Here, you've got supination of the forearm, external rotation of the shoulder, scapular retraction/posterior tilt, and thoracic spine extension/rotation occurring simultaneously on the "lay back" component.  And, the opposite occurs as the athlete returns to the starting position.  Again, to reiterate, this is NOT a drill that is appropriate for a large chunk of throwing shoulders who already have crazy external rotation; it's just one we use with specific cases of guys we discover need to gain it. With the broomstick dislocation, you're going to be throwing a lot of valgus stress on the elbow - and as I noted in my recent six-part series on elbow pain, pitchers already get enough of that.  To read a bit more, check out Part 3: Throwing Injuries.

A while back, I had the privilege to experience Thomas Myers in seminar for the first time.  For those who aren't familiar with Myers, he is the author of Anatomy Trains and a pioneer in the world of bodywork and fascial research.

There were a wide variety of attendees present, and Myers made dozens of interesting points - so the take-away message could easily have been different for everyone in attendance as they attempted to fit his perspective into their existing schemeta.

While I enjoyed all 150 minutes of his presentations, the portion of Myers' talk that jumped out at me the most was his list of the eight means of improving "fascial fitness:"

1.       Use whole body movements

2.       Use long chain movements

3.       Use movements including a dynamic pre-stretch with proximal initiation

4.       Incorporate vector variation

5.       Use movements that incorporate elastic rebound - this consists of cylic motions of a certain speed (for instance, cycling wouldn't count)

6.       Create a rich proprioceptive environment

7.       Incorporate pauses/rest to optimize hydration status

8.       Be persistent, but gentle (prominent changes can take 18-24 months)

A big overriding them of Myers' lecture was that the role of the fascia - the entire extracellular matrix of the body - is remarkably overlooked when it comes to both posture and the development of pathology.  He remarked that he doesn't feel like we have 600+ muscles in the body; he feels like we have one muscle in 600+ fascial pockets because they are so interdependent.  And, in this fascia, we have nine times as many sensory receptors as we've got in muscles.

Think about what that means when someone has rotator cuff problems - and treatment only consists of ice, stim, NSAIDs, and some foo-foo rotator cuff exercises.  Or, worse yet, they just have a surgical intervention.  It overlooks a big piece of the puzzle - or, I should say, the entire puzzle.

For me, though, these eight factors got me to thinking again about just how atrocious distance running is for pitchers.  I have already ripped on it in the past with my article A New Model for Training Between Starts, but this presentation really turned on a light bulb over my head to rekindle the fire.  Let's examine these eight factors one-by-one:

1.       Use whole body movements - Distance running may involve require contribution from the entire body, but there is not a single joint in the body that goes through an appreciable range of motion.

2.       Use long chain movements - Pitching is a long chain movement.  Jumping is a long chain movement.  The only things that are "long" about distance running are the race distances and the length of the hip replacement rehabilitation process.

3.       Use movements including a dynamic pre-stretch with proximal initiation - This simply means that the muscles of the trunk and hips predominate in initiating the movement.  While the hips are certainly important in running, the fundamental issue is that there isn't a dynamic pre-stretch.  This would be a dynamic pre-stretch with proximal initiation:

4.       Incorporate vector variation - A vector is anything that has both force and direction.  Manual therapists vary the force they apply to tissues and the directions in which they apply them.  There are obviously vectors present in exercise as well.  Here are 30,000 or so people, and pretty much just one vector for hours: forward (to really simplify things):

Incorporating vector variation into programs is easy; it just takes more time and effort than just telling someone to "run poles."  Take 8-10 exercises from our Assess and Correct DVD set and you've got a perfect circuit ready to roll.

5.       Use movements that incorporate elastic rebound - Sorry, folks, but even though the stretch-shortening cycle is involved with jogging, its contribution diminishes markedly as duration of exercise increases.  And, frankly, I have a hard time justifying bored pitchers running laps as "elasticity."

6.       Create a rich proprioceptive environment - There is nothing proprioceptively rich about doing the same thing over and over again.  They call it pattern overload for a reason.  Pitchers get enough of that!

7.       Incorporate pauses/rest to optimize hydration status - Myers didn't seem to have specific recommendations to make regarding work: rest ratios that are optimal for improving fascial fitness, but I have to think that something more "sporadic" in nature - whether we are talking sprinting, agility work, weight training, or dynamic flexibility circuits - would be more appropriate than a continuous modality like jogging.  This is true not just because of duration, but because of the increased vector variation potential I outlined earlier.

8.       Be persistent, but gentle - This one really hit home for me.  Significant fascial changes take 18-24 months to really set in. I am convinced that the overwhelming majority of injuries I see in mature pitchers are largely the result of mismanagement - whether it's overuse, poor physical conditioning, or improper mechanics - at the youth levels.  Poor management takes time to reach the threshold needed to cause symptoms.  In other words, coaches who mismanage their players over the course of the few months or years they coach them may never actually appreciate the physical changes - positively or negatively - that are being set into action.

Distance running might seem fine in the short-term.  Overweight kids might drop some body fat, and it might make the practice plan easier to just have 'em run.  Kids might not lose velocity, as they can compensate and throw harder with the upper extremity as their lower bodies get less and less powerful and flexible.

However, it's my firm belief that having pitchers run distances not only impedes long-term development, but also directly increases injury risk.  Folks just don't see it because they aren't looking far enough ahead.

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When these structures get overused, they shorten - and as we discussed in Part 1, the zones of convergence (where tendons bunch up and create friction with one another) are where we develop some nasty soft tissue adhesions.

