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Understanding Elbow Pain – Part 2: Pathology

In case you missed Part 1 of this series (Functional Anatomy), you can check it out HERE.

Elbow issues can be really tricky at times from a diagnostic standpoint. Someone with medial elbow pain could have pronator and/or flexor (a.k.a. Golfer’s Elbow) soft tissue issues, ulnar nerve irritation or hypermobility, ulnar collateral ligament issues, or a stress fracture of the medial epicondyle – or a combination of two or more of these factors. All of these potential issues are “condensed” into an area that might be a whopping one square inch in size. Throw lateral elbow pain (commonly extensor overuse conditions - a.k.a. "Tennis Elbow" - and bony compression issues) and posterior (underside) pain in the mix, and you’ve got a lot of other stuff to confound things.

lateralepicondyle1

To make matters more complex, it’s not an easy diagnosis. The only way to recognize soft tissue restrictions is to get in there and feel around – and even when something is detected, it takes a skilled clinician with excellent palpation skills to determine just what is “balled up” and what nerves it may affect (especially if there is referred pain).

In these situations, I’ll stick with the terms “soft tissue dysfunction” and “tendinopathy” or “tendinosis” to stay away from the diffuse and largely incorrect assumption of “elbow tendinitis.” We’re all used to hearing “Tennis Elbow” (lateral) and “Golfer’s Elbow” (medial), and to be honest, I’d actually say that these are better terms than “epicondylitis,” as issues are more degenerative (“-osis”) than inflammatory (“-itis”).

golfers

Ulnar nerve pain patterns can present at or below the elbow (pinky and ring finger tingling/numbness are common findings), and may originate as far up as the neck (e.g., thoracic outlet syndrome, brachial plexus abnormalities, rheumatologic issues, among others) and can be extremely challenging to diagnosis. A doctor may use x-rays to determine if there is some osseous contribution to nerve impingement or a MRI to check on the presence of something other than bone (such as a cyst) as the cause of the compression. Nerve conduction tests may be ordered. Manual repositioning to attempt to elicit symptoms can also give clues as to whether (and where) the nerve may be “stuck” or whether it may be tracking out of course independent of soft tissue restrictions.

Childress reported that about 16% of the population – independent of gender, age, and athletic participation – has enough genetic laxity in the supporting ligaments at the elbow to allow for asymptomatic ulnar nerve “dislocation” over the medial epicondyle during elbow flexion. In the position of elbow flexion, the ulnar nerve is most exposed (and it’s why you get the “funny bone” pain when you whack your elbow when it’s bent, but not when it’s straight). Ulnar nerve transposition surgeries has been used in symptomatic individuals who have recurrent issues in this regard, and it consists of moving the ulnar nerve from its position behind the medial epicondyle to in front of it.

ulnarnerve

An ulnar collateral ligament (UCL) issue may seem simple to diagnosis via a combination of manual testing and follow-up diagnostic imaging (there are several options, none of which are perfect), but it can actually be difficult to “separate out” in a few different capacities.

First, because the UCL attaches on medial epicondyle (albeit posteriorly), an injury may be overlooked acutely because it can be perceived as soft tissue restrictions or injuries.  The affected structures would typically be several of the wrist flexors as they attach via the common flexor tendon, or the pronator teres.

Second, partial thickness tears of the UCL can be seen in pitchers who are completely asymptomatic, so it may be an incidental finding. Moreover, we have had several guys come our way with partial thickness UCL tears who have been able to rehab and return to full function without surgery. While the UCL may be partially torn and irritated, the pain may actually be coming to “threshold” because of muscular weakness, poor flexibility, or poor tissue quality.

Medial epicondyle stress fractures can be easily diagnosed with x-rays, but outside of a younger population, they can definitely be overlooked. For instance, I had a pro baseball player – at the age of 23 – sent to us for training by his agent last year as he waiting for a medial epicondyle fracture to heal.

stressfracture

While these are the “big players” on the injury front – particularly in a throwing population – you can also see a number of other conditions, including soft tissue tears (flexor tendons, in particular), loose bodies (particularly posteriorly, where bone chips can come off the olecranon process), and calcification of ligaments. So, long story short, diagnosis can be a pain in the butt – and usually it’s a combination of multiple factors.  At a presentation last weekend, Dr. Lance Oh commented on how 47% of elbow pain cases present with subluxating medial triceps ("snapping elbow"), but this is rarely an issue by itself.

That’s one important note. However, there is a much more important note – and that is that many rehabilitation programs are outrageously flawed in that they only focus on strengthening and stretching the muscles acting at the elbow and wrist.

As I’ll outline in Part 3 of this series, a ton of the elbow issues we see in throwers occur secondary to issues at the glenohumeral and scapulothoracic joints. And, more significantly, not providing soft tissue work in these regions grossly ignores the unique anatomical structure of the elbow and forearm and its impact on tendon quality. If you’ve got elbow issues, make sure you’ve got someone doing good soft tissue work on you. Just to give you a little visual of what I’m thinking, I got a video of Nathaniel (Nate) Tiplady, D.C. (a great manual therapist who works out of Cressey Performance a few days a week) performing some Graston Technique® followed by Active Release ® on my forearms.  Here's the former; take note of the sound of his work on the tissues; the instruments actually give the practitioner tactile (and even audible) feedback in areas of significant restrictions.  You'll see that it is particularly valuable for covering larger surface areas (in this case, the flexors of the anteromedial aspect of the forearm):

As for the ART, you'll see that it's more focal in nature, and involves taking the tissue in question from shortened to lengthened with direct pressure.

