Article: Shoulder Impingement Q & A

[Heezy1323]

Heralded Twins prospect Brusdar Graterol was recently shut down and placed on the IL for ‘shoulder impingement’. This is concerning given the promising start to the 2019 season Graterol had and what it could mean for his future.

 

So what is ‘shoulder impingement’? And when might it need surgery? Let’s see what we can figure out:Disclaimer: I am not a team physician for the Twins. I have not treated or examined any Twins players. The information I am using is only that which is publicly available. My goal with these posts is to provide some education to TD readers around general injuries that are peculiar to baseball players.

 

Question 1: What is shoulder impingement?

Shoulder impingement is a sort of catch-all term that can be used to mean a number of different things depending on the specifics of the situation. It Is a term that is often used in application to patients who have pain in their shoulders, often without any specific structural damage or a particular injury. Most frequently, people have pain in their shoulder area that gets worse when working above chest level.

 

It is often treated with physical therapy, activity modification, oral medication and occasional cortisone injections. It is uncommon for these patients to require surgery, but it is sometimes needed after the preceding treatments have failed to provide adequate relief.

 

Some also refer to this condition as shoulder bursitis. It involves irritation of the rotator cuff and the bursa, which lies between the rotator cuff tendons and a part of the bone of the shoulder blade (called the acromion). You may have friends or family members who have been told they have ‘impingement’- this is a fairly commonly used diagnosis. More specifically, this condition is referred to as ‘external impingement’.

 

Shoulder impingement in pitchers, however, often means something entirely different than what is described above. Whereas external impingement occurs between the rotator cuff and the acromion (outside of the ball and socket joint of the shoulder), pitchers more commonly have problems with what is called ‘internal impingement’. This occurs specifically in overhead athletes because of the tremendous motion that is necessary to hurl a baseball 90+ mph accurately.

 

During the course of throwing, the arm is cocked back, placing it in an awkward position. In this position, part of the rotator cuff can get pinched between the bone of the ball and the bone of the socket (also often including pinching of the labrum). This may not seem like a big deal, but over time this repetitive motion can begin to take its toll.

 

Experts agree that some changes/damage to the structures of the shoulder are likely normal and adaptive in pitchers rather than problematic. In some cases, however, these structural changes progress down the spectrum and become an issue- causing pain, lack of velocity and/or control and fatigue of the shoulder.

 

There is not perfect agreement among experts about why exactly these athletes begin to have pain in some cases. Regardless, it is likely a very complex combination of factors ranging from subtle changes in mechanics to core strength to gradual loosening of shoulder ligaments over time (and many others). Each individual case is likely different, and treatment needs to be tailored to the specifics of the athlete.

 

Question 2: How/when did this injury occur?

Typically, this is not an injury that results from a single trauma (though theoretically it can happen that way). It is much more typical for this to be the result of an accumulation of ‘microtraumas’ over a long period of time.

 

Question 3: Does this injury always need surgery?

No. As mentioned above, painful shoulder impingement in throwers is likely related to a complex set of factors. Because of this, treating any ONE thing with a surgery is somewhat unlikely to be effective. As a result, treatment is almost always begun by trying to calm down inflamed tissues.

 

This typically involves rest from throwing. It may also involve oral medications and in some instances, cortisone injections. There is some discussion around PRP and so-called ‘stem cell’ injections (what orthopedists refer to as Bone Marrow Aspirate Concentrate or BMAC) for these types of problems, though this is not yet something I would consider standard of care. During this time, the athlete is also likely to undergo physical therapy to work on improving some of the other factors mentioned above- core strength, range of motion, rotator cuff strength, etc.

 

As the pain and inflammation improve, the athlete is likely re-examined by trainers and physicians. This can take anywhere from a week or two to several weeks depending on the case. When things have improved sufficiently, the athlete is likely to begin an interval throwing program, which involves progressively more aggressive throwing sessions. Once they have completed this, they would likely return to the mound and begin throwing from there. Once appropriate progress has been made (and of course presuming no setbacks are encountered), they are likely cleared to return to play.

 

The success of non-surgical treatment for these types of problems is all over the map in the literature. There are ranges from percents in the teens to 70%+. Again, it likely depends on a large number of factors which makes prognosticating nearly impossible.

 

Question 4: How do we tell which cases of impingement need surgery and which do not?

This can be among the most difficult decisions to make when dealing with pitchers. One of the problematic elements is that surgery to treat this problem is comparatively not very successful. As noted above, in general there are likely a number of different structural abnormalities in the shoulder that are in play with this injury. Some of them are adaptive and are considered ‘normally abnormal’ for pitchers. Others are problematic. Separating these two is something about which even experts readily disagree.

 

It is difficult (and perhaps foolish in this setting) to quote surgery success rates, but in general they are not the best. There is a reason behind the old saying that for pitchers “If it’s the elbow, call the surgeon. If it’s the shoulder, call the preacher.”

 

Question 5: What is done during surgery?

This is widely variable depending on the specific structures that are injured, and (quite honestly) the particular views of the operating surgeon. I was recently watching a lecture on just this subject that featured a panel of a number of the preeminent North American surgeons that treat these problems. The differences of opinion and differences in strategy between surgeons were substantial. Yet another reason to make significant efforts to make non-surgical treatment successful.

