Preventing Pitching Injuries: You Get What You Train
Written on April 2, 2013 at 5:34 am, by Eric Cressey
Today’s guest post comes from my friend and college, physical therapist Eric Schoenberg. Eric is an integral part of our Elite Baseball Mentorships, and will be contributing more and more regularly here to outline some of the topics we’ll cover in these mentorships.
As this great article from Tom Verducci at Sports Illustrated pointed out a few years ago, injuries cost MLB clubs $500 million dollars (an average of $16+ million/team) in 2011. In addition, over 50% of starting pitchers in MLB will go on the disabled list each year. Although there are many factors that contribute to these staggering numbers, an overwhelming majority of these injuries are due to five simple words:
“You Get What You Train.”
This saying was made popular by the great physical therapist Shirley Sahrmann in her work at Washington University in St. Louis. This premise (in baseball terms) covers almost every issue that we encounter in the areas of injury prevention and performance enhancement. Here are some examples to illustrate the point:
If a pitcher is allowed to throw with bad mechanics (misuse), the result is a kid who is really good at throwing wrong and an increased risk of injury.
If high pitch counts (overuse) are allowed at a young age, the result is a pitcher throwing with fatigue, mechanical breakdown, and ultimately decreased performance and injury.
If a pitcher “throws with pain” (poor communication) due to pressure from coaches, parents, and teammates (culture of baseball), the result is compensated movement, decreased performance, and ultimately injury.
If a “one-size fits all approach” is rolled out in a strength and conditioning program or a pitching academy, then the result will be a program that doesn’t adequately “fit” anyone.
If performing “arm care programs” and long toss programs incorrectly before a game or practice is the norm, then the result will be athletes that are improperly “tuned” neurologically and fatigued before they even step on the mound for their first pitch.
If a hypermobile athlete performs a stretching program to “get loose”, then the result will be an athlete that has more instability than he can handle ultimately will get injured.
If we teach an athlete to get his shoulder blades “down and back” when his throwing shoulder is already depressed and downwardly rotated, then what we get is more strength in a dysfunctional position.
If we don’t teach proper movement, then we will get exactly what we train. The correct exercise performed incorrectly is a bad exercise.
This point is illustrated in the videos below. In the first video, the only instruction given to the athlete was to hold the top of a pushup on the elevated surface. As you can see, there is clear dyskinesia in the scapulae which if repeated without correction would result in reinforcement of the faulty movement pattern. Without actually seeing the shoulder blades (shirt off) or at the least putting your hands on the athlete, this faulty pattern is missed and the athlete will get worse.
In the next video, the athlete is instructed to get into the same position, however the athlete is cued to “engage the shoulder blade muscles and don’t let the shoulder blades come off your ribcage”. This simple cue can be coupled with some manual correction to activate the proper muscles to achieve a proper movement pattern.
In summary, both of these videos can be called a “pushup hold” or “elevated plank,” but only one achieves the desired movement and activation pattern.
This concept of “you get what you train” becomes a bigger problem when you realize that baseball players rarely play for the same coach or in the same “system” for more than a year or two (different leagues/levels, coaching changes, etc.). In addition, it takes a while before faulty movements and overuse reach the threshold where an athlete becomes symptomatic. As a result, there is no direct cause and effect and no “blame” to assign. A coach that overuses a kid in his 13 year-old season is never identified to be the actual cause of that same kid’s UCL tear in his 16 year-old season. This lack of accountability is a huge factor in the injury epidemic across all levels of baseball.
The goal of the Elite Baseball Mentorships is to bring together leaders in the baseball and medical communities in an effort to be proactive and share ideas to help improve the overall health of the game of baseball and its players. We’d love it if you’d join us for one of these events; please visit www.EliteBaseballMentorships.com for more information.
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Eric nice post. I just have one thing I would like to address. I agree that the scapula is typically downwardly rotated but I disagree that it is depressed. The “depression” that you grossly visualize is caused by a combination of the scapula being downwardly rotated, anterior tilted, and internally rotated. In this position the AC joint does appear to be lower than the non-dominant side but the scapula isnt in true depression. I still think using the down and back cue is important since these players typically have an over dominant upper trap. Down and back is the motion that will increase muscle activity of the lower trap thereby improving the activation ratio between the upper and lower trap which is the goal. To correct the “depressed” position of the scapula you also will have to address the tight pec minor (anterior tilt) and the weakness/inhibition of the serratus anterior (internal rotation). By removing the “down” portion of the cue you reduce the amount of lower trap activation and potentially increase the upper trap activation. This is just my take on it.
