Updated: Jul 3
Why Do Baseball Players Tear Their Rotator Cuffs?
Rotator cuff tears are one of the most common shoulder injuries, as I discussed in my previous blog post. In it, I covered the anatomy, causes, and basic rehabilitation of a rotator cuff tear. In this post, I want to discuss rotator cuff tears as they relate to baseball players. Most of my clients are baseball players, so I wanted to look at the research to educate all of you, but also myself. A huge bonus of writing this blog has been crystallizing my own thoughts and understanding of subjects, so thank you for that opportunity. Let’s start by taking a look at why baseball players tear their rotator cuffs.
Many rotator cuff tears are due to wear and tear. Some can be from a slip and fall or a sudden tear when lifting, but a majority are from chronic stress. The prolonged stress typically occurs in older populations, but it can be expedited based on your career and activities. Manual laborers are prone to rotator cuff tears, but baseball players probably abuse their shoulders even more.
Pitchers in particular place incredible stress on their shoulders. Throwing a baseball is the fastest movement in sports and much of the force is generated by the shoulder. The rotator cuff is responsible for helping the shoulder move, but it primarily stabilizes the shoulder joint. Rapid force from throwing requires incredible strength and stability of the rotator cuff to prevent your humerus from moving too far. Too much humeral movement can wear on the shoulder joint, labrum, and other structures including the rotator cuff.
To get an idea of how much force the rotator cuff undergoes with pitching, a study by Escamilla and Andrews looked at muscle activation during throwing. They found that rotator cuff activity in layback is 49-99% of its maximal contraction. During deceleration the rotator cuff activity is 37-84% of its maximal contraction. Each time you pitch, you are asking the rotator cuff to perform an almost maximal contraction to accelerate your arm and an almost maximal contraction to decelerate your arm. If I created a workout plan that involved using a muscle at almost 100% of its possible strength 100 times, that would be malpractice. When it involves the rotator cuff on a baseball field, we call it pitching.
Is There Any Way To Prevent A Rotator Cuff Tear in Baseball Players?
Injury prevention is a very difficult topic nowadays. We realize that a lot more goes into injuries than we previously thought. Sometimes you may lift a weight that is too heavy and tear your rotator cuff. Other times you lift a weight that you have used a hundred times before and you tear your rotator cuff. Maybe the second time you have worked out your shoulder too many days in a row, maybe you did not warm up enough, maybe your form broke down, maybe you did not sleep enough, maybe your fish passed away and you are upset, maybe there is no clear reason. Injury prevention is very complicated and it can be difficult to isolate individual factors.
All of that being said, a study by Tooth, et al. looked at risk factors for overuse shoulder injuries in 8-18 year olds who played overhead sports. This is not an ideal study because it includes multiple sports other than baseball, but it is a systematic review so it analyzed many other studies. The consistent risk factors that they found included decreased internal rotation of at least 13 degrees compared to the non-dominant hand, external rotation and internal rotation weakness, and poor workload management.
Glenohumeral Internal Rotation Deficit or GIRD is a complicated topic that has been disproven as being a driver of shoulder injury in baseball players. Adaptive changes to your skeletal system can lead to GIRD. Your body changes to allow for increased external rotation to create layback, and internal rotation is sacrificed. Also, in a study of 8-18 year olds, there is minimal change in range of motion when you are young because the forces are not strong enough to cause anatomical adaptations. However, the better athletes who throw more will tend to develop GIRD earlier in their career, and they may also be subject to overuse. In every study there is the possibility of competing variables that need to be considered.
Shoulder weakness is an obvious risk factor for shoulder injury, as strength is one of our best ways to prevent injury. A stronger shoulder can handle more force without breaking down. Workload also makes sense because throwing too many pitches will tax any arm. A tired arm is more likely to be injured.
Is Surgery Required for a Rotator Cuff Tear?
