DR HQ: Anatomy 101—Shoulder capsule injuries

In 2012 during a rash of oblique injuries, I introduced an "Anatomy 101" column covering the topic and it was well received by BaseballHQ.com readers. I was able to help explain the injury, which has always been the goal of my work. Very few readers have any anatomy background, and a lot of the injuries we read about every day can be confusing. Starting today, I will investigate a new topic or term each week (often related to a current injury) in hopes of broadening our knowledge base just a little.

Shoulder capsule Injuries

At the end of spring training, we learned that Johan Santana (LHP, NYM) had been diagnosed with a second capsule tear in his pitching shoulder. Let’s take a look at capsule injuries in pitchers, and what the future holds for Santana and others who suffer this injury.

Anatomy: Below is a graphic that helps illustrate the shoulder and the capsule.

The capsule (the white area in the graphic above) is a combination of ligaments and soft tissue. One medical site described it as a small 'bag" that covers the shoulder (glenohumeral) joint. That might be an over-simplification, as the structure is complex. The capsule is vital in providing stability to the shoulder joint because ligaments that connect bones in the shoulder joint are part of the capsule structure. If the athlete suffers a sublaxation (dislocation), the capsule can be stretched out to a degree that causes laxity. That’s the medical term for looseness. Laxity of the shoulder capsule can and often does lead to various ailments of the shoulder. In other cases the shoulder can be "frozen." And in severe injury cases, the capsule is torn.

Injuries: A "frozen shoulder" (adhesive capsulitis) is a condition where the capsule becomes inflamed and difficult to move. The inflammation or swelling causes stiffness in the shoulder, reducing the athlete’s range of motion. Also contributing to the shoulder stiffness is a lack of synovial fluid which works as a lubricant. While the ailment frozen shoulder is known by some, it is rarely known that it involves the shoulder capsule. In baseball circles, a frozen shoulder is very rare, even rarer than a tear to the capsule.

Throwing a baseball requires a full range of motion of the shoulder joint; the overhand motion is in fact unnatural. A torn capsule usually involves a tear in the anterior (front) of the shoulder. Once torn, the athlete or pitcher loses range of motion. If the tear is small enough, it can heal on its own and the player can avoid surgery. Baseball players usually try to avoid surgery on the capsule at almost any cost. Rich Harden suffered a torn anterior capsule way back in 2007. He attempted multiple rehabs returns in an attempt avoid surgery and suffered a variety of injuries in the meantime. Harden finally underwent surgery on his right shoulder capsule in February 2012.

Pitchers avoid the surgery to repair a torn capsule because it is so difficult to return from and regain their prior level of production. No matter who skilled the surgeon, the range of motion in the shoulder is almost always decreased and results in a loss of velocity. In addition, the task of repeating one's delivery is difficult and usually leads to a decline in both command and control of their pitches. The bottom line: Pitchers aren't the same when they return from shoulder capsule surgery.

However, there may be a little light at the end of the tunnel. In his first full season since the surgery, southpaw Johan Santana pitched well early in 2012, including a 134-pitch no-hitter on June 1, 2012 against St. Louis. After that outing, he recorded an 8.27 ERA over his next 10 starts before returning to the disabled list, which ended his season. The Mets deny that the 134-pitch effort was the cause of Santana suffering a second capsular injury, but the post no-hitter evidence says otherwise. The obvious nagging question: Did Santana suffer a second tear of the shoulder capsule due to the high pitch count in his no-hitter or was it inevitable that he would suffer a second tear?

Santana was the most successful pitcher after undergoing capsular surgery—albeit short-termed. Now he gets a second chance to recover and return to the majors, though sports medicine history is dubious. In all likelihood, we have seen the last of Santana.

Conclusion: The reported list of pitchers having surgery to repair a torn capsule in their pitching shoulder is very short (it includes Bret Saberhagen, Mark Prior, Chien-Ming Wang, Johan Santana, Dallas Braden, Chris Young, Dustin Moseley, Tim Byrdak and John Danks). And the list of a complete and lasting return remains zero.

Our only hope: We used to say the same thing about tears of the ulnar collateral ligament in the elbow until Dr. Frank Jobe changed sports medicine history with the creation of elbow reconstruction surgery;  a.k.a. Tommy John surgery. We await another breakthrough.

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  For more information about the terms used in this article, see our Glossary Primer.