Journal of

Back and
Musculoskeletal
Rehabilitation
ELSEVIER Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17

The influence of the spine on the shoulder in the

throwing athlete

Jeffrey L. Young*a, Stanley A. Herring b , Joel M. Press a, Brian A. Casazzaa

aSPOI1S Rehabilitation Program, Depal1ment of Physical Medicine and Rehabilitation, Rehabilitation Institute of Chicago,
NOl1hwestem University Medical School, Chicago, IL, USA
b Puget Sound SpOI1S and Spine Physicians, Depal1ment of Rehabilitation Medicine, Department of Ol1hopaedics, University
of Washington, Seattle, WA, USA

Abstract

Analysis of shoulder dysfunction in throwing and overhead athletes can no longer be restricted to evaluation of the
glenohumeral joint alone. The isolated shoulder is incapable of generating the force necessary to hurl a baseball at
velocities of 90-100 miles per hour or serve a tennis ball in excess of 120 miles per hour. The purpose of this paper is
to provide a literature based theoretical framework for the role of the spine during these activities. The spine is a
pivotal component of the kinematic chain which functions as a transfer link between the lower and upper limbs, a
force generator capable of accelerating the arm, and a force attenuator which dampens shear forces at the
glenohumeral joint during the deceleration phase of the pitching motion. Side bending and rotation of the cervical
spine facilitates visual acquisition of the intended target. Inflexibility of the hip musculature and weakness of the
muscles which attach to the thoracolumbar fascia have profound effects upon spine function which secondarily places
greater stress upon the glenohumeral joint and rotator cuff. Shoulder rehabilitation and injury prevention programs
should include evaluation of and exercise regimens for the lumbar, thoracic and cervical spine.

Keywords: Sports Medicine; Baseball Injuries; Biomechanics; Shoulder; Spine

1. Introduction that imperfections in the glenoid architecture,

For many years, the concept of shoulder dys-
function in the throwing athlete had been synony-
mous with glenohumeral joint dysfunction. As the
ultimate region of pathology, it was often thought
* Corresponding author, Sports Rehabilitation Program,
Center For Spine, Sports and Occupational Rehabilitation,
1030 North Clark Street, Chicago, IL 60610, USA. Tel: + 1
312 9087767; fax: + 1 3129084499.
strength imbalances in the intrinsic shoulder mus-
cles, or ligamentous laxity within the
glenohumeral joint were the major sources of
shoulder, particularly rotator cuff, degeneration
and injury. Thus, the majority of surgical and
rehabilitative efforts were directed at restoring
what was theorized to be normal glenohumeral
relationships. However, as our understanding of
shoulder function evolved, it was evident that this
focus was too narrow, as even 'isolated' shoulder

1053-8127/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved.

PII:SI053-8127(96)00193-5
6 J.L. Young et al. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-]7

motion requires the contribution of no fewer than
four joints and 17 muscles. With more complex
motions such as the baseball throw or the tennis
serve, the shoulder girdle, by itself, is incapable of
generating the necessary forces (60 Nm of inter-
nal rotation torque) to produce the phenomenally
high angular velocities (Over 7000° S-1 during the
transition from external to internal rotation going
from arm cocking through the acceleration
phase)commonly reported [1,2]. Recent literature
supports the notion that:
1. These forces must come from somewhere else
along the kinetic chain.
2. The shoulder musculature's primary function
is that of stabilization and protection of the
joint, and not acceleration of the arm [1,3-5].
It is our contention that as the link between
the shoulder and the lower extremity, the spine
and its associated musculature is responsible for
transferring much of the ground reactive forces
into the upper extremity, and is capable of gener-
ating additional forces which contribute to the
throwing motion on its own. We will explore
direct and indirect evidence in support of this
hypothesis and will attempt to identify key issues
related to the throwing motion at the different
regions of the spine.
2. Overview of the pitching motion
The baseball pitch is the most dynamic motion
in sports. Andrews and Jobe and their respective
co-workers divided the pitching motion into
phases, with Jobe describing five phases and An-
drews describing six [3,6].
1. Wind-up (Andrews, Jobe) - the initiation of
the pitching motion. The knee is brought toward
the chest, which raises the pitcher's center of
gravity (Fig. 1A). Formation of a 'closed packed
position' while maintaining good balance is criti-
cal. This maximizes the potential to eventually
impart velocity to the ball. Body weight is kept

