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Wilk et al describes the throwing athletes' predicament by defining The thrower's paradox: The thrower's shoulder must be lax enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability. The etiology behind a throwing injury can be analyzed by looking at the different phases of an overhead throw.
The wind up phase is defined as the initial movement to maximum knee lift of stride leg.[3] During the initial movements the pitcher brings his or her hands overhead and lowers to chest level. The picture below depicts an overhead view of the alignment of the body during the acceleration phase of throwing. The arm deceleration phase begins at ball release and ends at maximum shoulder internal rotation.[3] Typically the concern in this phase is safely decelerating the forward progression of the arm. Olsen et al surveyed 14-20 year old baseball players to determine possible risk factors for surgery among adolescent baseball pitchers. Compared with the control group, the shoulder injury group pitched significantly more months of the year, innings per game, pitches per game, pitches per year, and warm-up pitches before a game.
The ability to provide the best physical therapy for the throwing patient involves understanding the phases and biomechanics behind throwing. Athletes with throwing injuries typically present with an increase in shoulder external rotation and a decrease in shoulder internal rotation. Changes in the tissue structure of the anterior capsule of the GH joint is theorized to be the greatest contributor to increase in shoulder external rotation.
The osseous adaption most notably seen in a throwing athlete is an increase in retroversion of the humeral head in the glenoid.
Common strength deficits demonstrated by throwing athletes are weak shoulder external rotators and strong shoulder internal rotators and adductors. The scapula plays an important role throughout any movement of the arm especially with overhead throwing. The physical examination of an overhead throwing athlete should involve a thorough upper quarter examination that includes the joints above and below the shoulder. While preventative and conservative treatments are the most critical components of rehabilitation for common injuries affecting the throwing athlete, concomitant medical management is indicated for certain conditions. Imaging Concerns: Failure to demonstrate marked progress by 3 months or return to asymptomatic competition by 6 months necessitates imaging if not already obtained. In younger throwing athletes, especially pitchers ages 13-16, radiographic images may be useful to rule out a stress fracture to the proximal humeral epiphysis.
The radiographic evidence of humeral torsion (retrotorsion) in the dominant arm of the throwing athlete is a normal and benign finding regardless of age, gender, or sport. Imaging may be useful to detect osseous changes or osteophyte formation, especially in the older throwing athlete due to repetitive trauma. Imaging is also used to detect type and severity of other conditions such as SLAP lesions, Rotator Cuff lesions, and Rotator Cuff Tears. SLAP Lesions: Of the four main categories of SLAP lesions, throwing athletes typically present with a Type II tear which includes a full or partial detachment of the biceps brachii tendon from the superior labral attachment in addition to labrum involvement. Rotator Cuff Lesions: Injury to the rotator cuff muscles or the bicipital tendon may be due to primary or secondary impingement of the subacromial structures. Acute Traumatic Instability: Although the majority of pathologies related to the dominant shoulder in the throwing athlete are categorized as overuse or damage resultant from repetitive trauma, the occurrence of acute traumatic instability or dislocation most often indicates surgical management. Please refer to this Physiopedia link for surgical information on shoulder Internal Impingement. The ballistic six exercises were developed to reproduce the conditions under which the shoulder girdle musculature must act to control the head of the humerus on the glenoid during the overhead throwing motion.

