Shoulder Pain in the Young Athlete - William Seeds, MD

Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I’m talking once again with Dr. William Seeds. Dr. Seeds is an orthopaedic surgeon who practices orthopaedic surgery in Ashtabula, Ohio. He also provides sports medicine and orthopaedic surgery services all over northern Ohio. Dr. Seeds is also the Sports Medicine and the Medical Director of the Great Center in Geneva, Ohio. Good afternoon, Dr. Seeds.

Dr. Seeds: Good afternoon, Randy. Thanks for having me.

Dr. Sechrest: Today we’ll be talking remotely with Dr. Seeds and I really want to cover some more ground in terms of the young athletes. Dr. Seeds has a significant amount of experience with treating young athletes due to his relationship with the Great Center and I think today, Bill, if it’s okay with you, what I would like to discuss is a fairly common problem in the young athlete stretching from the 8 year old who begins baseball mostly, and then all the way through a college-aged athlete. The situation I really want to focus on today are the injuries and the problems that arise from overhead throwing athletes, and most of those athletes are really baseball pitchers or infielders or outfielders that spend a lot of time throwing, but we really see this most in the pitchers. Now clearly overhead throwing is a part of other sports such as football with the quarterbacks and that sort of stuff, but the crux of the problem really is in that baseball pitcher that we see starts out young and then progresses and begins to develop problems in the shoulder. Now I think you and I know, as orthopaedic surgeons, that problems can occur all through the upper extremity including the elbow and sometimes even the wrist. But what I want to really focus on today and really clarify for patients are the problems that you and I see in the shoulder in these athletes. So, first, let’s define the problem a little bit and let’s look at it from the standpoint of the shoulder and how this problem arises in the shoulder in these younger athletes.

Dr. Seeds: Sure, Randy. I think this is a great topic to start the discussion on upper extremity injuries in throwing type of athletics. In particular, in baseball in our younger athletes, unfortunately what we’re finding is that our pitchers, specifically, are spending a significant amount of time in their younger years throwing the ball with repetitive type of pitches that add up over time and affect the mechanics of the shoulder. What we’re seeing is that these young athletes are throwing the ball so much that they’re not able to develop the appropriate musculature around the shoulder to develop as they continue to throw, and what we find is that our pitchers lagging with the amount of recovery that they need. Number one, they’re fatiguing these muscles earlier and number two they’re not developing all of the muscles around the shoulder to adequately compensate for the degree of activity. I think this has been a problem all over the country and we’re trying to do things by obviously limiting their pitching, the number of pitches they throw in a day, and working specifically on those mechanics of the shoulder to try to avoid these problems.

Dr. Sechrest: You know, Dr. Seeds, I think we see a huge explosion in the number of kids who are playing some sort of baseball, softball, T-ball, at younger and younger ages. I think some of these kids are pushed pretty early and pretty hard. When do you start seeing these overuse injuries of the shoulder becoming obvious to the parent, to the coach, and to the patients themselves? What age group do you see these things beginning in?

Dr. Seeds: Well, we typically see these injuries, I think, throughout the age differences in minor league, major league, the high school and collegiate athletes. We’re seeing them all the way through but we are obviously, as you’ve indicated, we’re seeing them at an early age now, around the ages between 10-13 in the minor leagues where they’re throwing a significant amount of pitches in a game and they have multiple games during the week. Some of these teams play year round and, something to keep in mind, when these kids are practicing the amount of pitches they throw in a practice should be counted towards the number of the pitches they throw that week. We’ve got to be very concerned about how many times these kids are throwing the ball especially if they’re not doing any strengthening exercises or exercises to prepare them for this type of activity.

Dr. Sechrest: It’s interesting, you continue to come back to the number of pitches. I guess what I’m hearing is that really just doing more and more of the activity is not necessarily the same thing as rehabilitation. It’s not the same thing as conditioning. Where these kids are throwing the pitches, a lot of them probably think that, “Well, I’m doing more and more and more. I’m throwing more and more and more. Should I not get used to this?” I think what I hear you saying is that’s not necessarily the way to get to a point where you’re either treating this or conditioning the arm and the shoulder girdle to actually do this in the right way. Is that accurate or am I butchering that to some degree?

Dr. Seeds: No, that’s absolutely true. There are very few programs that start with these younger groups and are actually, number one, teaching the proper mechanics of pitching, and number two, teaching the appropriate exercises to prepare the shoulder for that progressive increase through the season of pitching and keeping that person from fatiguing and being adequately able to recover. So, these are concepts that are basically not well known and a lot of these younger teams with parent coaches are in the right mind-frame of helping the kids but, unfortunately, they don’t understand that sometimes, as you’ve indicated, by thinking that continually working on these pitches and throwing every day is going to increase and improve their ability, it’s actually counter-productive and leads to some significant problems down the road that can really alter the mechanics of the shoulder and are what we’re seeing today.