Fig. 1. (A-G) The phases of the pitching motion. Based upon classification systems of J. Andrews and F. Jobe (references 3, 6) Fig.
adapted from Oilman et al. Biomechanics of pitching with emphasis upon Shoulder mechanics, J Orthop Sports Phys Ther,
1993;18(2):403. See text for details.
 J.L. Young et al. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17
over the supporting foot with the non-throwing
shoulder and hip facing the catcher's target or
slightly turned toward the throwing arm side. The
throwing and glove hands are together.
2. Stride (Andrews), Early Cocking (Jobe) -
lower extremity movement toward home plate
begins with the simultaneous actions of separat-
ing the pitching and glove hands (Jobe) and initia-
tion of stride toward home plate (Andrews). The
stride leg moves toward the plate while the chest
remains 'pre-rotated,' not yet facing home plate
(Fig. 1B). Prior to stride foot contact, the throwing
arm sweeps downward, then upward as the
shoulder begins to assume an externally rotated
(ER) position. This places the arm in a semi-
cocked position. Stride foot contact signifies the
end of early cocking.
3. Arm Cocking (Andrews), Late Cocking (Jobe)
- once stride foot contact is made, the hips and
trunk begin to rotate. The spine remains lordotic
and the shoulder achieves maximal external rota-
tion in abduction (Fig. 1C), signifying the
shoulder's maximum potential to accelerate the
ball.
4. Arm Acceleration (Andrews), Acceleration
(Jobe) - the rapid transition from shoulder ER
to shoulder internal rotation (IR). The upper
torso now faces home plate and the trunk begins
to flex. As the arm is brought forward, the elbow
begins to extend and the forearm begins to pro-
nate with high valgus forces being placed upon
the elbow. The entire time from stride foot con-
tact through initiation of shoulder IR (Fig. 1D) to
ball release (Fig. IE) is in the order of 1/8th of a
second, with the highest shoulder IR angular ac-
celerations being achieved during the initiation of
shoulder IR [1-3].
5. Arm Deceleration (Andrews), Follow-through
(Jobe) - shoulder IR continues but angular ve-
locity decreases as the muscular stabilizers of the
scapula and humeral external rotators contract
eccentrically and the trunk flexes, bringing the
center of gravity over the stride leg (Fig. IF).
Follow-through (both) - completion of the
pitching motion (Fig. 10) The pitching arm is
adducted and the stride knee extends. The push
off leg is brought toward home plate as the pitcher
squares to field a batted ball.
7
3. The spine as a force generator for the throwing
athlete
The notion that the spine and the pelvis are the
driving forces behind limb acceleration is not
new. Oracovetsky noted that the forces generated
at the level of the trunk and pelvis that are the
'engine' which enables bilateral lower extremity
amputees to walk with prostheses and lumbar
level paraplegics to ambulate with long leg or-
thoses [7]. Clearly, a functional unit that is able to
summon enough force to accelerate large passive
structures plus the superincumbent weight of the
upper body is more than capable of imparting
such forces upward into the smaller, lighter upper
extremity with even more spectacular results. This
section details how the finely coordinated and
sequential motions of the lower limbs, spine and
upper limbs enables the pitcher to utilize much of
the ground reactive force and forces generated at
the level of the spine in the pitching motion.
During the windup phase, the muscles of the
legs and torso generate potential energy by rais-
ing the center of gravity [8]. Arm cocking and
acceleration, represent a 'controlled falling phase,'
during which a change from potential energy (PE)
to kinetic energy (KE) occurs. As noted by Abrams
[8], if there is not excessive dissipation of this
energy in the ensuing motions, and the arm (rela-
tively small mass) accepts the forces from the legs
and trunk (large mass) below, by the formulae:
1. KE=PE
2. KE = 1/2mu 2 and
3. 1/2(mbody)(u body )2 = 1/2 {marm){uarm)2.
The reduction in kinematic chain segment mass
results in acquisition of greater rotational velocity
in the upper extremity [9,10]. Rotational velocity
will be further influenced by how far the mass of
the object is from the center of rotation. The
more tightly packed position of the arms during
the initial stages of the pitching motion allows the
trunk to attain a higher velocity before it has to
'tum over' its rotational energy to the throwing
arm [10]. By the time this this transfer occurs, the
pitching arm has gone from the tightly packed
position to one of humeral abduction and maxi-
8 J.L. Young et at. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17
mal ER. This abducted, maximal ER position
winds the glenohumeral ligament complex tight
and places the powerful shoulder IR muscles
(latissimus dorsi, pectoralis major) on stretch. An
explosive transition from maximal ER to IR en-
sues, as the combined efforts of the trunk and IR
muscles lead to development of a peak angular
velocity at the shoulder in excess of 7000° s - 1, a
velocity the shoulder girdle could never generate
in isolation [2]. Inefficiency of pitching motion
(e.g. keeping ball and glove hands separated from
each other and away from the body during wind-
up, or 'opening up' too soon during arm-cocking),
results in a loss of force imparted to the shoulder
and requires that the shoulder girdle impart more
KE to the ball on its own. Amateur and lesser
skilled pitchers exhibit high percentages of maxi-
mal muscle activation of all rotator cuff muscles
throughout the pitching motion. Professional
pitchers (who are considered to be more efficient)
exhibit both less use of the supraspinatus during
arm abduction and more selective activation of
the remaining rotator cuff muscles in general
than lesser skilled amateurs [11,12]. The profes-
sional pitcher's more highly coordinated motion
and ability to utilize larger muscles for force
generation also leads to deactivation of the all
cuff muscles except subscsapularis during arm
acceleration [12]. Isokinetic shoulder muscle
strength appears to have little bearing upon
throwing velocity, further suggesting that these
muscles are not the primary movers of the
throwing arm [13]. Even when isokinetic shoulder
internal and external rotation strength has been
shown to be greater in pitchers than non-pitchers,
the speeds at which tests were performed were
less than one twentieth of the angular velocities
typically observed in actual pitching [14].
The key to reducing the work of the shoulder
appears to be transforming an anterior-posteri-
orly directed ground reaction force into a rotatio-
nal force in the upper extremity, and, when nec-
