In Part 1 of this off-season baseball strength and conditioning series, I outlined the first five of my top 10 priorities when dealing with baseball players at the start of their off-season.  Today, I round out the top 10 “general” things always seem to be addressing with players coming in after a season.

1. Regaining lost mobility - This is an incredibly loaded topic that goes far beyond the scope of any blog or article, as it's an entire two-day seminar or book! You see, losses in mobility - the ability to reach a desired position or posture - can be caused by a number of issues - and usually a combination of several of them.  Tissues can actually lose sarcomeres and become short after immobilization or significant eccentric stress (as with the deceleration component of throwing).  They can become stiff because of inadequate stability at adjacent joints (learn more HERE), protective tension (e.g., "tight" hamstrings in someone with crazy anterior pelvic tilt), or neural tension from an injury (e.g., disc herniation causing "tight" hamstrings).

The "Short vs. Stiff" issue is why you need to have a variety of tools in your "mobility toolbox."  You need focal modalities like Active Release, Graston, and ASTYM techniques to assist with dealing with short tissues, whereas you need more diffuse modalities like traditional massage and foam rolling for dealing with stiffness (although both modalities can certainly help in the other regards, this is how I prefer to use them).

You need to understand retraining breathing appropriately and how posture affects respiratory function.  If you live in extension, you'll have a poor zone of apposition in which the diaphragm can function.  The average human takes over 20,000 breaths per day.  If you don't use your diaphragm properly, more of the stress is placed on the supplemental respiratory muscles: sternocleidomastoid, scalenes, pec major and minor, upper trapezius, and latissimus dorsi (to only name a few).  What are some insanely common sites of trigger points in just about everyone - especially thrower? Sternocleidomastoid, scalenes, pec major and minor, upper trapezius, and latissimus dorsi.  Improving respiratory function can be a complete game changer when it comes to enhancing mobility.  If you see a baseball player with a low right shoulder, prominent anterior left ribs, adducted right hip, huge anterior pelvic tilt, and limited right shoulder internal rotation, it's almost always a slam dunk.

(Check out www.PosturalRestoration.com for more details on this front)

You may need low-load, long-duration static stretches to improve length in tissues that have lost sarcomeres.  This research has been around in the post-surgery community for decades (1984 research example here), but it's actually not used all that much in strength and conditioning programs - presumably because of time constraints or the fact that most coaches simply don't know how well it can work in the right people.

Finally, as we noted in our Assess and Correct DVD set, you also need dynamic flexibility drills in your warm-ups to reduce tissue and joint stiffness, and subsequent strength exercises in your strength and conditioning program to create adequate stability at adjacent joints to "hold" that new range of motion in place.

Many physical therapist employ heat early in a session to decrease stiffness prior to strengthening exercises, too.  The point is that there may be many different ways to skin a cat - but there are also a lot different types and sizes of cat.  And, for the record, I don't condone skinning cats; it's just a really gruesome analogy that has somehow "stuck" in our normally very politically correct society. Weird...but let's move on.

2.Improving dynamic stabilization of the scapula - I say "dynamic stabilization" because you don't just want scapular stability; you want a scapula with appropriate tissue length, stiffness, and density to allow for the desired movement.  A scapula that doesn't move might be "stable," but that's not actually a good thing!

Truth be told, the scapular stabilizers generally fatigue before the rotator cuff does.  And, when the scapula isn't positioned appropriately, the rotator cuff is at a mechanical disadvantage, anyway.  Additionally, poor scapular control can present as an internal rotation deficit at the shoulder, as you'll just protract the shoulder excessively in place of internally rotating.  In other words, you can do all the rotator cuff exercises you want, but you don't increase strength of the periscapular muscles, you'll be spinning your wheels.  There are loads of drills that we use, but forearm wall slide variations are among our favorites:

3. Enhancing global strength while minimizing reactive training - As I've already noted in this series, we're certainly spending a lot of time addressing specific areas of weakness like the rotator cuff, scapular stabilizers, and anterior core. However, I should be very clear that we're still using "money" strength exercises like variations of the deadlift, single-leg exercises, squatting (in some of our guys), pull-ups, rows, push-ups, and dumbbell bench presses to get strong.  That said, the volume and intensity come down a ton on the reactive training side of things.  We'll give our guys a few weeks off altogether from sprinting, as they've usually done a lot of that all season.  Plus, nixing all the sprinting and jumping for a few weeks ensures that they won't tweak anything, given the soreness they'll be working with from the strength training program - and it allows us to increase strength faster.