Dr. Sechrest: It is interesting because I do think there is this concept out there that endurance comes from doing an activity over and over and over again, and I think what you’re saying is that that’s not true in this, especially in this pitching paradigm because we’re actually creating an overuse syndrome. In some ways that’s what an overuse syndrome is. It’s doing the activity too much to where it actually begins to stress the growing skeleton, stress the connective tissue and actually begins to cause damage. So some is good, a little bit more may be better, but I’m assuming that what the take home message here is that overdoing it can lead to problems that need to be addressed and it’s not just going to be a matter of just pitching through the pain or exercising through the pain to the point where you finally get past that. You’re not going to get past it. You need to step back and take a different approach. Let’s talk a little bit about the symptoms that parents and coaches and even the older kids, the patients themselves, can begin to monitor. What are you seeing, as an orthopaedic surgeon, when these athletes begin to complain? What type of symptoms are you seeing?

Dr. Seeds: Well, unfortunately, when they reach my office most of these athletes are there because of some specific complaints of pain in the shoulder. It could be a generalized pain. It could be a specific anterior type of pain in the shoulder. Or it could be related to after a couple of pitches or halfway through the game they start to elicit pain and what we find is that in questioning the athlete and specifically the parents, and sometimes we have the luxury of having the coaches there also, because it may be one of their star pitchers and the coach is very interested in the outcome and the family is close to the coach. But we find out that, number one, if you go back in the history of what’s been occurring with this pitcher, you find that the first sign of the process is that they start to fatigue and they lose control. There is no pain associated, they just lose that control of getting the ball over the plate like they typically do, or have been during practice, and that’s the first thing that they start to notice. And they start to notice that this expands. Then the pain symptoms start to progress, and this could actually take weeks or months before this starts to develop. It’s an insidious process that not everybody recognizes and realize immediately until that pain process sets in. So we may be 2 or 3 months down the road or 6 months down the road where we’ve got some specific mechanics that we have to address to try to correct the problem.

Dr. Sechrest: So if you had some ideas for parents and coaches about what they should look for, can you be a little bit more specific in terms of when to notice there’s a problem. I think you mentioned the lack of control and this fatigue phenomenon that we’re seeing, where the performance begins to degenerate. Can you give some guidelines to parents and coaches of things they want to watch for either in their child or their athlete in terms of beginning to say, “Maybe there’s a problem. Let’s stop. Let’s get some help with a trainer, or a physical therapist, or even an orthopaedic surgeon before this becomes a problem.”

Dr. Seeds: Yes, I think the most obvious signs that any parent can recognize, or coach specifically can recognize, number one is, reduction in the ball speed where the pitcher is not able to keep that constant speed, especially at the younger age when they’re only really trying to throw mainly fast balls. They’re not throwing curve balls or anything like that. Where they can actually see a change in the ball speed and, concurrent with that, they can also see that they’re having difficulty keeping that ball in control. So loss of speed, loss of control, are very easy to pick up consistently in any practice or game. I think that, at least in our experience, as we’ve had these discussions and right now we’re involved in teaching coaches some of these specific things to look for, and how we can help them with the mechanics early, coaches are absolutely recognizing this. They see it, and they can respond to it.

Dr. Sechrest: Now when that situation occurs, when either you, as the physician see it, or the trainer or the coach or maybe the parent sees it, what are you recommending, at that point, that the athlete do? What type of a program are you going to institute to try to, I guess, make the throwing mechanics better, and try to, in some ways, prevent this problem from getting worse?

Dr. Seeds: Well, that’s a good question, Randy. I think it all stems back to what is the most consistent process that we see with these young pitchers? Usually it’s the lack of appropriate musculature around the shoulder and the shoulder blade, the scapula, working together, almost as an orchestra, in working to get that ball across the plate. We focus on a couple of things. Number one, to recognize the fact that this can occur, that we should limit the amount of pitches in a day, specifically between anywhere from 50 to 75 pitches. 75 would be an extreme number. Some of the numbers in some leagues, that’s the number they use. Understanding that if you’re throwing 75 pitches one day, it’s going to take you 2-3 days to recover. If you’re throwing hard for that specific amount of time, it’s going to take that time to recover. So you may want to knock down a couple days after that if you’re throwing the ball. Also, in combination with that, is working on specific training exercises that you can do to train the scapular muscles, the shoulder blade muscles, and the shoulder muscles to work on that strengthening so that we don’t see some of the common problems when these patients present and I can go into in a little bit more detail if you’d like what we see on physical examination. These are some early recognizable things that even the parents can see and institute with the coach and can make significant gains in what these athletes are capable of doing and ensuring a very productive life in their younger athletic endeavors in baseball.