essary, relying upon the larger muscle groups of
the axial skeleton to generate forces which can be
used in the throwing motion as well. Assuming a
kinematic chain model exists, this is acco~plished
via the successive acquisition of KE from the
contiguous caudal segment with development of
rapid acceleration as that caudal segment decel-
erates or stops. This has often been referred to as
'sequencing' of motions, with the final ball veloc-
ity being the summation of previous sequentially
developed velocities in all the more proximal
moving joints [15-17]. The sequencing pheno-
menon has also been demonstrated in Olympic
javelin throwers from the time of final foot con-
tact to javelin release [18]. It is important to
recognize that the orderly sequencing of motions
(e.g. a kinematic chain) is not necessarily synony-
mous with an orderly sequencing of forces (kinetic
chain). Hong reported observing sequential kine-
matics but not sequential torques in a group of
minor league pitchers [16]. However, this may
have been related to use of less skilled pitchers as
well as a different mathematic model from previ-
ous investigators [16]. Similar patterns of muscle
activation and funneling of forces up the kinetic
chain appear to take place in the tennis serve as
well, although the presence of a racquet at the
end of the kinetic chain allows for more 'catch
up' (Le. more force generation at a more distal
link in the chain) if sequencing has not been
smooth [5,19].
Many authors have described varying aspects of
body segment kinematics during throwing and the
tennis serve [3,5,12,15,16,20-24]' There is, more
or less, a consensus that the back, trunk, and hips
serve as both center of rotation and the transfer
link from the legs to the shoulder. This, in con-
junction with the assumption that sequencing does
occur leads us to the following (note that all
subsequent references will assume a right handed
pitching motion).
1. During wind-up and early arm cocking, the
major forces at work are in the lower half of
the body with development of a forward mov-
ing 'controlled fall.'
2. Increased tensile forces are developed in the
abdomen, hip extensors and spine with me-
dial (internal) rotation of the lead hip occur-
ring prior to contact with the ground.
3. The subsequent counterclockwise rotation of
the pelvis and trunk (when viewed from above)
abruptly place the arm behind the body in an
externally rotated position.
 J.L. Young et al. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17
4. Lateral trunk flexion is the determining fac-
tor in arm abduction [20,22]. When viewed in
the coronal plane, the relative abduction of
the humerus to the long axis of the trunk is a
relatively constant 90-100°, regardless of style
[3,20,22]. The overhand athlete leans con-
tralaterally, while the sidearm or submarine
thrower actually leans toward the throwing
arm. Rotation of the trunk also aids in this
abducting motion [22]. The muscles of the
shoulder are minimally involved in producing
abduction during the early cocking phase of a
well executed throw [25].
5. Large muscles, outside the rotator cuff, are
responsible for subsequent acceleration of the
arm. This will include muscles of the anterior
chest wall as well as the muscles and fascia
that surround the spine, and will be discussed
in later sections. For review of the critical
role of the muscles controlling scapu-
lothoracic motion (scapular positioning and
stabilization against the thorax), the reader is
referred to the work of Kibler [4].
6. The intrinsic muscles of the shoulder actually
serve as 'passengers along for the ride' with
their primary function being that of attempt-
ing to keep the humeral head within the
glenoid. This is particularly apparent in the
deceleration phase, during which time all of
the intrinsic and extrinsic shoulder muscles
fire at significant percentages of their maxi-
mum attempting to develop the 500+ N to
slow the arm down [1,3,10]. Once again, in the
properly thrown pitch, the spine and its asso-
ciated musculature have have a significant
role, but this time as a force attenuator.
7. Toward the end of the pitching motion, the
torso, having decelerated so the arm could
acquire kinetic energy in the arm acceleration
phase, begins to rotate forward [10]. The for-
ward rotation of this larger link segment helps
to re-acquire some of this energy, which theo-
retically reduces the burden on the serratus
anterior and other stabilizers which are at-
tempting to eccentrically maintain position of
the scapula and maintain humeral head con-
tainment.
9
We then asked, 'what happens to the throwing
performance when the motion of the axial skele-
ton is inhibited or the potential ground reaction
force is reduced?' In both cases, the throwing
velocity is markedly lower. Toyoshima analyzed
contributions of the hip, trunk, and shoulder seg-
ments to thrown ball velocity by placing relative
physical restrictions at each of these levels. With
a normal overhead throw rated as 100%, peak
velocities dropped to 84% when a forward stride
was not allowed, and down to 63.5% and 53.1 %
when the lower body and lower body plus trunk
were restricted, respectively [26]. A model of se-
quential muscle activation created by Alexander
also demonstrated maximum ball velocity
achieved with trunk restriction to be on the order
of one half of that achieved during unrestricted
throwing [15]. Whiting's work with the United
States men's water polo team revealed peak ball
release velocities to be approximately 20 m s --I ,
or approximately one half the velocity that a
thrown baseball might reach on land where a
ground reaction force can be generated [27]. Mc-
Master similarly speculated that lack of a base of
support in water polo (along with the larger di-
ameter and slightly heavier ball) resulted in a
shifting of more forces to the shoulder stabilizers
with consequently reduced elbow angular acceler-
ation and ball release velocities [28]. Further-
more, any breakdowns along the kinematic chain
(ie strength imbalances, inflexibility, fatigue, in-
stability, improper sequencing) creates less effi-
cient energy transfer. This leads to a breakdown
in pitching mechanics and loss of throwing veloc-
ity [4,15,17,26].
4. Lumbar spine
The lumbar spine is instrumental in providing a
level foundation that remains stable during the
throwing motion. If the spine and its associated
musculature are not adequately mobile and
strong, there is the potential for loss of pitching
control, dissipation of energy and altered shoulder
biomechanics throughout the pitching motion.
The presence of lumbar lordosis and the extent
to which it should occur during the baseball pitch-
10 J.L. Young et af. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17

