When a patient presents with this complaint, the initial differential should include dynamic instability often associated with SLAP tears and internal impingement as well as muscle weakness and scapular dyskinesia. Throwing is an extremely complex athletic maneuver and relies on the specific coordination of the entire kinetic chain. This chief complaint is often among the most difficult to discern because, by its nature, it implies that the athlete is able to throw, and thus the impediment is usually a subtle one. In addition, as this often is a dynamic complaint (i.e., only demonstrated when the patient is throwing), reproducing the patient's symptoms may not be possible in the office. It is sometimes necessary to go to the field or the weight room to illicit signs or reproduce the patient's symptoms. In spite of the difficulty of symptom reproduction, there are some techniques that will help in the approach to this chief complaint.
Does the loss of control/decreased speed happen in initial or in later innings? In the thrower who complains of decreased velocity or loss of control that is present at the outset of throwing, the initial differential should point more toward a static condition affecting the kinetic chain. It is important to remember that the chain starts in the core with the legs and trunk, and although here we emphasize the shoulder, it is important to appreciate that such problems often originate lower in the chain. The astute examiner will do well to inquire and examine the lower extremities and trunk for causes of shoulder pathology. If the core is functioning properly, then the shoulder differential should include causes of weakness, subtle instability, SLAP tears, and cuff problems. We refer the reader to those sections for the focused examinations for those pathologies.
If a pitcher starts out normally but loses command later, the problem is more likely dynamic. This makes the evaluation more challenging because findings may be minimal in an office evaluation. The importance of "revving up" the shoulder is emphasized. The initial differential includes dynamic fatigue or instability. As a pitcher continues to throw, he may become fatigued in any segment of his kinetic chain, leading to compensatory maneuvers like "dropping the elbow," a straighter lead leg, or less external rotation at the shoulder.48 Although it is beyond the scope of this chapter to specifically address these
compensations, they have been noted by pitching coaches for years and lead to increasing strains in the shoulder should the athlete continue to pitch. This may lead to new shoulder problems that will be difficult to completely eliminate until the more proximal elements of the chain are evaluated and rehabilitated.
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