As you can probably tell (even without seeing me sweat or hearing me curse), it doesn’t feel great while he’s doing it – but the area feels like a million bucks when he’s done.

While there is no substitute for having a qualified manual therapist work on you, using The Stick on one’s upper and lower arms can be pretty helpful.

More on that in Part 3…

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Is Pitching Velocity Really that Important?

About this time last year, I attended and spoke at at big sports medicine conference organized by Massachusetts General Hospital and the Harvard Medical School.  Given that it was baseball season, and the event's organizers were all also on staff with the Boston Red Sox, a big focus of the event was the diagnosis, treatment, and causes of throwing injuries to the elbow and shoulder. One of the organizers happened to be my good friend Mike Reinold, who is the head athletic trainer and rehabilitation coordinator for the Red Sox.  As you probably know, we collaborated on the Optimal Shoulder Performance DVD set as well.

shoulder-performance-dvdcover

One of the resounding themes of Mike's talks was that throwing hard is not the single-most important factor in being a successful pitcher.  Rather, success is all about changing speeds and hitting spots.  The point is an important one - and it's backed up by the success of the likes of Jamie Moyer, Tom Glavine, and Greg Maddux.

Why is it so important for youth pitchers and parents to understand this?  It's because it demonstrates that long-term success is not about dominating in little league; it's about acquiring skills that allow for future improvements.

Youth pitches should focus on commanding their fastballs with consistent repetition of their mechanics early-on - not just throwing hard.  If you think you have the fastball mastered at age 9 and simply learn a curveball so that you can dominate little league hitters, you're skipping steps and trying to ride too many horses with one saddle.  It's not that the curveball is inherently more stressful than any other pitch; it's just that - as the saying goes - "if you chase two rabbits, both will escape."

youthpitcher

While kids need variety, they shouldn't try to master too many different complex skills at once.  Step 1 is to have command of your fastball - not just to throw it hard.

Step 2 is to learn a good change-up to start creating the separation to which Mike is referring.  Breaking pitches can come later.

Need proof?  I recently saw some statistics that demonstrated that the MLB average against off-speed pitches has decline each of the past three years.  Meanwhile, not surprisingly, the average MLB fastball velocity has increased by about 1mph.  Throwing harder made all those off-speed pitches more effective by creating more separation.  So, yes, throwing the crap out of the ball is still important - but only if you know where it's going - otherwise the average fastball velocity wouldn't be higher in Low A ball than it is in the big leagues.

Oh, and in case you need further proof of how MLB general managers perceive the importance of off-speed pitches, Phillies First Baseman Ryan Howard gave you $125 worth when he signed a new five-year contract last month.  While the MLB average against off-speed pitches has steadily declined over the past three seasons, Howard has gotten better.

ryanhoward

The take-home message is that youth pitchers need to develop the mechanical efficiency and physical abilities that will eventually make them able to throw hard in conjunction with a solid assortment of off-speed pitches.  They don't need to light up radar guns and showcase curveballs when they're still regulars at Chuck 'E Cheese.

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Understanding Elbow Pain – Part 1: Functional Anatomy

Today's piece kicks off a multi-part series focusing specifically on the elbow.  I'm going to start off this collection by talking about the anatomy of the elbow joint, but in appreciation of the fact that a lot of you are probably not as geeky as I am, I'll give you the Cliff's Notes version first: The elbow is the most "claustrophobic" joint in the body; there is a lot of stuff crammed into very little space.  This madness is governed not just by the joint itself, but (like we know with all joints) by the needs of the forearm/wrist and what goes on at the shoulder and neck. Even for the geeks out there, in the interest of keeping this thing "on schedule," I'm just going to focus on your pertinent information.  I would highly recommend The Athlete's Elbow to those of you interested in learning more; it's insanely detailed. Your big players on the osseous (bone) front are going to be the humerus, ulna, and radius.  At the humerus, in the context of this discussion, all you really just need to pay attention to are the medial and lateral epicondyles, as they are crucial attachment points for both tendons and ligaments (as well as sites of stress fractures in younger athletes).

elbow_labelled

Posteriorly, you'll see that olecranon process of the ulna sits right in the olecranon fossa of the humerus.  This is a pretty significant region, as it gives the elbow its "hinge" properties and prevents elbow hyperextension.  Fractures of the olecranon can occur and leave loose bodies in the joint that will prevent full elbow extension.  And, not to be overlooked is the attachment site of the triceps (via a common tendon) and anconeus on the olecranon process.

elbowxray

The "elbow" may just be a hinge to the casual observer, but in my eyes, it's important to distinguish among the humeroulnar joint (described above) and the humeroradial (pivot) and proximal radioulnar joints - which give rise to pronation and supination.

0199210896pivot-joint1

Likewise, the wrist (and the fingers, for that matter) is directly impacted in flexion/extension, radial deviation/ulnar deviation, and pronation/supination by muscles that actually attach as far "north" as the humerus.  Muscles aren't just working in one plane of motion; they're working for or against multiple motions in multiple planes.