ing motion has been a concern of coaches and

clinical scientists for many years. During the arm
cocking phase, virtually all professional pitchers
exhibit some degree of lumbar lordosis (J. Bos-
cardin, M.D., personal communication). However,
we believe that this is a 'controlled' lordosis, in
part modulated via eccentrically contracting ab-
dominal musculature. Should the supportive mus-
culature of the lumbosacral spine fatigue, a more
'passive' lordotic posture ensues. This creates hip
extension with greater reliance upon the 'Y' liga-
ment of Bigelow (iliofemoral ligament) and poste-
rior elements of the spine for passive restraint.
From the standpoint of the shoulder, this lordosis ______________ _____________ oo
~

is harmful in a number of ways. Early assumption

of spine extension, ('locking out' of the spine)
prevents achievement of the 170-175° of shoulder
external rotation (measured as shown in Fig. 2),
which is necessary to 'fully load the tank' in arm
cocking [1,3]. The work of Watkin's group further
establishes the problems that lordosis produces
[29]. They theorized that trunk fatigue induces
lumbar spine lordosis which places the pitching
shoulder and arm behind in the acceleration phase
of the pitching motion ('slow arm' theory). They
developed the notion that a slow arm leads to a
higher ball release point, loss of pitching accuracy
and the potential for compensatory muscular in-
jury [29].
On the other hand, if lordosis is always present
during arm cocking, a slightly different explana-
tion is offered. Lordosis that is actively controlled
through the eccentrically contracting and spine
stabilizing musculature (i.e. hip and spine flexors
and thoracolumbar fascia) is a normal process
and serves as part of the 'pre-loading' of these
muscles in anticipation of subsequent force gen-
eration in the direction of the throw. Further-
more, the appropriately timed reversal of lordosis
is critical in the transition from late cocking to
acceleration. However, in the presence of muscu-
lar fatigue or weakness, the 'passive' lordotic pos-
ture is assumed. With passive extension, less pre-
loading of the abdominals occurs. Under this
condition, in order to deliver the pitch at a high
velocity, one of two things must happen - either
more energy has to be expended by trunk flexors
and rotators to bring the spine and torso forward
Fig. 2. Measurement of shoulder external rotation during the
pitching motion. Rotation is measured in the sagittal plane
and is described as a function of rotation of the forearm
relative to an axis described in the upright spine. When
measured in this manner, 180· of external rotation represents
the combined effects of pure glenohumeral joint external
rotation plus scapulothoracic motion and spine extension (ref-
erences 1, 3). Fig. adapted from Oilman et al. Biomechanics of
pitching with emphasis upon shoulder mechanics, J Orthop
Sports Phys Ther, 1993;18(2):406.
again, with reacquisition of proper setting up of
the shoulder (unlikely if the muscles are already
fatigued), or more force has to be generated at
the level of scapular and shoulder musculature to
compensate for the biomechanically disadvanta-
geous positions of the scapulothoracic and
glenohumeral joints (trailing behind the body). It
is thus, a 'slow spine' that results in the obselVed
loss of the strike zone and eventual overload
injuries. In Watkin's study, dynamic EMG record-
ings revealed the non-throwing arm (NT) side
rectus abdominus and NT side paraspinal muscles
to be highly active in arm cocking phase, high
 J.L. Young et al. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17
levels of throwing arm (T) side gluteus maximus
activity during a pre-cockingjwind-up (coiling
with rotational loading) phase, and rather con-
stant NT side abdominal oblique muscle activity
[29]. Under these conditions, the obliques serve
as a trunk rotator, the rectus as an anterolateral
flexor, the paraspinals as lateral flexor and rota-
tors, the T side gluteus maximus as a push off
force, and the NT side gluteus as a pelvic stabilizer
during hip flexion. It is of interest that the most
highly skilled pitchers consistently demonstrated
greater NT side than T side oblique activity
throughout and greater NT side rectus and
paraspinal muscle activity from late arm cocking
through release. This is significant because the
activation patterns of these muscles, creates con-
tralateral flexion and counterclockwise (viewed
from above) rotation of the trunk, which con-
tributes to the forces producing abduction of the
throwing arm. Thus, the appropriately timed and
coordinated activation of muscles influencing
spine motion reduces the need for the shoulder
muscles to act as the prime movers of the arm.
All of these muscles either directly or indirectly
attach to the thoracolumbar fascia (discussed
below).
Another possible reason for increased lumbar
lordosis is inflexibility at the level of the hip.
During the properly performed pitch (right