Can you recommend a quality “arm care program” that should be used prior to practice or a game? I have found it difficult to find something that is a good fit for 12-13 year old baseball players.
The best arm car program is to make sure the lower body supports the upper body in the throwing motion! Thoracic mobility, hip mobility and stability will all go a long way to keeping a shoulder healthy!
I agree with Stephen. When evaluating pitchers you rarely see a LSST that is less than ND side. The original article says no greater than 1.5cm. The down and back cue is to remind the athlete to use the serratus and lower trap to help facilitate upward rotation. The synergists with upper trap, rhomboids and levator allow the scap to “open the bridge” of the AC.
The cue may be down and back, but the motion that you are trying to achieve is to suck the inferior angle back to the thoracic wall to posteriorly tilt the scapula, much as you would with a pelvic tilt.
The rub with all this, and I know that you address, is to not allow the compensaotry lumbar lordosis/anterior tilt of the pelvis to achieve this motion. I was speaking with our Medical Coordinator and his straw pole of SLAP rehabs is 90% have a high level lumbar curve. Is that the chicken or the egg in the injury?
Thanks for the comments. I’ll let Eric S. chime in on this one, as it’s his article. However, I think the issue we’ve seen is that the down and back cues have “left out” two specific cases that we’ll encounter quite a bit:
1. Folks who’ll preferentially recruit lat over lower traps to achieve the movement. Mark hit the nail on the head with the inferior angle/thoracic wall comment; that’s what we want, but what we often see athletes do is simply pull into aggressive depression instead. I think it’s exacerbated by a) a lot of therapy happening in a group setting where it might not be specifically controlled, b) not much therapy happening shirtless, where it’s easier to visualize, and c) a lot of the cues being given out without much hands-on instruction.
2. Folks who are already heavily adducted (rhomboid dominance). We’ll see a lot of athletes where the scapula is practically touching the spine at rest, so it’s like they are starting the upward rotation “race” from 10yds behind the starting line. The back cue isn’t necessarily right for them, even if the intention is great.
I agree with the a, b and c. That is why all exercise that I do with the down and back cueing is done where upward rotation is combined with above 90 abduction or flexion as the goal thus negating the Lat. My upward rotation series is:
Wall Angels – 1/4 squat where low back, shoulders,
elbows, wrist and head are in contact with the wall, then military press, contact the whole time, open the chest.
Scapular wall/towel slides – 90/90 tube around forearms (don’t let them cheat with it at wrists, get that isometric ER) slide up to forward flexion.
Combination – taken a little from You, and a combination of the above – 1/4 squat, head and back on the wall and do a wall free 90/90 tube on forearms scapular slide to straight arms goal is the thumbs touching the wall above the head.
(My thanks to Phil Donley for the above.)
As Stephen knows from my comments on his great blog. Forget the RC, unless deficient, the lower trap and serratus are the key to upward rotation and keeping the shoulder healthy.
Also loved your side plank and low row. Have added it to my mix, but in blackburns 6 positions and the “Hersheiser” (side ER to punching into 90 abduction and then an eccentric lowering mimicking the follow through.)
Thanks for reading the post guys. I appreciate your feedback.
A few thoughts:
1. I would argue that the upper trap. in baseball players is actually too lengthened and inhibited (as opposed to overactive). Massive amounts of training with arms by side (DLs, carries, lunge variations, etc.), poor postural habits, long bus
rides all contribute to this finding. In addition, due to poor training program design,
we see lat dominance, poor anterior core, extension/ant. pelvic tilt bias as part of their movement dysfunction.
2. Clinically, these guys come in moving poorly and are unable to properly upwardly rotate and elevate their scapula. Although I would still argue that a lot of guys present with scapular depression, the bigger point is that they are not “getting up” when the bring the arm up into the throwing position. So I think we can debate whether the scapula is depressed, but it is very clear that there is a lack of elevation and upward rotation due to stiffness of lats and scapulothoracic musculature among other things.
3. I think it is critical to be assessing movement vs. muscles. More specifically, I’m not sure how to assess ratios of muscle activation (ie. lower trap vs. upper trap) in the clinic or on the field. However, it is certainly possible to measure and evaluate proper scapular movement, arm position at different points in the delivery, excessive anterior humeral glide, etc.
4. Lastly, the videos in the post were simply to illustrate bad movement vs. improved movement. The take-away was we did not increase strength, length, soft tissue extensibility, etc. for this
athlete. We did not talk muscles or ratios. We
simply taught motor learning through simple cuing
and his movement cleaned up dramatically. We want to make sure that we are not reinforcing bad movement patterns.