In all, you have 16 muscles crossing the elbow.  For those counting at home, that's more than you'll find at another "hinge" joint, the knee, in spite of the fact that the knee is a much bigger joint mandating more stability.  More muscles equates to more tendons, and that's where things get interesting.

As any good manual therapist, and he'll tell you that soft tissue restrictions occur predominantly at: A.       Areas of increased friction between muscles/tendons B.       Areas where forces generated by a myofascial unit come together (termed "Zones of Convergence" by myofascial researcher Luigi Stecco): this is generally the muscle-tendon-bone "connection," as you don't typically see prominent restrictions in the mid-belly of a muscle. This is a double whammy for the muscles acting at the elbow.  In terms of A, you have many muscles in a small area.  Most folks overlook the importance of B, though: a lot of them share a common (or at least directly adjacent) attachment point.  The flexor carpi radialis, flexor carpi ulnaris, palmaris longus, and flexor digitorum superficialis all attach video the common flexor tendon on the medial epicondyle, with the pronator teres attaching just a tiny bit superiorly.  There's ball of crap #1.

medialepicondyle

Ball of crap #2 occurs at the lateral epicondyle, where you have the common extensor tendon, which is shared by extensor carpi radialis brevis, extensor carpi ulnaris, supinator, extensor digitorum, and extensor digiti minimi - with the extensor carpi radialis longus attaching just superiorly on the lateral supracondylar ridge.  Ball of crap #3 can be found posteriorly, where the three heads of the triceps converge to attach on the olecranon process via a common tendon, with the much smaller anconeus running just lateral to the olecranon process. You can see both balls of crap (double flusher?) coming together here:

lateralepicondyle

Ball of crap #4 is a bit more diffuse consisting of the attachments of biceps brachii (radial tuberosity), brachioradialis (radial/styloid process), and brachialis (coronoid process of ulna) on the anterior aspect of the forearm.

distalbiceps

This last graphic demonstrates that there are a few other factors to consider in this already jam-packed area.  You've got fascia condensing things further, and you've also got a blood supply and nerve innervations - most significantly, the ulnar, median, and radial nerves - passing through here. The median nerve, for instance, passes directly through the pronator teres muscle.

Oh, and you've also got ligaments mixed in - some of which are attaching on the very same regions that tendons are attaching.  The ulnar collateral ligament attaches on the medial epicondyle in close proximity to the flexors and pronator teres, for instance.  These ligaments are heavily reliant on soft tissue function to stay healthy.  As an example, flexor carpi ulnaris is going to be your biggest "protector" of the UCL during the throwing motion.

elbow

So what's the take-home message of this functional anatomy lesson?  Well, there are several.

1. Lots of stuck is packed in a very small area.

2. When things are stuck together, they form dense, fibrotic, nasty balls of crud.

3. These gunked up muscles/tendons can impact everything from nerve function to ligamentous integrity - or they can just give out in the form of a tear or tendinopathy.

4. Diagnosis can be tricky because all the potential issues take place in a small area, and may have very similar symptoms.  Different pathologies take place in different athletic populations, too.  We'll have more on this in Understanding Elbow Pain - Part 2: Pathology.

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Where “Throw Like a Girl” Originated

Many baseball fans thought that it was a bit inappropriate of President Obama to wear a Chicago White Sox hat as he threw out the opening pitching at the Washington Nationals game several years ago.  However, many others - including those of us on the baseball development side of things - overlooked this fashion faux pas, and instead pointed out that the commander-in-chief's throwing mechanics closely paralleled those of an 11-year-old girl.

Now that I've irritated a good chunk of my readership, please allow me to explain.

We are all born with a certain amount of humeral retroversion.  For the lay population out there, think of retroversion as a bony positioning that allows for more shoulder external rotation.  As we age, we actually gradually lose retroversion (gain anteversion); this process moves the most quickly from ages 8-13, which isn't surprising, as this is when kids rapidly become more skeletally mature.  It's why we see more torn ACLs than broken bones in the late teenage years; the bones are no longer the path of least resistance.

However, we actually see something different in kids who are involved in overhead throwing sports during this crucial developmental period.  They don't gain anteversion as quickly in their throwing shoulder; in other words, they preserve at lot of the bony positioning that gives rise to external rotation (the lay-back position), which in itself is a predictive factor for throwing velocity.  Very simply, it's easier for them to get their arm back to throw because the bones (specifically, the proximal humeral epiphysis) have morphed to allow for it.  There's even a theory out there that this bony positioning actually spares the anterior-inferior glenohumeral ligaments from excessive stress during external rotation, but that's a topic for another day (and president?).

How much of a difference are we talking?  Well, in a study of 54 college pitchers, Reagan et al. found that had 36.6° of humeral retroversion, as compared with just 26° in non-dominant shoulders.  Here's our fearless leader throwing a cream puff from a different angle at a previous All-Star Game; you'll notice that he leads with the elbow and his arm doesn't "lay back" - a technique we've come to term "throwing like a girl," as politically incorrect as it is. Think he could use an additional 10° of shoulder external rotation?

The good news, however, is that he's in good company; Mariah Carey has sold hundreds of millions of albums and rocks a 12-foot palmball, too.

