Transcription:
Throwing Shoulder

Prakash:    Playing sports on a regular or professional basis can take a serious physical toll on the body. When athletes perform repetitive overhead motions, they can experience a number of injuries including throwing shoulder. We'll learn about it today with Dr. Barry Hyman, an orthopedic surgeon at Montefiore St. Luke's Cornwall Hospital. This is Doc Talk, the podcast from Montefiore St. Luke's Cornwall Hospital. My name is Prakash Chandran. So first of all, Dr. Hyman, it is great to have you here today. I'd love to start by you telling us a little bit about your background and what you do as an orthopedic surgeon.

Dr Barry Hyman: I finished my residency in orthopedic surgery. And then I did a fellowship in sports medicine orthopedics at Johns Hopkins in Baltimore, where I worked with Dr. Charles Silverstein, who was the team physician for the Baltimore Orioles. So while I was there, I developed an interest in throwing shoulder, as I worked with him help cover the team.

When I later came to St Luke's area in Newburgh, there was a new team coming in for farm club. It was at that time the Texas Rangers are just starting, they're called the Hudson Valley Renegades. And because of my baseball experience, I contacted them and they were happy to have me become the team physician. A few years later after the baseball strikes, Tampa Bay took over and I was working with him for about 24 years. Now, this year, again, after a year break from COVID, the Yankees are coming in and I'll be helping them as well.

Prakash: Okay. That's awesome. That's a good primer to why you got interested in this throwing shoulder. So let's talk a little bit about what exactly throwing shoulder is.

Dr Barry Hyman: The throwing shoulder really means pain or injury of somebody who throws. And there are many, many different mechanisms where people who throw a lot develop pain.

Prakash: Okay. And when you say pain from someone who throws, is it like localized pain? Does it feel like a pinch or is it just all over the shoulder? Talk a little bit about that.

Dr Barry Hyman: So it often occurs in the different stages of throwing. So for instance, we know with pitchers, when they start to pitch, there's a windup, they have early cocking, late cocking, acceleration, deceleration and follow-through. So there are different stages of that. And the shoulder has more stress during different parts. For instance, the late cocking is where the arm is way back and that puts a lot of stress in different areas of the shoulder. But it could be at any point in the throwing mechanism that could cause an injury or what we sometimes call pathology to the shoulder joint.

Prakash: I see. And is this something that happens suddenly that you sustain this injury or is this something that kind of develops over time?

Dr Barry Hyman: Oh, it can do both ways. More often, it's a gradual onset and occasionally there is a sudden event that can occur. But for most of the throwing shoulder problems, they're usually gradual onset from overuse or from incorrect mechanics.

Prakash: Is throwing or thrower's shoulder something that only affects baseball players?

Dr Barry Hyman: No, it affects anybody who's an overhead athlete, or even sometimes it could be a softball pitcher as well, because not only do they pitch underhand, but they have to toss the ball overhead as well. So tennis players get it quite commonly, volleyball players as well.

Prakash: Okay. So I want to go into a little bit about diagnosis now. How do you separate out a sore shoulder versus the onset of throwing shoulder?

Dr Barry Hyman: So basically, most of the time, if you have pain that lasts more than a day or two, that's not good. I mean, anybody who does any sort of muscular stress, for instance, somebody who goes to the gym and starts weightlifting. In the beginning, the muscles aren't used to that, then you can get some muscle soreness from that. That's something that if it's done correctly, it's not a big problem and nothing to worry about.

Other than that, pain in the shoulder should be considered a problem and should be thought about, because if you detect early, you can prevent a major problem and often prevents surgery and allow the athlete to continue at a high level.

Prakash: Okay. So typically, an athlete will come to you with either acute shoulder pain or something that's more gradual. Then what? How do you go about diagnosing and then initially treating it?

Dr Barry Hyman: So let's say it's one of the professional baseball players and they have shoulder pain. First of all, before they even get the shoulder pain. And I must say that the major league baseball has done a tremendous job at this. They have a trainer who works with them and teaches them what to do to sort of prevent this from happening.

So they're doing what we call rotator cuff and scapula stabilizing strengthening exercises which actually protects the shoulder and puts it in an environment that will not allow it to cause what we call impingement or secondary impingement, which causes trauma. The other thing that they do is they examine range of motion ahead of time. And sometimes some people with a shoulder problem has loss of motion, especially what we call it internal rotation. External rotation is what we're talking about in the cocking stage. But the internal patient is where they don't really even pay attention to and that's the opposite. And if you get tight there, that causes shoulder problems.

So when somebody comes to us with pain, the first thing we ask them is have they been doing their exercises? And we examine them of course, and see if they have a tight shoulder, and try to figure out by the physical exam where their pain is.

Prakash: I see. And the exercises that are available to professional athletes, is this something as a lay person that I can look up and to start doing, if I had shoulder pain?

Dr Barry Hyman: Yes. In fact, somebody who's a throwing athlete or an overhead athlete, whether they're a baseball player or a tennis player, should be doing these exercises and they go online and they can look them up as baseball throwing shoulder exercises. They could look at rotator cuff and scapula stabilizers strengthening exercises. And that's one of the group of exercises. There's also core body strengthening. The core body needs to be strengthened. And that also tremendously protects them from injury.

