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Recently, I received an email inquiry about the value of strength training for pitchers. The individual emailing me had come across the following quote from a pitching "authority:"

"Training will not teach you how to apply more force...only mechanics can do that. And pitching is not about applying more effort into a pitch but is about producing more skilled movements from better timing of all the parts. That will help produce more force.

"No matter how hard you try, you will not get that from your strength training program...no matter who designed it, how much they have promised you it would or your hope that it will be the secret for you."

To say that this surprised me would be an understatement. I'll start with the positive: I agree with him that pitching is all about producing skilled movements secondary to appropriate timing of all the involved "parts." I've very lucky to work hand-in-hand with some skilled pitching coaches who really know their stuff - and trust in me to do my job to complement the coaching they provide.

With that said, however, I disagree that you can't gain (or lose) velocity based exclusively on your strength and conditioning program. On countless occasions, I've seen guys gain velocity without making any changes to their throwing programs or mechanics. I know what many of the devil's advocates in the crowd are thinking: "you're just making that up!" So, if my word isn't enough, how about we just go to the research?

From: Derenne C, Ho KW, Murphy JC. Effects of general, special, and specific resistance training on throwing velocity in baseball: a brief review. J Strength Cond Res. 2001 Feb;15(1):148-56.

[Note from EC: Yes, it's pathetic that this REVIEW has been out almost seven years and people who are supposedly "in the know" still haven't come across ANY of the studies to which it alludes.]

Practical Applications

Throwing velocity can be increased by resistance training. A rationale for general, special, and specific resistance training to increase throwing velocity has been presented. The following findings and recommendations relevant to strength and conditioning specialists and pitching coaches can be useful from the review of literature.

In the "further reading" section at the end of this article, I have listed ten different studies that each demonstrated a positive effect of weight training on throwing velocity. The authors in the review above also have a table that summarizes 26 studies that examined the effect of different strength protocols on throwing velocity, and 22 of the 26 showed increases over controls who just threw. In other words, throwing and strength training is better than throwing alone for improving velocity -

independent of optimization of mechanics from outside coaching.

The saddest part is that the training programs referenced in this review were nothing short of foo-foo garbage. We're talking 3x10-12 light dumbbell drills and mind-numbing, rubber tubing blasphemy. If archaic stuff works, just imagine what happens when pitchers actually train the right way - and have pitching coaches to help them out?

Oh yeah, 10 mph gains in six months happen - and D1 college coaches and pro scouts start salivating over kids who are barely old enough to drive.

With that rant aside, I'd like to embark on another one: what about the indirect gains associated with strength training? Namely, what about the fact that it keeps guys healthy?

We know that:

a) Pitchers (compared to position players) have less scapular upward rotation at 60 and 90 degrees of abduction -and upward rotation is extremely important for safe overhead activity.

b) 86% of major league pitchers have supraspinatus partial thickness tears.

c) All pitchers have some degree of labral fraying - and the labrum provides approximately 50% of the stability in the glenohumeral joint

d) There is considerable research to suggest that congenital shoulder instability is one of the traits that makes some pitchers better than others (allows for more external rotation during the cocking phase to generate velocity).

e) Most pitchers lack internal rotation range-of-motion due to posterior rotator cuff (and possibly capsular) tightness and morphological changes to bone (retroversion). Subscapularis strength is incredibly important to prevent anterior shoulder instability in this scenario.

We also know that resistance training is the basis for modern physical therapy - which I'm pretty sure is aimed at restoring inappropriate movement patterns which can cause these structural/functional defects/abnormalities from reaching threshold and becoming symptomatic. Do you think that a good resistance training program could strengthen lower traps and serratus anterior to help alleviate this upward rotation problem? Could a solid subscapularis strengthening protocol help with preventing anterior instability? Could a strong rotator cuff and scapular stabilizers allow an individual to work around a torn supraspinatus?

And, last time I checked, strength and conditioning was about more than just being the "weights coach." We do a lot of flexibility/mobility and soft tissue work - and it just so happens that such work does wonders on pec minor, levator scapulae, rhomboids, infraspinatus/teres minor, and a host of other muscles in pitchers.

I also like to tell jokes, do magic tricks, and make shadow puppets on the wall. Am I to assume that these don't play a remarkable role in my athletes' success? I beg to differ. Sure, banging out a set of 20 chin-ups because one of my athletes called me out might make me look like a stupid monkey when my elbows refuse to extend for the subsequent ten minutes, but I still think what we do plays a very important role in our athletes success; otherwise, they wouldn't keep coming back. And, for the record, my shadow puppets are great for building camaraderie and bolstering spirits among the Cressey Performance troops - even if I'm just a "weights coach" or whatever.