4. Putting guys in the right footwear - One thing that many folks don't appreciate about playing baseball every day from February to October is the sheer amount of time one spends standing around in cleats, which will never be as comfortable as sneakers or going barefoot.  As such, one of the first things we do with most of our guys is get them into a good pair of minimalist shoes for training, as it gets them away from the rigidity, separation from the ground, and ankle mobility deficits that come with wearing cleats.  As I wrote previously, I'm a big fan of the New Balance Minimus.

Keep in mind that we ease guys into these minimalist shoe options, rather than throwing them in the footwear 24/7 right away.  They'll start out just wearing them during training, and increase from there, assuming all goes well.

5. Normalizing sleep schedules - Professional baseball players (and really all professional athletes) have terrible sleep schedules.  Because most games are night games, they generally go to bed around 1-2AM and wake up anywhere from 7AM to 11AM.  The early risers I know will usually take a nap before going to the park, whereas the guys who sleep in roll out of bed and go straight to the park.  Additionally, much of this sleeping comes on planes and buses, which aren't exactly comfortable places to get quality sleep.  I'm a firm believer that one hour of sleep before midnight is worth two hours after midnight - but this simply isn't an option for professional baseball players.

That said, we try to normalize things as much as possible in the off-season.  All our athletes are encouraged to try to go to bed and wake up at the same time - and to hit the hay before 11pm every night.  Any naps they can get during the day are a bonus, too!

Wrap-up

While I've outlined ten things we address in the early off-season, these are really just the tip of the iceberg, as every player is unique and needs an individual approach.  That said, the one general theme that applies to all of them is that we're shifting paradigms - meaning that some things about our philosophy may differ from what they've experienced.  Some guys may be accustomed to just "football workouts."  Others may have been coddled with foo-foo training programs where they didn't work hard.  Some guys ran distances. Some guys crushed the rotator cuffs every day while ignoring the rest of the body.

The point is that it's not just our job to find what we feel is the best fit for these athletes, but also to educate them on why the unique program we've designed for them is a better approach than they can get anywhere else.

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Last summer, a college pitcher came up to Cressey Performance from the South to train for a month before his summer league got underway. He was seven months post-op on a shoulder surgery (Type 2 SLAP) and had been working his way back. Unfortunately, his arm was still bothering him a bit when he got up to see us.

After the first few days at CP, though, he told me that his arm felt as good as it’s felt in as long as he could remember. He’d been doing a comprehensive strength and conditioning program, but the “impact” stuff for him had been soft tissue work, some Postural Restoration Institute drills, an emphasis on thoracic mobility, and manual stretching into internal rotation, horizontal adduction, and shoulder flexion. From all the rehab, his cuff was strong and scapular stabilizers were functioning reasonably well – which led me to believe that his issues were largely due to tissue shortness and/or stiffness.

This realization made me immediately wonder what he’d been doing in the previous months for mobility work for his arm – so I asked. He then demonstrated the manual stretching series that every pitcher on his team went through every day on the table with their athletic trainer. Each stretch was done for 2x20s – and two of those stretches took him into extreme external rotation and horizontal abduction. I was pretty shocked.

Me: “You’re probably not the only guy on your team rehabbing right now, huh?”

Him: “No; there are actually too many to count.”

Me: “Elbows, too, I’m sure.”

Him: “Yep.”

Want to irritate a labrum, biceps tendon, or the undersurface of the rotator cuff? Stretch a thrower into extreme external rotation and simulate the peel-back mechanism. This also increases anterior capsular laxity and likely exacerbates the internal impingement mechanism over the long-term. To reiterate, this is a bad stretch!

