04:57):
possible and to spare their armand the structures in their
shoulder.
So it's super important thatthey have enough shoulder
external rotation.
We find ourselves interveningto get more external rotation
for them.
They're actually limited.
They need like 140 to 130 to145, 150 degrees of pure
(05:20):
external rotation in theirshoulder.
It's like to get back there tohave the right throwing
mechanics that they need andspare their arm.
A lack of pure shoulder externalrotation, it stresses other
structures to overcompensate andthat's what gets painful and
that's why we're interveningwith what we do right.
And oftentimes people ask like,okay, what hurts?
Well, with anterior frontshoulder pain with a thrower at
(05:45):
layback, it's very commonly thebiceps tendon that's just
irritated and painful.
It's getting chronicallyover-lengthened and it's
chronically required too muchstability of that structure when
that's not really what it'sdesigned to do and that causes
pain right in the front of theshoulder.
So the long head of the bicepstendon traverses up the shoulder
(06:08):
joint and attaches to thesupraglenoid tubercle of your
scapula and that is where thebiceps anchor of the superior
labrum is.
So your biceps tendon actuallyhas an attachment to the
superior labrum.
So if somebody has chronicbiceps pain seems to be an
increased risk of a slap tear intheir labrum.
(06:31):
The slap tear means superiorlabrum, anterior to posterior
SLAP slap and that's theconnection with the biceps
anchor to the labrum at the topof their shoulder joint all
right and their shoulder glenoid.
So that's what that's theinfluence of the biceps tendon
in the labrum and the slap tearAll right.
That's where that comes from.
(06:51):
Interesting fact slap tears arereally common in overhead
athletes.
Like 80% of overhead athleteshave some kind of a slap tear
labrum involvement, if it's mildto moderate, some kind of level
.
So it actually is really common.
But you don't see 80% ofthrowers having pain all the
time.
(07:11):
So the structural abnormalitiesaren't always correlated with a
lack of functionality and painand the trajectory of like,
their athletic career.
Slap tears are really common.
Just the same message as before.
As we talk about with likelumbar disc herniations or
cervical disc herniations,there's plenty of people that
have herniated discs and theyhave no pain and they're totally
(07:32):
fine, right?
So there's a disconnect betweenimaging abnormalities,
structural abnormalities foundin the image and the actual pain
and functionality andtrajectory project prognosis for
somebody.
But anyway, so that's theinvolvement and the correlation
between the biceps tendon andthe top part of the labrum.
(07:55):
So as somebody goes back intolayback there's a lot of torque
and rotation involved in theshoulder and tensile tension
against the biceps tendon,against the biceps anchor labrum
.
So if somebody's lacking pureshoulder external rotation at
layback, there's going to bemore anterior translation of the
(08:17):
humeral head.
All right, the humeral head isgoing to slide forward
excessively and there's only onemajor structure, one structure
that's active, that preventsthat on the anterior side and
that's the subscapularis muscle.
All right, the biceps tendontraverses the front part and it
contributes a little bit toanterior stability but that's
(08:39):
not its main job and with therotation component added into it
, that just caused a lot ofstretch strain and it can cause
a lot of irritation to thebiceps tendon.
So anyway, that's why it getslit up.
It's hanging on for dear lifeand it's not supposed to be
doing that kind of stabilityrequirements for the anterior
part of the shoulder, the frontpart of the shoulder at layback,
the anterior capsule, the jointcapsule also, is what gets
(09:01):
irritated.
There's a ton of nerve endingsin the joint capsule also is
what gets irritated.
There's a ton of nerve endingsin the joint capsule of the
shoulder.
They're all joint capsules, allright, no-transcript.
And all those nerve endings aresuper sensitive and they get
irritated.
So if the anterior capsule isgetting chronically stretched
and overly stretched andstrained and it's overly
stressed with that excessiveanterior translation of the
(09:23):
humeral head, the biceps tendonis going to get lit up and the
anterior capsule is going to getlit up and that's why the front
of the shoulder gets reallytender and hurts.
That's where the pain comesfrom.
All right, but we're thinkinglike okay, why the biceps tendon
is lit up, the anterior capsuleis lit up.
I wouldn't be surprised if thesupraspinatus, like part of the
rotator cuff, is lit up too,because it's just overworking
(09:44):
and overwhelmed.
That's a super common thing,it's almost understood.
I guess the rotator cuff isprobably going to be involved in
some capacity a little bit.
But anyway, the question we askis why?
Why?
What is this thrower doingdifferently that's causing the
biceps tendon and the anteriorcapsule get lit up?
We know what the angry tissueis.
It's not that hard to figureout.
But the question is like why,and as a biomechanics and pain
(10:05):
experts, that we do withathletes.