This only encompasses a few of the seemingly countless examples I can come up with at a moment's notice. Pitchers are an at-risk population; your number one job in working with a pitcher is to keep him healthy. And, I'm going to go out on a limb and say that a guy who is healthy and super-confident over his monster legs and butt is going to throw a lot harder than a guy who is in pain and as skinny as an Olsen twin because his stubborn pitching coach said strength training doesn't work. You've got to train ass to throw gas!

Last fall, I started working with a pro ball player whose velocity was down from 94 to 88 thanks to a long season - but also because he'd had lower back issues that have prevented him from training. In other words, he counts on strength training to keep his velocity up. And, sure enough, it was a big component of getting him healthy prior to this season.

Putting it into Practice

I suspect that some of the reluctance to recognize strength training as important to pitchers is the notion that it will make pitchers too bulky and ruin pitching-specific flexibility. Likewise, there are a lot of meatheads out there who think that baseball guys can train just like other athletes. While there are a lot of similarities, it's really important to make some specific upper body modifications for the overhead throwing athlete. Contraindicated exercises in our baseball programs include:

• Overhead lifting (not chin-ups, though)
• Straight-bar benching
• Upright rows
• Front/Side raises (especially empty can - why anyone would do a provocative test as a training measure is beyond me)
• Olympic lifts aside from high pulls
• Back squats

The next question, obviously, is "what do you do instead?" Here's a small list:

• Push-up variations: chain, band-resisted, blast strap
• Multi-purpose bar benching (neutral grip benching bar)
• DB bench pressing variations
• Every row and chin-up you can imagine (excluding upright rows)
• Loads of thick handle/grip training
• Medicine ball throws
• Specialty squat bars: giant cambered bar, safety squat bar
• Front Squats
• Deadlift variations

The Take-Home Message

There is nothing fundamentally wrong with strength training program for pitchers. In reality, what is wrong is the assumption that all strength training programs are useless because some are poorly designed and not suited to athletes' needs and limitations. Be leery of people who say strength training isn't important. Everyone - from endurance athletes, to grandmothers, to pitchers - needs it!

Further Reading

1. Bagonzi, J.A. The effects of graded weighted baseballs, free weight training, and simulative isometric exercise on the velocity of a thrown baseball. Master's thesis, Indiana University. 1978.

2. Brose, D.E., and D.L. Hanson. Effects of overload training on velocity and accuracy of throwing. Res. Q. 38:528-533. 1967.

3. Jackson, J.B. The effects of weight training on the velocity of a thrown baseball. Master's thesis, Central Michigan University,. 1994.

4. Lachowetz, T., J. Evon, and J. Pastiglione. The effects of an upper-body strength program on intercollegiate baseball throwing velocity. J. Strength Cond. Res. 12:116-119. 1998.

5. Logan, G.A., W.C. McKinney, and W. Rowe. Effect of resistance through a throwing range of motion on the velocity of a baseball. Percept. Motor Skills. 25:55-58. 1966.

6. Newton, R.U., and K.P. McEvoy. Baseball throwing velocity: A comparison of medicine ball training and weight training. J. Strength Cond. Res. 8:198-203. 1994.

7. Potteiger, J.A., H.N. Williford, D.L. Blessing, and J. Smidt. Effect of two training methods on improving baseball performance variables. J. Appl. Sport Sci. Res. 6:2-6. 1992.

8. Sullivan, J.W. The effects of three experimental training factors upon baseball throwing velocity and selected strength measures. Doctoral dissertation, Indiana University,. 1970.

9. Swangard, T.M. The effect of isotonic weight training programs on the development of bat swinging, throwing, and running ability of college baseball players. Master's thesis, University of Oregon,. 1965.

10. Thompson, C.W., and E.T. Martin. Weight training and baseball throwing speed. J. Assoc. Phys. Mental Rehabil. 19:194-196. 1965.

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A New Model for Training Between Starts: Part 2

By: Eric Cressey

For more information, check out Maximum Strength.

As I mentioned last week, this past weekend was Ron Wolforth's Ultimate Pitching Coaches Bootcamp just outside of Houston, TX.  To say that it was an awesome experience would be an understatement.  I considered myself really lucky to be presenting alongside the likes of Brent Strom (St. Louis Cardinals), Phil Donley (Philadelphia Phillies consultant who has rehabbed loads of million-dollar arms), Perry Husband (Downright Filthy Pitching), and Ron himself.  These guys are not only getting important information out there for coaches, but also getting their hands dirty in the trenches to take athletes and coaches to the next level with new information.

