Shoulder injuries in the javelin throwerROBERT F. SING, ao.Philadelphia, Pennsylvania

Painful shoulder syndromes occurfrequently in athletes competing insporting events involving overarmthrowing movements. Injuries to thethrowing shoulder are particularlycommon in the javelin thrower, andan understanding of thebiomechanics of the javelin throw isnecessary if a proper diagnosis is tobe reached. Appropriate therapy maythen be instituted to assist in theathlete's return to a healthy,competitive capacity. An explanationof the biomechanics of the javelinthrow, as well as descriptions of thevarious types of throwing shoulderinjuries and their respectivetreatments are reported.

Javelin throwing is particularly strenuous on thethrowing shoulder because of the wide range ofmotion that it must go through in a violent man-ner. Chronic shoulder problems affect from thenovice to the world-class javelin thrower. Onestudy revealed that 29 percent of collegiate javelinthrowers sustained some type of shoulder injuryduring their careers. 1-2 Miklos Nemeth, the 1976Montreal Olympic gold medalist and the thenworld-record holder, was almost forced into retire-ment after the 1980 season because of "tendonproblems of the throwing shoulder."3 The javelincareer of Montreal Olympic silver medalist HannuSiitonen was halted prematurely because of a "lin-gering shoulder problem" and he "is said to be hap-py that his arm is 'normal.' "4

BiomechanicsAn understanding of injuries to the shoulder re-gion in the javelin thrower is dependent upon thecomprehension of the biomechanics of the actualthrowing motion and the contribution of each indi-vidual body part to the throw.

Throwing the javelin requires exceptional co-ordination; all parts of the body are involved. The

throwing action involves the transfer of momen-tum from the larger, more powerful, lower seg-ments of the body, to the hip, shoulder, arm, hand,and ultimately to the shaft of the javelin. The com-petitor builds up forward momentum via his runup, and after a series of "cross steps" (where thefoot on the side of the javelin crosses in front of theother foot), the leading leg located opposite thethrowing arm lands in front of the thrower, form-ing the "plant" (Figs. 1 and 2). All of this occurswhile the javelin is pulled back, far behind, in acocked position.

From this position, the hip is violently thrustforward by the powerful pressor force of the driveleg and the simultaneous pulling force of the for-ward plant leg. The twisting of the trunk awayfrom the side of the throwing arm causes the trunkto arch forward, forming a "reverse-C" position(Fig. 3). The javelin is still as far behind as possi-ble. It is in this position that the truncal and lowerextremity musculature act to transfer the bodyweight forward from the drive leg to the plant footin the direction of the throw. At the completion ofthe hip thrust, the throwing shoulder is pushed(dragged) forward by the abdominal and truncalmusculature. The hand and javelin remain far be-hind. This "hip-shoulder" motion generates a verypowerful and solid throwing base from which theinvolved shoulder now becomes the fulcrum for theentire upper extremity. The shoulder, which upuntil this point has been comfortably locked in ex-treme external rotation and abduction, is violentlypulled upward and forward, mainly by the largepectoral, deltoid, and latissimus musculature.However, contributions are also made from thefiner, more specialized muscles comprising the ro-tator cuff: supraspinatus, infraspinatus, subscapu-laris, and the teres minor.

The arm is then pulled through in a flail-likemanner, striking fast with a high elbow (Fig. 4). Itis the whip-like action of the hip-shoulder-elbow-hand sequence that produces this flail. The elbowshould be pulled high over the throwing shoulder,thus forcing the elbow into an extension motionand minimizing the torsional forces upon the el-bow. The more lateral the elbow positioning, themore rotational torque applied to the elbow and re-sultant increase in stress to the anterior structures

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Fig. 1. Forward momentum obtained through the thrower's run up; a series of "cross steps" is employed. Fig. 2. The leading leg willland in front of the thrower forming the "plant." Fig. 3. The "reverse-C" position.

Fig. 4. The arm is pulled through in a flail-like manner. Fig. 5. The release of the javelin.' Fig. 6. Thrower in the "follow-through"position.

of the throwing shoulder. It is important to notethat the spatial orientation of the shoulder andarm is ultimately dependent upon the degree oflateral truncal flexion away from the throwingarm during the throwing phase. This allows for ahigh release of the implement (Fig. 5).5

The follow-through or recovery phase starts atthe release of the javelin and ends with the com-plete cessation of forward bodily movement. It usu-ally occurs over one long step (Fig. 6). After the re-lease, the "drive" leg is pulled forward in a spring-like fashion and lands in front of the body, therebyabsorbing the forward momentum and arrestingany forward motion. (A technical foul will be in-curred if the thrower steps over the restraining toeboard.) The shoulder has been violently pulledfrom as far behind to as far forward as possible,with the joint being fully internally rotated, the el-bow extended in the direction of the throw, and theforearm locked in pronation.