We can't fault these folks (well, maybe for their attire, but that, too, is another blog post), as females traditionally haven't had exposure to baseball at young ages in order to develop these osseous (bony) adaptations that favor throwing hard.  And, with just a little reconnaissance work on President Obama, I quickly came across this quote from him in the NY Daily News: "I did not play organized baseball when I was a kid, and so, you know, I think some of these natural moves aren't so natural to me."  There's your answer.

Contrast his delivery with that of George W. Bush, who not only played baseball as a kid, but actually owned the Texas Rangers for a while, and you'll see what a few years in Little League will do for a shoulder.

Interestingly, the Iraqi journalist who threw his shoes at Bush actually displayed some decent lay-back, too.  It makes me wonder if he was born with some congenital laxity, played cricket or tennis, or just practiced a ton for his first international shoe-throwing appearance (cap?).

As an interesting little aside, in our Optimal Shoulder Performance, Mike Reinold talks about how European soccer players have actually served as the control group against which we can compare overhead throwing shoulders in research, as these athletes are the same age and gender as baseball pitchers, but rarely participate in overhead throwing sports.  So, perhaps we should say "throw like a European soccer player" instead of "throw like a girl" - particularly since more and more female athletes have started participating in overhead throwing sports at a younger age!

However, in the interim, what can President Obama do to get over this hurdle?  It goes without saying that it's too late to get that retroversion, as he's already skeletally mature.  However, there is research out there that shows that pitchers gain external rotation over the course of a competitive season - so President Obama would be wise to get out in the rose garden and play some catch because, you know, presidents have plenty of time to do that!

Likewise, there are several things he could do to improve his pitching-specific mobility.  The most important thing is to avoid spending so much time hunched over a desk, as being stuck in this position will shorten the pectoralis major and minor, lats, subscapularis, and several other small muscles that need adequate length and tissue quality to get the arm "back" via good humeral external rotation, scapular posterior tilt, and thoracic spine extension/rotation.  To keep it simple, I'd probably just have him do a lot of the side-lying extension-rotation drill:

Of course, there's a lot more to it than just this, but these quick modifications would be a good start.  For more information, check out our new Optimal Shoulder Performance resource, which is on sale for 20% off through the end of the day today. Just enter the coupon code 20OFF to get the discount.

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Baseball Showcases: A Great Way to Waste Money and Get Injured

Q: I read your blog here the other day about your "ideal competitive year" for a baseball player.  What's your take on showcases and college camps?  They always occur during the "down periods" you mentioned: fall ball and the early winter.  How do these fit in to a baseball player's development?

A: To be blunt, while there are some exceptions to the rule, they rarely fit into development. In reality, they usually feed into destruction - at least in the context of pitchers.  I openly discourage all our young athletes and parents from attending them almost without exception.

I know of very few showcase directors and college baseball coaches who legitimately understand anatomy, physiology, the etiology of baseball injuries, the nature of adolescent development, or motor skill acquisition.

Showcase directors specialize in promoting and running showcases.  College coaches specialize in recruiting players, developing talent, planning game and practice strategy, and winning games.  To my knowledge, understanding scapulohumeral rhythm and the contributions of a glenohumeral internal rotation deficit (GIRD) to SLAP lesions via the peel-back mechanism isn't all in a day's work for these folks.

nomo

The fundamental issue with these events is their timing.  As you noted, they almost always occur in the fall and winter months.  Why?

1.  It's the easiest time to recruit participants, as they aren't in-season with their baseball teams.

2. It's not during the college baseball season - so fields and schedules are open and scouting and coaching man-power is free.

You'll notice that neither #1 or #2 said "It's the time of year when a pitcher is the most prepared to perform at a high level safely."  It is just profitable and convenient for other people - and that occurs at the expense of many young pitchers' arms.

In 2006, Olsen et al. published a fantastic review that examined all the different factors associated with elbow and shoulder surgeries in pitchers by comparing injured pitchers (those who warranted surgery) with their non-injured counterparts.  Some of the findings of the study:

-Pitchers who eventually required surgery threw almost EXACTLY twice as many pitches as the control group (healthy pitchers) over the course of the year...from a combination of pitches per outing, total outings, and months pitched per year.  For those of you who think your kid needs to play on multiple teams simultaneously, be very careul; add a team and you instantly double things - at least acutely.

-The injured pitchers attended an average of FOUR times more showcases than non-injured kids.

-Interesting aside:  injured pitchers were asked what their coaches' most important concern was: game, season, or athlete's career.  In the healthy group, they said the coach cared about the game most in only 11.4% of cases. In the injured group, it was 24.2%!  These crazy little league coaches are often also the ones running the showcases...

The big problem is that these issues usually don't present until years later.  Kids may not become symptomatic for quite some time, or pop NSAIDs to cover up the issues.  They might even go to physical therapy for a year before realizing they need surgery.  It's why you see loads of surgeries in the 16-18 year-old population, but not very often in 15 and under age groups.

elbowsurgery

So why are appearances like these in the fall and winter months so problematic?  Well, perhaps the best way I can illustrate my point is to refer back to a conversation I had with Curt Schilling last year.

Curt told me that throughout his career, he had always viewed building up his arm each year as a process with several levels.

