Night Pain in a Starting Pitcher: When the Screen Does Not Explain the Symptoms
A 19-year-old right-handed starting pitcher reports to the athletic performance staff in week four of fall practice with tightness in the back of his shoulder that began two weeks ago. He has thrown 62 innings since June across summer league and fall scrimmages. He threw 38 pitches two days ago and felt it in the third inning. On screening, glenohumeral internal rotation on the throwing side is 38 degrees versus 52 on the non-throwing side; external rotation is 118 versus 108. Total arc is essentially symmetrical. A scapular assistance test produces relief, and there is mild scapular dyskinesis on the throwing side. There is point tenderness posteriorly and night pain when he rolls onto that side. He is otherwise healthy, and the team radar shows velocity down 1.5 mph. His pitching coach says, He is just tight - stretch him out and keep him on his bullpen day. The team physician is not at the facility today; the certified athletic trainer is.
1. Interpret the screening findings, decide the next actions, and identify what falls outside your scope.
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Read the numbers, then read the patient - and do not confuse the two.
- Throwing-side internal rotation loss with external rotation gain is a normal osseous adaptation. His internal rotation deficit is 14 degrees (38 vs 52), below the 20 degrees commonly used as a risk threshold, and the total arc is essentially symmetrical (156 vs 160; a difference above about 5 degrees is the usual flag). On range of motion alone this is unremarkable for a thrower.
- That is the trap. The presentation is dominated by findings the numbers do not capture: night pain, point tenderness, pain in the third inning of a 38-pitch outing, and a 1.5 mph velocity loss. Those are red flags for a structural problem - labral, cuff or otherwise - and they are not explained by tightness.
- Therefore the pitching coach's plan is the wrong action, and so is any aggressive stretching or sleeper-stretch protocol I might reach for reflexively.
Next actions within my scope. Stop throwing for the day. Notify the certified athletic trainer immediately and hand over the screening findings. The ATC arranges physician assessment, which may include imaging. I do not diagnose, do not clear him to throw, and do not perform manual therapy outside my licensure.
What I keep doing. Lower-body and non-throwing conditioning within pain-free limits, so he does not detrain while the shoulder is evaluated.
Document. Record the screen, the symptoms including night pain, the referral, and who was informed and when. The record is what distinguishes a reasoned hand-off from a delayed one.
2. Assuming the physician later clears him, outline a six-week movement-quality and throwing-load progression, with the criteria that hold it back.
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Principles. Build scapular and cuff capacity, restore pain-free motion without chasing range, and reintroduce throwing load with explicit volume caps and recovery days.
Weeks 1-2, no throwing. Daily serratus anterior and lower trapezius work, low-load external rotation endurance, thoracic extension and rotation, hip and trunk control. No aggressive end-range posterior stretching; if tightness is addressed, use low-load long-duration pain-free positions.
Weeks 3-4. Short toss at 45-60 ft, three days per week with a day between, total throws capped (for example 25-35), no mound work. Re-screen internal and external rotation, scapular control and pain each session.
Weeks 5-6. Extend to 90-120 ft, then a controlled bullpen with a pitch cap and two days between throwing days. Velocity is not the target; symptom response is.
Criteria that hold the progression. Any night pain, pain with empty-hand external rotation, loss of total arc, or a measured drop in cuff strength means step back rather than push through. Progress only if pain stays at 0-2/10 and range of motion is stable across sessions.
What I would not do. Force external rotation gain at the expense of internal rotation, aggressively stretch the posterior shoulder, or let the pitch count creep because he feels good on the day.
Communicate. Share the re-screen data with the ATC and physician at each phase so clearance remains a shared, documented decision rather than a coach's impression.
3. How do you handle the pitching coach's request, and why would you handle it that way?
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Acknowledge his goal first. The pitching coach wants the athlete available, and so do I. Framing this as the fastest thing that is actually safe keeps the conversation collaborative rather than a jurisdiction fight.
Be specific and non-judgemental about the request. Stretching him out will not address night pain, point tenderness or velocity loss, and continuing to throw through those findings risks a much longer absence. Say what was observed rather than what is suspected: the range-of-motion numbers are within normal throwing asymmetry, and the symptoms are the issue.
Show the plan, not just the restriction. Give a written timeline - no throwing now, physician review this week, re-screen before any progression, then roughly 4-6 weeks of return-to-throw work after clearance - and state what he can still do: conditioning, lower-body work, non-throwing drills. Coaches tolerate restrictions far better when they can see the endpoint and the athlete is not simply idle.
Keep the role boundary visible. I do not make the return-to-play decision and I do not negotiate it with the coaching staff. The ATC and team physician own clearance; I own the physical preparation. If the coach pushes, the response is to route the question to the ATC, not to soften the recommendation.
Document the conversation. Note the date, what was requested, what was advised, and the referral. If the athlete is later injured after continuing to throw, the record should show a consistent, reasoned decision rather than a preference.
Why this way. The coach is not the adversary - he is the person who controls the athlete's daily workload, and an adversarial handling of this conversation makes future red-flag reports less likely to reach me.