THEMATIC ISSUE
The Pediatric Overhead Athlete: What is the
Real Problem?
Aaron Sciascia, MS, ATC and W. Ben Kibler, MD
Objective: The purposes of this article are to examine shoulder and
elbow injuries in pediatric athletes, to evaluate the pathophysiology
and pathomechanics that may be associated with the pathoanatomy,
and to present suggestions for the prevention of those injuries.
Data Sources: This article will review the published sports
medicine literature on these topics in baseball and tennis injuries and
present a kinetic chain–based perspective on the possible causative
factors that are present in the young thrower.
Results: The published literature shows that there are multiple
intrinsic and extrinsic factors that contribute to the risk of injury in
young throwing athletes. These factors appear to develop over time; if
not recognized or addressed early, they have undesirable outcomes.
Conclusions: A multitude of factors, including anatomical, biome-
chanical, and environmental concerns, can contribute to the dys-
function of the shoulder and elbow in young overhead athletes.
Understanding the force-generating and load-absorbing processes of
the body will help clinicians, coaches, and others prevent or limit the
deleterious effects of such occurrences.
Key Words: should, elbow, injury, pediatric overhead athletes
(Clin J Sport Med 2006;16:471–477)
INTRODUCTION
Pediatric overhead athletes have a relatively high in-
cidence of shoulder and elbow injuries. A general perception
has been that injury of the upper extremity occurs due to
musculoskeletal intrinsic factors, such as the skeletal im-
maturity of this group and weak muscles around the shoulder
and elbow. Some authorities have suggested that athletes of
a young age should be limited in participation of these sports
on the basis of the potential injury risk to these parts of the
body but have argued that injury can be prevented if safe and
proper mechanics are taught.1,2 Extrinsic factors, such as the
level of competition, intensity of play, duration, and frequency
of play, as well as the biomechanical and physiological
demands of each sport also affect the durability of the young
athlete and may increase the risk of injury.1,3 Finally, it has
From the Lexington Clinic Sports Medicine Center, Lexington, Kentucky.
Reprints: Aaron Sciascia, MS, ATC, Lexington Clinic Sports Medicine
Center, 1221 South Broadway, Lexington, KY 40504 (e-mail: ascia@
lexclin.com).
Copyright Ó 2006 by Lippincott Williams & Wilkins
Clin J Sport Med  Volume 16, Number 6, November 2006
been noted that intensely young active athletes can develop
deleterious maladaptations in flexibility and strength in areas
subjected to repetitive tensile overload.4 This article will re-
view known extrinsic and intrinsic factors and will present
a kinetic chain-based perspective that includes both factors.
THE KINETIC CHAIN
Physiologic muscle activation results in several bio-
mechanical effects that allow efficient local and distal function.
The preprogrammed muscle activations result in anticipatory
postural adjustments (APAs) that position the body to with-
stand the pertubations to balance created by the forces of
kicking, throwing, or running.5,6 The APAs create the proximal
stability for distal mobility.