handed pitcher), the athlete strides towards home
plate with the length of the stride from the pitch-
ing rubber to the stride foot being equivalent to
almost 90% of the pitcher's height. The stride
foot lands slightly off an imaginary line extending
from the back heel toward home plate, and with
the stride foot pointed slightly inward [3]. Failure
to 'set up' in this manner leads to the pitcher
either 'opening up' too soon (the stride leg is
either excessively externally rotated or placed too
much toward the 1st base line), or 'throwing
across the body' (the stride leg is internally ro-
tated too much or crossing over to the 3rd base
line side). In either of theses situations, incorrect
femur position adversely affects lumbopelvic
rhythm and subsequent control of lordosis.
Hip inflexibilities that exist in overhead
throwing and racquet sport athletes can lead to
improper femur and foot positioning. Kibler has
11
shown tennis players to have reduced hip internal
rotation (tight or excessively strong external rota-
tors) on the contralateral body side to the serve
arm, which forces the femur into an externally
rotated position with foot planting [5]. Pappas
noted that pitchers with painful hips on the
throwing arm side have hip external rotator tight-
ness on the throwing arm side [30]. Tightness of
the hip rotators in either the push off leg or the
stride leg can interfere with proper location of
the stride foot and lead to opening up or throwing
across the body as described above. Similarly,
tight hip flexors, which induce ante-tilting (ante-
rior rotation) of the pelvis, could also contribute
to poorly controlled lordosis as well as reduce
stride length.
The thoracolumbar fascia is the critical struc-
ture in the preservation of normal spinal mechan-
ics. The anatomy of the thoracolumbar fascia has
been described in detail by Bogduk and expanded
upon by Gracovetsky [7,31-33]. It is a tough fi-
brous sheath like mass of connective tissue encas-
ing the spinal extensors and extending downward
from the posterior thoracic spine to the ilial and
sacral attachments of the hip extensor muscula-
ture [31]. It expands anteriorly in its mid portion
from the lateral border of the erector spinae to
interdigitate with the fibers of the muscles of the
abdominal wall such as the internal oblique,
transversus abdominus and the serratus posterior
inferior. The thoracolumbar fascia is a multi layer
structure. Its superficial fibers emerge from the
latissimus dorsi above and gluteus maximus below
giving it connections to both the upper and lower
extremities. Its deeper layers are directed caudi-
laterally from the midline and encase the erector
spinae and connect with the internal oblique and
transversus abdominus.
The thoracolumbar fascia has multiple roles.
First, as described above, it serves as an attach-
ment, or anchor site, for numerous muscles. This
can be of great use when these muscles are suf-
ficiently strong to provide counter forces to en-
sure the anchoring takes place,facilitate trunk
rotation and to maintain the semi-rigid cylinder
necessary for pitching performance. Second, in
combination with the posterior spine ligamenture,
it helps to maintain rigidity of the vertebral
12 J.L. Younget aL / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17
column [31,34]. It is much more effective in per-
forming its task and becomes maximally taut when
the spine is in flexion; development of lordosis
markedly reduces its effectiveness as a stabilizing
structure. Third, it plays a major role in the
dissipation of shear forces normally imparted to
the 'three joint complex' (intervertebral disk and
facets) [8,35]. This is extremely important in rota-
tional activities such as pitching; work by McGill
indicates that the U-lS disk may be subjected to
over 4800 N with resisted isokinetic trunk rota-
tion [36]. With regard to its other roles in pitch-
ing, it works on the humerus both through the
lateral flexion and rotation mentioned above and
via the latissimus dorsi which attaches directly to
the humerus at the level of the intertubercular
groove. Its function as the axial attachment site
for the latissimus is critical, as the latissimus must
be able to generate over 150% of its maximal
manual muscle activity during the late arm cock-
ing phase, (eccentrically contracting as the
humerus develops maximal ER), and 133% dur-
ing acceleration when it concentrically contracts
to forcefully internally rotate the humerus [11,25].
The high forces during late cocking in the latissi-
mus, along with the actions of other internal
rotators help contain the humeral head in the
glenohumeral joint as the arm goes into maximal
ER. Thus, the same structure that is greatly re-
sponsible for allowing muscles to generate the
forces necessary to accelerate the trunk (glutei)
and arm (trunk musculature) also helps to bring
the arm out of its fully cocked position and pro-
tect anterior capsular structures as well.