Want to make an acromioclavicular joint unhappy? Stretch a thrower into horizontal abduction like this (again, this is a BAD stretch that is pictured):

Want to irritate an ulnar nerve or contribute to the rupture of an ulnar collateral ligament? Make sure to apply direct pressure to the forearm during these dangerous stretches to create some valgus stress. This is a sure-fire way to make a bad stretch even worse:

These stretches are very rarely indicated in a healthy population – especially pitchers who already have a tendency toward increased external rotation. The shoulder is a delicate joint that can’t just be manhandled – and when you’re dealing with shoulders that are usually also pretty loose (both from congenital and acquired factors), you’re waiting for a problem when you include such stretches. In fact, I devoted an entire article to this: The Right Way to Stretch the Pecs.

Everyone thinks that shoulder external rotation and horizontal abduction alone account for the lay-back in the extreme cocking position.

In reality, though, this position is derived from a bunch of factors:

1. Shoulder External Rotation Range-of-Motion – and this is the kind of freaky external rotation you’ll commonly see thanks to retroversion and anterior laxity:

2. Scapular Retraction/Posterior Tilt

3. Thoracic Spine Extension/Rotation

4. Valgus Carrying Angle

So, how do you improve lay-back without risking damage to the shoulder and elbow?

1. Soft tissue work on Pec minor/major and subscapularis – Ideally, this would be performed by a qualified manual therapist – especially since you’re not going to be able to get to subscapularis yourself. However, you can use this technique to attack the pecs:

2. Exercises to improve scapular retraction/depression/posterior tilt – This could include any of a number of horizontal pulling exercises or specific lower trap/serratus anterior exercises like the forearm wall slide with band.

3. Incorporate specific thoracic spine mobility drills – In most pitchers, you want to be careful about including thoracic spine mobility drills that also encourage a lot of glenohumeral external rotation. However, when we assess a pitcher and find that he’s really lacking in this regard, there are two drills that we use with them. The first is the side-lying extension-rotation, which is a good entry level progression because the floor actually limits external rotation range-of-motion, and it’s easy to coach. I tell athletes that they should think of thoracic spine extension/rotation driving scapular retraction/depression, which in turn drives humeral external rotation (and flexion/horizontal abduction). Usually, simply putting your hands on the shoulder girdle and guiding them through the motion is the best teaching tool.

A progression on the side-lying extension-rotation is the side-lying windmill, which requires a bit more attention to detail to ensure that the range-of-motion comes from the right place. The goal is to think of moving exclusively from the thoracic spine with an appropriate scapular retraction/posterior tilt. In other words, the arm just comes along for the ride. The eyes (and head) should follow the hand wherever it goes.

Again, these are only exercises we use with certain players who we’ve deemed deficient in external rotation. If you’re a thrower, don’t simply add these to your routine without a valid assessment from someone who is qualified to make that estimation. You could actually make the argument that this would apply to some folks in the general population who have congenital laxity as well (especially females).

4. Throw!!!!! – Pitchers gain a considerable amount of glenohumeral external rotation over the course of a competitive season simply from throwing. Sometimes, the best solution is to simply be patient. I really like long toss above all else for these folks.

In closing, there are three important things I should note:

1. You don’t want to do anything to increase valgus laxity.

2. You’re much more likely to get hurt from being “too loose” than you are from being “too tight.” When it comes to stretching the throwing shoulder, “gentle” is the name of the game – and all mobility programs should be as individualized as possible.

3. Maintaining internal rotation is a lot more important than whatever is going on with external rotation. In fact, this piece could have just as easily been named "The Two Stretches Pitchers Shouldn't Do, Plus a Few That Only Some of Them Need."

To learn more about testing, training, and treating throwing shoulders, check out Optimal Shoulder Performance: From Rehab to High Performance.

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I have a policy when it comes to my writing:

If something is going to be controversial and potentially elicit a negative response from my readers, I "sit" on the topic for 24 hours.  During that time, I weigh the decision of whether me publicly writing about something is for the better good - meaning that it'll help people in the long-term even if it makes them recognize that they've been goofing up in the short-term.

I did some thinking on that front last night (actually, for the past several nights), and decided to go through with this blog, as I feel like it's something that every single baseball player, parent, and especially coach ought to read.  So, if you're in one of those categories - or are just a baseball fan who loves the game - please spread the word on what you're about to read, whether it's with a Facebook "recommend," "Tweet," or just a friendly email with the link to this article.

