THE PAINFUL SHOULDER IN THE THROWING ATHLETE

The nonoperative management of shoulder injuries in the throwing athlete requires a team approach. The physician, trainer, physical therapist, and coaches must work together with the athlete to enable a complete recovery. Each member of the team must have a clearly defined role. The trainer should initiate the process by recognizing the injury as early as possible. The physician must do a thorough evaluation and arrive at a clear diagnosis. A complete history and physical examination should be supplemented by appropriate radiographs and imaging studies. The physician needs to perform the evaluation in a manner such that the athlete and trainer feel confident in the diagnosis. The physician needs to spend an adequate amount of time with the player during the evaluation process to allow the player to express any concerns. Athletes often have their own insights into the injury that the physician should take the time to hear. Once a diagnosis is made the physician must, in consultation with the trainer, make several decisions: 1Can the athlete continue to participate? Only in exceptional circumstances is the athlete allowed to play through the injury. 2What medications are needed? In most incidences, an oral anti-inflammatory is indicated. Steroidal medications are not used because of the potential associated risks. Only in exceptional instances are narcotic pain medications used. 3Modalities such as cryotherapy, electric stimulation, and ultrasound are prescribed to decrease tissue edema and muscle stiffness. 4Injection therapy, particularly cortisone, rarely is indicated in this population. 5Physical therapy is usually the cornerstone of the treatment protocol. The conceptual structure of the program is designed by the physician in consultation with the physical therapist. The therapist and trainer carry out the program. Although the timing depends on the specific injury, in general, the player should demonstrate significant improvement in symptoms by the sixth week. If not, the player should be re-evaluated by the physician. On occasion the original diagnosis is modified at this juncture.