When throwing athletes are ready to return to play after injury or time off, it is necessary to provide them with steps for a gradual return. Due to the torque and stress placed on the body during throwing, athletes cannot start throwing hard or long right away; there needs to be an acclimation period. This is the primary reason for the use and implementation of a throwing program.

Throwing distance, velocity, accuracy, and control can be effectively regulated and progressed when returning from an injury. Failure to do so may be the difference between successful return to throwing and failure of the athlete’s recovery. Interval distance throwing progressions were designed to allow safe return through controlled increases in distance as the athlete’s body adapts to the demands placed on it during the throwing motion. Interval distance throwing also allows for gradual increase of joint loads, thus protecting the joint from pathologic problems as a result of excessive strain too early in recovery.

Throwing programs typically begin 4 to 6 months after a major surgical procedure and consist of interval distance throwing and specialized exercises designed specifically for throwers. For nonoperative injuries, the throwing program may begin earlier, based on physician approval, negative results from a clinical examination, sufficient range of motion, neuromuscular control, and demonstrated success with functional exercises (e.g., plyometrics). As an athlete returns from either surgery or injury, he or she must also exhibit normal strength of the rotator cuff and accessory muscles.

Over the years, various throwing programs have been developed and modified. At the professional, collegiate, and youth levels of sport, athletic trainers, therapists, and physicians have adapted their own specific exercises and versions of the throwing program progression. Many resources were used in the development of the throwing exercise program presented in this chapter, with a basic foundation of the Thrower’s Ten exercises outlined by Kevin Wilk and James Andrews (1).

Modifications to the program were made to account for the skill level of the athlete and injury status, allowing for variation depending on the status of the throwing athlete. Commonly, the rehabilitation consultant or athletic trainer will change distances slightly and tailor the exercises to the needs of each individual athlete in accordance with physician consent. Because the sports medicine health care team will frequently add or subtract components of the protocol depending on the athlete’s injury or rehabilitative status, frequent communication and consultation between the members of the sports medicine health care team is essential. This communication will ensure the athlete’s optimal recovery and return to play.

A throwing program should be functional and have a transitional approach involving gamesimulated activities. Early rehabilitative exercise stages are often specific and direct in protecting the healing tissues. However, controlled functional patterns can be added effectively in rehabilitation to initiate crossover to the sport and transition for the throwing athlete. For example, the arm is often put in a sling for protection and healing after shoulder surgeries. Shoulder dumping is a great way to incorporate early throwing movement while keeping the arm in a sling. The shoulder dump is executed by dropping the shoulder across the body to the opposite leg.

Functional exercises are selected in order to facilitate a strengthening process with sport-specific movement patterns that approximate those occurring in the throwing activity. Basic static exercises (e.g., external rotation with the arm at the side) are useful in early rehabilitation stages, but they do not involve transition to the dynamic requirements needed in throwing. For these reasons, distance throwing is an essential component for returning to optimal performance.

To date, few research studies have evaluated the importance of proprioception (joint sense) of the shoulder for throwing athletes (3,4,5,6). Proprioception training is an important aspect of the throwing program and imperative to the success of any athlete. Proprioceptive and neuromuscular exercises are also necessary for an overhead athlete returning from injury. Proprioceptive receptors, called mechanoreceptors, are damaged with any soft tissue injury. These mechanoreceptors communicate joint position and motion to the brain. The throwing motion involves a substantial amount of movement secondary to the range of motion provided by the shoulder. Thus, the athlete needs to be able to sense the position of the arm, forearm, and hand before release of the ball in order to execute a successful throw.

Stabilization and plyometric exercises that provide change in tension, position, pressure, and rate of movement to the muscle-tendon junction are essential for proprioceptive training and complete return to sport. Stabilization exercises of the shoulder allow the athlete to respond to change in movement and use co-contraction of the rotator cuff muscles. For example, the clinician can modify the rhythmic stabilization of external and internal rotators by having the athlete perform the exercise with his or her eyes opened or closed.

A throwing program has three basic components:

The throwing program should always begin with a proper warm-up phase. Athletes should begin the warm-up phase with a short toss or light catch exercise. Athletes should always include cardiovascular activity for 5 to 15 minutes, such as a light run, bike ride, or use of an upper body ergometer. Due to the extreme load of decelerating the arm, the posterior rotator cuff and capsule become tauter during throwing activities. Therefore, the warm-up includes upper extremity stretching of the posterior rotator cuff, posterior capsule, pectoralis minor, and latissimus dorsi muscles. Shoulder instability should be ruled out before initiating posterior rotator cuff and shoulder capsule stretches.

Overall athletic conditioning should be a significant portion of any program (2). Throwing requires a large demand on the trunk and arm muscles to get the ball to its target. Proximal muscular control is essential for a baseball player to throw—“proximal stability for distal mobility.” Conditioning should focus on core strength, as the trunk and gluteal muscles must be trained as the base of support for integrated arm movement. Once proximal control is achieved, then progression to distal muscle
control can be initiated. This concept is the foundation of the kinetic chain principle allowing a transfer of energy from the feet, to the legs, to the trunk, through the scapula and arm, and finally into the forearm and hand, resulting in ball release (7). It is essential that a good core program be developed in accordance with the athlete’s exercise regimen.

Both basic and advanced interval distance progressions are outlined in the following text and tables. Basic distance throwing progression (Table 14.1) starts with a shorter distance, is less rigorous, and is more suited for the youthful and occasional thrower. The advanced distance
throwing progression (Table 14.2) is longer in distance, more intense, and designed for the more avid or elite thrower. Both programs can be adjusted as necessary and tailored to the athlete’s postinjury status and position played.