Step 1: Playing easy catch
Step 2: Playing easy catch on a line
Step 3: Building up one's long toss (Curt never got onto a mound until he'd "comfortably" long-tossed 200 ft.)
Step 4: Throwing submaximally off a mound
Step 5: Throwing with maximum effort off a mound
Step 6: Throwing with maximum effort off a mound with a batter
Step 7: Throwing with maximum effort off a mound with a batter in a live game situation
Step 8: Opening day at Fenway Park in front of 40,000+ people

curt-schilling1

Being at a showcase in front of college coaches and scouts with radar guns is Step 8 for every 14-16 year old kid in America.  And, it comes at the time of year when they may not have even been throwing because of fall/winter sports and the weather.  Just to be clear, I'll answer this stupid question before anyone asks it: playing year-round and trying to be ready all the time is NOT the solution.

I can honestly say that in all my years of training baseball players, I've only seen one kid who was "discovered" at a showcase.  And, frankly, it occurred in December of his junior year, so those scouts surely would have found him during high school and summer ball; it wasn't a desperate attempt to catch someone's eye.

I'll be honest: I have a lot of very close friends who work as collegiate baseball coaches.  They're highly-qualified guys who do a fantastic job with their athletes - but also make money off of fall baseball camps.  I can be their friend without agreeing with everything they do; there is a difference between "disagree" and "dislike."

Fortunately, the best coaches are the ones who go out of their way to make these events as safe as possible, emphasizing skill, technique, and strategy improvements over "impressing" whoever is watching.  So, it's possible to have a safe, beneficial experience at one of these camps.  I'd encourage you to find out more about what goes on at the events in advance, and avoid throwing bullpens if unprepared for them.

As far as showcases are concerned, I'd encourage you to save your money and go on a family vacation instead.

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Overbearing Dads and Kids Who Throw Cheddar

Q: I run into a TON of Fathers who want their son to gain throwing velocity.  What are your keys to gaining velocity?

A: To be blunt, Step 1 is getting away from your crazy overbearing father and realizing that if you're going to throw the baseball harder, it's because YOU want to do it, and are willing to put in the hard work.  There are millions of American fathers who want their sons to throw 95+mph, but only about eight guys in the big leagues who consistently throw that hard.

Taking it a step further, the average fastball velocity is actually higher in A-ball than it is in professional baseball, so while throwing hard is important, it's just one piece of the puzzle.  I'd love to hear more fathers talking about learning to command the fastball and master a change-up.  And, most importantly, I'd like to see more fathers who are interested first and foremost in keeping their kids healthy so that they can have the continuity necessary to realize their potential.

Next, you have to consider what kind of velocity we're actually discussing.  Is it what the radar gun reads: actual velocity?  That's really just one of three kinds of velocity.

You also have perceived velocity - which is higher in a pitcher who gets down the mound further than his counterparts and therefore gives the hitter less time to react. Chris Young (at 6-11) gets the benefit of perceived velocity in spite of the fact that his average fastball velocity doesn't even approach 90mph.

young

Perceived velocity also explains the success of many pitchers with deceptive deliveries where the ball seems to just jump up on hitters.  Often, these pitchers stay closed and throw across their bodies.  While it may not be healthy, correcting it could take away their effectiveness.

Lastly, back in 2008, Perry Husband introduced me to the concept of effective velocity, which is a bit more complex.  The effective velocity a hitter appreciates is actually impacted by:

1.     pitch location (high and inside are faster, and low and away are slower)

2.     previous pitch location, type, and velocity (coming up and in with a fastball makes it seem harder if it follows a low and away change-up)

3.     the count (when behind in the count, the hitter must cover a larger strikezone, and therefore a larger effective velocity range)

If you need any proof of the value of effective velocity, just watch Jamie Moyer or Tom Glavine.  They nibble away over and over again, and then they come back inside on a guy and he looks blown away by the velocity even though it may only be low-80s.

jamie-moyer-getty2

That said, getting down to the nuts and bolts of throwing the ball hard (actual velocity) mandates that you understand that there are tons of factors that contribute to velocity, but they aren't the same for everyone.  Very simply, there isn't just one mechanical model that allows one to throw harder than others.

Some guys have congenital laxity that allows them to contort their bodies all over the place.  Others "muscle up" and shotput the ball to the plate.  Most pitchers are somewhere in the middle and rely on a balance of elastic energy and mobility to make things happy.  With that in mind, having mechanical efficiency and thousands of perfect throwing reps in this efficient model is what every pitcher should strive to achieve - just as a golfer would practice his swing or an Olympic lifter would practice the clean and jerk or snatch.

snatch

Second, it's imperative to prepare young pitchers' bodies for the rigors of throwing a baseball.  I've written extensively about the overwhelming extremes the throwing arm faces, and while it's important to improve arm strength, flexibility, and soft tissue quality, the rest of the body cannot be ignored.  Improving function of the scapular stabilizers, core musculature, and lower half is essential for taking stress of the throwing arm.  We encourage kids to get started with foam rolling, targeted flexibility work, and resistance training as soon as their attention span allows.  As I have written previously, the "stunting growth" argument doesn't hold water.

Third (and this piggybacks on my last point about resistance training), it's important to understand how to manage a young pitcher throughout the year. Contrary to popular belief, playing year-round is not a good idea.  In fact, it isn't even good enough to qualify as a "bad" idea; it is an atrocious idea.