Prakash: Okay. That makes a lot of sense. So let's talk about when things have potentially gone on a little too long and surgical treatment is needed. Talk a little bit about when that needs to happen and what surgery looks like.

Dr Barry Hyman: If you don't mind, I'd like to step a little further backwards. And let's say, when they first come, what do we do when they have pain? Because that may prevent surgery and then we'll go into the surgical part of it. So originally, what we do is when they come in, we actually shut them down. We do not allow them to throw any more and we have them take a break for maybe up to two weeks' time and let things rest. That's what I call the orthopedic four-letter word, R-E-S-T. And, in general, nobody wants to hear that. But it's absolutely necessary when somebody has a pain in the shoulder from throwing, that they take that break and they start an anti-inflammatory routine, whether it's an oral anti-inflammatory and just rest.

And then, they start, after that, doing the rotator cuff exercises, and then they go through with a throwing program, starting with short toss, long toss over another maybe 14 days, allows them to resume. And lot of people when they do all of this can resume throwing without pain.

And the other thing we have them do is we'll have their pitching coach look at their mechanics and make sure that they're doing everything right. Sometimes it's just a matter of lifting the elbow a little higher when they're doing their tosses. So that part, we start with. Occasionally, cortisone injection, but usually not initially, but occasionally that helps. And then, surgery is really a last resort because, to be honest, a lot of pitchers never go back to what they were before when there's a surgery. Some do, but a lot of times it doesn't happen.

Prakash: Okay. So what you're saying is really that surgery is the last resort option. There are plenty of proactive things, stretches and strengthening exercises that they can do because, once they do surgery, you'll never really go back to the way things were. Is that correct?

Dr Barry Hyman: Not never. The chances are not that great with a few exceptions. Now, somebody should have that sudden injury and they maybe tear the rotator cuff, that's a different example. And that time surgery has to be done. But I'm talking about the overuse injuries that are the most common in the throwing athlete.

Prakash: Okay. Understood. So let's say there is a younger athlete that is listening to this and, you know, they haven't necessarily gone professional yet, but they want to be proactive about keeping their shoulder safe and healthy because they do a lot of overhead movements. What advice might you have for them?

Dr Barry Hyman: So they should find a coach that they think is a really good pitching coach. And they should learn proper techniques and they should go to that coach regularly and have them check and watch their techniques to make sure that they're doing them correctly. They need to get involved in a rotator cuff and scapula stabilizer strengthening programs.

They need to make sure that their range of motion is good. And a good pitching coach can help them with that. If there's any question, then certainly me or any other orthopedic who specializes in throwing shoulder would be happy to see them.

The other thing is pitch counts. Especially with a young player, a lot of times they're in different leagues. They play for their school. They play for different teams that are out there. And each coach may not know what they're doing with the other one. So they have to have pitch counts and everybody who's involved in their career needs to know what else they're doing.

And the pitching counts are actually easily available online to know what the maximum should be, although they do have variations and certain States have rules. There are variations, but the idea is that not only do you have certain numbers that after you throw you should stop, then also how much you should rest. For instance, 15 to 18-year-olds throw over 76 pitches, they need to rest for four days. But if they pitch only 31 pitchers, they can maybe pitch after one day rest. So those are important.

Prakash: Yeah, it's amazing how much more of a science it is now, now that we understand so much more about the shoulder or about averages and technique. There are things like pitching counselors that can really help people and athletes do this in a safe way. Wouldn't you say?

Dr Barry Hyman: Absolutely. In fact, what's interesting, let's say, in the Minor League game, somebody's pitching a no-hitter. And usually, if they're pitching a no-hitter, they're not throwing that much. But whatever it is, it gets down towards the ninth inning and they've reached their pitching count, which they've decided for the Major Leagues what's the maximum, they'll stop them. They won't let them pitch the no-hitter. And I think that's wonderful. I think that's using science and being smart, protecting that pitcher so that they can perform in the future and have a better chance of making it to the majors.

Prakash: So just as we close here, in your history and past dealing with so many different types of people and shoulder injuries, is there anything that you wish more people knew before they came to see you?

Dr Barry Hyman: Well, basically what I sort of mentioned earlier is that they need to learn how to do the rotator cuff strengthening exercises. They need to work on their core body strength and work on their technique. And the better they would make their techniques, the more chance they have of lasting. And they should ask for help immediately, if they have pain.

Prakash: Well, Dr. Hyman, that is the perfect place to end. Thank you so much for your time and your insight today. That's Dr. Barry Hyman, an orthopedic surgeon at Montefiore St. Luke's Cornwall Hospital. For more information, head to MontefioreSLC.org to get connected with Dr. Hyman or another provider.

And also you can look up baseball throwing shoulder exercises or rotator cuff and scapula stabilizer exercises online if you'd like to look at some of these exercises yourself or, depending on your region, you can search for a pitching counselor just as Dr. Hyman was mentioning to get started early and be proactive about keeping that shoulder healthy.

If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks for checking out this episode of Doc Talk. My name is Prakash Chandran, and we'll talk next time.