The Overhead Athlete: Why Shoulder and Elbow Injuries Are So Common — And How to Prevent Them
Whether you're watching a pitcher deliver a 98 mph fastball, a tennis player serve an ace, or a volleyball player spike with force, you're witnessing the incredible mechanics of an overhead athlete in motion. These athletes rely on high-velocity, repetitive shoulder movements that push their joints and muscles to the edge of human capability.
But with great performance comes great risk—especially to the shoulder and elbow. Injuries in these areas are incredibly common among overhead athletes. Understanding why that happens is the first step toward effective injury prevention, performance optimization, and longevity in sport.
Let’s break it down.
Who Are Overhead Athletes?
An overhead athlete is anyone who performs repeated movements with the arm elevated above shoulder level, often at high speeds and loads. This includes:
Baseball and softball players
Tennis players
Volleyball players
Swimmers
Basketball players
Javelin and shot put throwers
Football quarterbacks
Even within sports that aren’t typically thought of as “overhead,” certain positions or movements still classify athletes as such due to their biomechanics.
The Shoulder: High Mobility, Low Stability
From an anatomical perspective, the shoulder joint (glenohumeral joint) is uniquely designed for movement, not stability. It’s often compared to the hip—both are ball-and-socket joints—but their design priorities differ.
The hip is highly stable with deep socket coverage and strong ligament support, which makes dislocations less common than shoulder dislocations.
The shoulder, in contrast, sacrifices stability for a greater range of motion, which increases the risk of dislocations, subluxations, impingements, and rotator cuff injuries.
Compared to other joints (i.e. knee, ankle, elbow), the hip moves more, but when compared directly to the shoulder, the hip is more stable and less mobile.
In short, the shoulder is a mobility powerhouse that lacks intrinsic stability—a recipe for trouble in high-load sports.
Breaking Down the Basic Overhead Motion
Let’s look specifically at the overhead motion—the foundation of overhead sports. Although each sport has uniqueness to the mechanics, there are three common phases.
Phase 1: The Wind-up & Cocking
In the cocked or wind-up phase, the arm is drawn back, with the elbow at shoulder level and the hand above the head. This places massive stress on the shoulder's external rotators — primarily the infraspinatus, teres minor, and posterior deltoid.
Phase 2: Acceleration
As the arm moves forward to release the ball (or hit the object), the internal rotators — the subscapularis, pectoralis major, latissimus dorsi, teres major, and anterior deltoid — fire with tremendous force.
Phase 3: Deceleration
Ironically, it’s not just about generating power — it’s about slowing the arm down afterward. The same tiny external rotators that started the motion must now decelerate the massive force generated by the internal rotators, trunk, and lower body in an eccentric contraction. This is where many injuries occur — not during the throw, but after release.
The Scapula: The Unsung Hero of Shoulder Health
The scapula (shoulder blade) plays a crucial role in shoulder mechanics. With 17 muscles attaching to it, the scapula is like a conductor in an orchestra — each muscle must fire at the right time and intensity to keep movement fluid and safe.
When even one of these muscles becomes overactive, underactive, or poorly coordinated, the scapula's movement becomes dysfunctional, increasing the risk of shoulder injuries like:
Impingement syndrome
Rotator cuff tears
Labral injuries
Scapular dyskinesis (abnormal movement) is a common yet often overlooked cause of shoulder pain in overhead athletes.
Foot Mechanics and Shoulder Health: A Whole-Body Connection
A lesser-known but fascinating connection exists between foot mechanics and upper extremity injury risk. One study examined Major League Baseball pitchers, categorizing them into three groups based on foot arch height:
Normal arches
High arches (pes cavus)
Flat feet (pes planus)
The findings? Pitchers with abnormal arches had a significantly higher rate of shoulder and elbow surgeries, including rotator cuff repairs and Tommy John procedures.
This suggests a broader truth: the body functions as a kinetic chain. Force generated from the ground travels up through the legs, hips, and trunk before being transferred into the arm. Disruptions anywhere along that chain — including something as seemingly unrelated as foot posture — can lead to breakdowns in shoulder or elbow integrity. The name for this potential phenomenon is “Regional Interdependence”.
Clinical Observations: What the Patterns Reveal
As a physical therapist with years of experience treating collegiate and professional overhead athletes, certain patterns emerge consistently:
Shoulder injuries often correlate with same-side leg weakness or instability. Think of a leftie softball pitcher with left shoulder pain and a weak left hip.
Elbow injuries frequently correlate with opposite leg imbalances. A right-handed pitcher with right elbow pain often has left-leg instability.
While more research is needed, these clinical observations underscore the importance of evaluating and strengthening the entire kinetic chain, not just the arm.
Injury Prevention: What Overhead Athletes Need to Focus On
Achieving elite performance requires volume, repetition, and intensity. But that also increases injury risk. Here are key areas overhead athletes must address:
1. Mechanics Optimization: Proper technique is the foundation. Faulty mechanics lead to overload and compensations. Work with knowledgeable coaches and therapists who understand the unique demands of your sport.
2. Scapular Control and Shoulder Stability: Strengthen the muscles that support the scapula and rotator cuff. Use exercises that mimic sport-specific movements under controlled conditions.
3. Lower Body Strength and Balance: Don’t skip leg day! The hips and core generate most of the power — the arm just transfers it. A weak base increases stress on the shoulder and elbow.
4. Nervous System Regulation: Chronic stress and dysregulated nervous systems can affect motor patterns, recovery, and injury susceptibility. Techniques like breath work, mobility flows, and mindfulness can make a difference.
5. Prehab Over Rehab: Prevention is cheaper — and more effective — than treatment. Physical therapy should be proactive, not reactive. A solid prehab routine can reduce injury risk while enhancing performance.
Conclusion: Take Care of the Whole Athlete
The overhead athlete is a marvel of coordination, strength, and power — but also at significant risk for injury. The shoulder and elbow are only the final links in a long kinetic chain that includes the feet, hips, spine, and even the nervous system.
To compete at the highest levels — whether in college, the pros, or the Olympics — you need more than talent and drive. You need durability, and that comes from a holistic approach to training, movement, and recovery.
If you’re an overhead athlete (or coach one), make shoulder health a year-round priority. Because the best ability — is availability.
DISCLAIMER: The content on the blog for Health Hive, LLC is for educational and informational purposes only, and is not intended as medical advice. The information contained in this blog should not be used to diagnose, treat or prevent any disease or health illness. Any reliance you place on such information is therefore strictly at your own risk. Please consult with your physician or other qualified healthcare professional before acting on any information presented here.