If You Throw, You Need A Different Kind of Rehab

Baseball and softball are growing in numbers and visibility in Ireland, especially at the recreational level. Injuries can and still do occur, but sports medicine is understandably built around hurling, Gaelic football and rugby. Throwing in baseball and softball is different. The forces are different. The long-term adaptations are different. Therefore the rehab has to be different too. If you throw, you need someone who understands throwers. Treating a thrower like a general shoulder is misguided.

The Hidden Forces of Throwing
Throwing a baseball is one of the most stressful movements in sport, especially for pitchers. At maximum layback, the elbow experiences roughly 60lbs of torque (the equivalent of five bowling balls pulling down on it). At ball release, the shoulder experiences a distractive force of about 1.2 times bodyweight, meaning the joint is resisting forces that are actively trying to pull it apart. All of this happens in less than a second, with the arm rotating at nearly 7,000° per second. These aren’t normal gym demands. Throwing places extreme stress on the shoulder and elbow at speeds and forces most rehab programs never prepare you for. Bands and light dumbbells might help early on, but if rehab never progresses to heavy strength work, eccentrics, plyometrics, medicine balls, and actual throwing, you’re not preparing for competitive throwing. If rehab doesn’t build you for the demands of throwing, it isn’t baseball rehab.

When Abnormal is Actually Normal
Because of the extreme forces involved in throwing, pitchers develop adaptations that don’t look “normal”, and they aren’t supposed to. The problem is that these adaptations are often treated as something to correct. A throwing shoulder is not a general population shoulder.

One of the best examples is humeral retroversion. After years of throwing, especially during youth development, the humerus gradually twists outward. This increases external rotation (ER) and decreases internal rotation (IR). This shift isn’t a flaw. More ER generally means more velocity. It also allows pitchers to achieve layback without over-stressing the front of the shoulder, because part of that motion is coming from bone structure and not just soft tissue laxity. But here’s where misunderstandings happen. A player presents with shoulder pain, IR looks limited, it gets labeled as GIRD (glenohumeral internal rotation deficit), and posterior capsule stretches are prescribed to “restore” the lost IR. Yet when both arms are measured properly, the total arc of motion in the throwing arm should be within about 5–10° of the non-throwing arm. If total arc is preserved, that “loss” of IR is just humeral retroversion — a normal and beneficial adaptation. Trying to aggressively correct that can mean altering the very adaptation that helps performance. This is why comparing a thrower’s shoulder to population norms can be misleading.

Labral findings are another example. Many throwers show labral changes on imaging due to the repetitive “peel-back mechanism” when throwing. However, many remain asymptomatic. Imaging findings alone do not equal dysfunction, especially in throwers. Treating the scan instead of the athlete is misguided. In throwers, the question isn’t “does this look normal?” It’s “is this functional and resilient for the demands of throwing?”

Asymmetry is a Feature, Not a Flaw
Baseball is inherently one-sided. You throw with one arm, you rotate in one direction, you load the same hip and shoulder, over and over again. The body adapts to this repeated stress - that’s the S.A.I.D. principle at work. Over time, throwers become structurally and functionally asymmetrical because the sport demands it. Rehab and strength training often aim for symmetry. Restoring baseline strength after injury is important but it’s in reference to the uninjured side. Perfect symmetry isn’t the goal in baseball; the goal is resilience within the asymmetry. A thrower doesn’t need to look balanced — they need to tolerate the demands of their position. In baseball, functional asymmetry is normal.

Return-to-Throwing is a Skill
Developing a return-to-throwing plan for a baseball or softball player is complex. Most interval throwing programs (ITPs) progress using distance (as a proxy for intensity) and number of throws (volume). This seems logical, but in reality, it’s far messier. Without wearable technology to measure elbow stress, or even a radar gun to monitor velocity, maintaining consistent intensity from session to session is difficult. Distance alone does not equal force as there is no perfectly linear relationship between how far you throw and how much stress is placed on the arm. Two pitchers who both throw 90mph do not necessarily place the same amount of stress on their arm either. Differences in mechanics, timing, strength, and body structure all change the equation. You can throw a short distance with maximal effort. You can throw farther with less effort. And that’s before we even introduce tools like weighted balls, long toss, and pulldowns. These methods may be effective for building arm strength and velocity because they intentionally increase stress on the system to drive adaptation, but they also alter mechanics and increase load. If used incorrectly or layered into a rehab process too early, they can easily set a player back.

Returning to throwing after injury is not just about being pain-free - it’s important but not the same as being ready to throw. Readiness requires: appropriate progression, controlled volume, gradual exposure to higher intensities, adequate recovery, and mechanical awareness. Returning to throwing is a matter of exposure to stress, and if you get the stress wrong, you can experience setbacks.

Specialized, Not Standard
If throwing creates unique adaptations, then our standards for assessment must reflect that. We cannot assess or rehab a thrower’s shoulder the same way we would a non-thrower’s. In general rehab, we often use the uninvolved side as the reference, but a thrower’s dominant arm should not look like their non-dominant arm or like the general population. Throwers often need greater ER strength, specific strength ratios that differ from standard “norms”, and unique endurance demands. If we apply generic shoulder strength standards to a thrower, we risk under-preparing them for the demands of throwing or over-correcting adaptations that are actually beneficial. A thrower’s shoulder isn’t broken because it doesn’t look symmetrical or textbook-normal; it’s specialized and specialized athletes require specialized assessment.

Protecting the Developing Arm
When we think about kids, we tend to imagine they’re indestructible — flexible, resilient, and able to bounce back from anything. Kids are just as susceptible to overuse injuries as adults, but the injuries look different. A common example is Little League Elbow (LLE). This is irritation of the growth plate on the inside of the elbow caused by repetitive throwing stress. In young athletes, the growth plate is the weak link in the arm. That’s why we don’t commonly see 10–14 year olds tearing their ulnar collateral ligament (UCL). The growth plate fails first. Once that plate closes (typically 15–17 years old) the weak link shifts and now the UCL becomes the structure at risk. The stress doesn’t change but rather the tissue that absorbs it does.

LLE is, at its core, an overuse injury and it reflects a broader issue in youth sports: early specialization and year-round competition. The baseball culture of today with travel teams, showcases, and constant exposure can quietly accumulate thousands of throws on a developing arm. This matters, especially when recovery, strength development, and overall athletic diversity are limited. Protecting young throwers isn’t about shutting them down. It’s about: managing throwing volume, respecting recovery, prioritizing long-term development over short-term exposure, and educating coaches and parents on how the throwing arm actually develops. Understanding the throwing shoulder and elbow isn’t just about rehab - it’s about prevention and giving young athletes the chance to keep playing for years to come.

Throwing is what makes baseball and softball unique and it’s also what makes players different to rehab. As the sports continue to grow in Ireland — in numbers, competition, and visibility — the need for informed, sport-specific injury management grows with them. Throwers cannot be assessed, progressed, or returned to play using generic shoulder guidelines. If you throw, you need someone who understands throwers. My role isn’t just to reduce your pain. It’s to understand the demands of your position, your schedule, and your long-term goals. It’s to manage load, guide progression, and prepare your arm for the realities of competition. It’s to return you to the field with confidence, not just clearance, because being pain-free isn’t the same as being ready.