Lastly, the lumbar spine influences the shoulder
on the the basis of its ability or inability to
laterally flex. As noted above, the major source of
abduction force upon the humerus during the
overhead throwing motion is the combination of
lateral spine flexion away from the pitching arm
and the trunk rotation which helps the arm
achieve a fully cocked position [20,22]. If the
athlete has reduced mobility at the U-lS and
LS-Sl segments (typically the major motion seg-
ments where over 80% of lumbar motion should
occur and the 'pivot point' upon which the semi-
rigid cylinder is perched), lower lumbar spine
lateral flexion is lost, and higher lumbar segments
and/or the thoracolumbar junction must com-
pensate. With an elevation of this 'pivot point' to
higher lumbar segments, there is a less efficient
transfer of forces from the pelvis, and obligatory
muscle substitution. Perry electrodiagnostically
demonstrated that there was greater activation of
the deltoids for abduction in pitchers with
impingement [37]. It would be interesting to ex-
amine such a population for evidence of spinal
segmental dysfunction or, for that matter, other
biomechanical deficits.
5. Thoracic spine
The thoracic spine influences scapulothoracic
position and glenohumeral motion. During the
throwing motion, there is first lateral and upward
rotation of the scapula and then migration of the
scapula around the thorax in the transition from
cocking to follow through [5,34]. In all, approxi-
mately 15 cm of retraction/protraction and 65° of
rotation/abduction must occur [4,5]. Alteration
of the shape of the thorax i.e. thoracic kyphosis,
produces both abduction and protraction of the
scapula [5,38]. This changes the orientation of the
glenoid (glenohumeral ante-tilting) which reduces
the clearance space for the humeral head and
increases forward shear [38-40]. Limitations in
rotation of the thoracic spine will affect the
throwing motion as well. Pappas, among others,
has noted the need for counterclockwise rotation
of the right handed pitcher's trunk in the late
cocking phase in preparation of forward accelera-
tion of the arm [30]. Pre-rotation of the trunk
(rotation of the trunk towards the dominant
shoulder), theoretically also adds to the force with
which the external oblique may contract [36]. In
addition, the ribs and their costovertebral connec-
tions, by limiting motion in the thoracic spine,
create a relatively stable attachment site which
accepts forces from below and from which mus-
cles of the upper extremity may emerge. Finally,
extension of the thoracic spine in late cocking
maximizes shoulder external rotation relative to
the upright body axis.
The stresses placed upon the thoracolumbar
spine may contribute to its being a frequent site
of injury in young athletes. Sward, in his review of
 J.L. Young et at. / Journal of Back and Musculoskeletal Rehabilitation 7 (J996) 5-17
such injuries, noted that scoliosis has been re-
ported in up to 80% of throwing and overhead
racquet athletes, whose activity places asymmetric
loading upon the shoulders and trunk [41]. How-
ever, the relationship between radiologic abnor-
malities in this region and pain or inability to
participate in sports has not been clearly es-
tablished [42,43]. These curvatures tend to have
Cobb angles of less than 15°, and much of the
observed asymmetry during forward flexion may
be attributable to dominant side back and
shoulder muscle hypertrophy [41,42].
6. Cervical spine
The role of the cervical spine in the throwing
motion is probably the least explored and least
understood of the axial regions. We propose that
the primary role of the cervical spine is to allow
full rotation so that the athlete may 'acquire' the
target he is trying to hit with the thrown ball. This
rotation is accomplished by the coupled motions
of lateral bending and flexion/extension. Normal
atlantoaxial, occipitoaxial, and zygoapophyseal (z)
joint motion, and lack of soft tissue (capital exten-
sors, scalenes, trapezius, sternocleidomastoid, and
cervical extensors) restrictions is necessary for
full cervical range of motion. If the appropriate
cervical motion does not take place, 'target acqui-
sition' for a right handed pitcher can only occur
via a compensatory premature counterclockwise
(viewed from above) rotation of the throwing
shoulder. This may occur either via excessively
left ward placement of the striding left leg, or
early axial trunk rotation. In either case, there is
squaring off (facing the target) too soon in the
pitching motion. The shoulder can no longer be-
come 'fully loaded' and the slow arm pheno-
menon ensues. A compensatory dropping of the
elbow and increased truncal rotation might occur
in order to achieve a fully externally rotated and
abducted position, which might increase tensile
forces placed upon ligamentous structures about
the shoulder and elbow. Elliot, in his 3D cine-
matographic study of skilled tennis players, notes
that they maintain a stable head position and a