If you want my ideal competitive season for a youth baseball player, it's to pick up a ball and start tossing around Thanksgiving, progressing to bullpen wok in early January after long-tossing distance has been progressed.  Then, the athlete throws up through his competitive high school season (late March- early June) and summer ball (through early August).  That's about 8-8.5 months of throwing throughout the course of the year - and it's plenty.

You'll see that this competitive year fits quite nicely with participation in a fall sport - whether it's football, soccer, or something else.  And, athletes can still "get away" with playing winter sports as long as they're willing to commit to a throwing program, even if they have to start playing a bit late.  If I had to give my ideal scenario, I'd say play football or soccer, and then play pick-up/intramural basketball in the winter alongside a throwing and lifting program.

pop-warner

Within this year, you have several crucial blocks during which to increase resistance training volume.  One, there is the entire winter break, obviously.  Two, there is generally a decent break between spring and summer baseball (late May-early June), and another during the month of August.  Three, kids can (and should) still train in-season, regardless of the sport.

This, of course, speaks to the high school athletes who have practice/games just about every day.  Managing a 10-year-old is a lot easier.  His sport practice may only be 2-3 days per week - meaning that he can participate in different activities throughout the week.  However, he can't do that if Dad thinks that playing on four different AAU teams at once is the secret to getting him to the big leagues.  He has to play multiple sports at a young age.

little-league

So, if I had to give the synopsis of my thoughts on how to get a kid to throw hard, it would go something like this:

1. Appreciate that throwing hard is just one piece of the "being a successful pitcher" puzzle - and that there are different types of velocity (actual, perceived, and effective).

2. Clearly outline his competitive season and stick to that outline.  Don't add showcases, camps, and additional teams.

3. Let him play for two teams: one spring (school) and one summer (AAU, Legion, etc.).

4. Find a skilled pitching instructor to work with him to optimize mechanical efficiency.  Before you start working with this instructor, have him explain his approach to managing your son both during a typical lesson and throughout the competitive season.  Then, go and observe him as he works with other pitchers.  Do they just "show and go," or do they warm-up before even picking up a ball?  Does he ask kids how they feel prior to each session, and does he pace them throughout the session?  Or, does he just grunt and spit dip juice all over the place.

5. Get him involved in a comprehensive strength and conditioning program that incorporates resistance training, medicine ball work, flexibility training, and movement training that all take into account the unique demands of baseball.  The strength and conditioning coach should provide a thorough evaluation that screens for all the mobility deficits and stability issues we commonly see in throwers.

6. Make sure that the pitching coach and strength and conditioning specialist communicate and collaborate. The CP staff is fortunate to have this kind of productive collaboration with Matt Blake all the time:

 

Kidding aside, very rarely will a pitching coach know about strength and conditioning, and very rarely will a strength and conditioning coach know about pitching.  It's unfortunate, but true.

7. Have him play multiple sports.  The younger the pitcher, the more sports he should play.  Specialization shouldn't come until age 17 at the earliest.

8. Make sure he continues to take care of his resistance training and mobility work in-season.

I could go on and on about all the subtle details of what we do with pitchers on a daily basis, but the truth is that I envision this blog as something that will be most popular with the Dads in the crowd who really just want to help their kids realize their potential and remain injury-free.  So, I'm keeping it more general - and referring you to the Baseball Content page for the more "geeky" stuff.

I do have one more closing thought, though.  We deal with a lot of very talented young pitchers who throw the ball very hard.  One anecdotal observation has been that their fathers are the ones who "get it."  These are the guys who are concerned about the important things: staying healthy, enjoying baseball, finding the right college, etc.  They don't boast about how many guys their sons struck out in little league. They are genuinely humble and respect the game - and this carries over to their kids, who work hard and carry themselves the right way.

Conversely, the kids who are always told that they're the best and get raved about by their fathers are the ones who invariably struggle to succeed long-term.  It may be because they're overworked, over-pressured, or just overrated in the first place.  It may be because coaches get frustrated with having to deal with an overbearing father, and the kid gets punished for it.  It may be that the kid doesn't think he needs to work as hard because he's already the best - because Dad told him so. Or, maybe he misses out on crucial development because he spends all his time playing in baseball games when he should be practicing, training, or participating in other sports - or just having fun and being a normal kid. Worst of all, a kid may just flat-out start to dislike the game because all the fun has been taken out of it because of Dad's hype and excessive pressure.

Is velocity important? Sure.  Can it sometimes be the trees that prevent us from seeing the forest?  Absolutely.

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Wrapping Up a Great Pro Baseball Off-Season

Today marks the end of one of the funnest "eras" of my life. Back on September 9, we officially kicked off the pro baseball off-season with Tim Collins' arrival at Cressey Performance for his first training session of the off-season.  Coming off a great season that included a promotion to Double-A at age 20 and a Blue Jays organizational pitcher of the year award, Tim was ready to get after it - and that's exactly what he did.  From that day in September through February 6 (when he was called to Florida for mini-camp), Tim added 21 pounds to his frame while getting leaner - and increased his vertical jump by four inches (to 37.9 inches).

Tim was one of over 30 pro guys we had this winter.  Results were typical. Chad Rodgers (Atlanta Braves organization) went from 206 to 233 while adding just under three inches to his vertical jump.  And he dominated "No Shave November."