The muscle activations create interactive moments that
develop and control forces and loads at joints. Interactive
moments are moments at joints that are created by motion and
position of adjacent segments.7 They are developed in the
central body segments and are key to developing proper force
at distal joints and for creating relative bony positions that
minimize internal loads at the joint. There are many examples
of proximal core activation providing interactive moments that
allow efficient distal segment function. They either provide
maximal force at the distal end, similar to the cracking of
a whip, or they provide precision and stability to the distal
end.7 Maximum shoulder internal rotation force to rotate the
arm is developed by the interactive moment developed by
trunk rotation.7 Maximum elbow varus torque to protect
against elbow valgus strain is produced by the interactive
moment resulting from shoulder internal rotation.7 Maximal
fastball speed is correlated with the interactive moment from
the shoulder that stabilizes elbow and shoulder distraction and
produces elbow angular velocity.8,9 Accuracy of ball throwing
is related to the interactive moment at the wrist produced by
shoulder movement.9
As a result of the activations and interactive moments,
there is a proximal to distal development of force and motion,
according to the ‘‘summation of speed’’ principle that includes
core activation.7 This is not always a purely linear development
strictly from 1 segment to the next. In the tennis serve, elbow
maximal velocity is developed before maximal shoulder
velocity. However, this general pattern of force development
from the ground through the core to the distal segment has
been demonstrated in the tennis serve and baseball throw.9–11
Force control is also maximized through the core. The
trunk is essential in reacquiring the forward momentum in
throwing, and approximately 85% of the muscle activation to
471
Sciascia and Kibler
slow the forward-moving arm is generated in the periscapular
and trunk muscles, rather than the rotator cuff.12,13
In a closed system, alteration in 1 area creates changes
throughout the entire system. This is known as the ‘‘catch up’’
phenomenon in which the changes in the interactive moments
alter the forces in the distal segments. The increased forces
place extra stress on the distal segments, which often result in
the sensation of pain or actual anatomic injury. The site of the
symptoms (victim) may not be the sole site of alterations
(culprit). Without elbow elevation and extension before maxi-
mum shoulder rotation, increased tensile loads are seen at the
elbow ligaments during arm acceleration. Baseball pitching
coaches have empirically known of this deleterious situation,
calling this position the ‘‘dropped elbow,’’ their term for the
elbow being positioned below the level of the shoulder in the
acceleration phase, and consider this the ‘‘kiss of death’’ for
the elbow.14 Marshall and Elliott have shown that ‘‘long axis
rotation,’’ coupled shoulder internal rotation and elbow prona-
tion around the long axis of the arm from the glenohumeral
joint to the hand that is accentuated by maximum elbow
extension before maximum arm rotation, is a key bio-
mechanical event just before ball release/ball impact.11 This
coupled motion creates rotation around the almost straight long
axis of the arm, running from the shoulder to the hand, also
minimizing the valgus loads that may be generated at the elbow.
THE VICTIM: PAIN AND INJURY IN THE
SHOULDER AND ELBOW
Pain is a frequent presenting symptom in young players,
especially pitchers, participating in little league baseball (9 to
14 years of age). Lyman et al has estimated that 26 to 35 per
100 youth baseball pitchers in a season are afflicted with some
variation of shoulder and/or elbow injury.1,2 These studies
found that self-reported shoulder pain presented in more than
30% of pitchers and that self-reported elbow pain occurred in
more than 25% of pitchers immediately after a game.
Widening of the proximal humeral epiphysis, instability,
and impingement are some of the more common injuries seen
in pediatric overhead athletes. In our clinical practice, labral
injury is being seen with increasing frequency. These injuries
result from repetitive torsional forces in the shoulder; in
combination with poor mechanics, they place increased forces
across the anterior capsule and shoulder joint.15 Repetitive
valgus and distraction forces are also seen at the elbow and are
thought to be causative in injuries as medial epicondylitis,
collateral ligament injuries, and medial epicondyle avulsions.15
Shoulder and elbow pain and injuries are common in
tennis as well. Twenty to forty-five percent of all injuries that
occur in tennis are located within the upper extremity, with the
shoulder and elbow being the most frequently injured.16
Survey data from the 1998 USTA Boys’ (16- to 18-years-old)
and Girls’ (16-years-old) National Championships showed
25% to 35% of the participants had previous or current