Surgery is a difficult discussion because it depends on your individual circumstances. Rotator cuff tear surgeries are uncommon in baseball players because they result in prolonged recovery and it may be difficult to truly fix the problem. It is also important to ask if the torn rotator cuff is even the issue. As I mentioned before, injuries can be multifactorial, and even if imaging reveals a rotator cuff tear, it can be difficult to determine if that caused your pain or injury.
A study by Mihata, et al. looked at 87 college baseball players and performed an ultrasound to look for rotator cuff tears. Some of the players had shoulder pain, but all were able to compete despite the pain that they were experiencing. The athletes were broken up into groups based on the presence of rotator cuff tears. When comparing the groups, there was no difference in shoulder strength or pain based on the presence of rotator cuff tears. 47% of the players actually had a rotator cuff tear, so they are probably more common than we think.
However, a rotator cuff tear is not always something that can be ignored. A study by Park, et al. examined professional pitchers who had rotator cuff tears on MRI and were re-evaluated at least 2 years later. 75% of pitchers had a progression of their tear. Of those whose tear progressed, 87% of the pitchers had an increase in their rotator cuff tear by one grade, while 12.8% had an increase of at least two grades. Grading of rotator cuff tears looks at the extent of the tear and how much of the muscle and tendon are compromised.
Another interesting factor involved the researchers looking at on-field performance from the pitchers. The graphs below highlight their findings
The damaged season refers to the first MRI that diagnosed the initial rotator cuff tear. The most noticeable statistics are the decrease in innings pitched after the injury. Also, WHIP and FIP increased. These look at your individual pitching performance while removing outside factors including the team around you. It appears that after the initial rotator cuff tear, the pitchers saw a significant decrease in their individual pitching performance.
These two studies contradict one another, but they highlight the need for individual context. The first study looked at pain and shoulder strength, two factors that healthcare professionals will typically consider. Your physical therapist will typically discharge you if you have less pain and normal strength in the shoulder. However, they often do not consider your on-field performance. Coaches typically consider pitching statistics above everything else. If you are discharged from physical therapy, but your pitching statistics are not where they need to be, then what should you do?
What Surgery is Performed for Rotator Cuff Tears in Baseball Players?
Surgery should be a last resort, but if the above information is correct, then it may be necessary. Fortunately, Erickson, et al. studies all Major League Baseball players who underwent surgery to fix a rotator cuff tear between 2010-2016. 151 players were included in total. Of the 151, 130 of them or 86% underwent debridement. This consists of the surgeon going into the shoulder and trimming the torn part of the rotator cuff. If the tear is small enough, then the damaged part can be trimmed and leave a viable muscle. This results in less healing time as there is no repair, but it may leave a weaker muscle. 21 athletes went through a rotator cuff repair, which involves the surgeon sewing the muscle into place. While this may provide a long term solution, it requires prolonged immobilization. Also, the repaired rotator cuff will never be as strong as the old muscle and complications may arise.
The researchers looked at how the athletes fared after surgery. The group receiving the debridement had 50.8% return to baseball, but only 42.3% at the same level or higher. The repair group had 33.3% return to baseball, but only 14.3% at the same level or higher. Essentially, less than 1 in 2 players returned to their previous level following a debridement and less than 1 in 5 returned to their previous level following a repair. These are terrible numbers.
Part of the reason for the poor outcomes may be the last resort nature of the procedure. If everyone knows that return to sport outcomes are so poor, then they will do everything they can to avoid the surgery. Therefore, those receiving the surgery may not have much hope of returning to the field anyway. However, these numbers are still very low compared to many other surgeries for athletes.
Interestingly, a study by Azzam, et al. looked at return to sport frequency in athletes less than 18 years old after a rotator cuff tear. They found that 93% of athletes returned to the same level of play or higher. The same percentage of overhead athletes (93%) were able to return to play, but 57% were forced to switch positions. An example would be someone who pitched prior to their injury, but switched to outfield to put less stress on their shoulder. Of the athletes studied, 91% had a traumatic event. This is disappointing because these athletes are younger and did not suffer wear and tear injuries that may result in worse outcomes. A young player being forced to switch positions due to an injury is a poor outcome and concerning for the overall effectiveness of the surgery.
