Shoulder pain when throwing: the rotator cuff, the labrum, instability, throwing load and what helps

What a throw asks of the shoulder, and how common the pain isStrong evidence

A throw winds the body up from the legs through the hips and trunk, then whips the arm forward. The American Academy of Orthopaedic Surgeons (AAOS) says the late-cocking phase (the arm up and turned right back) and the follow-through put the greatest forces on the shoulder: cocking stretches the front, and the back has to slow the arm after release. In 26 skilled pitchers, the shoulder took about 1,090 newtons of compression just after release.

So a sore throwing shoulder is common and usually an overload. Half of 476 pitchers aged 9 to 14 had elbow or shoulder pain in one season, and 5% of 481 had surgery or retired from a throwing injury over 10 years. About a fifth to a third of elite handball players have shoulder problems at any one time. In one survey of English county cricketers, 23% reported a shoulder injury in a season and 18% pain on throwing, though few missed matches. No study counts the causes across all throwing sports; most of the evidence is from baseball, handball, volleyball and cricket.

Sources 1, 2, 3, 4, 5, 6, 7, 8, 9

Where it hurts and when in the throwEmerging evidence

Pain deep at the back as the arm cocks back, with stiffness, a long warm-up or lost speed or control, is typical of internal impingement: the cuff tendons at the back pinched between the ball and the rim of the socket, often with a tight back of the shoulder and some looseness at the front. Pain from the front to the side of the arm, with throwing and later at rest or at night, is typical of the rotator cuff.

Deep pain with catching, locking, popping, lost speed or a "dead arm" can be a SLAP tear (a tear at the top of the labrum) or a loose shoulder; the AAOS says that in throwers looseness develops gradually, and pain and lost speed come before any feeling of slipping. Clinical tests for SLAP tears are poor. In a young thrower, pain on the outside of the upper arm is often Little League shoulder.

Sources 3, 1, 10, 11, 12, 50, 51

What a scan shows, and what it doesn'tStrong evidence

Scans find a lot in throwing shoulders that don't hurt. In 20 elite overhead athletes without pain, 40% of throwing shoulders showed rotator cuff tears on MRI (magnetic resonance imaging), and none developed problems over 5 years; the authors say MRI alone "should not be used as a basis for operative intervention" in these athletes. The labrum looked abnormal in 79% of 14 pain-free professional pitchers' shoulders, and in 21 pain-free Major League pitchers, 11 had cuff tears and 10 SLAP tears, which didn't predict time on the injured list.

A scan helps when surgery is being considered, sometimes as an MRI with dye in the joint. A child with suspected Little League shoulder needs X-rays of both shoulders, which show widening of the growth plate on the throwing side.

Sources 15, 16, 17, 10, 50, 52

Blood vessels and nerves: rare, but worth knowingEmerging evidence

Thoracic outlet syndrome, where a nerve or blood vessel near the top of the ribs is squeezed, is mostly the nerve type (82% of 526 people referred to one centre); the vein type affects about 0.5 to 1 in 100,000 people a year and can cause a clot in the arm, with a swollen, throbbing, red, warm arm. Artery damage in throwers is rarer still: 9 athletes in 10 years at one large centre, with arm fatigue, finger numbness or a cold hand, and clots can travel to the hand. All 9 went back to professional baseball after treatment.

In volleyball players and overhead servers, the nerve to the back of the rotator cuff can be stretched, and the muscle over the back of the shoulder blade wastes, usually without pain; most players kept playing with strengthening. Quadrilateral space syndrome, a squeezed nerve and artery at the back of the armpit, is rare and diagnosed when other causes have been ruled out.

Sources 53, 54, 55, 56, 57, 58, 59, 60

How it usually goesEmerging evidence

Internal impingement usually settles with time off throwing and rehab when it is caught early, with stiffness and a slow warm-up (stage I) or pain as the arm cocks back (stage II); pain that keeps returning despite rehab is stage III. Athletes with SLAP tears who completed rehab usually returned within 6 months. In one series, Little League shoulder settled at a mean of 2.6 months and children were back in competition at 4.2 months. After a dislocation, the NHS says recovery takes 6 to 12 weeks, and up to 16 weeks for some sports. No one can promise a date.

Sources 3, 18, 51, 52, 14

Rehab first: throwers often do poorly after surgeryEmerging evidence

Across 5 studies of 244 athletes with SLAP tears treated without surgery, 78% of those who completed rehab returned to play. After SLAP repair, 63% of overhead athletes got back to their previous level, and in one professional baseball organisation only 7% of pitchers returned to their previous performance after surgery. In a trial of 118 people (not athletes), repair did no better than sham surgery. After a full rotator cuff repair, 1 of 12 professional pitchers returned to a high level.

These are mostly case series, but they agree: rehab is the first treatment, and surgery is for a minority who don't improve.

Sources 18, 19, 20, 21, 22, 23, 3

Throwing load: fatigue and volume matter mostEmerging evidence

In 140 adolescent pitchers, fatigue and overuse had the strongest links with shoulder or elbow surgery, and more than 100 innings in a year went with 3.5 times the risk of serious injury over 10 years. Pitch Smart, the guidelines from Major League Baseball and USA Baseball, set daily pitch limits from 50 at age 7 and 8 to 105 at 17 and 18, with rest days by pitches thrown, innings caps and at least 4 months a year off throwing.

After US high schools made pitching limits compulsory, overall shoulder and elbow injury rates didn't change, though rules with a rest-day requirement or a 105-pitch daily cap went with fewer injuries; that analysis is weak. Curveballs aren't clearly the problem: they went with more pain in one season but not with serious injury over 10 years.

