Shoulder Pain in Overhead Athletes Case Scenarios
Abstract
Overhead throwing involves complex biomechanical sequences[1] that generate high forces through the kinetic chain, from ground reaction forces through the lower extremity, pelvis, trunk, and ultimately to the throwing arm.[2] Breakdown at any point in this chain can lead to compensatory mechanisms and increased stress on the shoulder and elbow.[3] Understanding these biomechanical relationships is essential for effective assessment and management of shoulder pain in overhead athletes.
Two fictional case scenarios are presented in this page. Each scenario describes a baseball pitcher who presents with shoulder pain. Their histories and the potential biomechanical causes of their shoulder pain are explored. Specific diagnoses are not discussed in these scenarios. Instead, the focus is on the systematic assessment of biomechanical contributors. For any patient with shoulder pain, a full assessment, including a cervical screen, must be undertaken.[4]
Case 1: The Young Pitcher with Anterior Shoulder Pain
Examination Findings
An 18-year-old baseball pitcher presents with anterior shoulder pain that is localised to the biceps tendon during the late cocking (layback) phase of throwing. The pain has been present for around four weeks and has had a gradual onset. Initially, the athlete attempted to "pitch through" the discomfort, but the pain has progressively worsened, and is now affecting his performance and confidence on the mound.
The athlete has no history of a traumatic shoulder injury, and there was no specific incident before the onset of symptoms. The pain has a clear mechanical pattern, as it is consistently aggravated by throwing activities and is relieved by rest.
Biomechanical Analysis
Anterior shoulder pain during late cocking could have a number of causes. A systematic assessment of the entire kinetic chain is necessary to ensure effective management. The following sections highlight potential causes of anterior shoulder pain for this athlete.
Total arc of motion loss: The total arc of motion is the sum of an athlete's external and internal rotation range of motion. It should be equal between the dominant and non-dominant shoulders.[5][6] An external rotation loss of 5 or more degrees increases injury risk by 2.8 times.[7] An internal rotation loss of 5 or more degrees increases a baseball pitcher's injury risk by 2.5 times.[8]
Reduced shoulder external rotation range: Limited external rotation can prevent an athlete from achieving an optimal position during the late cocking phase. If they cannot achieve adequate external rotation (i.e., the hand and ball are at least parallel to the elbow), they will increase stress on their shoulder or elbow. Potential causes of an external rotation deficit include: overactive subscapularis, teres major/latissimus dorsi, scapular malpositioning, and thoracic spine dysfunction.
Reduced shoulder internal rotation range: An internal rotation loss can increase tensile stress on the structures of the shoulder. Potential causes include: infraspinatus, teres minor and posterior deltoid deficits and issues with scapular and thoracic positioning.
Multi-segmental extension deficits: Achieving the late cocking position requires coordinated extension through the thoracic spine, lumbar spine and hips, combined with adequate shoulder flexion. Early flexion or an inability to maintain lordosis can prevent an athlete from achieving an optimal late cocking position, increasing the stress on the shoulder.
Kinetic chain dysfunction:[9] Altered kinetic chain function can impact throwing mechanics and increase stress on the shoulder. This can occur when there is a lack of pelvis-torso separation. This lack of separation is most often caused by limited thoracic rotation, but it can also be seen with reduced trail hip external rotation, reduced lumbar rotation, or a lack of motor control. Reduced pelvis-torso separation may require professional coaching if adequate mobility and motor control are already present. This dysfunction tends to impact performance, resulting in reduced velocity or inconsistent control. However, it can occasionally influence shoulder pain.
Interventions
Treatment for this athlete would aim to systematically address all identified deficits and contributions from the kinetic chain.
The pyramid of corrections provides a general framework for treatment. In this approach, pain is addressed first, followed by mobility, motor control, strength, functional strength, functional drills, and, finally, pitching.
A range of soft tissue, self-massage and stretching techniques can help restore external rotation deficits. Similarly, soft tissue release and the sleeper stretch are beneficial for internal rotation deficits. See Treatment Strategies for Range of Motion Limitations for more information.
Multi-segmental extension training can help an athlete achieve and maintain the extension range necessary for optimal throwing mechanics. Kinetic chain sequencing drills can address timing and coordination issues necessary for proper pelvis-torso separation during throwing. See Three-Phase Approach to Treating Kinetic Chain Impairments in Overhead Athletes for more information.
Case 2: The Experienced Pitcher with Posterior Shoulder Pain
Examination Findings
A 30-year-old male baseball pitcher presents with posterior shoulder pain during the follow-through phase of throwing. This athlete reports a dull ache in the posterior aspect of his shoulder that has been gradually worsening over the past six weeks. He describes his pain as deep and aching. It intensifies during the arm deceleration and follow-through phases of pitching.