Dr. Sechrest: I do think it would be very useful to understand the mechanics of what’s going on with the shoulder blade. What’s going on with the shoulder through the throwing motion. So, yes, I would very much like to hear your description of that, and the other thing I would like you to do if possible, is to really give the viewers some idea of where they’d go to try to get the information necessary to make these changes. Is this an athletic trainer? Is it a physical therapist? Do they need to go to some sort of a special physician or physical therapist in order to get these exercises to begin working on this before this becomes a problem? So first, tell us a little bit about what goes on in the shoulder in terms of the throwing motion, how that goes wrong, and then follow-up a bit with some ideas about how patients can access information or the expertise necessary to correct that?

Dr. Seeds: Well, to start off, I think we want to keep it simple and discussing this as far as the mechanics of the shoulder itself. When I sit down with a family and we go through the changes that we see with their child or a pre-teen in the office, the best way that I can try to describe these mechanics and discuss this process with the families, I try to compare it to something they can visualize and then I’ll show them. I’ll have the patient turn around and we’ll look at the back of the patient and look at how the scapula, the shoulder blade, looks from one side compared to the other. 9 times out of 10, to start off with, when you’re looking at the patient and observing just their standing position, we’re going to see what we call a protraction of the scapula where the shoulder blade is going to be pushing itself out and the shoulder is going to roll over a little bit, and it’s always very easy for the family to see that and to understand. “Well, okay, I can see that. So there is some kind of an imbalance here that I can see the doctor is talking about.”

What I try to do is tell them that when your son is out there pitching, when he’s throwing the ball, just imagine that this scapula is to keep that shoulder, the ball of the shoulder, in the socket and to keep it there throughout the complete arc of the pitch. You can almost imagine it as a seal trying to hold a ball on its nose and keep that ball spinning and spinning and spinning. Once you kind of give them that picture they get that idea that, “Okay, that’s a pretty simple process.”, and of course we understand that the mechanics are a lot more complex than that but that gives a visualization of, “Okay, this is what that shoulder blade has to keep that ball straight. Well, it has to keep that ball in the socket” and then we go from there as far as discussing, “Okay, this is what we need to get that shoulder blade back to help to keep the shoulder in place throughout the complete arc of pitching.”, and that makes it very easy then to progress on to these exercises that we’ll discuss with them as far as involving the shoulder blade and the shoulder. It’s fantastic because when they come back and they’ve gone through this training it usually will be a 6 week to up to 3 month process where we’ll see some significantly drastic changes of where they’ll see that scapula come right back down. It’s a pretty satisfying thing to sit there with the family where they’ve been involved from the beginning where they’ve seen it visually and then have seen the results. It’s something that, again, protects that athlete for the rest of the their life and we encourage them to continue that obviously that for the rest of their throwing career. Now as far as where do they go for this information, as far as our facilities, we’re focused on training the coaches already in this aspect. But any trainer that’s involved in that realm of athletics as far as pitching and baseball, they’re all very familiar with the mechanics and the common problem of the scapula. Parents or the coaches can sit down with the trainers or the physical therapists are also very well versed with this. Typically, like I said, as an orthopedist, I’ll see them when they’re in pain and where they’ve gotten past some of these early steps that they could have taken with the therapist or the trainer. But I do believe that instituting early education in any of the athletic leagues, if you can, with the coaches who are typically parents, if you can sit down there and give them a little education, a little visualization like this, it can go a long way and it can make a significant difference in their training regimen for the rest of the season.

Dr. Sechrest: Well, it sounds like most of these, especially when they occur early and are picked up early, can really be managed simply by a good change or a good rehabilitation program or a change in the conditioning program that the athlete is using on an everyday basis. When do you become concerned as an orthopaedic surgeon, when you begin to see this go beyond that, so that now the athlete is presenting with some sort of a pain complaint, when do you get concerned that maybe it’s gone too far and there’s a more serious problem going on and you’re going to have to address either with more aggressive treatment or perhaps even with surgery?