Impingement syndromeBy most estimations, chronic rotator cuff impinge-ment syndrome is the cause of the vast majority of

shoulder complaints in athletic events that in-volve overarm throwing motions. 6 '" Anatomically,the impingement results from inflammatorythickening of the structures located underneaththe coracoacromial arch (the coracoid process, theacromion, and taut coracoacromial ligament), thuscompromising the "space needed for clearance be-tween the humeral head and the coracoacromialligament." 6 The anatomic structures affected bythe impingement include the subacromial bursa,the muscles comprising the rotator cuff, and the bi-cipital tendon as it courses beneath the arch nextto the supraspinatus muscle and through the bici-pital groove of the humerus. The explosive twist-ing action on these structures during the throwingmotion (severe external rotation, maximal exten-sion, and abduction of the involved shoulder) is thecause of their inflammation.'

In my experience, many javelin throwers exhibitsigns and symptoms referable to chronic impinge-ment syndrome, particularly over the bicipitaltendon. Yokoe and associates 1 reported that 90percent of the shoulder complaints in javelinthrowers were a result of bicipital tendinitis secon-

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dary to impingement. A recent excursion to Hel-sinki, Finland, for the World Track and FieldChampionships revealed that many of the world-class javelin throwers exhibited bicipital tendini-tis. Most throwers note that the pain subsides aftera vigorous warm-up, only to resume after theevent is completed. One of Finland's finest javelinthrowers claims that he must take 100 mg. of indo-methacin after each competition or his shoulderpain becomes "very severe" and incapacitating; iteven awakens him at night.8

Physical examination may reveal a positive"hesitation test," a break in the rhythm of abduc-tion as the arm rises above the horizontal plane in-dicating pain. Brunet and coworkers9 stress theimportance of examining the acromioclavicularjoint, because a thickened joint capsule can signifi-cantly impinge upon the structures passingthrough the acromial arch anteriorly. The "im-pingement sign" is another important test. Thethrowing arm is forcibly flexed upward and pain isproduced at the site of impingement—between thegreater tuberosity of the humerus and the anter-oinferior surface of the acromion. 1°.11 Described asone of the most definitive tests by various authors,the injection of 5 to 10 cc. of 1 percent lidocaine (orother local anesthetic) beneath the anterior acro-mial arch into the subacromial bursa causes im-mediate relief of the pain and weakness. However,if there is a true tear of the rotator cuff, a painlessweakness around the shoulder joint will re-sult.9,11,12 Palpation over the greater tuberosityand anterior acromion will reveal point tender-ness.

Further investigation of the impingement syn-drome is necessary in the more debilitating orchronic stages of the syndrome. Arthrography and/or arthroscopy of the shoulder joint is warranted.Obviously, roentgenograms are always necessaryin the evaluation of a painful joint; the impinge-ment syndrome may present as osteophytic forma-tion along the anteroinferior border of the acromi-on, with osteophytic and sclerotic changes over thegreater tuberosity. 11 Calcium deposits may some-times be observed in the rotator cuff. 13 For furtherdelineation of the bicipital groove of the humerus,the Sachs-Hill x-ray technique is probably the bestmeans of roentgen examination of this area."'15

Treatment of impingement syndrome primarilydepends upon the extent of the injury. The syn-drome is best prevented with thorough flexibilitytraining and adequate warm-up. Modification ofan individual's throwing technique is sometimesrequired. Strengthening of the shoulder joint is ac-complished through weight training in conjunc-tion with isometric-isotonic exercises and avoid-ance of impingement positioning. Conservativetherapy of impingement syndrome consists of cold

and heat therapy (including diathermy and ultra-sound), selective or total rest, depending upon theseverity of the lesion, and nonsteroidal, anti-in-flammatory medications. Local steroid injectionscan also be beneficial, particularly in the long-standing, chronic phases. Steroids are injected lo-cally around the areas surrounding the bicipitaland supraspinatus tendons and into the subacro-mial bursa. Be aware of the hazards of steroid in-jections. The weakening of the tendon tensilestrength after such injections is well documented,and the possibility of this weakness resulting incomplete tendon rupture is ever present.18•17