Jeremiah Bayer (Red Sox organization) packed on muscle mass faster than just about any athlete I've ever seen - to the tune of 13 pounds in only two months - while adding an inch to his vertical.  That's a 5.6% improvement in predicted peak power in a short amount of time - and one that is carrying over to the mound already. Heck, Pat Bresnehan packed on 14 pounds and jumped 37.5 inches (a 6.3 inch) improvement - and got himself signed by the Mariners - after coming to us in the latter phases of his rehab period! Craig Albernaz (Rays organization) increased his vertical jump by over five inches while adding seven pounds before heading to big league camp - and this is a guy who has always struggled to put on any weight, let alone good weight! Cory Riordan (Rockies) and Steve Cishek (Marlins) win the awards for the longest commutes to train.  Cory drove two hours to CP, and two hours home to Connecticut to get in his work with us - and he's got a new body and a lot more athleticism to show for it.  Cishek wasn't far behind with his 1 hour, 45 minute commute from Cape Cod four times a week all the way up through January.  I can say without wavering that both of them would tell you that the ride was 100% worth it. Two other Braves guys - Derick Himpsl and Matt Kramer - also put in some great work that is already carrying over to the field.

Zach Piccola's headed to White Sox camp with a great few months of training under his belt alongside free agent Nick Asselin.  Jim Fuller (Mets) committed himself to train like he never had before, and looks fantastic now.  Another Mets guy, Tim Stronach, has busted his hump to get better alongside his rehabilitation from shoulder surgery. Steffan Wilson leaned out and dramatically changed the way he looks and moves - and it helped get him a much-deserved call-up to big-league camp last week.

Kevin Youkilis had a great off-season as well - due in part to his love of pushing the sled.  So far this spring, Youk's looked good (much better than his strength coach, as is shown below), and we're excited about the Red Sox season ahead.

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Will Inman (Padres), Phil Negus (White Sox), and Kevin Nolan (Blue Jays) put in a great few months in the fall, and Steve Hammond (Giants), Kevin Pucetas (Giants), Nick McBride (Rangers), Benji Johnson (Braves), Matt Morizio (Royals), Justin Edwards (Cardinals), and Howie Clark (Blue Jays) made the most of all their visits to Boston this winter.

And, some "distance-based" guys of mine - Chad Jenkins (Blue Jays) and Anthony "A-Tan" Seraterelli (Royals) - made some excellent progress by following everything to a "T."  A-Tan, Howie, and Morizio even made a hilarious video about their experiences (a joke, FYI):

One athlete, though, stepped it up big time on Thursday to set himself apart from all the rest. Tim Kiely (Angels) added 11 pounds and seven inches to his vertical jump, but his biggest claim to fame is that he took home the Gold in the first ever Cressey Performance Elite Baseball Olympics on the last day.  Granted, the "Olympics" were limited to five participants who collectively agreed to not tell the most athletic guys of the bunch about the event ahead of time - but that doesn't mean that the boys didn't bring their A games!  The Silver (5-lb) went to CP pitching coach Matt Blake, and the Bronze (2.5-lb) went to free agent Alex Szymanski.  Shawn Haviland (A's) finished fourth, but he has a Harvard degree, and probably would have won if Sabermetrics trivia and word searches had been part of the contest.  Here's the much-anticipated medal ceremony:

I am not sure where the championship belt fit in, but the entire day didn't make much sense, so it seemed right.  Congratulations, Tim.

From these videos, a lot of people might think that we're all about goofing around - but that couldn't be further from the truth.  Our guys have a good time, for sure, but it always comes after they've busted their butts in the gym.  And, frankly, if we didn't have such great camaraderie and the guys weren't such good friends, the motivation to train would never approach the level it has.  A good culture and outstanding results absolutely, positively go hand-in-hand.

Most of my writing on this blog is obviously geared toward educating folks on the training, research, nutrition, and other geeky science stuff.  However, I should make it absolutely clear that all the knowledge in the world in these regards won't matter if you don't have a good culture established for your athletes and clients.  They need to enjoy training and look forward to each and every session because they enjoy the process as much as the destination.

They need to be willing to come to you to critique the best man's toast they've written (happened this winter).  They need to feel comfortable staying at your place if they're in town for a few days (happened multiple times this winter).  They need to feel welcome spending Thanksgiving with your family (two of my athletes came home with me this past November).  And, they need to respect you enough as a person to value your opinion as a professional.  As the saying goes, they don't care how much you know until they know how much you care.

That's why most of our pro guys train six days a week from September/October all the way up until now, whereas many other places pro guys frequent consist of 3x/week "workouts" for the 4-6 weeks before spring training starts.  And, I feel like it is one of many things that differentiates us from our competition (whatever that may be).  We are about making athletes better, not just "working them out."

I'm proud of all our guys not only for their hard work this off-season, but for taking an ownership stake in Cressey Performance to make it something special now and in the future.

Thanks for an awesome 5+ months, guys.  We can't wait to do it again.

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Should Pitchers Overhead Press?

The following video excerpt is from my November seminar with Mike Reinold.  It is available in its entirety on our DVD series, Optimal Shoulder Performance: From Rehabilitation to High Performance. I just thought you might like a teaser!

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Should Pitchers Bench Press?

