Strength in Numbers #195
Part 1 introduced referred pain. It’s complete and utter pain, confusion. It baffles many players, coaches, parents, sports medicine experts, and specialized psychologists, who all converge on trying to identify the source. It’s frustrating for everyone when it is recurring and doesn’t let up.
The convergence of pain signals, long-lasting inflammation, the literal inability to put a finger on the pain, and vast and diffuse region of soreness requires not just an exploration, it’s a expedition – you are hunting for the pain center, and it can be functionally, structurally, biomechanically, or psychologically activated.
In high-speed throwing sports, we cannot exist in a land of confusion; critical data-led approaches must exist to survive. Utilizing the ArmCare platform is not only the best step in prevention but also essential in rehabilitation. Sore muscles tend to be weak muscles. They tend to want to guard, they do not want to stretch, they do not want to recoil, they do not want to be subjected to high-speed actions. They are not in harmony – you want lightning coming out of your arm, but all you feel is radiating pain.
But if muscles are well balanced, they are strong relative to your body weight, they recover well, they are resistant to fatigue, and they complement joint mobility by balancing the length of tissues and the tension they can produce – only then will you see a beam of light in the darkness.
This article further explores the uncharted territory of blending art and science in connecting the dots between your pain and the actual cause.
Rethinking Traditional Methods to Determine the Source of Referred Pain
Proper diagnosis requires a multi-faceted approach, and, strangely, they often do not examine strength metrics as a part of the pain process – remember, stronger arms are harder to kill!
In many cases, I see, athletes come in with unusual pain, only to find that it alleviates once their strength increases and their shoulders are balanced. While an athlete throws, the head of the shoulder moves in many directions. If it is not stabilized, excessive motion at the back can cause stretching at the front of the capsule, not to mention excessive tension on the labrum with the biceps tendon being stretched and twisted.
There are countless times where athletes have ZERO pain on testing and throwing causes them significant pain, and it causes serious confusion. If your situation is non-surgical, and you are built up to test maximally, understanding your strength profile is essential.
Priority #1 in My Opinion – Assess Throwing Arm Strength Consistently
You cannot always ask for perfection from your throwing arm, but when you see PRs, it reduces your odds of increased microdamage. In this image, the rotator cuff is unbalanced toward the back of the body. This player has had a much stronger internal rotator cuff in the past, so a training adjustment to restabilize the ratio is needed to reduce increased wear and tear to opposing muscle groups and control excessive motion in the shoulder joint in provocative positions that elicit pain.
I think a picture is worth a 1000 words but when it comes to looking at a 3D animation close up, there’s some mystery about what is happening in the shoulder joint – picture a top spinning back and then spinning forward while its moving all around in cup – check out this video to see what I mean. You will see that the animation cannot truly locate where the upper arm is moving around in the shoulder socket, as under 240 frames per second, the shoulder is moving all over the place in the joint, while it’s moving all over the place in 3D space. The upper arm is the spinning top, while the socket of the shoulder blade is the cup, trying to keep the spinning top central to its surface.
In My Opinion, These are Necessary, but Late Stage Detection Approaches
Strength Matters Most is the message, but that doesn’t mean other things do not matter. This is just my opinion, but below are some additional elements that need to be checked to know what’s going on under the hood.
Like a car, with strength testing, we have a good gauge about the check engine light, suspension, and braking system. Still, some unnoticed cracks in the pipes and gas lines could need additional manual and diagnostic testing to determine the root cause.
- Physical Examination
- Palpation and Range of Motion Testing: Helps determine if pain is due to a specific muscle, joint, or nerve. Often, these tests are designed to cause pain and apprehension, a response to guard against pain, and the force the clinician can manually apply to alleviate the pain. When a clinician isn’t there to put your shoulder more central to the socket to relieve pain, strength programming is key to applying a force to reduce apprehension and guarding internally.
- Trigger Point Examination: Identifies myofascial pain that can refer to other areas. Our muscles are encased in fascia, a saran wrap-like tissue that encases muscles and can cause restrictions and adhesions that impact muscle tone, stretch-shortening, and contractile performance.
End-range testing is safest in a clinical setting, where end-range training could be a career-ender. Athletes have SLAP tears; training in the same way we diagnose structural damage creates excessive risk. You will learn a variety of alternatives to increase your strength in the layback position in the new Certified ArmCare Specialist Course.
2. Imaging Studies
- MRI & Ultrasound: Can detect structural issues such as labral tears or UCL damage. I don’t love this one as there’s a lot of concentrated radiation and contrast injection into the arm. I am claustrophobic and not a big fan of needles whatsoever, but if you cannot solve the referred pain problem, and your activities of daily living are impacted by pain and loss of throwing arm function, this is likely the avenue you must take to determine the extent of structural damage leading to pain. To reiterate, this test is occurring in a passive state and your pain may only be with throwing which makes the determination of referred pain more challenging as there are number of mechanical reasons for tissue damage, and you may find no trace of injury, yet it all stems from Priority #1 not being in check, as athletes who have referred throwing arm pain fail to optimize their ability to absorb, transmit, and contain high speed forces placed upon them.