I enjoy reading the posts the are put on Eric Cressey’s website. They illuminate to me that unfortunately trainers in the field of athletics are often more educated that therapists in athletic performance. i am in the process of creating a website that will be titled injury free pitching/the pitching authority.com it has been the culmination of my life’s work. I was a former professional pitcher that susta
I enjoyed reading this post. They illuminate to me that unfortunately for us therapists trainers in the field of athletics are often more educated that therapists in athletic performance and specificity of exercise. I am in the process of creating a website that will be titled injury free pitching/the pitching authority.com it has been the culmination of my life’s work. I was a former professional pitcher that sustained injuries to my shoulder and elbow that ended my career. I have been a practicing physical therapist and a specialist in orthopedic manual therapy for ten years and became a therapist to eradicate injuries in throwing athletes. I founded the Overhead Athletic Institute with the intent to medically manage the return to throwing for injured athletes. In reference to the scapular positioning on the rib cage during the acceleration phase of the trowing motion it is important to recruit the serratus more aggressively at the full upwardly rotated position which is best accomplished in multiple positions of protraction and glenohumeral internal and external rotation with progressively more resistance at endrange. I have never read these posts and would be interested after your identification process of scapular malposition or dyskinesis what exercises you prescribe to address this and what you do during your retraining of the throwing mechanics to force the athlete to engage the serratus more and restore a proper glenohumeral scapulothoracic rhythm which will decrease the compressive force under the acromion and allow the bicep to eccentrically load later in the throwing motion and have less load placed on it to decrease the probability of external labral deformation.
April 2nd, 2013 at 11:36 am
Eric nice post. I just have one thing I would like to address. I agree that the scapula is typically downwardly rotated but I disagree that it is depressed. The “depression” that you grossly visualize is caused by a combination of the scapula being downwardly rotated, anterior tilted, and internally rotated. In this position the AC joint does appear to be lower than the non-dominant side but the scapula isnt in true depression. I still think using the down and back cue is important since these players typically have an over dominant upper trap. Down and back is the motion that will increase muscle activity of the lower trap thereby improving the activation ratio between the upper and lower trap which is the goal. To correct the “depressed” position of the scapula you also will have to address the tight pec minor (anterior tilt) and the weakness/inhibition of the serratus anterior (internal rotation). By removing the “down” portion of the cue you reduce the amount of lower trap activation and potentially increase the upper trap activation. This is just my take on it.
April 2nd, 2013 at 11:44 am
Can you recommend a quality “arm care program” that should be used prior to practice or a game? I have found it difficult to find something that is a good fit for 12-13 year old baseball players.
April 2nd, 2013 at 12:54 pm
Great stuff, Eric! Can’t wait for the next seminar.
April 2nd, 2013 at 6:51 pm
The best arm car program is to make sure the lower body supports the upper body in the throwing motion! Thoracic mobility, hip mobility and stability will all go a long way to keeping a shoulder healthy!
April 2nd, 2013 at 9:19 pm
I agree with Stephen. When evaluating pitchers you rarely see a LSST that is less than ND side. The original article says no greater than 1.5cm. The down and back cue is to remind the athlete to use the serratus and lower trap to help facilitate upward rotation. The synergists with upper trap, rhomboids and levator allow the scap to “open the bridge” of the AC.
The cue may be down and back, but the motion that you are trying to achieve is to suck the inferior angle back to the thoracic wall to posteriorly tilt the scapula, much as you would with a pelvic tilt.
The rub with all this, and I know that you address, is to not allow the compensaotry lumbar lordosis/anterior tilt of the pelvis to achieve this motion. I was speaking with our Medical Coordinator and his straw pole of SLAP rehabs is 90% have a high level lumbar curve. Is that the chicken or the egg in the injury?
April 3rd, 2013 at 10:19 am
Mark and Stephen,
Thanks for the comments. I’ll let Eric S. chime in on this one, as it’s his article. However, I think the issue we’ve seen is that the down and back cues have “left out” two specific cases that we’ll encounter quite a bit:
1. Folks who’ll preferentially recruit lat over lower traps to achieve the movement. Mark hit the nail on the head with the inferior angle/thoracic wall comment; that’s what we want, but what we often see athletes do is simply pull into aggressive depression instead. I think it’s exacerbated by a) a lot of therapy happening in a group setting where it might not be specifically controlled, b) not much therapy happening shirtless, where it’s easier to visualize, and c) a lot of the cues being given out without much hands-on instruction.
2. Folks who are already heavily adducted (rhomboid dominance). We’ll see a lot of athletes where the scapula is practically touching the spine at rest, so it’s like they are starting the upward rotation “race” from 10yds behind the starting line. The back cue isn’t necessarily right for them, even if the intention is great.