I also tried to get folks to think about what they already are doing with respect to distance running, "core" training, upper and lower body lifting, assessments, warm-ups (check out the Monster Mobility Pack for ideas), and post-throwing flexibility work.  I discussed the difference between inefficiency and pathology and how your can have a terrible-looking MRI and/or x-ray and still be pain free.

In Part I, I went into some detail on why I really didn’t like the catch-all term “shoulder impingement.” This week, I’m going to talk about the different kinds of shoulder impingement: external and internal.

External impingement, also known as outlet impingement, is the one we hear about the most. Here, we’re dealing with compression of the rotator cuff – usually the supraspinatus, and over time, the infraspinatus (and biceps tendon) – by the undersurface of the acromion. This impingement can lead to bursal-sided rotator cuff tears - and happens a lot more with ordinary weekend warriors and very common in lifters (not to mention much more prevalent in older populations.

External impingement can be further subdivided into primary and secondary classifications. In primary impingement, the cause is related to the acromion – either due to bone spurring or congenital shape. As you can see in the photo below, hook (II) and beak (III) are worst than flat (I), as there are marked difference in “clearance” under the acromion.

Secondary impingement, on the other hand, is usually related to poor scapular stability (related to both tightness and weakness, as described in last week’s newsletter), which alters the position of the scapula. In both cases, pain is at the front and/or side of the shoulder and is irritated with overhead activity, scapular protraction, and several other activities (depending on the severity of the tissue problems). You’ll also generally see a lack of external rotation range-of-motion, as these are folks who do too much bench pressing and computer work (both of which shorten the internal rotators).

Conversely, internal impingement, also known as posterosuperior impingement, really wasn’t proposed until the early 1990s. This form of impingement is more common in younger individuals who are involved in overhead sports, making it more of an “athletic impingement.” Adaptive shortening and scarring of the posterior rotator cuff in these athletes causes a loss of internal rotation and an upward translation of the humeral head during the late cocking phase of throwing (or swimming): external rotation and abduction.  These issues are magnified by poor scapular control, insufficient thoracic rotation, and weakness of the rotator cuff.

When the humeral head translates superiorly excessively in this position, it impinges on the posterior labrum and glenoid (socket), irritating the rotator cuff and biceps tendon along the way. So, pain usually starts in the back of the shoulder, as you are seeing irritation of the posterior fibers of the supraspinatus and anterior fibers of the infraspinatus tendons. Gradually, this pain may “shift” toward the front as the biceps tendon, and that implies labral involvement.  At least initially, the pain is purely mechanical in nature; it won't bother an athlete unless the "apprehension" position (full external rotation at 90 degrees of abduction) is created.

We often hear about SLAP lesions in the news. This refers to a superior labrum, anterior-posterior injury. In reality, when we are talking about labral injuries in overhead athletes as they relate to internal impingement, it’s mostly just posterior (although serious cases can eventually affect the anterior labrum, too). There are different kinds of SLAP lesions (1-4). Every baseball pitcher you’ll meet has a SLAP 1, which is just fraying. SLAP 2 lesions are far more serious and often require surgical intervention. SLAP 1 issues become SLAP 2 lesions when poor mobility and dynamic stability aren't established.

So, just to bring you up to speed, we’ve got two different kinds of impingement, one of which (external) has two subcategories that mandate different treatment strategies (primary = surgery, secondary = corrective exercise). We also have two separate areas where pain presents (external = front/side, internal = back). That’s just the tip of the iceberg, though, as we have two more considerations…

First, symptomatic internal impingement tends to be "mechanical pain." Unless you’re dealing with a more advanced case, athletes with symptomatic internal impingement only have pain when they get into the late cocking phase (and sometimes follow-through). It usually isn’t present when they’re just sitting around – and for this reason, they can usually be more aggressive in the weight room with upper body training. Keep in mind that I use the term “symptomatic” because I think that internal impingement is a physiological norm, just like I observed last week with external impingement.  You're essentially just going to go out of your way to avoid this "apprehension" position in the weight room by omitting exercises like back squats.  An apprehension test - illustrated in the most enthusiastic video in internet history - is a quick and easy assessment many doctors and rehabilitation specialists use to check for symptomatic internal impingement, as it reproduces the injury mechanism.

