Differentiating soreness, fatigue, and pain in baseball pitchers.

One of the more challenging questions in baseball is how to determine when a pitcher is having pain, soreness, or fatigue.  As a physical therapist, athletic trainer and strength coach, I have the fortune of working at all levels of baseball, from youth to professional.  And this question comes up over and over again and is really hard to determine.  So, I want to dive in and give you some guidelines . . .  some ideas on how you can tell the difference.  

One of the first things that we need to understand is people perceive pain differently.  And, the younger the person is, the more likely that they will perceive it differently than you do.  Meaning as a coach or a parent, you might not perceive pain the same as a younger person.  And when I say younger,  I'm saying that this goes all the way through college. Depending on the person's previous experience of pain, they may be very sensitive to pain or they may be less sensitive. . . just how they're internally wired and their previous interaction with their environment.  So, this is one of the reasons this question is so hard to answer, because we all perceive pain differently.  

So how do we tell the difference?  What does it look like?  Well, the first thing we need to do is define a few terms.   We've got to talk about fatigue, soreness, and pain.  And these can occur on a continuum . . . meaning it can start out as fatigue, and then become soreness a few days later, and then ultimately develop into pain.  Or they can occur independent of each other.   So, it's really important to understand, though, that they're very closely intertwined and have some similar characteristics.   

But let's start off with fatigue.  Here are some of the characteristics of fatigue: muscles feel tired,  they feel full and blood engorged (like a muscle pump after weightlifting).  Fatigue may start to change your mechanics and your ability to locate pitches.   But, you also have to remember, that can be a characteristic of pain as well.  But that muscle tiredness, muscle fullness feeling, are key characteristics.  

Soreness on the other hand, usually develops within 24 to 48 hours after the activity and resolves by 72 hours.  We're not going to have, necessarily, immediate soreness when we're talking in terms of delayed onset muscle soreness.  This is going to be something that's after the activity, the next day as those metabolites in the area are removed (local inflammation).  This soreness should ideally be in multiple areas of the body and in multiple muscles.  The muscle may feel tender or tight. The muscle may feel stiff.  It may feel relief with movement.  Stretching definitely helps with soreness.  So in the case of defining soreness, time frame is really important. Additionally, where it's located, that it's in the muscles, as well as, that stretching helps it, and that we feel it in a lot of different areas.  

Pain, on the other hand, usually is localized to only one place.  It tends to come on more quickly, it's a sharper quality, but that sharpness may be deep in the joint as well.  And it's either in the bone or the joint, unless we have a true trauma where we know the muscle was injured (hit by a ball, a strained muscle with a known time of injury).  This sensation tends to linger more than three days and it gets worse with activity.  The more activity you have, the worse it feels.   

So, we've got a lot of different characteristics here.  But, as you can see, these characteristics can overlap each other, and that's what makes it a challenge.   So how do we determine whether our pitcher is experiencing fatigue, soreness, or pain?  

It's multifactorial.  We can't just take one factor and determine “Oh, well, it's located here so that must be it.  Or, it's been going on for more than 72 hours, so it must be pain.”  We have to put it all together.  We have to put it all together while also considering how our player perceives pain. I will say, though, I think most of the time most coaches and parents tend to diminish or minimize their players' pain.  And so I want to caution you against that.   

But here's some ways to look at it.  First step:  try to define it.   Does it meet the characteristics of fatigue, soreness, or pain?  Really dive into that.   Where is it located?  How long does it last?  When does it come on?  What relieves it?  What makes it worse?  Try to define it . . . try to put it in one of those categories there.  

Where is the sensation located? This can give us a lot of insight.  So when we think about this . . . where are good and bad places and maybe can we differentiate what pain and soreness look like.  

So if we are going to have fatigue or sorenes, it's good if we see it in the back of the shoulder,  glutes, and abs.  This is where we want to feel fatigue and soreness.  Unless there's a very acute injury where  something happened, and we know it's a real sharp localized pain, these are exactly where you want to feel soreness, fatigue with pitching.  Anytime a player tells me, “Oh I'm hurting,” and they show me these areas (back of shoulder, glutes, abs), I love it.  I say that's great, and this is a good opportunity to teach the player the difference between soreness, fatigue, and pain . . .because this is either soreness or fatigue, depending on what time frame it's happening.  

Now we have some areas where I'm going to put red dots.  These are areas that are almost always considered pain . . . right in the front of the shoulder, right on the bony area of the shoulder, and on the inside of that elbow, right on the bone or just off of the bone. . . we're going to almost always call this pain, especially in isolation.  If it meets those other qualities . . . that it's sharp, that it hurts quite a bit, it gets worse with activity . . .  this is definitely going in the pain category.  

Now I'm going to talk about the yellow areas, caution areas.  Here is where sometimes I'm okay with it, sometimes I'm not.  When we're looking at the bicep and the forearm, right in the muscle belly,  this  can be an okay area.  This is an area that does fatigue, so I'm not saying this is worrisome.  But it can also be a precursor to developing shoulder and elbow problems as well.  This is kind of a warning light.  It's kind of a sign that causes me to say “wait a second, how are things going?”

I will say that if we have good fatigue in the abs and the back of the shoulder and the glutes, I'm absolutely okay with this fatigue in the biceps and the forearm.  That's a natural thing.   We are distributing that load throughout the body, which tends to be a better sign. 

However, if this is the only place we're feeling it, particularly in the younger athletes, we better make sure their movement and mechanics are solid. Because poor movement, poor mechanics, poor core control, will lead us to overuse as these muscles try to stabilize the biceps and the forearm.  

I'm going to point out one other area that can be a yellow light.  This one is being very point tender in the back of the shoulder especially if they describe it more as a pinch.  If it's being described more as a pinch than a soreness, and it's located right on that back side of the shoulder where that yellow dot is there, that's going to be a caution light.  That's going to be something I'm going to be more concerned about.  

Then the final thing that we're going to look at as we try to determine the difference between fatigue, soreness, and pain is the question: are there any red flags present?  

First red flag: if  a player is taking Advil or Tylenol for the feeling, for the sensation that they are having, that is pain.  So we really should not be taking Advil, Tylenol, either to be able to pitch, or after pitching, because that's not normal.  Now, if the soreness is that bad such that you have to take anti-inflammatories, it's probably actually pain. 

If it is soreness, we want them to actually feel that soreness so they can guide themselves through their activity levels over the next days.  So that evening, we're going to do our tissue recovery. We're going to do our exercises to help recover that day of pitching, as well as throwing, you know, the next day, doing some  additional recovery exercises the next day, and having a very solid plan of recovery after pitching.   

Remember, anti-inflammatories are not vitamins.   We're not deficient in ibuprofen or acetaminophen in our body.   So really, if your players are taking this, that's a red flag.  That tells us that we have pain.  

Another red flag is pain in the elbow and shoulder at the start of throwing and pitching, particularly if that pain doesn't get better.  That really tells us a lot.  Pain in the front of the shoulder, pain in the elbow right when we start . . . that's not what we want, and especially if it gets worse as we throw more.  

So I hope these guidelines have helped you answer the challenging question of differentiating fatigue, soreness, and pain.  If you have any questions, don't hesitate to reach out to me.  I love answering questions.  Also, if you're looking for more information like this, sign up for the newsletter below.  I put out information weekly to try to help us make our athletes better.