In case you missed them, check out Part 1 (Functional Anatomy) and Part 2 (Pathology) of this series from last week. With that housekeeping out of the way, let's move forward to today's focus: elbow injuries in throwing athletes. I work with a ton of baseball players and I know we have a lot of not only players, but parents of up-and-coming baseball stars that read this blog - so it's a topic that is near and dear to my heart. While my primary focus within the paragraphs that follow will be baseball, keep in mind that the many these issues can also be seen in other overhead athletes. They just tend to be more prevalent and magnified in a baseball population.
Obviously, in dealing with loads of baseball guys, I see a lot of elbow issues come through my door. The overwhelming majority of those folks are medial elbow pain, but we also see a fair amount of lateral elbow pain. What's interesting, though, is that in a baseball population, most of these issues are purely mechanical pain; that is, the discomfort is usually only present with throwing, as it is tough to reproduce the velocities and joint positions present during overhead (or sidearm/submarine) throwing.
The question, logically, is why do some throwers break down medially while others break down laterally, or even posteriorly?
In other to understand why, we first have to appreciate the demands of throwing. And, that appreciation pretty much always leads back to the valgus and extension forces (termed valgus-extension overload by many) that combine to wreak havoc on an elbow during throwing.
At late cocking - where maximal external rotation (or "lay-back") occurs - there is a tremendous valgus force of 64Nm on the elbow, according to Fleisig et al.
As Morrey et al. determined, the ulnar collateral ligament (UCL) "takes on" approximately 54% of this valgus force - meaning that it's assuming about 35Nm of force on each pitch. This is all well and good - until you realize that in cadaveric models, the UCL fails at 32Nm.
If the valgus forces are so crazy that they actually exceed the UCL's tolerance for loading, why don't we just rip that sucker to shreds on every pitch?
It's because the UCL doesn't work alone. Rather, we've got soft tissue structures (namely, the flexor carpi ulnaris and radialis) that can protect it. This is why cadavers don't usually pitch in the big leagues. The closest thing I've seen is 84-pound Willie McGee, but he was an outfielder.
Keep in mind that it isn't just the UCL that's stressed in this lay-back position. Obviously, the flexor-pronator mass takes a ton of abuse in transitioning from cocking to acceleration. It's also a tremendously vulnerable position for the ulnar nerve as it tracks through some tricky territory. That just speaks to the medial side of things; there is more to consider laterally.
You see, the same valgus force that can wreak havoc medially also applies approximately 500N on the radioulnar joint during the late cocking phase of throwing; that's about one-third of the total stress on the elbow. In this case, a picture is worth a thousand words:
So, the same forces can cause a thrower to break down in multiple areas both medially and laterally! What usually separate the medial from the lateral folks?
Let me ask you this: when was the last time you saw an 8-year old rupture his ACL? Never.
Now, when was the last time you saw an 8-year-old break a bone? Happens all the time.
This same line of reasoning can be applied to the pitching elbow. The path of least resistance - or the area of incomplete development - will generally break down first. As such, in a younger population, we generally see more lateral, compression-type injuries to the bones. These are your growth plate issues and Little League Elbows, usually.
As athletes mature and the bones become sturdier, we get more muscle/tendon, ligament, and nerve issues on the medial side.
This isn't always the case, of course; you'll see young kids with medial elbow pain, and experienced throwers with lateral issues as well. It generally holds pretty true, though.
The issues at the cocking-to-acceleration transition would be bad enough by themselves, but there is actually another important injury mechanism to consider: elbow extension.
This lateral area also takes on about 800N of force at the moment arm deceleration begins with elbow extended out in front as posteromedial impingement occurs between the ulna and the olecranon fossa of the humerus. This bone-on-bone contact at high velocities (greater than 2,000 degrees/second) can lead to fractures and loose bodies within the joint.
This wraps up the causative factors with respect to elbow pain in throwers - but I need to now go into further detail on the specific physical preparation and mechanical factors one needs to consider to avoid allowing these issues to come to fruition. Stay tuned for Part 4.
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1. It's been a while since I published a Random Friday Thoughts blog, but in reality, it's by design. You see, if I just publish every Friday, it isn't very "random," is it?
2. Pretty cool stuff: Cressey Performance and Lawrence Academy athlete Tyler Beede was featured on the cover of ESPN Rise magazine this month. Tyler's headed to Vanderbilt on a baseball scholarship.
3. After seven years, I'm switching from Sprint to Verizon for my cell phone. I feel liberated...like an old man busting a move. That's a random - but awesome - way to kickstart your weekend!
4. At the other end of the spectrum, you have THIS GUY, who was awarded (in a court of law) the title of "Worst Tennis Professional on the Planet." I wonder if he gets a trophy for his mantle for that one....
5. Here's a book recommendation for you that's somewhat related to fitness: The 7 Rules of Achievement. It's written by Tom Terwilliger, a former Mr. America. I met Tom at a seminar back in January, and his enthusiasm is absolutely contagious. He's got a pretty cool story himself, but the real gold in this book is how he breaks things down step-by-step in helping people get to where they want to be in their professional and personal lives. It's self-help stuff, but more entertaining and less preachy than anything else I've read in this regard.
6. In addition to my own article at T-Muscle last week (Favorite Supersets), I also contributed on a compilation by Nate Green, Your Training Split Sucks. Check 'em out, if you haven't already.