Sources 36, 5, 4, 37, 38, 39

Cricket: bowling limits protect the back; throwing has no limitEmerging evidence

The England and Wales Cricket Board (ECB) caps fast bowlers aged 19 and under at 4 overs a spell and 8 a day at 11 and under, rising to 7 and 18 at 18 and 19, with guidelines on weekly overs, rest days and breaks. They aim to protect the lower back from stress fractures, and there's no limit on throwing in the field. In 28 elite cricketers, more than 75 throws a week went with more injury. Sudden spikes in bowling went with more injury in fast bowlers, though the way that spike is usually measured is disputed.

Sources 40, 41, 42, 43, 44

A shoulder warm-up 3 times a week helpsEmerging evidence

In 660 elite handball players, a warm-up done 3 times a week (turning the arm in and out, shoulder-blade strength and trunk work) lowered shoulder problems from 23% to 17% over a season. In Swedish handball schools, the Shoulder Control programme more than halved shoulder injuries, and a youth baseball warm-up cut shoulder and elbow injuries from 3.1 to 1.7 per 1,000 practices and games. These are single trials in particular sports, and a 2018 review called the overall evidence limited.

Sources 45, 46, 47, 48, 49

Lost inward turning and the shoulder blade: weak, mixed warning signsMixed evidence

Throwing arms often turn inward less than the other arm, called glenohumeral internal rotation deficit (GIRD). It predicted injury in high-school players and in pooled baseball data, but not significantly in 122 or 296 professional pitchers or across 17 studies of overhead athletes; in the largest cohort, too little outward turning mattered more. In handball and volleyball it didn't predict problems at all.

An abnormal-looking shoulder blade raised the chance of later shoulder pain from 25% to 35% in 419 athletes, but didn't predict injury in handball players, and a consensus says its role "is not clearly defined". Both are things a physiotherapist checks and trains, not proven causes.

Sources 24, 25, 26, 27, 28, 29, 30, 34, 35

Stretching the back of the shoulder: small gains, cross-body firstEmerging evidence

In 54 adults without pain, a cross-body stretch (5 holds of 30 seconds, once a day, for 4 weeks) gained about 20 degrees of inward turning, while the sleeper stretch's 12 degrees wasn't significant. Across 6 trials in overhead athletes with GIRD, stretching added about 7 degrees. No trial shows that stretching alone prevents injury, so stretch only a clear side-to-side loss.

Sources 31, 32, 33

Injections: short-lived, and one is enoughStrong evidence

The AAOS lists an injection only after rest, medicines and physiotherapy haven't helped. A 2025 UK care pathway for rotator cuff pain says one steroid injection can be considered after 6 to 8 weeks without improvement, that the benefit is short-lived (under 12 weeks), and that repeat injections add nothing. It isn't specific to throwers.

Sources 1, 77

Throwing load, rest days and the off-season (written steps)

Our 3D figure can't show these. They come from Pitch Smart, the ECB, the AAOS and NHS pages; where a step is our suggestion, it says so.

• 1. Stop throwing, bowling and serving while it hurts to throw, and keep the arm moving for everyday jobs: the NHS says don't completely stop using your shoulder.
• 2. Young pitchers: follow Pitch Smart for their age. Daily maximums are 50 pitches at 7 and 8, 75 at 9 and 10, 85 at 11 and 12, 95 at 13 to 16 and 105 at 17 and 18. For 9 to 14 year olds, no rest day is needed after 1 to 20 pitches, 1 day after 21 to 35, 2 after 36 to 50, 3 after 51 to 65 and 4 after 66 or more. No pitching on 3 days in a row, at most 80 innings a year at 9 to 12 and 100 at 13 and 14, at least 4 months off throwing a year, one team at a time, no catching while not pitching, and fastballs and changeups only up to 12.
• 3. Young fast bowlers in England and Wales: follow the ECB's spell and day limits (4 overs a spell and 8 a day at 11 and under, rising to 7 and 18 at 18 and 19), at most 4 bowling days in any 7 with only one pair of days in a row, a 7 to 10-day break mid-season, a lighter week every 4 to 5 weeks and a 4-week break after the season.
• 4. Fielding throws in cricket have no official limit. Keep the number steady from week to week, and below about 75 throws a week while it's sore (our suggestion, from one study of elite cricketers).
• 5. Build up gradually after any break: the ECB notes that "bone strength is reduced after only two weeks" and builds bowling back step by step; the same logic suits throwing (our reading).
• 6. Get your throwing mechanics looked at by a coach or physiotherapist once you are throwing again (the AAOS).

Sources 3, 64, 37, 40, 41, 42, 1, 78

The interval throwing programme (written steps)

From a US hospital's patient handout based on a published programme, with distances in metres. A review of 9 such programmes found they agree on the basics but "have minimal clinical validation".

• 1. Start when you have full movement and strength without pain, and your clinician agrees.
• 2. Throw every other day, and only move on when the last session was pain-free with no soreness the next day.
• 3. Use a crow-hop (a hop, a skip, then the throw), an arcing throw, and don't throw flat-footed.
• 4. Step 1: warm-up throws, 25 throws at about 14 m (45 feet), a 15-minute rest, warm-up throws, then 25 more at 14 m. Step 2: 3 sets of 25 at 14 m with 10-minute rests. Then the same pattern at about 18 m, 27 m, 37 m, 46 m and up to 55 m (60 to 180 feet), two or three steps at each distance.
• 5. Then pitching from the mound, or full practice at your position. For cricket no programme has been published: build bowling back gradually as the ECB advises, and fielding throws by the same steps (our suggestion).
• 6. Follow the soreness rules in the pain rule above at every step.

Sources 72, 74, 75, 73, 41