Second, and perhaps more importantly, you are dealing with two rotator cuff tears that are fundamentally different. It’s these differences that make me think doctors need to get rid of the term “impingement.” Here’s the scoop:

Let’s say that we have two guys with partial thickness tears of the supraspinatus – one from external impingement and one from internal impingement.

With external impingement, we’re usually dealing with a bursal-sided tear, as the rubbing comes from the top (acromion). These issues will generally heal more quickly because the bursa actually has a decent blood supply.

With internal impingement, on the other hand, we’ve got an articular-sided tear, meaning that the wear on the tendon comes from underneath (glenoid). The tear is more interstitial in nature. Blood supply isn’t quite as good in this area, so healing is slower (or non-existent).

Traditionally, articular has been an athletic injury, and bursal has been a general population issue. This is not always the case, though.

Factor in the activity demands of overhead throwers, and they have more challenging tears and greater functional demands. Fortunately, they also typically have age and tissue quality on their sides, so things tend to even out.

With all these factors in mind, if a doctor ever tells you that you have "shoulder impingement," ask:

1. Internal or external?

2. If external, is it primary or secondary? (It’ll probably be both)

3. If internal, is there labral involvement? Biceps tendon?

4. If internal, what is the internal rotation deficit? (They should measure it, as this will begin to dictate the rehabilitation plan)

5. Given my age, activity level, and the nature of the tear, do you feel that surgical or conservative treatment is best?

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This past weekend, I attended a great seminar here in Boston with Dr. William Brady.  In fact, it was among the best I've seen.  I was the only non-chiropractor/manual therapist in attendance, but walked away from the seminar with some tremendously valuable insights that'll help me with each and every one of my clients moving forward.

The first lesson of the day is that those of you who have an opportunity to see Dr. Brady speak should absolutely, positively check him out: Integrated Diagnosis.  Diagnostically, he's among the best I've ever seen - and that includes his ability to teach others.

The second lesson of the day revolves around an important concept Dr. Brady extended - and my take on how you can modify this message to accommodate your role as a coach, trainer, or fitness enthusiast/athlete.  There is a reason that almost any doctor or physical therapist gets results - and it resolves around understanding where symptom threshold occurs.  To illustrate this, let's examine a shoulder problem purely from a soft tissue perspective.

Dr. Brady talked about how you have building blocks to threshold.  Let's say that after an accurate physical examination, this particular shoulder problem (supraspinatus tendinosis, for example) presents with soft tissue restrictions at the infraspinatus, teres minor, subscapularis, inferior capsule, and pec minor.  So, symptom threshold (the dotted line) might look like this relative to baseline (straight line):

Pec Minor - - - - - - - - - - - Inferior Capsule Subscapularis Teres Minor Infraspinatus BASELINE - NO SYMPTOMS

So, imagine a therapist who just addresses pec minor.  He gets that patient below threshold, but doesn't necessarily "fix" him; he might be back in with the same problem weeks later.  This is confounded by the fact that "overuse" is actually one of the building blocks, too.  So, even if you leave all the soft tissue restrictions alone, simply resting will get someone below threshold - even if the therapist has done ZERO to address the underlying problems.

This is one reason why a MRI might not tell you much at all about someone's problem.  With this problem, the MRI would probably just say "supraspinatus tendinopathy" and recommend physical therapy and rest from painful activities.  So, in the "full picture" - where soft tissue work is one of several components (assume they are equal contributors, for the sake of our argument) - the building blocks to threshold might look something like this:

Overuse Rotator Cuff Weakness Scapular Stability Poor Glenohumeral (Ball-and-Socket) Range of Motion - - - - - - - - - - - - - - - - Soft Tissue Restrictions Poor Thoracic Spine Mobility Type 3 Acromion (non-modifiable, without surgery) Poor Exercise Technique Poor Cervical Spine Function Opposite Hip/Ankle Restrictions (baseball pitchers are great examples) Inappropriate Structural Balance in Programming (e.g., pressing more than pulling) Faulty Breathing Patterns BASELINE - NO SYMPTOMS

So, what do we do in an ideal scenario (not always possible with today's insurance plans)?

1. More time with patient education (exercise technique, programming strategies - or just outsource it to a qualified professional or good book/article or DVD). 2. Address Thoracic Mobility (Assess and Correct is a great resource for this)

3. When present, address Hip and Ankle Mobility 4. Retrain some breathing patterns with initial instructions home exercises 5. Provide some take-home neck drills and get people out of chronic forward head posture

All told, I think this could be as simple as 4-5 extra drills in each shoulder rehab program plus a brief sit-down conversation with each patient on exercise program modifications; it really is that simple.  Unfortunately, it rarely happens - and that's when things become chronic.