Surgical intervention is sometimes necessaryfor relief of shoulder impingement syndrome, par-ticularly if conservative measures fail to relievethe painful symptomatology and the athlete wish-es to continue competing. Hawkins and Hobeikal°resort to surgical measures (dividing the coracoa-cromial ligament) after 1 year's trial of conserva-tive therapy without pain relief. Bauer and Caw-ley 13 recommend shaving the bony surfaces "fordecompression of the tendons," while Brunet andcoworkers9 advocate the resection of the coracoa-cromial ligament with the anterior portion of theacromion as a means of treating this malady.Neer18 clearly described his technique for anterioracromioplasty in the treatment of chronic im-pingement syndrome. Results of surgical treat-ment are variable depending upon the source of in-formation, but favorable outcomes for manyathletes have been reported.9'11'18

Anterior and posterior capsulitisIt seems as if a significant number of shoulder in-juries occur more from the reaction of the shoul-der's anatomic structures than from the action ofthrowing; that is, the musculotendinous and liga-mentous structures that anchor the joint to pre-vent disruption of the joint after the implementhas been launched are the structures quite ofteninjured. Batemen2° noted, "The momentum of thefollow-through places tremendous traction stresson the anchoring structures (of the shoulder). . . ."

Chronic, recurrent capsulitis of the shoulder canbe a source of frustration for both the athlete andphysician. Anterior capsulitis results from the se-vere, abrupt external rotation and abduction of theshoulder at the initiation of the throw. Sometimes,there is complete disruption of the capsule. (Dis-ruption of the capsule and rotator cuff can result ina recurrent dislocating shoulder—a more commoninjury in the baseball pitcher.) Posterior capsulitis(posterior cuff strain, teres minor capsular strain,and infraspinatus syndrome) and capsular rentsare fairly common in the javelin thrower. Theseconditions result from the traction stress previous-ly described in association with the follow-through

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phase of the throw. Ossification of the posteriorcapsule with associated fibrous tissue formationfurther contributes to the clinical picture.

Lombardo and associates21 further explored themechanism of injury by examining the possibilityof posterior capsular impingement between thehumeral head and the posterior glenoid rim duringthe shoulder-thrust phase of the throw. Chronic,repeated stress to this area apparently results ininflammatory changes, scarring, and microtraumato the posterior capsule. Physical findings includepain and tenderness over the damaged area,warmth, and decreased range of motion of theshoulder. Pain is increased upon extreme externalrotation and shoulder hyperextension in the anter-ior capsulitis. However, posterior capsulitis is ag-gravated by internal rotation with the tendernessnoted inferiorly behind the humeral head some-times extending medially along the spinous pro-cess of the scapula. The infraspinatus and supra-spinatus muscles are affected. Diagnostic studiesshould include standard roentgenograms of theshoulder in conjunction with a complete and accu-rate history and physical examination. The roent-genograms may reveal ossification and osteophy-tic development of the posterior inferior glenoidarea of the shoulder in chronic cases.20,21

Treatment consists of rest (sometimes requiringcomplete shoulder immobilization), cold-hot ther-apy, and nonsteroidal, anti-inflammatory medica-tion. Intra-articular and intralesional corticoste-roids can also be used as a later therapeuticmodality, but arthrography of the shoulder shouldprobably first be undertaken for delineation of sig-nificant soft tissue rents and surgically reparablelesions. 22 Prevention of these types of injuries andrehabilitation after capsulitis has been diagnosedinvolve stretching, soft tissue massage, soft rangeof motion exercises of the shoulder, and weighttraining to increase the strength and stability ofthe shoulder girdle.

Scapulocostal lesionsScapulocostal lesions are a very common source ofpain in javelin throwers. 2° Minute musculotendi-nous tears occur at the medial scapular border ofthe throwing shoulder as a result of repeated trau-ma due to traction stress during the follow-through phase of the throw. The resultant tendini-tis can cause spasms of adjacent structures, even tothe point of severe, unilateral, cervicodorsal ten-sion, with resultant tension cephalalgia and lum-bosacral dysfunction. Physical examination re-veals exquisite tenderness along the above-mentioned areas, with increased pain duringrange of motion testing.

Treatment is primarily conservative. Therapyconsists of rest, contrast thermal baths, ultra-sound and/or diathermy, soft-tissue massage, non-steroidal, anti-flammatory agents with or withoutmild muscle relaxants (depending on the degree ofpalpable muscle spasm), and injections to the af-fected area with long-acting anesthetic agents forsymptomatic relief. The last treatment method de-scribed is practiced relatively often by Europeanphysicians when compared to American stan-dards.8 Corticosteroid injections to the affectedarea are to be condemned here for fear of tendonweakness and rupture as a result of the steroidmolecule effect on the tendinous matrix.18'17