 

Question 6: How concerning is this for Graterol?

This is hard to know from the information available. As stated earlier, the term ‘impingement’ can mean a wide variety of things- some more concerning than others. One of the positives in this case would seem to be that Graterol was pitching very effectively quite recently. Thus, this doesn’t seem to be something that has been festering for months. Hopefully that means they’ve ‘caught it early’ and can get things back on track sooner than later. I would imagine he will be out for a few weeks at least, but I would be surprised if he required any surgery in the near future.

 

Overall, many pitchers have occasional blips on the radar with things like this that are improved with rest and rehab and don’t recur in the future. Predicting the future is difficult for anything- and this type of issue especially- but hopefully Graterol can get back on the mound throwing gas soon.

 

Go Twins!

 

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[biggentleben]

Tremendously well-done, well-researched, and well-written.

 

Mike Soroka was originally diagnosed with an impingement last year when he was shut down for the Braves. The Braves have been very cautious with his arm since, and he's seeing tremendous success in the rehab that he did. What exactly he did would be something I could ask Mike, but he really didn't want to get into details until he was on the other side of things and knew that it had worked for fear that some kid somewhere might begin doing similar activities to "heal" his own arm without knowing whether it would be successful.

 

I appreciated that stance by Mike at the time, and your piece makes it even more clear that even if Mike is 100% successful in his rehab on the shoulder and becomes the pitcher everyone dreamed he could be, his method of rehabbing his shoulder may not work for the next guy to come along with a similar diagnosis, or even with the same exact diagnosis.

 

Once again, great stuff!

[rdehring]

Great report.  Was curious if you are in the medical field or have a medical background?

 

As for Graterol, let's hope for the best as the Twins need him beginning sometime next year.

[Curveballjesus]

I wonder if they’ve done an MRI yet? I was diagnosed with a shoulder impingement while pitching in college after a physical exam of my shoulder. It never got better and eventually an MRI showed a torn labrum.

[Aerodeliria]

Thanks. It sounds scary enough. Let's hope for the best.

[Heezy1323]

 

I wonder if they’ve done an MRI yet? I was diagnosed with a shoulder impingement while pitching in college after a physical exam of my shoulder. It never got better and eventually an MRI showed a torn labrum.

I would guess that yes, he's gotten an MRI. A torn labrum is often part of the spectrum of this problem termed 'internal impingement', so they are not mutually exclusive and are, in fact, often found together.

[Squirrel]

I was diagnosed with an impingement years ago ... I'm a tennis player, although I was still occasionally playing a pick-up softball game or two at the time ... it had me out for a few months. I did a combination of rest, physical therapy, anti-inflammatories (prescribed vs over-the-counter), and personal training. As I said, out for a few months.

 

[Heezy1323]

 

Great report.  Was curious if you are in the medical field or have a medical background?

 

As for Graterol, let's hope for the best as the Twins need him beginning sometime next year.

Thanks for comment. Yes, I am an orthopedic surgeon with a subspecialty in sports medicine. I did my sports medicine fellowship (1 year of additional training after completing residency) with Dr. James Andrews, which was a great opportunity to learn first hand about treating throwing athletes.

[Post-Concussive Blues]

I am still hopeful that giving Graterol such a nonspecific diagnosis reflects a lack of anatomical injury on MRI (i.e. rotator cuff tear, labral tear, etc). It certainly could be that his shoulder hurts when lifting his arm above his head, probably common in pitchers and any other overhead arm use profession, and this is a good opportunity to shut him down to rest.

 

I predict he will be back pitching later this season, and will be called up to the Twins for our playoff run.

[Oldgoat_MN]

Thank you Heezy1323. This is very helpful for those of us who get absolutely nothing from the announcement of a 'shoulder impingement'.

Much appreciated.

[Alex Schieferdecker]

Is this something that might be caused by a fault or inefficiency in the pitcher's mechanics? If so, is it something the Twins are likely to try to address by tweaking those mechanics to reduce the wear and tear?

[rdehring]

 

Thanks for comment. Yes, I am an orthopedic surgeon with a subspecialty in sports medicine. I did my sports medicine fellowship (1 year of additional training after completing residency) with Dr. James Andrews, which was a great opportunity to learn first hand about treating throwing athletes.

It is great getting this type of information from someone with your creds.  Thanks for sharing.  With your tie to Dr. Andrews, have you heard of a Dr. Clancy?

[biggentleben]

 

Thanks for comment. Yes, I am an orthopedic surgeon with a subspecialty in sports medicine. I did my sports medicine fellowship (1 year of additional training after completing residency) with Dr. James Andrews, which was a great opportunity to learn first hand about treating throwing athletes.

 

We discussed your time with Andrews after I put together a piece on Thoracic Outlet Syndrome, and it's great to have that level of insight in this discussion. I think it's interesting how TOS blew up and suddenly disappeared as a diagnosis that you'd see in pitchers while elbows and shoulders persist.