So, fitness professionals and coaches need to step up as advocates for their clients and athletes, respectively, and fitness enthusiasts need to be relatively informed "consumers" to look out for themselves.

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The Mainstream Media Lag Why Wait to Repair an ACL? (Abbreviated) Random Friday Thoughts

Shoulder Impingement….Yes, We Get It.

Roughly 10-15 times per week, I get emails from folks who claim that they have "shoulder impingement.” Honestly, I roll my eyes the second I read these emails.

Don’t get me wrong: I’m not making light of their pain. It’s just that it drives me crazy when doctors throw this blanket statement out there. I will be completely and 100% clear with the following statement:

Shoulder impingement is a physiological norm. Everyone – regardless of age, activity level, sport of choice, acromion type, gender, you name it – has it.

Don’t reach up to touch that mouse on your computer; you’ll aggravate your impingement and your supraspinatus will explode!

And, don’t scratch that itch on the back of your neck; your impingement will go crazy and your labrum will disintegrate!

Don’t believe me? Check out research from Flatow et al. from 1994.

Yes, this has been out since 1994.

So, the next logical question is: why do some people have pain with impingement while others don’t?

In reality, there are several factors that dictate whether or not someone is in pain, including:

1. Tissue quality – the most “impinged” structures are more likely to break down in older age than they are in earlier years.  Younger individuals can regenerate faster even when overall stress on the tissues is held constant, so how you handle a 50-year-old with "impingement" is going to be somewhat different from how you handle a 15-year-old with "impingement."

2. Degree of elevation – the more one abducts or flexes the humerus, the greater the degree of impingement. This is why folks need to start in a more adducted (arm at side) position early on in rehab.  Those that impinge early in their arc tend to be dealing with subacromial impingement, whereas those who hit it at the absolute top tend to be more AC joint impingement.

3. Acromion type – flat acromions have significantly less contact area with the rotator cuff tendons than hooked or beaked acromions. These structures may change over time due to…

4. Bone Spurs – bone spurs on the underside of the acromion will increase the amount of impingement.

5. Strength of the rotator cuff – the stronger the cuff, the better its ability to depress the humeral head and minimize this impingement

6. Scapular stability – the more stable the scapula, the more likely it is to posteriorly tilt and upwardly rotate effectively when the humerus is raised into the zones of greater impingement. This scapular stability includes adequate length of the downward rotators (pec minor, levator scapulae, and rhomboids) with adequate strength of the upward rotators (lower traps, serratus anterior, upper traps).

7. Thoracic spine mobility – the posture of the thoracic spine dictates the position of the scapulae, which in turn affects impingement as noted in #6.  Assess and Correct is an awesome product for improving thoracic spine mobility - and you can also find some good drills in my recent post, Shoulder Hurts? Start Here.

8. Increased internal rotation – Certain movements that lock the humeral head in internal rotation increase the degree of impingement during dynamic activities. It’s why some people can’t bench press early-on in their rehabilitation programs, yet they can do dumbbell bench presses with a neutral grip pain-free. It’s also the reason why upright rows are a stupid exercise, in my opinion.

9. Breathing patterns – think about what happens when someone has poor diaphragmatic function and becomes a “chest breather:” the shoulders shrug up, and you get extra tightness in the levator scapulae, scalenes, pec minor, and sternocleidomastoid (among other supplemental respiratory muscles). In the process, the degree of impingement can increase.

10. Other issues further down the kinetic chain – I could go on and on about a variety of issues in this regard, but it’s impossible to be exhaustive – so I’ll just give an example. If someone has poor core stability in the sagittal plane that is manifested in an inability to resist the effects of gravity during a push-up, the hips will “sag” to the floor. As this happens, and the upper body remains strong, the scapulae are shifted into an anterior tilt –which increases the amount of impingement on the rotator cuff. So, weakness and/or immobility in other areas can certainly predispose an individual to shoulder problems.

This can also be carried forward to pitchers. We know that shoulder problems are more likely to occur in throwers who have poor lead leg hip internal rotation, as it causes the stride leg to open up early, leaving the arm “trailing behind” where it should be.

Speaking of pitchers, a phrase that has been coined with respect to the “unique” kind of impingement you see in them is “internal impingement.” In next week’s newsletter, I’ll discuss the different kinds of impingement – and why it’s still a cop-out diagnosis for any health care professional to just say you have one or the other rather than tell you explicitly what dysfunctions need to be addressed.

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