contralateral shoulder that doesn't deviate from
the direction of the hit prior to impact [21]. From
13
this, it follows that failure of target acquisition
necessitates alteration of stroke mechanics result-
ing in placement of greater tensile and shear
forces on connective tissue structures about the
shoulder.
The increased tensile forces placed on the
shoulder may also place stress upon neurologic
structures such as the suprascapular and long
thoracic nerves. Repeated traction upon these
nerves can lead to neurapraxic, or if sustained,
axonotmetic lesions with loss of loss of external
rotation strength, loss of scapular control or overt
scapular winging [44-47]. Tennis players, because
of the severity of the overhead reaching motion in
their serve appear to be particularly vulnerable to
this problem [19,44]. Electrodiagnostic studies may
help distinguish axonal from demyelinative
processes, and in doing so, aid in determining age
of injury and prediction of recovery [45,46].
The cervical spine may actually be involved in
force generation during the throwing or tennis
serving motions. The concept of torque-counter-
torque (see subsequent section) may apply here
as well as in the lower spine segments. The initial
rotation and lateral flexing of the cervical spine
toward the non-throwing shoulder side could aid
in throwing shoulder abduction via tensing fibers
of the trapezius, sternocleidomastoid and strap
muscles which attach to the clavicle and scapula,
and by increasing rotational velocity of the
thoracic region [17]. This is even more evident in
the throwing events such as the discus, in which
larger and more forceful rotations of the cervical
spine are required. Atwater reported three first
rib fractures in baseball pitchers [20]. Although
not documented as the cause, one might suspect
that repetitive tensile forces, e.g. those produced
during vigorous countertorquing, might have
played a role and that these were in fact stress
fractures.
Applications of this concept may prove useful
in analysis of shoulder injuries in swimmers as
well. Restricted cervical motion would theoreti-
cally alter the amount of either axial rotation (log
rolling) or shoulder abduction in external rotation
the swimmer exhibits in order to breathe and the
force that the swimmer must push the water with
to propel himself forward. The need for increased
14 J.L. Young et al. / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17
axial rotation requires increased muscular
effort/energy expenditure to perform the same
task (decreased mechanical efficiency). Increased
abduction in external rotation could increase the
likelihood of 'impingement' while increased force
developed in the latissimus and pec major places
more tensile load upon the rotator cuff muscles
which are trying to reduce labral shear by con-
taining the humeral head in the glenoid. Clearly,
this is an area which needs to be investigated
more thoroughly.
7. The zygapophyseal (facet) joints
In addition to their contribution to support of
the spine as load bearing structures, the zy-
gapophyseal (z) joints may also playa role in the
obligatory motion of the spine and ground reac-
tion force transmission in the throwing athlete. In
the lumbar region, the z joints are vertically ori-
ented. Flexion/extension, particularly in the
lowest lumbar segments is maximized in this plane.
A.. mentioned above, when the thoracolumbar
fascia is tightened, there is creation of a rigid
cylinder so that the forces may be brought up
from the pelvis to the upper body. A flexed spine
posture maximizes the thoracolumbar fascia's
lever arm and places little stress upon the z joints.
However, fatigue and the accompanying loss of
thoracolumbar fascia rigidity results in reduced
ability to fight the posteriorly directed counter-
force when the pitcher strides forward. By their
orientation, the less protected facets also allow
the spine to move in a path of least resistance
(extension) which increases lumbar lordosis. On
an acute basis, this may result in the slow arm
phenomenon. On a repeated basis, this could
conceivably lead to z-joint irritation or stressing
of the pars interarticularis.
In the thoracic spine, the z joints become more
obliquely oriented. This allows for more rotation
of the spine which enables the anterior-posterior
forces from the level of the lumbar spine to be
converted into the more appropriate rotatory
torque necessary to accelerate shoulder and arm
about the long axis of he body. Eighty percent of
the twisting of the spine occurs at thoracic spine
levels [36]. Thoracic rotation is a key motion early
in the throwing sequence during cocking phase
[11,30]. Thoracic facet injury or abnormal curva-
ture of the thoracic spine could theoretically limit
the potential rotation and upward transfer of the
ground reaction force.
In the cervical spine, the z joints are more
horizontally oriented, allowing for lateral flexion
and,in the upper segments, rotation. Loss of facet