Amen on the lordosis/anterior tilt comment!!!
April 3rd, 2013 at 4:32 pm
Eric-
I agree with the a, b and c. That is why all exercise that I do with the down and back cueing is done where upward rotation is combined with above 90 abduction or flexion as the goal thus negating the Lat. My upward rotation series is:
Wall Angels – 1/4 squat where low back, shoulders,
elbows, wrist and head are in contact with the wall, then military press, contact the whole time, open the chest.
Scapular wall/towel slides – 90/90 tube around forearms (don’t let them cheat with it at wrists, get that isometric ER) slide up to forward flexion.
Combination – taken a little from You, and a combination of the above – 1/4 squat, head and back on the wall and do a wall free 90/90 tube on forearms scapular slide to straight arms goal is the thumbs touching the wall above the head.
(My thanks to Phil Donley for the above.)
As Stephen knows from my comments on his great blog. Forget the RC, unless deficient, the lower trap and serratus are the key to upward rotation and keeping the shoulder healthy.
Also loved your side plank and low row. Have added it to my mix, but in blackburns 6 positions and the “Hersheiser” (side ER to punching into 90 abduction and then an eccentric lowering mimicking the follow through.)
April 3rd, 2013 at 5:46 pm
Great stuff, Mark! Let me know when you guys are in the area; would be great to meet up!
April 4th, 2013 at 6:02 am
Thanks for reading the post guys. I appreciate your feedback.
A few thoughts:
1. I would argue that the upper trap. in baseball players is actually too lengthened and inhibited (as opposed to overactive). Massive amounts of training with arms by side (DLs, carries, lunge variations, etc.), poor postural habits, long bus
rides all contribute to this finding. In addition, due to poor training program design,
we see lat dominance, poor anterior core, extension/ant. pelvic tilt bias as part of their movement dysfunction.
2. Clinically, these guys come in moving poorly and are unable to properly upwardly rotate and elevate their scapula. Although I would still argue that a lot of guys present with scapular depression, the bigger point is that they are not “getting up” when the bring the arm up into the throwing position. So I think we can debate whether the scapula is depressed, but it is very clear that there is a lack of elevation and upward rotation due to stiffness of lats and scapulothoracic musculature among other things.
3. I think it is critical to be assessing movement vs. muscles. More specifically, I’m not sure how to assess ratios of muscle activation (ie. lower trap vs. upper trap) in the clinic or on the field. However, it is certainly possible to measure and evaluate proper scapular movement, arm position at different points in the delivery, excessive anterior humeral glide, etc.
4. Lastly, the videos in the post were simply to illustrate bad movement vs. improved movement. The take-away was we did not increase strength, length, soft tissue extensibility, etc. for this
athlete. We did not talk muscles or ratios. We
simply taught motor learning through simple cuing
and his movement cleaned up dramatically. We want to make sure that we are not reinforcing bad movement patterns.
Great input guys. Thanks!
April 17th, 2013 at 5:52 pm
I enjoy reading the posts the are put on Eric Cressey’s website. They illuminate to me that unfortunately trainers in the field of athletics are often more educated that therapists in athletic performance. i am in the process of creating a website that will be titled injury free pitching/the pitching authority.com it has been the culmination of my life’s work. I was a former professional pitcher that susta
April 17th, 2013 at 6:00 pm
Thanks, Ed! Good luck with the project.
April 17th, 2013 at 6:06 pm
I enjoyed reading this post. They illuminate to me that unfortunately for us therapists trainers in the field of athletics are often more educated that therapists in athletic performance and specificity of exercise. I am in the process of creating a website that will be titled injury free pitching/the pitching authority.com it has been the culmination of my life’s work. I was a former professional pitcher that sustained injuries to my shoulder and elbow that ended my career. I have been a practicing physical therapist and a specialist in orthopedic manual therapy for ten years and became a therapist to eradicate injuries in throwing athletes. I founded the Overhead Athletic Institute with the intent to medically manage the return to throwing for injured athletes. In reference to the scapular positioning on the rib cage during the acceleration phase of the trowing motion it is important to recruit the serratus more aggressively at the full upwardly rotated position which is best accomplished in multiple positions of protraction and glenohumeral internal and external rotation with progressively more resistance at endrange. I have never read these posts and would be interested after your identification process of scapular malposition or dyskinesis what exercises you prescribe to address this and what you do during your retraining of the throwing mechanics to force the athlete to engage the serratus more and restore a proper glenohumeral scapulothoracic rhythm which will decrease the compressive force under the acromion and allow the bicep to eccentrically load later in the throwing motion and have less load placed on it to decrease the probability of external labral deformation.