Q: One of my favorite (insert generic sarcastic look here) things to watch in the weightroom is my pitchers getting under the rack for bench presses.  It's not the fact that they're benching that upsets me, but the "Beach Body" mindset that is behind it.  What's the most efficient way for a pitcher to work on his bench, and more importantly, what should he be trying to gain by performing the bench press correctly?

A: Okay, let's get right to opening this can of worms.

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With any exercise, we look for carryover to the functional demands of our sport.  However, we accept that general strength gains transfer in most cases.  As an example, we know that we can improve throwing velocity with a variety of training initiatives, but training specificity like this is stupid:

Now that we've all gotten a bit dumber, let's continue...

As it relates to pitching, the fundamental problem with the conventional barbell bench press (as performed correctly, which it normally isn't) is that it doesn't really train scapular movement effectively.  When we do push-up variations, the scapulae are free to glide - just as they do when we pitch.  When we bench, though, we cue athletes to lock the shoulder blades down and back to create a great foundation from which to press.  It's considerably different, as we essentially take away most (if not all) of scapular protraction.

Additionally, the closed-chain nature of push-ups is much more shoulder friendly, even if pitching is an open-chain exercise.  In fact, most rehabilitation progressions - regardless of the shoulder issue in question - will begin with push-up variations before any open-chain pressing exercises.

With dumbbell benching, we recognize that we get better range-of-motion, freer movement of the humerus (instead of being locked into internal rotation), and increased core activation - particularly if we're doing alternating DB presses or 1-arm db presses.  There is even a bit more scapular movement in these variations (even if we don't actually coach it).

With a barbell bench press, you don't really get any of these benefits - and it's somewhat inferior from a range-of-motion standpoint.  While it may allow you to jack up the weight and potentially put on muscle mass a bit more easily, the truth is that muscle mass here - particularly if it leads to restrictions in shoulder and scapular movement - won't carry over to throwing the way the muscle mass in the lower half and upper back will.  I've seen a ton of guys with loads of external rotation and horizontal abduction range-of-motion throw the crap out of the baseball, but can't say that I've ever seen any correlation - in the research or my anecdotal experience - between a good bench press and throwing velocity.

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That said, I recognize that there are still a lot of "wannabe meatheads" in the pitching world, so we do our best to meet our athletes halfway and please the bench press gods. Most of the time, dumbbell bench pressing and push-up variations will be sufficient, but we will sometimes us the multipurpose bar with our pitchers because it puts them in a more shoulder-friendly neutral grip.

Add some chains to the bar, and you have a great stabilization challenge that works the true function of the rotator cuff.

That said, if you absolutely feel like you need to do traditional benching, keep the volume down, keep the elbows tucked, and keep the shoulder blades stable underneath you.  And, be sure to recognize that your ego probably isn't doing much for your success on the mound - as there are training initiatives with better returns on investment.  Remember that pitchers have loads of competing demands - from throwing, to mobility training, to soft tissue work, to fielding practice, to movement training - so what you do in the weight room has to highly effective to justify its inclusion.  I just struggle to consider bench pressing "highly effective" for pitchers.

 

For more information on managing throwing shoulders, be sure to check out the Optimal Shoulder Performance DVD set.

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From the Little Leagues to the Big Leagues? Nope.

Today marks another great blog Q&A from Matt Blake. Q: I was quite shocked to learn that only three pitchers have ever made it to the Big Leagues from the Little League World Series (LLWS). It makes perfect sense, as the mature kid at 12 generates more velocity than little Billy. Most parents assume that since he is more mature he can handle more stress when in actuality it just means his muscles are stretched out farther and are more susceptible to injury. More specifically, Tom House claimed that the stretched out muscles could be counteracted by dropping your center of gravity. Any input would be great! A: I think this speaks to a lot of problems with how the players got to Williamsport and the developmental path that carries into their teenage years. The main concerns with the 11-12 year olds that are competing in the LLWS is how skilled they are for such a young age. Typically, this means that they have had a tremendous amount of repetition at a young age, and have competed in a very large number of games over the course of the spring and summer to make it to Williamsport.

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Three issues that might speak to why only three pitchers have gone on to play professional ball include: Issue #1 - These players are not skeletally mature to handle the amount of stress placed on their bodies, so they will probably turn up with more overuse injuries in their teen years that have been accumulating due to the high demand from 9-12. Issue #2 - This could be a simple timing of maturation. A lot of the dominant players are taller, weigh more, throw harder and have probably entered certain stages of maturation quicker than their peers. This doesn't necessarily mean they'll be ahead of their peers at 13-15 or even 16-18; it just means that at the age (11-12) we happen to televise, they were more developed. There are at least six more years before this player can even think about playing professionally, so a lot of things can happen to level out the playing field. Issue #3 - There's a good chance the amount of repetition that these players have put in at an early age could lead to "burnout" down the road or a feeling of satisfaction and less of a demand to work hard, because everything came to the player so easily at a young age. This game will eat you up if you don't continue to get quality repetition over the long haul.

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At some point, an abundance of talent will be matched, whether it's in high school, college, or the minor leagues. This is where the intangible qualities separate players and hard work is required to keep your competitive edge. Needless to say, I'm still shocked that only three pitchers have made it from the LLWS. For me, this signifies a serious red flag in the way we are developing talent in the baseball industry if our best players at age 12 don't translate well to the upper levels. Have a question for Matt?  Drop him an email at mablak07@gmail.com. Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!
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