Whiteley's review entitled: "Baseball throwing mechanics as they relate to pathology and performance - A review," does an exceptional job relating the biomechanics of throwing to physical therapy based on the research of over 100 articles. In the article: “Risk Factors For Elbow And Shoulder Injuries In Adolescent Baseball Pitchers,” Olsen et al focused on the little clinical evidence surrounding current safety recommendations for little league pitchers. The purpose of the article: “Shoulder Injuries in the Overhead Athlete,” is to discuss the physical characteristics of the overhead athlete, common pathologies, and the non-operative, surgical, and postoperative treatment.
Learn about the shoulder in this month's Physiopedia Plus learn topic with 5 chapters from textbooks such as Magee's Orthopedic Physical Assessment, 2014 & Donatelli's Physical therapy of the shoulder 2012. The phases of an overhead throw consist of a wind up, stride, cocking, acceleration, and deceleration phase.[3] Each phase will illustrate the definition, injury occurrence rate, and lastly pathological possibilities. Due to the circumstances the scapula and shoulder muscles are highly activated to promote and sustain movements of the shoulder, especially external rotation. Improper stabilization of the scapula may be the cause of increased risk of shoulder impingement in this phase.
Escamilla et al states that a shoulder compressive force slightly greater than bodyweight is generated to resist shoulder distraction, while a posterior shear force of 40–50% of bodyweight is generated to resist shoulder anterior subluxation.
95 players were placed in the injured group (66 elbow, 29 shoulder injuries), and of 300 prospects contacted for the control group only 45 fit the criteria.
These pitchers were more frequently used as starting pitchers and pitched in more showcases. It is important to note that while these athletes are throwing with their arms, that they gain a large, important amount of momentum and force through the use of their legs and torso. In order to properly assess and evaluate a thrower’s shoulder an understanding of physical characteristics and clinical presentation is necessary.
The decrease in shoulder internal rotation can be further defined as glenohumeral (GH) internal rotation deficit (GIRD).[1] Ranges of motion for an overhead throwing athlete’s shoulder vary from researcher to researcher. The hypermobility seen in throwing athletes has been further defined as “thrower’s laxity” which signifies the laxity present in the anterior and inferior capsule of the GH joint.
Unilateral muscle ratio at the shoulder and more specifically antagonist-agonist muscle strength ratio have been utilized to assess muscle balance necessary at the shoulder to maintain dynamic stabilization. A common issue faced with throwing athletes is scapular dyskinesis which is the alteration in motion of the scapula during coupled scapulohumeral movements. The injuries incurred by these athletes are wide-ranging, requiring an in depth evaluation to tease out the pathology. This injury results from repeated tensile and torsion forces from external rotation in the late cocking phase as well as the eccentric biceps brachii contraction through deceleration.
Although primary impingement is rare in throwing athletes, both conditions typically respond well to conservative therapy. Current research demonstrates very poor return to play outcomes for throwing athletes who undergo surgical intervention for full rotator cuff tears, especially baseball pitchers.
The sets, reps, and progression of the ballistic six training regimen was developed to follow the SAID principle of progressive resistance exercise and also to tax the anaerobic and aerobic systems of the pitcher in a similar pattern to that of a baseball game. By doing a retrospective survey they were able to identify four significant risk factors surrounding adolescent pitchers who required elbow or shoulder surgery versus those who didn’t. It was found that the thrower’s shoulder must be lax enough to allow excessive external rotation but stable enough to prevent symptomatic humeral head subluxations, thus requiring a delicate balance between mobility and functional stability.
Current evidence necessitates performing a comprehensive examination to differentially diagnose the multiple deficiencies that may result from the substantial repetitive forces on the shoulder complex of a thrower.

Humeral Head Retroversion in Competitive Baseball Players and Its Relationship to Glenohumeral Rotation Range of Motion.
Users' Guide To The Musculoskeletal Examaniation: Fundamentals for the Evidence Based Clinician.
Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. 2011, The Advanced Throwers Ten Exercise Program: a new exercise series for enhanced dynamic shoulder control in the overhead throwing athlete.
Effect of Pitch Type, Pitch Count, and Pitching Mechanics on Risk of Elbow and Shoulder Pain in Youth Baseball Pitchers. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. EMG studies show that the upper trapezius has a maximum voluntary isometric contraction (MVIC) of 18%, serratus anterior 20%, and anterior deltoid 15%. External Rotation can range actively at 90o abduction from 118o to 141o and passively at 136.9o. Controversially, research has also shown posterior capsule laxity in throwing athletes without anterior capsule issues and mixed deficits in range of motion. Chant et al theorized that a larger angle in retroversion of the humeral head would constitute an increase in shoulder external rotation prior to the anterior capsule and GH ligaments. Specifically a syndrome known as “SICK” scapula is faced by throwing athletes who have postural issues that essentially maligns the scapula. Therapeutic consideration of the involved tissues should lead treatment and decisions of return to play as ROM and strength are properly restored.
Type II & IV SLAP tears often do not respond well to physical therapy or corticosteroid injection. The most common mechanisms for secondary impingement of rotator cuff muscles is joint instability and laxity, most often involving lack of adequate scapular control. Please note that decreasing the distance away from center or decreasing the angle did not result in increased anterior force on the shoulder. Overtime the excessive utilization of the biceps brachii could lead to a superior labrum anterior to posterior (SLAP) tear. These muscle groups have shown the greatest muscle activity in EMG studies during all phases of throwing and contribute to mobility and stability of both the humerus and scapula. The anterior, inferior, and posterior portions of the joint capsule must be evaluated to determine whether a hyper or hypomobility is present. So, because of the increased anterior force on the shoulder, it can be assumed that over time the anterior ligamentous structures to the glenohumeral joint may be compromised. Total motion, which is the combination of external and internal rotation, was found to be approximately equal on both the throwing and non-throwing shoulder of professional baseball pitchers. Wilk et al concludes that in order to maintain stability during throwing movements the external rotators would have to constitute 65% of the strength of the internal rotators which is near the optimal 66 to 75%.

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