If you've perused my Baseball Content page much in the past, you'll know that I don't try to hide the fact that throwing a baseball is an incredibly unnatural and flat-out dangerous motion.  It's the single-fastest motion in all of sports, and every day, physically unprepared athletes go out and essentially play with fire every single time they try to light up a radar gun - or even just play catch.

Not surprisingly, when you mix physically unprepared bodies with arguably the most dangerous sporting challenge on the planet (the folks in Pamplona, Spain might argue with me, but that's a blog for another day), athletes get hurt.  Arm injuries (like all youth sports injuries) are rising exponentially thanks to not "less athletic athletes" taking part in high-risk sports, but also this participation taking place at all-time high rates thanks to the proliferation of little league all-star teams, AAU teams, fall ball, private pitching instruction, and the baseball showcase industry.  A fantastic study by Olsen et al. in 2006 (must-read for anyone involved in baseball development) clearly demonstrated strong associations between injuries requiring surgery and pitching "more months per year, games per year, innings per game, pitches per game, pitches per year, and warm-up pitches before a game" as well as showcase appearances during adolescence.  The message was very clear: throw too much - especially at a young age - and you're going to wind up hurt.

Unfortunately, though, many people glaze over numbers in studies (if they ever read them), and while they may walk away with the "overuse is bad" message, they don't appreciate what true overuse really is - especially since it's age-dependent.  Fortunately, a February 2011 study from Fleisig et al. showed in no uncertain terms that, in ages 9-14, throwing more than 100 innings per year was associated with a 3.5 times higher risk of elbow or shoulder surgery - or retirement altogether.

To put this into context, I'll first ask you: do you realize how challenging it is to throw 100 innings in a little league season?  Let’s say you start baseball the first week of April (little league) and even manage to play on a summer team that runs through the end of July.  That’s a four month season: exactly what I was accustomed to growing up - at the absolute most.

If you look at the Major League Baseball leaders in innings pitched, those at the top of the list generally throw about 35 innings per month (4-5 starts each). In other words, high-performance, skeletally mature pitchers in the most elite baseball league in the world are on pace for roughly 140 innings pitched over the first four months of the year.  However, there are parents and coaches out there that actually think it's okay to send an 11-year old out there for a comparable number of innings?  It's especially troublesome when you realize that younger kids always throw more pitches per inning than their older counterparts, as they don't have good command and insist on trying to strike everyone out instead of pitching to contact here and there.

Just think about how hard that is to do.  Major League pitchers throw on a five-day rotation, and Little league games are, at most, twice a week.  If a kid pitches once a week for four months, even if he throws complete games every time out (not something I'd advise, for the record), he'd still struggle to hit 100 innings (16 starts x 7 inning games =112 innings).  Rats!  It's actually tough to overuse kids when the season is kept in check.

So, instead, they add seasons.  Join an AAU team (or seven of them). Play fall ball so that you can rack up another seven innings every weekend.  Be sure to hit up a few college camps on Saturdays and throw as hard as you can so that your Sunday outing in 25-degree weather is extra miserable.  Make sure you see your pitching coach for bullpens as soon as fall ball ends.  Get your registration in early for that showcase that's taking place the first week in January.  Just do some band work and a couple of half-ass stretches and you'll be fine.  Riiiight....good thinking.

At risk of sounding arrogant, I'm good at what I do.  I've devoted my life to keeping baseball players healthy. They comprise 85% of our clientele at Cressey Performance, and I work with millions of dollars of arms every off-season and see players from ages 9 to 50+. I do my best to surround myself with the smartest people in strength and conditioning, rehabilitation, and skill-specific training in and outside of the game.  I managed the first subpectoral biceps tenodesis in major league history. I can talk mechanics with the best pitching coaches around, write strength and conditioning and throwing programs, manually stretch guys, you name it.  I've got two fantastic therapists in my office to do massage, ART, Graston, chiropractic adjustments, and a host of other manual therapy approaches - not to mention great physical therapists nearby who can handle all our complex cases.  You know the only things I, we, or anybody on this planet can't control?

Poor judgment by athletes and their parents and coaches.

