Throwers Elbow

Do you have pain in your elbow and forearm? Especially while batting or throwing?

Baseballers and Javelin throwers in particular may experience throwers elbow. Keep in mind that this is an umbrella term for a range of elbow injuries and not specific to any one presentation. These injuries are most commonly seen in baseball pitchers and other athletes who perform repeated throwing motions during games and practices but can also occur in anyone who tends to load their elbows repetitively during certain activities.

These conditions commonly called throwers elbow include:

  • Ulnar collateral ligament injuries
  • Posterior elbow impingement
  • Lateral and medial epicondylitis
  • Olecranon stress fractures
  • Ulnar neuritis
What are the causes of ulnar collateral ligament injuries in throwing athletes?

In order for us to understand more about throwers elbow, we first have to appreciate the demands of throwing on both the medial and lateral aspect of the elbow, especially the valgus and extension forces (termed valgus-extension overload by many) on the elbow joint during throwing.

According to Fleisig, at late cocking phase – where maximal external rotation of the shoulder (or “lay-back”) occurs, there is a tremendous valgus force on the elbow. The ulnar collateral ligament (UCL) “takes on” approximately 54% of this valgus force.

An illustration of the steps of someone throwing a baseball | Featured image for Throwers Elbow.
Two guys playing baseball.
Throwing and pitching mechanics:

A study by Fleisig (1995) discussed few factors that may predispose and contribute to increased elbow stress among throwing athletes. To start, leading with the elbow too much  increases valgus stress by about 2.5N per degree of horizontal adduction that the arm must travel.  The problem with this is that every successful pitcher you’ll ever see leads with the elbow to some degree, so it becomes an issue of “how much” and “when.”

Another factor is getting to maximal external rotation of the shoulder too early, which can also increase valgus stress on the elbow. Unfortunately, this is one contributing factor to one’s velocity, so these results must be interpreted cautiously.  If we take away that external rotation, we may take away a few miles per hour.  Again, the same goes for horizontal abduction.

Last but not least:

Coordination of the lower extremity with the torso and upper extremity also has a significant impact on the stress imposed on the elbow. This is termed “hip-shoulder separation”, whereby the hips fully rotate open right before the foot gets planted on the ground, which creates rubber band effect. At this position the trunk has more ability to rotate the largest degree of where it wants to aim and gain the most velocity. When a thrower or pitcher rotates their torso and “flies open” too early, what happens is that their arms are going to get forced to come through earlier, and if their arm wasn’t up in the arm cocking position and going into abduction, then their arms are going to get caught dragging, which can end up imposing increased stress through their medial elbow region.

Scapular Stability Importance for Cricketer.
So then…How do we avoid throwers elbow?

Essentially, there is no one single mechanical model that governs how one should pitch or throw, for instance the arm slot (i.e., the angle, relative to the ground, that the pitcher’s arm comes through at the Release Point). Besides, changing these mechanics too drastically may take away what makes these professional pitchers successful.

In addition, we cannot accurately predict and prevent injuries (as the human body is comprised of a multitude of systems and tissues that influence each other, while also being influenced by external considerations respective to the task being performed, specific task demands, and environment the task is being performed within.)

A man playing tennis | Featured image for Throwers Elbow.
A woman's torso holding her elbow with her elbow highlighted to display pain | Featured image for Throwers Elbow.

Nevertheless, we can aim to minimize the risk of UCL injuries of the elbow (especially for little leaguers), via key foundational throwing qualities, such as training and optimizing hip- shoulder separation, which can then allow better coordination and transferring of forces along the lower extremity to the upper extremity, from large mass of the hips and torso to the small mass of the hand.

Other than improving foundational mechanics, other important factors to consider include: physical preparation, load management/ proper programming, and recovery.

Physical Preparation:

Often when it comes to physical preparation among throwing and pitching athletes (and many other sporting athletes), “sport-specific training” can be overly redundant leading to the athlete not having as much variability and adaptability. For example, a baseball athlete whose training only involves doing a bunch of rotation, swing heavy bats and swing an incredibly high volume etc., especially when they’re already doing a lot of rotation and swinging during competitive exercise practice.

Off-season training is a great opportunity to increase more variability, “fill the gaps” and address individual limiters. Essentially we want to match the stimulus of the sport to our physical preparation, and to match training exposures to task exposures and build familiarity to stimulus.

A close up of a woman's torso laying down while another person is bending their elbow and holding their bicep | Featured image for Throwers Elbow.
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