The athlete has no history of traumatic injuries but states that his training intensity has recently increased and, since then, his pain has progressively worsened.
Biomechanical Analysis
Posterior shoulder pain during follow-through can have a number of causes. A systematic assessment of the entire kinetic chain helps identify any potential contributing factors.
The following sections highlight a range of potential causes of posterior shoulder pain that could be relevant for this athlete.
Reduced internal rotation and horizontal adduction: During follow-through, pitchers decelerate their arm, with a combined internal rotation and horizontal adduction movement. Insufficient internal rotation essentially "shortens the runway", reducing the range available to decelerate the arm and increasing stress on the shoulder structures.[5]
Scapular compensation: When internal rotation and horizontal adduction are limited, the scapula might compensate by moving excessively forward and into internal rotation during deceleration. This alters the ability of the scapula to provide a stable base, which, in turn, increases stress on the rotator cuff during deceleration.[5]
Reduced pelvis-torso separation: When athletes cannot lead and rotate with their pelvis while maintaining a torso lag (ideally ~40° separation), they will tend to bring their pelvis forward early, forcing them to throw across their body and increasing posterior shoulder stress.
Interventions
As in Case Scenario 1, rehabilitation for this athlete would focus on systematically addressing all identified impairments.
A range of soft tissue and stretching techniques can be introduced to address internal rotation and horizontal adduction mobility restrictions.
Scapular stabilisation exercises could be beneficial. The initial focus would be on improving scapular control and stability before progressing to more challenging strengthening exercises. For more information, see Scapular Interventions for Overhead Athletes.
Pelvis-torso separation deficits can be addressed with a three-phase approach. Phase one focuses on mobility, flexibility and motor control. Phase two focuses on strengthening and stability. Phase three focuses on integration and functional movement. For more information on these exercises, see Three-Phase Approach to Treating Kinetic Chain Impairments in Overhead Athletes.
Conclusion
Managing shoulder pain in baseball pitchers requires clinicians to understand the demands of pitching. Effective assessment starts with a thorough evaluation of the shoulder itself, including the total arc of motion and the external-to-internal rotation strength ratio. Other aspects of the kinetic chain should also be assessed, including the scapula (i.e., scapular resting position, passive range of motion, active range of motion, dyskinesia and strength), thoracic spine, pelvis, pelvis-torso separation and multi-segmental extension capacity.
Optimal rehabilitation must address any impairments identified in the assessment. The pyramid of corrections provides a useful framework to guide treatment. In this approach, pain is addressed first, followed by mobility, motor control, strength, functional strength, functional drills and pitching.
References
- ↑ Kibler WB, Sciascia AD, Grantham WJ. The shoulder joint complex is involved in the throwing motion. Journal of Shoulder and Elbow Surgery. 2024 Feb 1;33(2):443-9.
- ↑ Jones Jr SD, Safran MR. Current concepts: the hip, core and kinetic chain in the overhead athlete. Journal of Shoulder and Elbow Surgery. 2024 Feb 1;33(2):450-6.
- ↑ Owens LP, Coyles G, Khaiyat O. Alterations to the Kinetic Chain Sequence After a Shoulder Injury in Throwing Athletes. Orthopaedic Journal of Sports Medicine. 2024 Nov;12(11):23259671241288889.
- ↑ Ward K. Foundations for clinical assessment in sports and exercise therapy. In Routledge Handbook of Sports and Exercise Therapy 2024 Jun 13 (pp. 361-506). Routledge.
- ↑ 5.0 5.1 5.2 Kaplan A. Shoulder Assessment and Treatment Principles in Overhead Athletes Course. Plus, 2025.
- ↑ De Luigi AJ, Raum G, King BW, Bowers RL. Osteopathic approach to injuries of the overhead thrower’s shoulder. Journal of Osteopathic Medicine. 2025 May 22;125(6):285-98.
- ↑ Camp CL, Zajac JM, Pearson DB, Sinatro AM, Spiker AM, Werner BC, et al. Decreased shoulder external rotation and flexion are greater predictors of injury than internal rotation deficits: analysis of 132 pitcher-seasons in professional baseball. Arthroscopy. 2017 Sep;33(9):1629-1636.
- ↑ Wilk KE, Macrina LC, Fleisig GS, Porterfield R, Simpson CD 2nd, Harker P, Paparesta N, Andrews JR. Glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers are correlated. Am J Sports Med. 2011 Feb;39(2):329-35.
- ↑ Wada N, Otsuka M, Yamaguchi Y, Tsuji T, Kojo T, Kono T, Nishiyama T. The association among ball speed and the rotation of pivot leg, pelvis, and trunk separation in collegiate baseball pitchers. Heliyon. 2025 Feb 15;11(3).