And that - no doubt about it - is the primary reason that kids get hurt.  We can do all the strength training, mobility work, and soft tissue treatments in the world and it won't matter if they're overused - because I'm just not smart enough to have figured out how to go back in time and change history. Worried about whether they're throwing curveballs, or if their mechanics are perfect?  It won't matter if they've already accumulated too many innings.

While athletes might be playing with fire each time they throw, the pain presentation pattern is different.  You burn your hand, and you know instantly.  Pitching injuries take time to come about. Maybe you do microscopic damage to your ulnar collateral ligament each time you throw - and then come back and pitch again before it's had time to fully regenerate.  Or, maybe you ignore the shoulder internal rotation deficit and scapular dyskinesis you've got and it gets worse and worse for years - until you're finally on the surgeon's table for a labral and/or rotator cuff repair.  These issues might be managed conservatively if painful during the teenage years (or go undetected if no pain is present) - but once a kid hits age 18 or 19, it seems to automatically become "socially acceptable" to do an elbow or shoulder surgery.

Of course, this isn't just applicable to coaches in the 9-14 age group.  You see "criminal" pitch counts in the high school and collegiate ranks as well, and while they may be more physically mature than the 9-14 year-olds, that doesn't mean that they're exempt from the short- and long-term consequences.

This is why we need the best coaches at the youngest levels.  It's also why we need pitching coaches that understand "managing pitchers" as much as - if not more than - teaching pitching mechanics.  And, it's why coaches need to understand the big picture in terms of what different kids can do at different ages, at different times in the year.

It's also while parents need to be proactive with their young pitchers.  If a coach isn't going to track his innings - and a 9-year-old kid certainly can't be expected to do so - the parent needs to step up and do so.  I've met a lot of parents of kids who have been injured at ages 17-21, and most of them look back with a lot of anger toward coaches at younger levels for overusing their sons.  Hindsight is always 20/20, but foresight is what saves an arm.  Don't be afraid to step up and say something, as you aren't telling a coach how to do his job; you're protecting your kid, just as you would be locking the door at night or making sure he brushes his teeth.

In terms of planning the competitive year, I have no problem with a 9-14 year-old kid playing baseball 4-5 months of the year, as the other 7-8 months per year should be devoted to at least two other sports.  It's basically the "rule of thirds" for long-term athletic development: three sports, four months apiece.  Kids can strength-train year round.

At ages 15-16, I'm fine with kids changing things up and going to only two sports.  Baseball might occupy 7-8 months, but a big chunk of that should be focused on preparation.  So, a kid might start playing catch in November, start his high school season in March, and then play summer ball through the end of July.  August through November would be devoted to a fall sport and fall ball would be altogether omitted, as it was the only idea worse than making Rocky V.  Kids would, of course, strength-train year-round.

At ages 17 and up, it's fine with me if you want to specialize in baseball, but that doesn't mean you should play year-round.  I actually advocate kids only throw for 8-9 months of the year (at most) - which is right on par with what most professional players do.  The only thing that'd be different is that the season would be shifted up a bit in the year, as the high school season usually starts a few weeks before the professional season.  Pro guys get half of October, then all November and December off from throwing.  "Specialized" high school players get August, September, and October off (again, because fall ball is as useful as a trap door in a lifeboat).  Strength training is year-round.

You'll notice that there isn't a single penny spent on off-season baseball showcases.  That wasn't an accidental omission (read here why I don't like them).  If you insist on going to one, pick one between June and early August.

I'm convinced that the next big thing in Major League Baseball's "scouting revolution" is meticulously analyzing what players did when they were younger.  If they are going to draft kids, they want to know that they haven't been overworked for years prior to entering professional baseball.  You're already seeing this taking place in collegiate baseball based more on an assumption: pitchers from the North are getting more and more opportunities to play down South because coaches recruit them (beyond just talent) under the assumption that they've accumulated less wear and tear on their arms.

This piece might have ruffled some feathers.  Kids want to play year-round.  Parents want to make kids happy - and they enjoy watching them play.  You know what else?  Kids love chocolate, and parents want to see kids happy - but that doesn't mean that kids should get a limitless amount of chocolate to consume, right?  You put away the Easter candy this week to stress moderation and look out for their long-term well-being.

