What Throwers Need to Know About Arm Pain

Strength in Numbers #193

Pain is an essential part of the human experience—it serves as a warning system, signaling injury or potential harm. Pain is an ever-present challenge for athletes, especially throwing athletes like pitchers and quarterbacks. Understanding how we sense pain, factors that influence pain tolerance, and strategies to manage pain can be the difference between a successful recovery and chronic issues.

In this article, we will break down:

• How we perceive pain
• Factors that influence pain tolerance
• Specific research on upper extremity pain in throwing athletes
• The science behind phantom and referred pain
• Strategies to increase pain tolerance for rehabilitation

We have created a great course called Eliminating Arm Pain and Soreness, and we need to dive into this matter—the beginning of the season is the highest injury-risk time point. You cannot ignore pain, but let’s learn a little more about it and consider taking the course to understand how to expedite recovery, go through a critical diagnostic cycle to determine the course of action, and return to throwing safely.

You can choose the pain of discipline, or the pain of disappointment – you have a choice.

How Do We Sense Pain?

Pain perception, or nociception, begins when specialized nerve endings called nociceptors detect harmful stimuli. These nociceptors send electrical signals through the peripheral nervous system (PNS) to the central nervous system (CNS), where the brain interprets the signal as pain.

Pain can be classified as:

• Acute pain: A sudden sensation caused by injury, inflammation, or strain.
• Chronic pain: Pain lasting beyond normal healing time, often due to nerve sensitization.
• Neuropathic pain: Pain arising from nerve damage, often described as burning or shooting.  These are often sensed with ulnar neuritis and TOS. 

Factors Influencing Pain Tolerance

Pain tolerance—the ability to endure pain without significant discomfort—varies between individuals.

Several factors can increase or decrease pain tolerance:

Factors That Decrease Pain Tolerance

1. Fatigue – Prolonged exertion can lower an athlete’s ability to cope with pain.  Make sure you evaluate our fatigue score function in the ArmCare.com platform.  With notable fatigue, you must consider that the risk of injury increases and also the intensity of damage that can occur.
2. Stress and Anxiety—Psychological distress increases pain perception by activating stress hormones like cortisol. This is one of the features that seems to be associated with players who perform poorly. In my career, I tend to see more injuries in players who slump at the plate or struggle on the mound. 
3. Sleep Deprivation – Lack of sleep disrupts pain-modulating neurotransmitters, increasing sensitivity.  You need rest to increase growth hormone to repair tissue.
4. Previous Injuries—Chronic pain conditions may make athletes more sensitive to new injuries. Monitoring strength levels is key to preventing primary injuries.
5. Poor Nutrition – Inadequate intake of anti-inflammatory nutrients can exacerbate pain tolerance. Our MLB Recovery Habits course will give you key insights into this one.

Factors That Increase Pain Tolerance

1. Mental Resilience – Mindset plays a significant role in how pain is processed. Athletes trained in mindfulness or cognitive behavioral therapy (CBT) often have higher pain tolerance.  Attacking thinking errors can reduce the intensity of pain.
2. Endorphin Release – Exercise stimulates the release of endorphins, natural painkillers.  Light exercise, such as arm biking, promotes relaxation and circulation.
3. Cold and Hot Exposure – Techniques such as ice baths may help desensitize nerves initially, but contrast baths may improve pain by sequentially constricting and dilation of vessels that cause pressure on nerves.
4. Gradual Exposure to Pain – With strength programming, controlled exposure to discomfort (e.g., progressive overload in training) can build pain resilience.  It is important that you plan enough recovery from intense training days that do not add to the risk with high-intensity throwing days.  Typical soreness cycles follow 48 hours that approach baseline at 72 hours.  I always say STRONGER ARMS ARE HARDER TO KILL, so if we increase throwing arm strength, the extent of muscle damage reduces, and that expedites recovery.
5. Support System – Athletes with strong social and medical support networks tend to tolerate pain better.  With players who are experiencing injury, working on physical, cognitive, and emotional strategies to deal with pain goes a long way. 

Research on Upper Extremity Pain in Throwing Athletes

Pain in the shoulder and elbow is one of the most common complaints among throwing athletes. Studies have identified several key insights:

• Shoulder Pain and Scapular Dysfunction: When the arm is not in the right position at the right time, additional stress may be applied to the shoulder and if the strength of the muscle is not matched to increases in length of tissue, the strength-length imbalance can lead to greater risk of microdamage and delayed onset muscle soreness.  If intensified, more extensive injuries can be present that could require surgery.

• Elbow Pain and Ulnar Collateral Ligament (UCL) Injuries: Research has linked increased throwing velocity to higher stress on the UCL, which can increase the likelihood of elbow pain.  Although velocity may be associated with injury, it is not very high in professional pitchers.  In amateurs, this relationship is less clear, but what has been seen in 3D labs is that 1 mph increase in velocity roughly translates to 1 unit of loading of the elbow.  The key is having the strength capacity to withstand loading.  When it comes to the forearm, our minimum standard is 15% body weight in three-finger grip strength, but most importantly, pitchers should have a Strength-Velocity Ratio higher than 1.6, meaning that the athlete has 60% more strength than velocity to reduce the risk of injury.

• Pain as an Indicator of Fatigue: Studies show that pitchers with an increased workload and reduced rest are more likely to experience pain, reinforcing the need for proper load management. Other work has shown that throwing arm fatigue is the most significant contributor to pain and injury, with an almost 36x increase in risk.  

Here’s a clip from our Eliminating Arm Pain and Soreness Course that talks about the biggest sideliners in baseball – flexor strains, UCL sprains, and SLAP tears.  Learn more about how the inverted W becomes a risk factor, not by the position of the arms, but more so, the position of the trunk at foot contact.

Well, there you have it – an overview of pain and how to increase your pain tolerance and reduce soft-tissue damage.

We will have more on this subject as we want to change the old adage from, “No Pain, No Gain”,  to “No Pain with Arm Strength Gain.”  Many of you reading this right now have a sore arm, and you need to get ahead of it.

Dive into our Eliminating Arm Pain and Soreness Course and make a STRONG start to your season.  As I said before, you have a choice of the pain of discipline or the pain of disappointment, but there will be pain, and we have a solution. 

Strength Matters Most,

Ryan

Ryan@armcare.com