gliding at this level could theoretically interfere
with target acquisition and with the ability to
maintain a laterally flexed and counterclockwise
rotated position from which counter torques to
the cephalad portion of the upper extremity can
be generated.
8. Other axially derived forces - the Serape
effect
Northrip and Logan described the concept of
torque-countertorque, or the Serape Effect [17].
They wrote that during high velocity throwing, the
torque exerted upon the chest wall in order to
provide upper body rotation results in a counter-
torque exerted upon the pelvic girdle. The impli-
cation with regard to the throwing motion is that
the ballistic action of muscles distant to the
glenohumeral joint proper could impart accelera-
tory forces upon the arm if performed in a well
sequenced and coordinated manner. For example,
in a javelin throw, the contralateral pelvic rota-
tion matched against the still ipsilaterally rotated
trunk theoretically would place stretch upon many
of the muscles· that ultimately rotate the torso.
Coordinated concentric activation of pre-
stretched muscles 'diagonally related' to each
other (i.e. muscles along a serape or 'shawl'-like
path from the left hip to the right shoulder)
would lead to greater force generation and pro-
jectile velocity [17]. This concept does not appear
to be that different from what is more often
referred to as a 'stretch shortening cycle', or an
axially based version of plyometrics. Although the
actual amount of anatomic stretch placed upon
any of the individual muscles may be 'small' (less
than 110% resting length), McGill's three-dimen-
sional model predicts a trunk axial torque gain of
9% with a 30° prerotation of the trunk against an
immobilized pelvis [36]. In the true throwing mo-
 J.L. Young et aL / Journal of Back and Musculoskeletal Rehabilitation 7 (1996) 5-17
tion, with linking of the lower extremities and
pelvis to the torso, the potential for even greater
force generation would seem likely. Conversely,
too early cessation of pelvic rotation or incom-
plete truncal pre-rotation would lead to a rela-
tively reduced axial torque with a slower arm
speed, necessitating increased activation of the
shoulder musculature to achieve the same
throwing arm acceleration. Incorrect placement
of the striding left foot ('opening up' too soon), or
too backward a lean (increased lordosis), would
also prevent the stretching of these key muscles
and potentially reduce throwing velocity.
9. Implications for rehabilitation
The expansion of our view of potential causes
of shoulder dysfunction to the levels of the spine
and pelvis has important implications for both
rehabilitation and research. If what we suspect is
true, in addition to ensuring proper glenohumeral
range of motion and scapulothoracic relation-
ships, it is clear that sports medicine professionals
who work with competitive throwing and racket
sport athletes will need to look well beyond the
shoulder during their preparticipation screens,
during evaluation of athletes with shoulder in-
juries, and, when planning rehabilitation pro-
grams. The higher the level of competition, the
greater the chances are that any weak link in the
kinetic chain can become over stressed, with con-
sequences felt both within and distant to that
body segment.
Cervical, thoracic, and lumbar spine mobility,
and lower extremity flexibility should be ad-
dressed. Should weakness or inflexibility exist,
development of strength, power and endurance of
the muscles in these regions will optimize the
chances that the athlete can continue to partici-
pate or resume activity. Spinal segmental dysfunc-
tion should be addressed through the removal of
myofascial restrictions, reestablishment of proper
lumbar segmental motion, and then development
of a neutral spine stabilization program. This is
followed by more aggressive proprioceptive neu-
romuscular facilitation and dynamic challenges of
the athlete's ability to maintain a neutral spine
under sport specific conditions. Resolution of
15
symptoms alone is not the goal of rehabilitation.
For. athletes and non-athletes alike, rehabilitation
must continue until conditioning has been op-
timized and can be maintained [48-50]. The ben-
efit of correcting functional biomechanical defic-
its and muscular imbalances carries over to activi-
ties of daily living as well.
In summary, there appears to be considerable
reason to include examination of the axial skele-
ton during the evaluation and rehabilitation of
athletes with shoulder pain. Further research is
needed to evaluate the actual extent to which
abnormal spinal and pelvic motion cause shoulder
problems and to see if addressing abnormal find-
ings discovered in preparticipation exams can re-
duce the occurrence of subsequent injury.
Acknowledgements
Special thanks to Augustus Young for provid-
ing the primary author with his first lessons in
baseball and biomechanics.
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