How Long Are You Out After Surgery?
If you do end up having surgery, it is important to have a timeline of your return to sport. Namdari, et al. studied Major League Baseball pitchers who underwent surgery for rotator cuff tears. They evaluated the athletes’ performances for 3 years after the surgery to look at their return rates as well as their performance. 61% of pitchers returned one year after their surgery, 9% returned after two years, and 3% returned after three years. It is important to understand that the best pitchers on the planet who have the best resources show a 61% return to playing one year after surgery. That is a very long layoff that would be daunting for a high school baseball player trying to make a college team.
Take a look at the performance measures observed in these pitchers before and after their surgery.
The biggest change is in innings pitched. This number shows that the pitchers who underwent surgery tended to pitch more innings than their counterparts, but their numbers dropped significantly when injured and in the seasons following surgery. All of the numbers reflect these factors, as the group who underwent surgery were more likely to be higher performers. They were statistically older pitchers who were more likely to be starters.
Some of the statistics appear to improve in the three seasons following surgery, but they do not return to the pre-injury levels. The pitchers who underwent surgery may end up better than the control group several seasons after their surgery, but they do not return to their typical numbers prior to surgery. It is important to note that even though the pitchers returned to play, their individual statistics stayed below their typical levels for at least three seasons.
So, What Do We Do About Rotator Cuff Tears in Baseball Players?
These numbers can seem daunting and they should. Rotator cuff tears are a problem for baseball players, particularly pitchers. Unfortunately, we do not have a good system in place to treat these injuries and allow for effective return to sport. Surgery to fix the problem decreases outcomes for at least three seasons after the operation, and anywhere from 1 in 2 to 4 out of 5 players will not return to their previous level of performance. Conservative care including physical therapy can be helpful in maintaining strength and decreasing pain, but on-field performance still suffers. Also, the tear will probably worsen over time which only makes surgery more likely. So, what can we do?
I am not a surgeon, so I am unfamiliar with any new techniques in surgery that may allow for better outcomes. The way I interpret the data, surgery leads to the worst possible statistics and should be avoided if at all possible. I think that we need to re-interpret what conservative care includes. It is clear that there is a disconnect between the healthcare team that prioritizes strength and pain and the on-field team that wants a lower WHIP and FIP. Communication needs to improve to allow for a bridge between both camps.
If a pitcher is struggling with his statistics, a more thorough medical evaluation may be necessary. Similarly, before being discharged from physical therapy, a coach should take the pitcher through some throwing assessments and game situations to determine if further care is needed. Too often we discharge an athlete from physical therapy before they are ready and switch entirely into their sport. There should be a more gradual on-ramping to allow both sides to have input and ensure that the athlete is progressing appropriately.
Traditional physical therapy often underloads athletes and does not prepare them for the field. More aggressive exercise prescription is crucial to allow for a true readiness to return to the game. Too often, players fall through the cracks by not getting enough stress in physical therapy before being overly stressed on the field.
At Eclipse Wellness, we try to bridge the gap between rehabilitation, training, and performance. We specialize in working with baseball players to build resiliency so that they can return to the field confident in themselves. We also communicate with coaches to provide a better atmosphere for the athlete. While this has served us well, there is always room for improvement which is why research is so important to understand. Hopefully, we continue to learn and grow to provide the best care for our athletes so that they can return to the field and dominate.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about rotator cuff tears and how they are diagnosed, what symptoms are typically felt, what treatment options are a possibility, and how physical therapy typically progresses. If you have interest in other shoulder injuries, check out our shoulder page. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you are in the Sterling, Virginia area and would like to work with me or you have any questions, please email me at firstname.lastname@example.org or follow me on Instagram or Twitter @drdannydpt.