That's what we're trying tofigure out, because that's what
we're going to fix.
What's the cause of the cause?
All right, so the anteriorbiceps, the biceps tendon, gets
lit up, the anterior capsulegets lit up and it's from
excessive anterior translationof the humeral head in the
shoulder joint, in the shouldergirdle, in relation to the
glenoid fossa, that's where itarticulates with the scapula or
(10:27):
the shoulder blade.
So that excessive anteriortranslation, we will call that
anterior instability or anteriorhypermobility.
Excessive anterior translation,we would call that anterior
instability or anteriorhypermobility.
So shoulder hypermobility,that's a standard, that's a
common thing.
The shoulder joint is superhypermobile, it's very unstable,
all right.
So that excessive anteriortranslation, that also can
(10:49):
create posterior impingement,all right.
So if the front part of theshoulder joint is, somebody goes
into layback like this and theshoulder joint glides
excessively forward toovercompensate for a lack of
shoulder pure external rotationrange of motion, the posterior
contents are going to abutagainst each other early or
(11:10):
excessively.
And that abutment of theposterior rim, of the glenoid
part, of the bone, of thescapula and the humeral head,
that causes posteriorimpingement and that's why the
posterior shoulder pain occurscommonly with this at layback.
When I go all the way back, ithurts in the back of my shoulder
.
It's excessive anteriortranslation and anterior
(11:31):
instability.
Hypermobility of the shoulderjoint and the posterior contents
are getting abutted into eachother.
Andmobility of the shoulderjoint, okay, and the posterior
contents are getting abuttedinto each other, and that would
be posterior impingement and thestructures that get posterly
impinged would be theinfraspinatus and teres minor
and the posterior capsule.
So those guys, those softtissues, is what's getting angry
and irritated and pinched orimpinged upon with a lack with
(11:54):
upon, with excessive anteriortranslation at the layback.
But why?
Again, it's because they'relacking pure external rotation.
We can always work on strengthand stability, so we would call
this it's an anterior shoulderstability problem.
All right, and there's onemuscle that really stabilizes
against this excessivetranslation anteriorly as they
(12:15):
go back and lay back, and thatmuscle is one of the rotator
cuff muscles and that's calledyour subscapularis.
The subscapularis rotator cuffmuscle is located on the ventral
side of the scapula and itspans across the anterior part
of the shoulder joint, of thehumeral head, and that's the
only active tissue that's mainjob is to prevent excessive
(12:36):
anterior translation.
So very commonly that thing'sgoing to be tight and weak, it's
going to be bound down or it'sjust not going to be active as
best it could be and it's goingto be inhibited.
It's not going to be superstrong and recruitable.
So we have to activate thatmuscle more, get it stronger,
get it more activated withfunctional movement overhead,
especially external rotation, toallow the shoulder to rotate
(12:57):
backwards and external rotationwithout excessively just
shifting forward at the sametime.
That takes just some time towork on right.
We also have to improve itspliability.
All right, we have to lengthenthe muscle pliability.
We have to improve itspliability.
So we have to do asubscapularis release too.
(13:18):
That doesn't feel good.
Maybe even dry needle it aswell, if someone's cool with
that.
So we're going to dry needle,we're going to release and work
on the pliability, extension,extension, pliability of the
subscapularis with theflexibility, dry needle it and
then also work on posteriorcapsule mobs of the humeral head
(13:39):
to reseat it in a betterposition and re-educate it to
rotate in a more establishedcenter of rotation.
We call that PICR path ofinstantaneous center of rotation
and then also work on someposterior rotator cuff soft
tissue work and then the subscapMET and then subscap exercises
(14:02):
on the gym floor that we'regoing to do corrective exercises
with overhead movement and withexternal rotation.
So anyway, that's where ourhead's at with that.
That's what our brains arethinking.
If somebody comes in withanterior shoulder pain as a
thrower, one of the first thingswe're looking at is do they
have enough pure externalrotation?
Having enough pure externalrotation is going to solve all
(14:22):
those problems.
It's going to prevent a lot ofthose problems.
That's the best recipe.
So an interesting thing withthat is GERD.
If y'all have ever heard ofGERD, g-i-r-d glenohumeral
internal rotation deficit.
So the shoulder joint rotatesright like this, okay, and if it
(14:42):
has excessive amounts ofexternal rotation, the thought
is they're lacking internalrotation because the shoulder
joint has developed andproliferated into accommodating
more pure external rotation.
So the thought would be likethey're lacking internal
rotation.
Well, that's accepted, that isunderstood to be the case.
(15:02):
That's that's going to betotally understood, expected,
right.
But I'm not going to work onmore internal rotation.