[Jham]

But do you have any theological background, since it's a shoulder? Dr. James Andrews is pretty good. Is there a Rev. James Andrews by chance?

[brvama]

Again another great explanation of the medical problems athletes often face. Also thank you for diagnosing my ailment - all along I thought it was just old age. Certainly not the cause in Graterols case. Where should mail the fee?

[Heezy1323]

Is this something that might be caused by a fault or inefficiency in the pitcher's mechanics? If so, is it something the Twins are likely to try to address by tweaking those mechanics to reduce the wear and tear?

 

It’s difficult to know for certain, but yes I suspect that rehab will be focused in this area. Refining mechanics and improving overall core strength with the goal of avoiding placing extra stress on any particular anatomic structures.

[Heezy1323]

It is great getting this type of information from someone with your creds.  Thanks for sharing.  With your tie to Dr. Andrews, have you heard of a Dr. Clancy?

 

Oh yes. Very familiar with Dr. Clancy.

[gil4]

 

I wonder if they’ve done an MRI yet? I was diagnosed with a shoulder impingement while pitching in college after a physical exam of my shoulder. It never got better and eventually an MRI showed a torn labrum.

Ugh. I can't find the Dislike button, and I really need it. (I guess you need it more, since it was your shoulder.)

[clutterheart]

What is this?

 

As you say "impingement" could be anything. All you are doing is speculating and generalizing. You dont know what caused it or the prognosis. For all you know he blew something while reaching for ice cream.

[ashbury]

What is this?

 

As you say "impingement" could be anything. All you are doing is speculating and generalizing. You dont know what caused it or the prognosis. For all you know he blew something while reaching for ice cream.

Moderator's Note: If you don't find the insights of a medical doctor interesting, move along to another topic. Heezy's disclaimer at the top of the article made clear the limitations of what he would write.

[Mr. Brooks]

I shudder at the thought of speculation and generalization on an internet fan forum.

[Heezy1323]

 

Again another great explanation of the medical problems athletes often face. Also thank you for diagnosing my ailment - all along I thought it was just old age. Certainly not the cause in Graterols case. Where should mail the fee?

For some reason Bonnes says all checks need to be made out to him...? 

[hybridbear]

These are my favorite articles on TD! Thanks Heezy1323 for helping us understand the medical side of baseball injuries. Your articles are always very clear & well written.

[Heezy1323]

We discussed your time with Andrews after I put together a piece on Thoracic Outlet Syndrome, and it's great to have that level of insight in this discussion. I think it's interesting how TOS blew up and suddenly disappeared as a diagnosis that you'd see in pitchers while elbows and shoulders persist.

 

TOS is a very complicated condition, indeed. I’d love to hear your thoughts about it.

[biggentleben]

 

TOS is a very complicated condition, indeed. I’d love to hear your thoughts about it.

 

I personally believe the TOS stuff was similar to the prevalence of back injuries among NFL linemen as the 300-350 pound weight for an offensive lineman became a requirement upon league entry instead of something teams developed in house after drafting a guy. Guys just built up muscle without regard to how those muscles were useful in the game and also without regard to developing the muscles to support that additional weight.

 

The push to have every arm throwing mid-90s or better has often been done without accompanying work at the high school (and lower) levels to strengthen core and upper legs. Ideally, velocity is generated through the turn at the peak of the delivery, generated through the hips, upper thighs, and lower back, using the arm as more of a slingshot rather than placing heavy stress on the chest, shoulder, and elbow. While there hasn't been an immediate change in how velocity is generated, the reports of TOS have gone down significantly as if there really has been a major change across amateur and pro ball. Ideal velocity generation is being taught more widely through places like Driveline, but certainly not enough that you should be hearing no reports of TOS.

 

 

[Heezy1323]

 

I personally believe the TOS stuff was similar to the prevalence of back injuries among NFL linemen as the 300-350 pound weight for an offensive lineman became a requirement upon league entry instead of something teams developed in house after drafting a guy. Guys just built up muscle without regard to how those muscles were useful in the game and also without regard to developing the muscles to support that additional weight.

 

The push to have every arm throwing mid-90s or better has often been done without accompanying work at the high school (and lower) levels to strengthen core and upper legs. Ideally, velocity is generated through the turn at the peak of the delivery, generated through the hips, upper thighs, and lower back, using the arm as more of a slingshot rather than placing heavy stress on the chest, shoulder, and elbow. While there hasn't been an immediate change in how velocity is generated, the reports of TOS have gone down significantly as if there really has been a major change across amateur and pro ball. Ideal velocity generation is being taught more widely through places like Driveline, but certainly not enough that you should be hearing no reports of TOS.

Thanks for the reply- very interesting to hear your take. I'm not even sure we know exactly what TOS is. I know we often divide it into neurogenic and vascular types, but it likely is even more complex than that, IMHO. I believe some component of UCL injury is that we are probably reaching the edges of human performance. Muscles can be made stronger, but ligaments have an intrinsic strength that probably can't be appreciably improved. Nerves and blood vessels likely similar...

 Did you see the injury Nick Burdi had, that was called basically a brachial plexus strain? He was in excruciating pain... not sure how to explain that one exactly.