- Electromyography (EMG) & Nerve Conduction Studies: This study helps identify nerve-related referred pain. Mixed symptomology, such as pins and needles, cold and hot symptoms, electrical pain (zingers and stingers), and muscle weakness, requires a look into how the nerves conduct signals. Sometimes EMG tests involve surface-based sensors, and in others, wires are injected into the muscle, which is typical of deep rotator cuff muscles, to see how high and how fast the neural charge is flowing, and in some cases, you can even hear how it sounds with an audio static noise.
Clinicians can see more profound layers of damage through ultrasound sonography. The frequency of the waves traveling beneath the skin can indicate changes in stiffness, fluid buildup, blood flow, calcification, and structural changes that contribute to pain and dysfunction.
How to Alleviate Referred Pain
I will admit, the shoulder is often a tough one. Pain in the front can be a problem at the back, mainly if the humeral head migrates forward in layback. Research has shown that the humerus will move to the largest muscles and activate the highest. With mismatched force, athletes may experience pain in the front of the shoulder from anterior instability. In contrast, others have posterior pain at the back of the shoulder and internal shoulder impingement, which is the upper arm banging against the back of the shoulder blade that pinches the fibers of the posterior cuff.
When you have referred pain and the causes are not clear on ultrasound or MRI, athletes can have pain with unremarkable reports on their MRI. It’s likely an issue with shoulder imbalances – pinching and pressure that is only recreated when throwing is also a challenge.
So, where is the first place you should go?
The first place to focus is ISOMETRICS and scapular stabilization exercises to start the evening out hypertrophy and activation process.
One of my favorite journals. These findings indicate that larger and stronger muscles tend to migrate the humeral head in their direction. Improving and balancing their activation enhances the ability to stabilize shoulder joint motion to reduce instability, a major source of referred pain.
The Strength Tester Function
The Strength Tester Function is a little-known secret of the ArmCare platform. I use it for athletes on certain days when they are not doing a post-exam to activate the throwing arm. It is an excellent option for submaximal isometric training because it quantifies the force produced without interfering with our normative data.
To improve referred pain and to minimize its resurgence, athletes, coaches, and sports medicine officials should scale the intensity of pressing, especially early on in therapy.
To contract isometrically to alleviate pain, the Strength Tester will be able to provide feedback to athletes and visualize their percentage of maximum effort. This is helpful because muscles and joints will not be overwhelmed, and the athlete and stakeholders alike can be data-led in restoring muscle function and attacking asymmetries.
On the app, the Strength Tester function is at the bottom of the list. Still, when it comes to working with injured athletes, especially ones who have had extensive injuries, or those who were not consistent in performing ArmCare exams, it moves to the top as we can progress loading and scale intensity.
In many of the injury cases I have undertaken in helping athletes make a comeback, I use the Strength Tester to rehabilitate throwing arms, especially SLAP tear cases, by giving an actual, quantified contraction goal rather than manual therapy. We also risk an athlete overdoing it by applying high-speed isometrics with no known force magnitude.
In simple terms, I can set a floor force value to work off and then build progressive percentages to increase the force applied over several weeks. The prescribed rate of load and subjective perceived level of effort allow us to get the athlete to a place where the throwing arm can be tested at 100% effort. When that occurs, it’s music to my ears as we can now work on activation and hypertrophy asymmetries.
Other forms of pain reduction augment strength improvement. If pain is controlled, strength can increase. Just like never throwing through pain, we cannot train through pain, as it causes excessive muscle guarding and can interfere with strength and joint length relationships
Key Takeaways: Managing Referred Pain for Long-Term Performance
Referred pain is a complex but manageable issue for throwing athletes. By understanding the neurological mechanisms, injury sources, and treatment approaches, pitchers and coaches can effectively prevent, diagnose, and treat strength issues that may precipitate a painful event and treat pain more effectively.
Focus on the following:
- Address the source and not just treat the symptoms
- Understand stabilization needs before expanding joint mobilization
- Optimize strengthening and rebalancing areas such as the rotator cuff, scapular stabilizers, and medial and lateral forearm to reduce nerve irritation.
- Maintain a strong arm relative to overall body weight
- Prioritize your recovery habits by managing sleep, stress, nutrition, and workload to improve pain tolerance and recovery.
If you have been dealing with pain that won’t resolve or irritated by injury cases that are not responding to traditional treatment methods, allow us to be a resource for you.
To dive deep into overcoming and protecting athletes from throwing arm injuries, I recommend you attend one of our upcoming ArmCare Accelerators launching in May.
It will be an incredible learning and networking opportunity that brings together extraordinary people who want to make a difference for their players, coaches, teams, facilities, and communities. By attending, you get to join our ArmCare Elite Group, which has a lot of momentum building this year in promoting our experts.
Strength Matters Most and There is Strength in Numbers,
Ryan