Dr. Seeds: That is a difficult problem sometimes in really discerning where do you start changing your thought process on being able to rehabilitate this patient because I would tell you that 9 times out of 10 if you get these kids within a range of 3-6 months of their problem you’re going to help improve most of these mechanics and that’s a great thing. As far as trying to address your question, I would say that once we’ve addressed the problem, we’ve progressed with the physical therapy, and we haven’t seen any changes after a 6 week time frame, then we start to get concerned, specifically if they’re still having pain and, again, on examination if we’re still detecting possibly some instability that we don’t feel has been corrected by any of the strengthening protocols, some of these things as they add up, may warranted further investigation such as using an MRI for evaluation that can really assist us in looking further at other possibilities of injury in the shoulder. It’s real important to have your therapist dialed in on this and understand again the mechanics of these problems, and you can work together in really finding these people that may be recalcitrant to not progressing with the conservative side of treating these problems.

Dr. Sechrest: So, if I hear you right, your approach is to always try rehabilitation unless there’s something just totally off the wall going on with the shoulder that tips you off that something else maybe not even related to throwing is going on. But your approach is that the vast majority of these athletes can be treated with an initial rehabilitation program and, if I heard you right, you’re looking at a time period of around 6 weeks to 8 weeks to see if they’re making progress and, at that point, reassessing the situation to see if you need to go further with additional evaluation. If they’re not getting better, what I think I heard you say is that you’re going to opt for some type of imaging and, most likely, an MRI scan. Tell me what you’re looking for on that MRI scan? What sort of processes, what sort of pathology, as we would refer to it, are you looking for on that MRI scan?

Dr. Seeds: Well, yes. Number one I agree with you exactly with what you said. That’s kind of the process that we look at and obviously, Randy, if there are any abnormal findings in our initial examination that may tip me off to a growth plate injury or something that’s out of the realm of the normal shoulder examination, we may go right to the MRI scan right away. But typically if they present in the fashion we’ve been describing we’ll go through that process. When we do get the MRI, specifically what I’m looking for are any abnormalities as far as the mechanics that could be involved in this problem and, number one, we look for inflammation that may be specifically subacromial, below the clavicle and above the shoulder. We look for redundancy in the capsule, where the capsule may look a little patulous or expanded. These are all subtle findings. We look for changes in what’s called the labrum, the cushion inside the shoulder where there possibly may be some tearing of that labrum or peeling of the labrum, and possible biceps injuries that we look for in the shoulder, and obviously any bony or cartilage problems and any growth plate injuries that maybe we missed and weren’t able to pick up. It’s an overuse repetitive process that involves the growth plate. But typically, we usually can pick those up on examination. So those are kind of the isolated early things that we look for in the use of the MRI if they haven’t progressed with the therapeutic protocol.

Dr. Sechrest: Now how are those findings going to change what you recommend to the athlete at that point in time? Are you going to move towards considering some type of surgical intervention? Are you going to move towards doing some type of specific injections? Or how does it affect your decision making at that point in time?

Dr. Seeds: Well, a couple of things. In the younger athletes I stay away from using any type of injections in the subacromial space, I’m not an advocate of injecting young athletes even though it could be beneficial for that inflammatory process, I tend to stay away from it. What I’ll do is if I see it’s more of an inflammatory process then I may back off with the process of where we’ve taken aggressive therapy protocol and I may say, “You know what? We just need to calm the shoulder down here for a little bit.”, and I would stop the sport. I would stop their activity and I’d give it a rest. I’d give them at least a 2-3 week period of where we just stop everything and I’ve found that to be very effective with the inflammatory states where we’ve just, as a physician and my team, we’ve been a little too aggressive also with trying to get them rehabilitated and back into their sport. We just caught it a little too late. So if it’s an inflammatory process, we’ll try to cool it down in that fashion and also I don’t really use any anti-inflammatories either in the younger people because I’m not a proponent of that either. I just try to let the body take care of itself in that process. If I see that there is a real significant impinging type of lesion or there’s something that is more specific to the laxity of the shoulder, which is more typically what we’ll see, I won’t then intervene with the surgical intervention at that point. What I’ll do is I’ll talk to the family and say, “Look, we still have the capability of trying to improve your child’s performance here with the shoulder, but it’s going to take more work.”, and I’ll go another 6 weeks of trying to work on this more specific strengthening phases of the rotator cuff and, if the scapula is involved, in trying to assist with that instability issue, which I believe is involved in that impingement; and give them another trial of where at least I know we’ve gone at least 3 months to try to improve that. Then, if I get to that point and we haven’t seen that improvement, well, then we’ll have the discussions about the possibility of working on the capsule and doing some things to try to decrease that volume of the shoulder to improve the stability.

