Strength in Numbers #194
I am getting back to pain as we are in a warzone. I keep saying our platform represents the pain of discipline, so our athletes avoid the pain of disappointment.
The beginning of the season has the highest injury incidence across all sports. Still, top to bottom, baseball sees more throwing injuries in the opening months than at any other point in the season.
In serving my athletes, one of the most challenging ailments to overcome for the throwing arm is referred pain. It is a common but often misunderstood issue among throwing athletes, particularly baseball pitchers and quarterbacks.
Unlike localized pain, referred pain originates from one area of the body but is felt in another, making diagnosis and treatment more convoluted, as you cannot treat the area of pain without understanding its source.
This article will explore the mechanisms, causes, complications, diagnosis, and treatment of referred pain in throwing athletes. It will also discuss the role of throwing arm strength in its onset and management.
Better to understand and prevent referred pain than to need a referral for a surgical procedure.
What is Referred Pain?
Referred pain occurs when the brain interprets pain signals from an injured structure as originating from a different location. This is due to how sensory nerves from other body regions converge on the same pathways in the spinal cord. For example, a pitcher with an irritated suprascapular nerve from a rotator cuff issue may experience pain in the upper arm or lateral shoulder rather than at the actual injury site.
Physiology and Mechanisms of Referred Pain
The key physiological mechanisms behind referred pain include:
- Convergence of Nerve Pathways: Pain signals from different anatomical areas merge within the spinal cord before reaching the brain. The brain may then misinterpret the source of the pain.
- Central Sensitization: Chronic irritation or inflammation can lead to heightened pain sensitivity, causing referred pain to spread beyond the original injury.
- Neurogenic Inflammation: When pain is prolonged, the nervous system can amplify pain signals, leading to wider pain distribution.
An athlete indicated where his source of referred pain is, which turned out to be subacromial impingement (pinching of the upper fibers of the rotator cuff under the acromial arch).
Causes of Referred Pain in Throwing Athletes
1. Shoulder Injuries
- Rotator Cuff Tears/Dysfunction: Can refer pain to the lateral deltoid, upper arm, or forearm.
- Labral Tears (SLAP Lesions): May cause referred pain into the biceps or down the posterior arm.
- Impingement Syndrome: Often leads to pain in the lateral shoulder or scapular region. I mentioned this one, and it needs attention as it can radiate and travel to other parts of the shoulder.
This clip from our Certified Biomechanist course shows inverted co-contraction training that can prevent and improve impingement pain. Incorporate this exercise and others we show to reduce chronic irritation, inflammation, and misinterpretation of pain in the brain.
2. Elbow Injuries
- Ulnar Collateral Ligament (UCL) Strain: Can create pain in the forearm, wrist, and even fingers. Areas where proximal tears may be experienced are along the medial border of the ulna, the long forearm bone on the pinky side.
Referred pain for a proximal UCL tear. The red circle is approximately the location of the proximal origin of the anterior band of the UCL. From this image, the pain reported was about an inch above the distal attachment of the UCL, which is generally treated with Tommy John Surgery or an internal brace.
From our Certified ArmCare Specialist Course, we talk about biceps training being the critical exercise selection and the importance of elevating the elbows in performing biceps curls, as the biceps is one of the strongest stabilizers of the inner elbow.
3. Cervical Spine Dysfunction
- Cervical Radiculopathy: A compressed nerve in the neck can refer pain to the shoulder, arm, or even hand.
- Trapezius Tightness: Often seen in pitchers with poor mechanics, leading to referred pain down the arm.
A key feature mentioned within the band training sections of our certifications involves cuing athletes to squeeze the handles maximally, as it reduces activation of the upper trap and increases activation of the forearm muscles and posterior rotator cuff. This can reduce referred pain because of nerve compression or shoulder impingement associated with highly active and tight upper traps.
4. Thoracic Outlet Syndrome
- Compression of the brachial plexus (nerve bundle controlling the arm) can cause numbness, tingling, and pain in the shoulder, forearm, and fingers.
Our MLB Habits course goes deep into circulation and how to promote it. As pitchers throw beyond 60 pitches, circulation plummets. One of the leading causes that exaggerates blood loss to the throwing arm is a lack of joint stability and a hypermobile shoulder. Coupled with nerve compression, this is a recipe for disaster, and symptoms can be felt in the fingertips that are far away from the leading injury site.
Complications of Referred Pain
In my experience, if left untreated, referred pain can cause several complications for throwing athletes.
- Misdiagnosis: Corrective treatments may be prescribed because pain is felt away from the actual injury. Other things I have noted are athletes taking heavy doses of anti-inflammatory medications with minimal relief. Long term, this is not good for the gut.
- Chronic Pain and Inflammation: Persistent referred pain may lead to chronic conditions, central sensitization, and impaired performance. This creates emotional pain as the athletes are searching for answers to their pain, and it is not being alleviated by treating symptoms, where the root cause is often missed.
- Altered Mechanics and Compensation Injuries: Athletes may unknowingly adjust their throwing mechanics, leading to secondary injuries (e.g., increased elbow stress due to shoulder pain). This is one of the most common injury mechanisms: an athlete changes their delivery, and joint loads increase while arm strength decreases to resist wear and tear.
Internal impingement is a common injury mechanism, and we go through this in detail in our Certified Pitching Biomechanist Course. Understanding 3D data and learning how to stabilize the shoulder is important to overcome referred pain. When the arm drops, potentially due to central sensitization, pain is all over the shoulder, but lessens with a lower arm slot. Internal impingement may occur, especially with more arm motion behind the acromial line.
Get Ahead of the Pain
The weather is changing; the demands are increasing. Athletes who are indoors are now outdoors and may not be using our guidelines for staging increases in pitch counts or even individualizing them.
The Spring Training ramp-up may have been too steep for the pros, with arms not ready to accept the demands. February – Mid May, the time when weather generally goes cold to warm, is a critical stage in reducing pain, and when it is referred, that pain is felt by everyone, as strength coaches, trainers, physical therapists, coaches, and front offices are often puzzled by athletes who can’t literally not put a finger on it.
Sink your teeth into our education and stop the insanity, as the pain of discipline or the pain of disappointment is essentially the only choice we have in the matter.
Strength Matters Most,
Ryan
Ryan@armcare.com