Initiating a Baseball Throwing Program after Shoulder or Elbow Surgery

A recent study from Hospital for Special Surgery (HSS) found that some baseball players need more time than others to recover after shoulder or elbow surgery, even when data indicate that they should be ready to resume throwing.

The researchers, who presented their findings at the American Orthopaedic Society of Sports Medicine’s Annual Meeting 2022, noted that 1 out of 4 baseball players in their study did not pass an objective return-to-throw evaluation by the time they were presumed to be ready.

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The timing of initiation of a throwing program following shoulder or elbow surgery in an overhead throwing athlete depends on a variety of factors, including the surgical procedure performed, time from surgery, in-office evaluation by the treating surgeon, level of competition, and successful progression through a physical therapy program.

Little Objective Data

“Determining when it is safe for an athlete to begin a post-surgical throwing program is vitally important to ensure a safe return to play, and objective data [are] often preferred to help accurately make such decisions,” said study author James B. Carr II, MD, an orthopaedic sports medicine surgeon at HSS Florida in West Palm Beach.

“However, there is a paucity of objective data available to help guide the decision for the timing of initiation of a throwing program following shoulder and elbow surgery in overhead throwing athletes.”

In addition, it is unknown what percentage of athletes typically achieve appropriate objective criteria at the presumed timepoint for initiation of a throwing program.

Study Methods

To help address this information gap, the HSS researchers developed a study with 3 goals:

  1. To create a reproducible, objective return to throwing protocol
  2. To determine what percentage of post-surgical competitive baseball players successfully satisfied the objective return-to-throwing criteria at the presumed time of throwing program initiation.
  3. To determine which risk factors were most common in athletes who failed to meet objective criteria for return to throwing

The study included 48 baseball players at 3 levels of competition:

  • High school (n=20)
  • College (n=19)
  • Professional (n=8)

A physical therapist with extensive experience in the rehabilitation of overhead athletes performed an objective return-to-throwing evaluation for patients who had undergone shoulder or elbow surgery by 1 of 2 orthopaedic surgeons. Prior to this evaluation, all patients had been cleared by their surgeon to resume throwing.

Patients were given passing grade by the physical therapist if they could accomplish all objective criteria at the time of evaluation. Patients who failed the initial objective evaluation were re-tested 2 weeks later. The surgical procedure, level of play, and reason for failing were recorded for all players.

Study Findings

A total of 36 players (75%) obtained a passing grade at the initial evaluation, while 12 players received a failing grade (25%). The distribution of passing grades based on surgery type was as follows:

  • Arthroscopic shoulder surgery: 4/7 patients
  • Ulnar collateral ligament (UCL) reconstruction: 23/31
  • UCL repair: 3/3
  • Other elbow surgery: 5/6

Players who failed the initial evaluation received focused physical therapy to address any insufficiencies. All received a passing grade when they were retested 2 weeks later.

“Players who received a failing grade demonstrated significantly more elbow extension, less dominant arm maximum shoulder internal rotation strength, and less dominant arm maximum shoulder external rotation strength,” Dr. Carr said.

No specific factor reached statistical significance for increasing the odds ratio or relative risk for receiving a failing grade, although UCL reconstruction demonstrated an insignificant trend for having a lower risk of failing.

“Our findings demonstrate that not all competitive baseball players will be objectively ready to throw at the presumed time point following shoulder and elbow surgery, and insufficient shoulder strength and/or endurance was the most common reason for failure,” Dr. Carr said.

“[Creating] objective criteria to help determine when to start a post-surgical throwing program is a critical step to ensure safe rehabilitation after shoulder and elbow surgery in competitive baseball players.”


Carr JB 2nd. Utility of Objective Testing for Initiation of a Throwing Program Following Shoulder and Elbow Surgery in Competitive Baseball Players (Paper 11). Presented at the American Orthopaedic Society of Sports Medicine’s Annual Meeting 2022, July 13-17, 2022, Colorado Springs, Colorado.

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