Shoulder Injuries in Cricket Bowlers
The act of bowling is a complex movement that requires a healthy functioning shoulder where muscles, tendons, ligaments, and bone all move in a synchronized and stable pattern. Because of the complexity of this movement, subtle abnormalities can lead to the development of shoulder pain and discomfort.
Types of shoulder pain experienced :
- Dull Aching Pain: Often deep in the shoulder or extending down the upper arm or upper back and often cannot be pin pointed by a finger.
- “Dead Arm Syndrome”: A sudden feeling of numbness and weakness/lack of strength of the involved arm for a couple of minutes.
- Night Pains: Sometimes the pain is not too bad during the day but causes pain in the night that can disturb sleep.
When people complain of a shoulder pain when bowling, it’s critical to understand exactly where in the bowling motion there is an abnormality, and what might be causing this problem. It is imperative to have an idea of the bowling mechanics before anyone proceeds with the treatment.
Phases of bowling :
Most of the shoulder pain is reported among the bowlers during the final 3/4 phases. We can compare the bowling phases to that of pitching ( most common source of literature on the web )
Phases of throwing in pitching compared with bowling :
Once you have a clear understanding of the biomechanics, a thorough detailed evaluation of the patient in necessary.
Patient age is relevant in that certain diagnoses are more common in particular age groups:
- Shoulder pain in adolescent bowlers shoulder raise concern of physeal injury.
- Young bowlers may have problems with laxity
- Older bowlers commonly have rotator cuff pathology.
- Those in the middle of their careers may suffer from both laxity and rotator cuff issues.
Timing of symptoms during the throwing/bowling motion is important in formulating a differential diagnosis:
- Pain during cocking is can suggest labral pathology, internal impingement, laxity and/or instability.
- Pain during acceleration phase is seen with anterior instability
- Pain after ball release or deceleration phase is frequently associated with rotator cuff pathology.
- Pain during follow through may indicate posterior instability.
Timing of symptoms during the game is also important. Pain occurring late in the game or after repeated bowling suggests fatigue typically of the rotator cuff muscles.
Common Throwing Injuries In the Shoulder
SLAP Tears (Superior Labrum Anterior to Posterior)
In a SLAP injury, the top (superior) part of the labrum is injured. This top area is also where the long head of the biceps tendon attaches to the labrum. A SLAP tear occurs both in front (anterior) and in back (posterior) of this attachment point.
Typical symptoms are a catching or locking sensation, and pain with certain shoulder movements. Pain deep within the shoulder or with certain arm positions is also common.
(Left) The labrum helps to deepen the shoulder socket.
(Right) This cross-section view of the shoulder socket shows a typical SLAP tear.
Biceps Tendinitis and Tendon Tears
Repetitive throwing can inflame and irritate the upper biceps tendon. This is called biceps tendinitis. Pain in the front of the shoulder and weakness are common symptoms of biceps tendinitis.
Occasionally, the damage to the tendon caused by tendinitis can result in a tear. A torn biceps tendon may cause a sudden, sharp pain in the upper arm. Some people will hear a popping or snapping noise when the tendon tears.
(Left) The biceps tendon helps to keep the head of the humerus centered in the glenoid socket. (Right) Tendinitis causes the tendon to become red and swollen.
Rotator Cuff Tendinitis and Tears
When a muscle or tendon is overworked, it can become inflamed. The rotator cuff is frequently irritated in throwers, resulting in tendinitis.
Early symptoms include pain that radiates from the front of the shoulder to the side of the arm. Pain may be present during throwing, other activities, and at rest. As the problem progresses, pain may occur at night, and the athlete may experience a loss of strength and motion.
Rotator cuff tears often begin by fraying. As the damage worsens, the tendon can tear. When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears in throwing athletes occur in the supraspinatus tendon.
Rotator cuff tendon tears in throwers most often occur within the tendon. In some cases, the tendon can tear away from where it attaches to the humerus.
Problems with the rotator cuff often lead to shoulder bursitis. There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.
During the cocking phase of an overhand throw, the rotator cuff tendons at the back of the shoulder can get pinched between the humeral head and the glenoid. This is called internal impingement and may result in a partial tearing of the rotator cuff tendon. Internal impingement may also damage the labrum, causing part of it to peel off from the glenoid.
Internal impingement may be due to some looseness in the structures at the front of the joint, as well as tightness in the back of the shoulder.
This illustration shows the infraspinatus tendon caught between the humeral head and the glenoid.
Shoulder instability occurs when the head of the humerus slips out of the shoulder socket (dislocation). When the shoulder is loose and moves out of place repeatedly, it is called chronic shoulder instability.
In throwers, instability develops gradually over years from repetitive throwing that stretches the ligaments and creates increased laxity (looseness). If the rotator cuff structures are not able to control the laxity, then the shoulder will slip slightly off-center (subluxation) during the throwing motion.
Pain and loss of throwing velocity will be the initial symptoms, rather than a sensation of the shoulder “slipping out of place.” Occasionally, the thrower may feel the arm “go dead.” A common term for instability many years ago was “dead arm syndrome.”
Glenohumeral Internal Rotation Deficit (GIRD)
As mentioned above, the extreme external rotation required to throw at high speeds typically causes the ligaments at the front of the shoulder to stretch and loosen. A natural and common result is that the soft tissues in the back of the shoulder tighten, leading to loss of internal rotation.
This loss of internal rotation puts throwers at greater risk for labral and rotator cuff tears.
Scapular Rotation Dysfunction (SICK Scapula)
This photograph shows abnormal positioning of the scapula on the right side.Reproduced with permission from Kibler B, Sciascia A, Wilkes T: Scapular Dyskinesis and Its Relation to Shoulder Injury. J Am Acad Orthop Surg 2012; 20:364-372.
Proper movement and rotation of the scapula over the chest wall is important during the throwing motion. The scapula (shoulder blade) connects to only one other bone: the clavicle. As a result, the scapula relies on several muscles in the upper back to keep it in position to support healthy shoulder movement.
During throwing, repetitive use of scapular muscles creates changes in the muscles that affect the position of the scapula and increase the risk of shoulder injury.
Scapular rotation dysfunction is characterized by drooping of the affected shoulder. The most common symptom is pain at the front of the shoulder, near the collarbone.
In many throwing athletes with SICK scapula, the chest muscles tighten in response to changes in the upper back muscles. Lifting weights and chest strengthening exercises can aggravate this condition.