Dr. Sechrest: One of the things that we ought to point out to parents and athletes and coaches, is that the younger the athlete, the more we have growth on our side. Unlike an adult, you’re not going to see any change in the skeleton, if the problem is occurring, growth is not going to correct that, and some of these conditions that we’re seeing with the shoulder, growth itself, over a period of time, is going to create some possibility for improvement in the situation, and the younger the athlete, I think, the more that comes into play. Once you get into the late teens, that’s probably not as much of an issue, but that’s a different factor here that parents and coaches and athletes need to understand. Most of them want to get right back to their sport. They think 3 months is a lifetime to them, if they’re missing 3 months out of their season, but a lot of times being down for 3 months will obviously allow these conditions to improve and growth to take its effect, in terms of the remodeling and some of the things that can occur in the younger ages, and that 3 months, to us, looks like a pretty good tradeoff for future health. I don’t know if you agree with that, but it’s something that I tend to try to talk with parents and athletes about.

Dr. Seeds: I totally agree. That’s a very good point that you brought up. You hit it on the head. It’s that time factor and growth totally work to the advantage of the younger athlete, and that’s for everything. The hardest message to convey is that timeframe, and because they’re all interested in getting back into that sport but, as you know, the experience we’ve had with those families that have taken that initiative, they always come back and thank you for really drilling that into their heads, and giving them that time where they otherwise may have sought other information to try to speed things up.

Dr. Sechrest: Well, I think I’m going to try to summarize where we are as we close with this discussion. One is, that I think you and I both are in agreement that, in the young athlete, the vast majority of throwing problems are probably coming from an overuse situation where they’re just using that shoulder in a manner that’s creating these problems and we need to back up and do a couple of things. One is, make sure that the mechanics are as best possible so that you can balance the mechanics of the shoulder girdle so that you know that when the athlete is throwing, he’s throwing with the best possible mechanics. The other thing I think we talked about is that rarely do these problems, either pain or anything else, really result in a problem that’s going to, first and foremost, need a surgical operation, that the vast majority of these problems are managed through physical therapy, conditioning, the appropriate use of the rest and restoration and very rarely does it require any sort of medication, and sort of injections, or any sort of surgery. Is there anything else that you would like athletes, coaches, and parents to take away from this discussion today that we haven’t covered up to this point?

Dr. Seeds: I think you hit them all on the head, Randy. I think it’s a team effort. I think the coach, the family, and the trainer, physician, therapist, they all need to be involved in a team effort to make this a win situation for everybody. It’s education. It’s what you’re doing right now that will make the difference for these younger athletes in the future.

Dr. Sechrest: One thing that I would like to get some specific recommendations from you for parents and coaches and the athletes, and that is, do you feel like that most of these rehabilitation programs need to be monitored by either a physician, a trainer, a physical therapist, or is this something that coaches and parents can get enough information to be able to sort of manage that process on their own? How would you advise patients?

Dr. Seeds: That’s a good question, and that enters into the protocols of specifically of what certain institutions will use in trying to get this message across. Typically what we’ll do is we’ll start off with the athlete and the parent, and we’ll go through anywhere from 2 up to 6 sessions of teaching the exercises and possibly the mechanics of throwing, whatever we’re working on. We’ll go through that with them until we feel that they have a good knowledge base of what we’re trying to accomplish. Then we’ll give them the home program to continue with and, again, it’s really specific to what the presentation is, but they’re all pretty much the same as far as working on the musculature work. What we’ll do is we’ll make it available to them to continue to follow with us once a week. If they need our assistance in helping them, but typically for us, like at the Great Center up there, if there are activities that are going on specific to any type of education we’ve given a parent or coach, they can always approach the trainer and make sure that we’re on board with that activity. So we try to make it an open-ended process, because everybody has questions that are different. Everybody has phases in that process that may be different, so we accommodate those changes.

Dr. Sechrest: Well, I think we ought to point out, that we can tell parents, coaches, and athletes, and we can give them good programs, we can tell them how important it is, but it’s really up to them to continue to do this, and they need to do this and put as much effort in these balancing exercises as they do their actual throwing. It won’t work if they don’t participate.

Dr. Seeds: Absolutely and that’s probably the homerun message that really should be heard on this today, is that really should be heard on this today is that this is a lifelong change you’re making for this athlete. If they want to continue to be at a competitive level in that sport. We try to make that very clear and it’s message that’s worth taking the time to try to ensure the coach, the family, and the player understand that this is a habit change that’s going to affect the rest of your life in this sport.

Dr. Sechrest: Well, I want to thank you for joining us, Dr. Seeds. Thanks a lot for the information. I know patients are going to find this useful and young athletes are going to find this useful. So next time what I would like to discuss is move down the upper extremity and talk a little bit about issues that occur in the elbow in the throwing athlete. So thanks for today and I look forward to our next discussion.

Dr. Seeds: Thank you, Randy. I look forward to our next discussion.