However, this doesn't just happen from gripping.  Think about what happens when you put the bar in this position to back squat:

That bar wants to roll off his back, and while the majority of the weight is compressive loading, a good chunk of it becomes valgus stress that must be resisted by the flexors and pronators that attach at the medial aspect of the forearm/elbow. It's not a whole lot different than the stress we see here; we just trade off the velocity and extreme range of motion in the throwing motion for prolonged loading in the lifting example:

As a general rule of thumb, the narrower the squatting grip, the more stress on the elbow.  Unfortunately, the wider the grip, the more shoulder problems we tend to see, as this position can chew up the biceps tendon.  The solution is to maintain as much specificity as possible with respect to one's chosen endeavor, but find breaks from the repetition of these squatting positions by plugging in options like front squats, giant cambered bar squats, and safety squat bar squats.

For these reasons, I also look at soft tissue work on the forearms - and particularly the medial aspect - as a form of preventative maintenance.  Regardless of the soft tissue modality you select, get some work done every few months and stay on top of your stretching in the area to maintain adequate length of these tissues.

We'll also see a fair amount of "underside" elbow pain in lifters, in most cases where the three heads of the triceps join up as a common tendon (another zone of convergence; does anyone see a pattern here?) to attach to the olecranon process.  The smaller anconeus - a weak elbow extensor - also comes in here.

Almost universally, the lifters who present with overuse injuries posteriorly are the ones who use loads of elbow-only extension movements like skullcrushers/nosebreakers/French presses/triceps extensions.  As a random aside to this, how can these movements have four different names, and not one of them begins with some Eastern European nationality?  "French" just doesn't get it done when we have Russian good mornings, Bulgarian split squats, Romanian Deadlifts.

Anyway, we vilify leg extensions and leg curls as being non-functional and overly stressful at the knee.  The knee is the joint most similar to the elbow, yet it's much bigger than the elbow, yet nobody contraindicates 4-5 elbow extension-only exercises per week in many routines as being inappropriate - or even excessive.  If you want to build big legs, you squat, deadlift, and lunge.  If you want to build big triceps, you bench, do weighted push-ups, overhead press, and do dips.  The absolute load is higher, but the stress is shared over multiple joints.

In just about every instance, when you drop the direct elbow extension work from someone's program, their elbow issues resolve very quickly and they don't miss a beat with training.

So, as you probably inferred, it's very rarely a lack of strength that causes elbow pain in lifters.  Rather, it's generally poor tissue quality, a lack of flexibility, and overuse of a collection of muscles that have "congested" insertion points.  Simply changing the program around, getting some soft tissue work done, and following it up with some stretching can go a long way to both prevent and address these issues.  That said, there will be cases where elbow pain may originate further up at the cervical spine or shoulder or - as I learned from a reader in the comments section of Part 5 - from an abducted ulna.  So, there is definitely no one-size-fits-all approach.

That wraps up this series.  Hopefully, you've gained insights into some of what's rattling around inside my brain with respect to elbows.  Thanks for putting up with me for all six installments!

I've trained Blue Jays left-handed pitching prospect Tim Collins for the past three seasons.  At a Double-A game earlier this year, Tim introduced me to his good buddy Trystan Magnuson, a right-handed pitching prospect who is also in the Jays system.  While Tim was a whopping 5-5, 131 pounds when he was signed right out of high school (now 5-7, 170), Trystan stands 6-7.  Check out this picture I recently came across from spring training:

Anyone who thinks these two are going to throw a baseball with velocity and safety via the same mechanics is out of his mind. As an aside, if you're interested in watching both of them throw, there is some decent warm-up footage of both HERE.

Changing these mechanics could take away everything that makes these pitches successful, so you have to look to the other three factors to prepare them physically and protect them from these stresses.  It's like making sure you give a guy a helmet if he is going to be banging his head against a wall!

All that said, finding the right mechanics is important for little leaguers and professionals alike - and it's the first step in protecting the elbow in a throwing situation.  As we realize that the very issues that increase elbow stress happen to be the same ones that a) increase velocity and b) are often demonstrated by elite pitchers, we appreciate once again just how unnatural an act throwing a baseball really is!

It's not just about what you do before an outing, either.  It's also about what you do in the 24 hours after an appearance that determines how you'll bounce back in your subsequent outing.  While the schmucks out there are doing "flush runs," the #1 thing I am worried about after a start is regaining lost range of motion.  Reinold et al. found that pitchers lost both shoulder internal rotation and elbow extension range-of-motion during a competitive season when an adequate stretching routine was not implemented.  It's no surprise, when you consider the overwhelmingly high eccentric stress that's placed on the shoulder external rotators and elbow flexors as they try to decelerate the crazy velocities we see with pitching.  As such, following an outing, the first thing we want our guys to do is get back their shoulder and elbow ROM (and get the hips loosened up).  There are some athletes who don't need to be stretched into internal rotation, so be careful about using this as a blanket recommendation (more on that in our Optimal Shoulder Performance DVD set).

For a bit more information on what we recommend for our pitchers between outings, check out A New Model for Training Between Starts: Part 2.

In closing, an important note I should make is that pitchers rarely get hurt because of just one of these factors; it's usually a combination of all of them. So, when evaluating a pitcher's health and performance, be sure to broad perspective.

We've got four down and two to go in this elbow series.  Stay tuned for more!

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.

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…

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.

Related Posts

Developing Young Pitchers the Safe Way Overbearing Dads and Kids Who Throw Cheddar

(just signed a 4-year, $68 million contract....Beckett, not Mike - sorry, Mike)

Okay, maybe there won't be any 1RMs featured, but we will talk about the importance of scapular positioning with respect to cuff function.

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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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And some favorite baseball-related DVDs:

The 2009 Ultimate Pitching Coaches Bootcamp DVD Set

Optimal Shoulder Performance (just released last week, and only around at the introductory price for a bit longer)