Coaches enjoy coaching and want to win - and they may take a commentary like this personally because they're the ones who sent a 9-year-old out for 120 innings one year - and now he's the one having the elbow surgery.  Or, maybe it's the college coach who let a kid throw 160 pitches in a game and killed his draft status because teams know he'll have a shoulder surgery in three years.  Admitting you're wrong is hard enough, but admitting you're wrong and learning from that mistake to help future kids is even harder - but all the more rewarding.

This post wasn't intended to make anyone feel bad, but bring to light an issue (throwing volume) that I think is the absolute most important consideration when taking care of arms.  We can do everything right in terms of physical preparation, but if you throw too much - especially at vulnerable ages - none of it matters.

Again, if you could help spread the word on this, I'd really appreciate it.  And, feel free to comment below; I'm here to help.

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While my thoughts from the initial article are still very much applicable, I do have some additional thoughts on the matter for 2011:

1. Is anyone surprised that the rise in oblique injuries in baseball is paralleled by the exponential rise in hip injuries and lower back pain? I don't care whether you work in a factory or play a professional sport; violent, repetitive, and persistently unilateral-dominant rotation (especially if it is uncontrolled) will eventually chew up a hip, low back, or oblique; it's just a matter of where people break down.

In other words, pro athletes are generating a tremendous amount of power from the hips - moreso, in fact, than they ever have before thanks to the advances in strength training, nutrition, supplementation, and, unfortunately, in some cases, illegal "pharmaceutical interventions."  Assuming mechanics are relative good (as they should be in a professional athlete), rotate a hip faster and you'll improve bat speed and throwing velocity; it's that simple.  This force production alone is enough to chew up a labrum, irritate a hip capsule, and deliver enough localized eccentric stress to cause a loss in range of motion.  The Cliff's Notes version is that we've increased hip strength and power (more on this in a bit), but most folks have overlooked tissue quality (foam rolling, massage, and more focal approaches like Active Release and Graston) and mobility training.

If the hips stiffen up, the lumbar spine will move excessively in all planes of motion - and, in turn, affect the positioning of the thoracic spine.  Throw off the thoracic spine, and you'll negatively impact scapular (and shoulder), respiratory (via the rib cage), and cervical spine.  Hips that are strong - but have short or stiff musculature can throw off the whole shebang.

2. "Strong" isn't a detailed enough description. I think that it goes beyond that, as you have to consider that a big part of this is a discrepancy between concentric and eccentric strength.  Concentrically, you have the trailing leg hip generating tremendous rotational power, and eccentrically, you have the lead leg musculature decelerating that rotation.

Moreover, because the front hip can't be expected to dissipate all that rotational velocity - and because the thoracic spine is rotating from the drive of the upper extremities - you put the muscles acting at the lumbar spine in a situation where they must provide incredible stiffness to resist rotation.  It is essentially the opposite of being between a rock and a hard place; they are the rock between two moving parts.  Structurally, though, they're well equipped to handle this responsibility; just look at how the line of pull of each of these muscles (as well as the tendinous inscriptions of the rectus abdominus) runs horizontally to resist rotation.  That's eccentric control.

How do we train it?  Definitely not with sit-ups, crunches, or sidebends.  The former are too sagittal plane oriented and not particularly functional at all.  The latter really doesn't reflect the stability-oriented nature of our "core."  The bulk of our oblique strain prevention core training program should be movements that resist rotation:

While on the topic, it's also important to resist lumbar hypextension, as poor anterior core strength can allow the rib cage to flare up (increases the stretch on the most commonly injured area of the obliques: at the attachment to the 11th rib on the non-throwing side) and even interfere with ideal respiratory function (the diaphragm can't take  on its optimal dome shape, so we overuse accessory breathing muscles like pec minor, sternocleidomastoid, scalenes, etc).

So, to recap: I don't think oblique strains are a new injury epidemic or the result of team doctors just getting better with diagnostics.  Rather, I think that we're talking about a movement dysfunction that has been prevalent for quite some time - but we just happen to have had several of them in a short amount of time that has made the media more alert to the issue.  The truth is that if we worried more about "inefficiency" and not pathology," journalists could have "broken" this story a long time ago.