8. In the past two weeks, I've had four people email me asking about a mentorship at Cressey Performance. If we were to do a 3-4 day mentorship consisting of lectures, hands-on teaching, and observing athletes in action, would you be interested? If so, shoot us an email at cresseyperformance@gmail.com. It would occur sometime between October and March. Nothing firm, but I thought I'd throw it out there to gauge interest.
9. I'm looking for some good recommendations for books on CD. I just finished up my last one, and always like to have a good one in my car for whenever I'm driving. The last three good ones have been What the Dog Saw, Switch, and Born to Run. I prefer non-fiction. Thanks in advance to anyone who has some suggestions to make in the comments section!
10. Finally, a big happy birthday goes out to CP pitching expert Matt Blake, who - as you can tell from the following video - turns 11 today.
Seriously? This is all the retroversion an Olympic gymnast has? See what happens when you specialize in one sports early? You get a gold medal, but get laughed at by all 27 people in attendance at a minor league baseball game.
PS - Think this cameraman was drunk, or just laughing so hard that he couldn't keep the camera steady?
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.
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”).
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.
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.
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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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.
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."
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.
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.
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).
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.
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.
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/tendonsB. 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.
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:
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.
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.
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.
Also, don't forget that today is the last day to get the $20 early-bird discount on The Single-Leg Solution. Don't miss out; the introductory price ends tonight at midnight.
About a year ago, Mike Robertson came out with an outstanding product, The Single-Leg Solution - and it reminded me of an experience I once had at a seminar. A guy posed the following question to a panel of speakers in which I was included:
"If you could only choose one exercise to do, what would it be?"
We all agreed that it was a pretty stupid and unrealistic question, but reluctantly, we each answered. In spite of my distaste for the question, I responded without hesitation: "Lunges - or any single-leg exercise, for that matter."
In my eyes, single-leg work really is that valuable - and for a lot of reasons.
(Gold star to none other than me for thinking of up the title for him. Booyeah.)
So why is single-leg work the best thing since sliced bread?
First, there is obviously going to be some direct carryover to the functional demands of life and athletics, as we spend most of our life on one foot in one capacity or another. Muscular recruitment patterns are different for bilateral and unilateral exercises, so in terms of specificity, single-leg work really can't be beat.
Second, it's much more lower-back friendly, as you can load single-leg exercises appreciably without axial loading. And, to take it a step further, it is easier to maintain neutral spine (and avoid lumbar flexion with compressive loading) with a split-stance - regardless of whether you axially load or hold the weights in the hands at one's sides. Simply stated, while single-leg exercises will never (at least in my eyes) take the place of squatting and deadlifting, they are absolutely essential supplemental exercises for one's training repertoire.
Third, in the case of back pain (or hip pain, with femoroacetebular impingement being an example), they're hugely helpful in allowing one to maintain a training effect in spite of whatever pain is present.
Fourth, single-leg exercises are hard. Let's face it: most people exercise like pansies and pick the exercises they like the most, not the ones that they need the most - or the ones that are the hardest. This is 225 pounds for eight pretty effortless reps, which makes girls want him and guys want to be him (or something like that).
Fifth, Robertson insists they are good, and this guy knows as much about knees as anyone I've ever met. If you want to keep your wheels strong and healthy for the long-term, including them is a no-brainer.
This is just five reasons to include single-leg work in your programming, and frankly, Mike includes a heck of a lot more in the 96-page tag-along manual that accompanies the 60-minute DVD in The Single-Leg Solution Package.
Knowing that single-leg work is important isn't enough, though, as I see exercise enthusiasts and fitness professionals alike absolutely butchering the technique on these exercises. And, they have absolutely no rhyme or reason for the "who, what, when, where, why" they include them; it is just throwing a wad of turd on the wall to see what sticks. Optimal progress is dependent on population-specific exercise selection, pristine technical execution, and pinpoint exercise progressions - and this is where Mike really shines with this product.
So, whether you're a personal trainer, bodybuilder, powerlifter, runner with knee pain, desk jockey with a bad back, or just some random dude who wants to get stronger, move better, and be just a little more awesome, I'd highly encourage you to check out The Single-Leg Solution..
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I have written a bit in this blog about elbow pain - both in throwers and lifters - but will be devoting some very specific, detailed articles to it in the near future. In the meantime, however, here is an interesting population-specific fact. Many baseball players wind up with elbow issues secondary to shoulder range of motion deficits. Most lifters run into trouble because of excessive gripping and terrible tissue quality in the region. Apparently, though, certain NBA players run into elbow issues because of KARMA.
Huh? Well, apparently if you treat ballboys like crap, it comes back to haunt you sooner than later.
I've come to realize that over the past ten years, I've gotten a little spoiled. Of course, there are a variety of reasons: TMUSCLE readers are some of the more educated weight-training consumers on the 'Net; I've been around Division 1 athletes who have four years of strength and conditioning continuity in their lives; I've lifted alongside world-class powerlifters; I have a host of athletes who are completely "indoctrinated" with my training philosophies, as it's the only thing they've ever known.
Yeah, I guess you could say that I've become a bit of a lifting snob; I'm always surrounded by people who know how to interpret my programs, leaving me to just program, coach technique, help select weights, and turn up the volume on the stereo.
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