All right, gerd is actually agood thing for shoulder overhead
throwers like baseball players.
All right, gerd is a good thing.
It's an accommodation that theyneed to throw well and have the
(15:26):
best mechanics possible withthat high velocity, high torque,
rotation, throwing motion.
It's an adaptation of threethings.
It's a bony adaptation wherethe humeral head actually
develops more in a retrovertedposition.
So that's going to be a comment.
Imagine like a young kid whothrows and plays baseball a lot.
(15:49):
I mean all the thousands andthousands of throws they've done
.
That influence.
And torque influences thegrowth of the bone over through
adolescence.
So I imagine something likegoes through adolescence years
and puberty, like as they learnhow to throw Like a 10, like
maybe it's like aneight-year-old who then throws
for their whole life.
And now that they're in collegeat 22, right, that's a long
(16:11):
time.
Right, that's what.
14 years, right, that's a longtime.
Right, that's what 14 years.
So, so bony changes getinfluenced in that direction.
Is to accommodate all the stressthey've been going through, all
right, um.
The other one is soft tissuedevelopment.
So like the joint capsuleitself, um develops to get more
lax and and the uh, the anteriordirection, and that bounds gets
(16:33):
bounded down in the anteriordirection.
And it gets bounded down in theposterior direction, I'm sorry,
yeah, in the opposite direction, the posterior structures.
That's to accommodate moreexternal rotation, again, all
right.
And then the other one is justmuscular.
So the muscles get moredeveloped and tight with the
posterior structures and thenalso in the anterior ones they
(16:54):
get more pliable and lax.
But over time compensationpatterns happen and maybe
throwing mechanics change andover over, overly doing, uh
overtraining can happen, like Itotally.
At some point you gotta, yougotta, modify training right.
Overtraining is uh always goingto be a concern.
Um, but at some point got toback it down a little bit right,
even point got to back it downa little bit right.
(17:15):
Even the pro athletes will backit down a little bit to allow
things to settle down.
It wouldn't be smart to justtrain through, but anyway.
So GERD, glenohumeral internalrotation deficit is actually an
expected good thing for throwers.
We're not going to work on moreinternal rotation.
So, as an example, I'm notgoing to do sleeper stretch with
with athletes, I'm not going todo the behind the back rope
pull with athletes or the elbowforward stretch with athletes or
(17:38):
with these throwers.
We're going to work on moreexternal rotation actually, and
that's going to prevent a lot offuture issues and resolve their
pain right.
That's what the ultimate goalis.
So what happens if somebodylacks a periaxial rotation?
Well, they have more anteriortranslation or anterior shifting
of the shoulder joint.
(17:59):
They have more hyperangulationat layback.
So that'd be like the W posture, the W throwing position, so
like if somebody throws andtheir arms out, like this,
they're going to retract theirscapulas more and they're going
to horizontally abduct All right, they're going to horizontally
abduct their shoulder and thatjust creates even more anterior
(18:21):
shift of their shoulder jointand that's no bueno.
Steven Strasburg was reallyhe's a, he was a pro pitcher and
he was really known to havethat W posture.
The thought would be like thathyperangulation position.
It just creates more anteriorshift and more stress and strain
on the anterior structures ofthe shoulder joint.
(18:41):
That has been also correlatedwith medial elbow stress.
So medial elbow stress, as anexample, like Tommy John issues,
that's the anterior band of theUCL ligament in the elbow, so
the owner collateral ligamentand there's an anterior band of
the owner collateral ligamentand that guy gets overly
stretched and strained with alot of valgus forces, which
(19:03):
would be this position herewhere imagine, like shifting
your arm inwards all the timeand your elbow goes forward.
Where imagine, like shiftingyour arm inwards all the time
and your elbow goes forward,that valgus stress on the elbow
stretches and stresses theanterior band of the UCL.
And imagine doing that athousand, thousands and
thousands of times at highvelocity.
But it's gonna cause somechanges and maybe some issues
(19:24):
and then it can cause a ligamentinjury at the UCL and that
surgical repair is called TommyJohn surgery.
All right, so a lack of pureexternal rotation seems to be
just a foundation for a lot ofthese issues to develop Biceps
tendon pain, anterior capsulepain, an excessive anterior
(19:45):
shift of the shoulder joint.
Anterior translation is what wewould call that Hyperangulation
at the shoulder, with throw atlayback with that W position,
creates even more anterior shiftand then more medial elbow
stress.
And the last one is oftentimesathletes will hyperextend their
low back.
So like lumbar hyperextensionand hyperextension rotation.
(20:06):
So another common thing forathletes is with throwers is
they get back pain right.
They excessively hyperextensionrotation.
So another common thing forathletes with throwers is they
get back pain right.
