If you’re a pitcher, quarterback, or the parent of a young thrower, you probably know the feeling. The elbow starts to ache after games. Velocity dips a little. Command isn’t quite what it was. And the question in the back of your mind is always the same: Is this something serious?
I’m happy to share that my colleagues and I recently published A Comprehensive Review of the Physical Examination of the Elbow in the Throwing Athlete in Arthroscopy Techniques, a peer-reviewed journal of the Arthroscopy Association of North America. The article walks through, step by step, the exam I use to sort out what’s going on in a thrower’s elbow. It also includes a video of the full exam for other physicians to learn from.
Here’s what that means for you, in plain language.
Throwing places unique stress on the elbow
The throwing motion puts tremendous force through the elbow. The inside (medial) side is pulled apart, the outside (lateral) side is compressed, and the back of the elbow experiences a shearing force. Because of this, injuries tend to follow predictable patterns, and more than one problem can be present at the same time.
Some of the most common conditions I see include:
Ulnar collateral ligament (UCL) injuries, the ligament repaired or reconstructed in Tommy John surgery
Valgus extension overload, which causes pain at the back of the elbow during follow-through
Ulnar nerve irritation, which can cause tingling or numbness into the ring and small fingers
Medial epicondylitis, or irritation of the forearm muscles on the inside of the elbow
Capitellar and growth plate problems in younger athletes, sometimes called “Little Leaguer’s elbow”
Where the pain is, and when it happens during the throw, gives us important early clues.
The exam starts well before the elbow
Throwing is a whole-body motion. Power starts in the legs and hips, travels through the core and shoulder, and finishes at the arm. When one link in that chain isn’t working well, the elbow often picks up the extra load.
That’s why I begin by looking at hip rotation and strength, core stability with simple squat tests, shoulder blade positioning, and shoulder range of motion. Finding and addressing these factors is often a meaningful part of both treatment and preventing future injury.
Then we focus on the elbow
After checking the kinetic chain, I look carefully at the elbow itself: comparing it to the other side, gently pressing on specific structures to find where the tenderness is, and checking motion and strength. From there, I use a series of special tests designed to recreate the stresses of throwing in a controlled way, including:
The moving valgus stress test, which places the arm in the “cocked” throwing position and gently moves the elbow through the range of motion where the UCL works hardest. Research supports this as one of the most reliable exam tests for UCL injury.
The milking maneuver, another way to gently stress the UCL.
The repetitive valgus stress test, which can bring out symptoms in longer-standing or partial UCL injuries that might not show up with a single test.
Tests for the ulnar nerve and the back of the elbow, since these problems often show up alongside UCL injuries.
When imaging helps
A careful exam is the foundation, but imaging often confirms the diagnosis. MRI, and especially MRI arthrogram (where contrast is placed in the joint), gives us the most detailed look at the UCL. Stress ultrasound, which lets us watch the elbow under gentle load in real time, has become a valuable complement. Using both together is more accurate than either one alone.
A normal exam doesn’t always rule out a UCL injury. If symptoms persist, imaging is an important next step, particularly for athletes who plan to keep throwing.
Why this matters for your care
My goal with every throwing athlete is an accurate diagnosis the first time, because the right treatment plan, whether that’s rest and rehab, a targeted throwing program, or surgery, depends on it. For young athletes especially, it’s important not to assume every elbow ache is a UCL problem, since growth plate injuries need a different approach.
If you or your athlete is dealing with elbow pain from throwing, call 864-454-7422 to schedule a visit.
Read the full article: Eskew JR, Soth BT, Alawa J, McGrath TM, Wanich T, Cirino CM, Carr JB. A Comprehensive Review of the Physical Examination of the Elbow in the Throwing Athlete. Arthroscopy Techniques. 2026. https://doi.org/10.1002/atn2.70313