shoulder pain, whereas 22% to 25% reported previous or
current elbow pain.16 Of those male athletes who reported
shoulder pain, 38% experienced anterior shoulder pain, 30%
experienced posterior shoulder pain, and 32% noted both
anterior and posterior shoulder pain. Of the female athletes
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Clin J Sport Med  Volume 16, Number 6, November 2006
who reported shoulder pain, 56% experienced anterior shoul-
der pain, 15% experienced posterior shoulder pain, and 31%
experienced both anterior and posterior shoulder pain.16
The shoulder is at a high risk of injury in tennis because
it faces high loads and forces while maintaining ball and
socket kinematics. Loss of ball and socket kinematics with
excessive translation of the glenohumeral joint may result in
labral pathology, including degeneration or tears.17 Rotator
cuff symptoms often occur secondary to glenohumeral insta-
bility.18,19 Other injuries can include humeral periostitis and
bicipital tendonitis.4,15 Unlike pediatric baseball injuries,
growth plate pathology is not a common occurrence in the
shoulder.15 Acute shoulder injuries are uncommon; however,
shoulder dislocations and acromioclavicular separations may
occur from direct trauma such as falling on the shoulder. There
is a risk of injury for the elbow as well. Lateral epicondylitis
(tennis elbow), medial epicondylitis, and injury to the medial
epicondylar growth plate can be seen in skeletally immature
tennis players.15 Lateral epicondylitis occurs more frequently
in recreational tennis players in comparison to elite level tennis
athletes, particularly in those (recreational) with poor
backhand mechanics.20 It has been noted that the frequency
of tennis elbow in world-class athletes ranges from 35% to
45%.21 This frequency is much lower in elite junior athletes.4,22
THE CULPRIT: BIOMECHANICAL AND
PHYSIOLOGICAL ALTERATIONS THAT
AFFECT KINETIC CHAIN MECHANICS
Baseball
The dysfunction of the shoulder and elbow in the
pediatric athlete appears to be multifactorial. Major contrib-
utors to shoulder and elbow pain in young baseball players are
age, height, and weight. Lyman et al noted the risk of elbow
pain increased as age and weight increased.1 As the athlete
increases in mass, the force generated by the body will in-
crease, having a potentially negative outcome on the skeletally
immature athlete. In the same study, the authors also reported
that elbow pain decreased with increased height. However, as
elbow pain decreased with height, shoulder pain increased.1
This may indicate that more stress is being placed across the
shoulder due to the existence of a longer lever (the arm).
The number of pitches thrown in a particular game could
affect the durability of the arm as well. Lyman et al examined
the number of pitches thrown in a game and during the season
among 9- to 14-year-old pitchers.2 The authors found no
significant difference between the number of pitches thrown in
a game and elbow pain. However, there was a significant
difference between increasing pitch counts and shoulder pain.
When examining the total number of pitches thrown over a
season, both shoulder and elbow pain increased as the pitches
thrown increased.2 Increased elbow pain was associated with
throwing more than 600 to 800 pitches per season, and
increased shoulder pain was associated with throwing more
than 800 pitches per season. It appears that the cumulative
effect rather than the acute effect may be the most important
factor.
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Clin J Sport Med  Volume 16, Number 6, November 2006
The type of pitch thrown is another factor that should be
considered. Escamilla et al found that throwing a curveball
requires an increased amount of force and torque at the elbow
and shoulder.23 The forces and torques are similar to throwing
a fastball or slider; however, the mechanics are dramatically
different, making the curveball a difficult pitch to master.
Similarly, Lyman et al showed that young pitchers are 50%
more likely to experience shoulder pain by throwing a
curveball and 80% more likely to experience elbow pain by
using a slider.2
Glenohumeral internal rotation deficit (GIRD) is
a common factor that has been associated with injury and
has been demonstrated in throwing athletes.17,24 GIRD is
defined as side-to-side asymmetry of more than 25 degrees,
an absolute value of less than 25 degrees, or a side-to-
side loss of total arc of motion more than 25 degrees.24 It is
thought to be produced by acquired posterior capsular con-
tracture and/or posterior muscle stiffness, and it is fre-
quently seen in various types of shoulder injuries.24,25
GIRD creates abnormal scapular kinematics due to the
‘‘wind up’’ effect of the arm on the scapula. As the arm is
forward flexed, horizontally adducted, and internally rotated
in throwing or working, the tight capsule and muscles pull the
scapula into a protracted, internally rotated, and anteriorly
tilted position that causes downward rotation of the acromion.