Osteopathic manipulative treatment is verybeneficial in the alleviation of somatic spinal dys-function of the affected area and any secondary le-sions found elsewhere along the axial and appen-dicular skeletons. The manipulative treatmentshould be geared to the correction of any flexion orextension spinal lesions by active articulation, softtissue techniques to aid in the lymphovenousdrainage of the shoulder and upper extremity,treatment of any myofascial trigger points discov-ered during the physical examination, and carefulattention and treatment to the posterior axillaryfold, as described by Zink and colleagues.23

Clavicular joint injuriesOther less common injuries involving the throw-ing shoulder girdle include sprains of the sterno-clavicular and the acromioclavicular joints. Greatstress is placed upon these joints during the "hip-shoulder" thrust, causing strain upon the connect-ing ligaments with resultant microtears, inflam-mation, and pain to these areas. -Fortunately,these lesions usually do not progress to disruptionsof the joints and respond adequately to a short pe-riod of rest, (from 4 to 5 weeks), nonsteroidal, anti-inflammatory drugs, and cold-hot compresses. Anoccasional athlete will require small-dose, intra-articular corticosteroids for further reduction ofinflammation. Strength training is imperative toimprove the stability of the joint after initial in-jury has healed.

1. Yokoe, K., et al.: Injuries of the shoulder in volleyball players and jav-elin throwers. Orthop Trau Surg 22:351-9, 19592. Hill, J.A.: Epidemiologic perspective on shoulder injuries. Clin SportMed 2:241-46, 19833. Track and Field News 32:45, Oct 804. Track and Field News 32:36, Sep 795. Atwater, A.E.: Biomechanics of overarm throwing movements and ofthrowing injuries. Exerc Sport Sci Rev 7:43-85, 19796. Jackson, D.W.: Chronic rotator cuff impingement in the throwingathlete. Am J Sports Med 4:231-40, Nov-Dec 767. Tullos, H.S., and King, J.W.: Throwing mechanism in sports. OrthopClin North Am 4:709-20, Jul 73

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8. Sing, R.F.: Personal observations9. Brunet, M.E., et al.: Rotator cuff impingement in sports. Physician inSports Medicine 10:86-94, Dec 8210. Neer, C.S.,H, and Welsh, R.P.: The shoulder in sports. Orthop ClinNorth Am 8:583-91, Jul 7711. Hawkins, R.J., and Hobeika, D.E. Impingement syndrome in theathletic shoulder. Clin Sport Med 2:391-405, 198312. Paulson, C.J., and Beckenbaugh, R.D.: Rotator cuff tears. Continu-ing Education 15:27-30, Dec 8013. Bauer, P.H., and Cawley, P.W.: Shoulder injuries in sports. FamilyPractice Recertification 5:39-63, Feb 8314. Hills, H.A., and Sachs, M.D.: The grooved defect of the humeralhead. A frequently unrecognized complication of dislocations of theshoulder joint. Radiology 35:690-700, Dec 4015. Badgley, C.E.: Sports injuries of the shoulder girdle. JAMA172:444-8, 30 Jan 6016. Kennedy, J.C., and Willis, R.B.: The effects of local steroid injec-tions on tendons. A biochemical and microscopic correlative study. Am JSports Med 4:11-21, Jan-Feb 7617. Unverferth, L.J., and Olix, M.L.: The effect of local steroid injec-tions on tendons. J Sports Med 1:31-7, 197318. Neer, C.S., II: Anterior acromioplasty for the chronic impingementsyndrome in the shoulder. A preliminary report. J Bone Joint Surg54:41-50, Jan 72

19. Penny, J.N., and Welsh, R.P.: Shoulder impingement syndromes inathletes and their surgical management. Am J Sports Med 9:11-5, Jan-Feb 8120. Bateman, J.E.: Athletic injuries about the shoulder in throwing andbody-contact sports. Clin Orthop 23:75-83, 196221. Lombardo, S.J., et al.: Posterior shoulder lesions in throwing ath-letes. Am J Sports Med 5:106-10, May-Jun 7722. Nelson, C.L., and Razzano, C.D.: Arthrography of the shoulder. A re-view. J Trauma 13:136-41, Feb 7323. Zink, J.G., et al.: The posterior axillary folds. A gateway for osteo-pathic treatment of the upper extremities. (Copy available on requestfrom Dr. Sing.)

Accepted for publication in December 1983. Updating, as neces-sary, has been done by the author.

Dr. Sing is an attending physician in the Department of Emer-gency Medicine, Metropolitan Hospital, Central Division,Philadelphia, Pennsylvania. A finalist in the javelin throw inthe 1980 U.S. Olympic trials, he is currently in active trainingfor a berth on the 1984 Olympic team.Dr. Sing, Metropolitan Hospital, Central Division, 203 NorthEighth Street, Philadelphia, Pennsylvania 19106-1098.

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