They excessively hyperextendtheir lumbar spine and
hyperextend, rotate their lumbarspine with the throw motion.
It's because they'reovercompensating to get back far
enough as they need to.
And the thing we're going tocheck out if an athlete is their
(20:28):
shoulder rotation, their pureexternal rotation range of
motion, even for an athletecoming in with back pain.
If a pitcher comes in with backpain, we're checking out their
shoulder for sure.
That's what they do, right,their shoulder is their main
driver and the torque that theydo with their throw.
And if their back hurts withthrowing, we're definitely
(20:48):
checking out pure externalrotation range of motion for
their back pain.
So it's just a compensation.
It's interesting how these likethese compensation patterns
lead to manifestations of painelsewhere.
So that's just where ourbrain's at and looking at that
stuff.
So the other things thatinclude.
Here's the last thing I wasgoing to talk about.
(21:09):
The other thing that isimportant to investigate is,
with a lack of pure externalrotation, they're getting
rotation somewhere.
If they're getting back there,the thoracic spine also needs to
rotate and their scapula needsto retract in order to get up
(21:31):
into full layback and their armslot.
So their scapula retracts andtheir thoracic spine rotates and
their shoulder joint externallyrotates.
We would call that the MERM-E-R, the max external rotation
.
So when you see the poster orthe picture of a pitcher in
baseball when they're at theirfull stride and they're at full
layback or late cocking positionfor the throw, they're like way
(21:54):
back there.
Their shoulder isn't the onlything rotating.
Their thoracic spine needs toextend and rotate and their
lumbar spine needs to extend androtate.
But it's mainly we're going tolook at the thoracic spine and
then their scapula.
Their shoulder blade needs toretract and upwardly rotate.
So all those factors, thosethings need to be functioning
well in order to get to a fulllayback position as best they
(22:16):
can and as efficiently as theycan and not have pain.
So we're also going to look atthe scapula for sure and we also
need to work at the thoracicspine rotation for sure.
It's not always T-spineextension rotation, sometimes
it's flexion rotation, but forlayback we need to look at the
rotation range of motion for thethoracic spine and that would
(22:36):
be the MER All right.
So exercises that we work on weneed to work on their scapula,
upward rotation and retraction,which is a tricky thing to work
on.
It's not that it's justsomething that people don't
consider which is a tricky thingto work on.
It's not that it's justsomething that people don't
consider, but we've had reallygood results with athletes when
we work on upward rotation andretraction at the same time and
(22:57):
then also thoracic spine, and wecan't neglect that.
Part of that is core stability,all right.
So it's just interesting to lookat all these factors to help an
athlete that has anteriorshoulder pain, all these pieces
to the puzzle that contribute,and we don't want to leave any
stones unturned as to like whythis athlete that developed
shoulder pain like this, whenthe answer of just overtraining,
(23:19):
that can be effective, for sure, but if that's just, it's just
too much, take a break, you'reworking too much, just rest.
That's a that's a cop-outanswer.
The reason is because all ofhis teammates pitcher teammates
they're throwing at the samevolume.
They don't have the sameshoulder pain that this other
athlete does.
So what is this athlete doingdifferent?
Right?
They're all throwing the sameamount.
(23:40):
Why don't they have shoulderpain?
The same way that this personhas shoulder pain?
It's because this guy's doingsomething different and we have
those compensation patterns weneed to figure out and we need
to work on.
Intervene that appropriatelywith a recipe of the purposeful
manual therapy, some soft tissuework, muscle activation and
recruitment, and then stabilitycorrective exercises out in the
(24:00):
gym, right, all those things.
That's the best recipe and thatshould translate to their
functional throwing motion thatwe're going to, later stages,
work on too, but that's the bestrecipe to actually fix shoulder
pain at layback and that's whatwe have to investigate and
differentially diagnose and it'sgoing to totally change the
trajectory for different peoplebased on their shoulder pain and
(24:21):
all the stuff I mentioned inthe beginning.
So those are just things thatwe got to consider.
So that's just a little sneakpeek and snapshot and like
what's going on in ourevaluative process differential
diagnosis where our brains arethinking if somebody comes in
with shoulder pain as a thrower.
So if any questions, don'thesitate to reach out.
We're always open tosuggestions, comments, questions
(24:42):
, concerns, conflicting opinionsand if you have any questions
yourself or you're battling pain, don't hesitate to give us a
call.
Reach out on our website.
You can DM us on Instagram.
Our phone number is561-899-8725.
Don't hesitate to reach out tous on our email.
The best email to reach us isteam T-E-A-M team at
(25:02):
athleteRCcom and we're alwaysexcited and optimistic to help
people and open to havingconversations.
So feel free to reach out andwe'll catch you all next time.
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