GIRD also affects glenohumeral kinematics by shifting the
humeral center of rotation posterior superiorly in cocking
and anterior superiorly in follow-through. The abnormal
kinematics have been significantly associated with labral
injuries.24,26,27
There are very few differences between the mechanics
of young pitchers and adult pitchers.28 There is a proximal
to distal kinetic chain of activation of the body segments in
both groups in order to propel the arm and ball. However,
there are differences in young and adult pitchers in the manner
of kinetic chain segment activation. Young pitchers demon-
strate increased trunk and leading hip rotation velocity from
cocking to acceleration compared with adult pitchers.8 This is
probably due to a decreased capability for lower core force
production. This disassociation between the upper and lower
trunk rotation produces a tendency to ‘‘open up’’, with the arm
trailing behind the body and may result in increased anterior
loads across the shoulder as well as increased medial loads
across the elbow.8
Tennis
Tennis involves high body-segment velocities, motions,
and loads.20 Data from adult players show that the elite player
must generate 4000 watts of energy (1.2 hp) in each serve.29
The entire body is involved in generating the energy.29 Trunk
rotation velocity is approximately 350°/s, shoulder rotation
velocity approaches 1700°/s, and elbow extension velocity
approaches 1100°/s.29 These velocities are developed rapidly
over 0.4 to 0.6 seconds, creating large accelerations in the
shoulder. The total arc of shoulder internal-external rotation
averages 146°. These velocities and accelerations produce ball
velocities of 95 to 110 miles per hour in women and 120 to
135 miles per hour in men. There are no comparable data for
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The Pediatric Overhead Athlete
loads in pediatric athletes, but the forces are quite high as
shown by serve velocities approaching 85 miles per hour in
female pediatric athletes and 105 miles per hour in male
pediatric athletes.
These loads are frequently applied and with high-energy
demands. The elite pediatric tennis player averages 2.3 hours
of practice or play per day, 6.1 days per week.30 Energy
expenditure evaluation reveals that the metabolic demands in
tennis are 70% alactic anaerobic, 20% lactic anaerobic, and
10% aerobic.29
The occurrence of tennis elbow has been associated with
equipment-related issues, including incorrect grip size, metal
racquets, heavier, stiffer, more tightly strung racquets, and
racquets with increased racquet vibration.21
GIRD is also a common maladaptation in pediatric
tennis players. This appears at an early age, and progresses
with age and years of play.31,32 Current thought recognizes
GIRD as a key initiator of a series of biomechanical alterations
that lead to altered humeral position in arm rotation that
predispose the shoulder and elbow to injury.24 There is no
consensus on the cause of GIRD. One explanation of the
changes in muscle flexibility may be an internal adaptation to
repetitive tensile load known as thixotropy, a biomechanical
property of muscle that represents internal stiffness of the
tissue. It is largely determined by the preceding history of
movements and contractions.33 Thixotropy is defined as the
passive stiffness that occurs after a chronic exposure of muscle
to tension.33–35 An acute change in stiffness can also affect
GIRD. When a muscle is contracted to a particular length,
once the muscle has relaxed, stable cross-bridges form in the
fibers at that length to give them their short-range elastic
component (SREC).35 If the muscle is then shortened, the com-
pressive forces on the sarcomeres, stiffened by the presence of
the SREC, may lead to detachment of the some of the
bridges.35 This detachment or damage has been found to be
a compounding issue that will remain in the muscular region
for an extended period of time. Therefore, both acute and
chronic changes in muscle due to eccentric load can affect the
amount of shoulder rotation.
There are proximal kinetic chain factors that should be
considered as well. It has been shown that mechanical
alterations during the tennis serve and the baseball pitch, such
as incomplete knee flexion in cocking or incomplete cocking
of the shoulder, create increased loads in the shoulder and
elbow as the athlete tries to maintain maximum serve or pitch
velocity.36 Elliot et al evaluated the effect of altered proximal
kinetic chain function on the amount of loads seen at the
elbow.36 In studying 2 groups of Olympic tennis players who
developed the same ball speed, they found that the group who
exhibited knee flexion less than 10 degrees in the cocking
phase of the tennis serve increased internal rotation force at the
shoulder and the normalized valgus load at the elbow by 21%
(body weight, 6.3% versus 5.2%) and that the resulting
absolute value, 73.9 Nm, was in the range that has been
documented to be above the ‘‘safe’’ level of repetitive load.37
This data show that lack of proximal activation can increase
the distal loads for the same force or energy output, thereby
placing the upper extremity at risk for sustaining an overload
injury.
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PHYSICAL EXAMINATION
It is possible to detect musculoskeletal maladaptations
early before they become deleterious. The musculoskeletal
base evaluation should evaluate for local alterations, such as
instability, muscle injury, and inflexibility, and screen for
kinetic chain alterations such as hip rotation inflexibility,
lumbar weakness, lack of core stability, and scapular dys-
kinesis. In our clinical practice, these alterations are very
common, being found in 49 to 100% of the time in association
with shoulder and elbow injuries.
The exam of the throwing athlete with elbow symptoms
should include evaluation of the proximal factors that may
influence elbow loading. Specific attention should be paid
toevaluation of the shoulder, trunk, and hip/leg. In the history,
questions should be asked about prior leg or back injury and
any shoulder symptoms. A relatively common finding is of
previous ankle sprain, especially on the contralateral (plant
foot) side. Also, many athletes will report previous problems
with the shoulder, either pain or decreased function (ball
velocity or ball location) before the onset of elbow symptoms.
In the physical exam, assessment of posture while
standing can check for lumbar lordosis, which is common and
decreases core trunk stability and APAs. Screening evaluation
of the hip/leg can be accomplished by the one leg stability
series, which includes one leg stance (Fig. 1A) and one leg
squat (Fig. 1B). Inability to achieve balance of the trunk over
the planted leg directs attention for further evaluation and
rehabilitation efforts as part of the treatment. Hip range of
motion is frequently altered, especially in rotation, and can be
evaluated by seated testing of internal/external rotation. Trunk
flexibility in flexion/extension and lateral bend also can be FIGURE 1. A, Single leg stance; B, single leg squat.
evaluated by asking the athlete to bend in these directions.
Scapular dyskinesis can affect shoulder and elbow loads
by altering the stable platform for long axis rotation, and by include passive stretches known as the ‘‘sleeper’’ stretch and
not allowing full cocking when the scapula is excessively ‘‘open book’’ stretch (Figs. 5 and 6). The goal is to bring the
protracted. Scapular assessment can be accomplished by side-to-side differences to less than 25 degrees.42 Rotator cuff
evaluation of resting scapular position and of dynamic scapu- strength should be evaluated, and testing for labral injury and
lar motion upon arm motion (Fig. 2). Alterations of scapular instability should be performed.
position/motion, termed scapular dyskinesis, are common in
association with arm injury and fall into 3 categories according
to the activations, strength, and flexibilities of the supporting
musculature.38 If 1 of the 3 patterns (type I, inferior medial
border prominence; type II, medial border prominence; type
III, superior medial border prominence) is present, rehabili-
tation of the scapular muscles should be included in the
treatment.38 Strengthening and re-education of the scapular
muscles can be achieved through the implementation of
exercises, which moderately activate the serratus anterior and
trapezius muscles (Figs. 3A and 3B). When working opti-
mally, both muscles have been suggested as being critical to
functional scapular movement.39–41
The shoulder should be evaluated closely for local injury
and because of its important role in elbow force generation
through interactive moments and regulation through long axis
rotation. Shoulder rotation can be evaluated by stabilizing the
scapula and determining the end ranges of glenohumeral FIGURE 2. Dynamic arm motion: assess scapular dyskinesis by
motion (Fig. 4). Range of motion exercises specific for rotation having the athlete actively flex arms 3 times in sagittal plane or
should be instituted if GIRD is found. Such exercises would scapular plane (scaption).

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FIGURE 3. Low row and lawnmower exercises which moderately activate the lower trapezius and serratus anterior muscles.
CONCLUSIONS
It is clear that optimum performance in throwing
or serving occurs when the athlete’s capability for kinetic
chain sequencing is appropriate to meet the anatomical,
physiological, and biomechanical demands of the throwing
FIGURE 4. Passive assessment of shoulder internal rotation with
the scapula stabilized.
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The Pediatric Overhead Athlete
or serving task. Likewise, injury can occur when the
kinetic chain sequencing is inadequate or the demands are
too high.3,24,26,36,43
Lack of proper kinetic chain function is a major
contributor to ‘‘what is the problem’’ in pediatric shoulder and
elbow injuries. A complete understanding of ‘‘the problem’’
may be accomplished by employing a more holistic approach
to the examination of the injured athlete. This approach may
also be used to develop interventions for injury prevention or
conditioning.
Interventions for prevention could be based on
a combination of understanding and modifying the sports
exposure and evaluating and maximizing the musculoskeletal
base. Monitoring the extrinsic demands (pitch count, number
of matches, periodization of conditioning, changes in
equipment) is critical. This can limit deleterious overexposure.
The athlete must play, compete, and be exposed to the sport
demands, but excessive exposure has been shown to have more
downside for injury risk than upside for increased perfor-
mance.3 Maximizing the efficient use of the kinetic chain by
teaching proper mechanics will decrease the magnitude of the
repetitive loads.
Periodic assessment of the musculoskeletal base will
allow delineation of extremity strength or flexibility
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FIGURE 5. Sleeper stretches can help combat GIRD by stretching the tight shoulder external rotators.

weaknesses or imbalances (ie, weak or tight scapula, hip, programs should be as sport-specific as possible, periodized
and/or trunk muscles). These factors, known to occur as to minimize deleterious overloads, and adjusted if the physical
maladaptations to sport-imposed demands, have been dem- examination demonstrates developed deficits. The authors
onstrated in many areas of the body and have been associated recommend integrating these programs with sport-specific
with injury.20,24,25,43–45 Close monitoring of these variables is activities, placing greater emphasis on mechanics and skills
especially important in the pediatric age group due to growth during the season while addressing strength, power, and
and development changes, which may accentuate these weight gains (or losses) during the off season. Musculoskeletal
imbalances. Also, since the engine of force development is flexibility should be emphasized daily. Proper recovery will
located in the core, this should be assessed regularly.46 There take place if the body is given frequent periods of rest. This
are several general protocols for the evaluation.47 A useful tool component of fitness is often overlooked and can lead injury if
for this sport-specific assessment for tennis players is the High not administered regularly (Table 1).
Performance Profile (HPP), developed by the United States
Tennis Association (www.usta.com/playerdevelopment). This
series of tests helps clinicians screen athletes for strength TABLE 1. Inherent Sport Demands
and flexibility deficits about the scapula, shoulder, trunk, and
Baseball2,3 Recommendations
hip, including a single leg stability series for assessing core
strength and shoulder internal rotation measures to assess the Number of innings or pitches
presence of GIRD. Other tests have been described for as- Per game 60–80
sessing functional core strength.46 Per season 600–800
Conditioning programs may be developed on the basis Per year 2500
of the findings of the musculoskeletal evaluation.47,48 Kinetic Changes in pitching rotation
chain deficits should be addressed before the implementation More frequency Avoid pitching with arm fatigue
of routine fitness components. Exercises targeting the scapula Shorter rest —
and trunk stabilizers as well as stretches aimed at regaining Different pitches Breaking pitches should be
flexibility of tight musculoskeletal structures (sleeper and open guided by height, weight,
and age (13 y/o or older)
book stretches) would be appropriate. The conditioning
Multiple teams Monitor closely for pain,
fatigue, and performance
declinations
Weather changes —
Tennis Recommendations*
Different racquet —
Different surface —
Change in serving technique Push-through serve recommended
Number of matches
Per tournament 2
Per season* Age 11: 40/yr maximum
Age 14: 70/yr maximum
Age 16: 90/yr maximum
Rest between matches One hour of rest per hour in
competition
FIGURE 6. Open book stretch helps regain flexibility of a tight *As recommended by the United States Tennis Association (USTA).
pectoralis minor.

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