It's time for the September installment of this series. With the baseball season wrapping up for many minor league and high school players - plus the start of post-season play nearly upon us - I've got a lot of new thoughts rattling around my brain.
1. There's no such thing as "catching the injury bug."
This is a term that gets thrown around a lot in professional sports. Certainly, there is a significant amount of happenstance in professional sports. Quarterbacks get sacked from the blind side and injure acromioclavicular joints (get well soon, Jimmy G!!!). Hitters get hit by pitches, and outfielders run into walls. Not all injuries are preventable, but not everything we assume to be "happenstance" is unpreventable, either. Additionally, there's something to be said about finding ways to shorten the down time on the disabled list when players are hurt. This recent article in Hardball Times does a good job of highlighting this observation: Doing What it Takes to Keep Players Healthy.
With respect to preventing injuries, most of the focus goes on training and rehabilitation initiatives. Is there a good strength and conditioning program? Are there good manual therapists on hand? Does the organization prioritize high quality nutrition? Are recovery options plentiful? The list goes on and on.
There are, however, many overlooked factors that are outside the control of the sports medicine staffs in these organizations. For instance, if a front office creates a roster of players who a) are older and b) have more extensive injury histories, it's going to be a lot harder to keep that team on the field. Additionally, how bullpens are managed factors into injury risk heavily. Some relief pitchers get absolutely abused between game appearances and scenarios where they warm up and don't go into the game. I once had a MLB lefty specialist say that he threw more in two months in the big leagues than he did in 100+ innings as a college starer.
The point is that while some injuries are, in fact, happenstance, the majority are highly preventable - particularly if as many different factors as possible are taken into consideration. The injury bug excuse just doesn't hold water.
2. There are varying levels of "strong enough."
In the strength training world, you'll often hear debates on the question, "how strong is strong enough for athletes?" Truth be told, it's not a simple question to answer.
First and foremost, you get what you train. So, I might just squat and deadlift all the time, but never build an appreciable level of single-leg strength. So, if my sport requires a ton of single-leg strength, I'm really not strong at all in a specific sense. That said, no competitive powerlifter is going to be able to hand his hat on a good Bulgarian split squat number; he's got to squat and deadlift heavy to be successful.
Taking this a step further, though, we have to consider what we're trying to strong enough to do? Is it strong enough to safely perform sprint work and plyos in training, as would be the case after a few months in post-op ACL rehabilitation scenario? Or, is it strong enough to be able to safely participate in athletics, as an athlete would be later in the rehabilitation timeline?
Does an athlete just need to be strong enough to need to even consider this continuum? Or, does he need to be strong enough to make good use of strength-speed and speed-strength training initiatives?
Is the athlete strong enough to not have to worry about training limit strength (the far left of this continuum) as much? Not many athletes ever get to this point because it takes a ton of hard work, consistency, and even a genetic predisposition to being strong to get there. However, I've seen several in my career, and we needed to spend a lot more time training absolute speed and speed-strength.
Above all else, I'd say that in the athletic world, the "strong enough" classification refers to a coach's refusal to push an athlete further due to the potential for injury. For example, there is no doubt in my mind that one of our pro outfielders could unquestionably train to attain a 600-pound raw squat in a matter of 3-4 months. The risk of pushing toward this goal just isn't worth the risk; he has other athletic qualities to which we can devote his training time and recovery capacity - and without the risk. If he could only squat 185 pounds, though, it would be an entirely different story.
3. If applied incorrectly, cross-training can beat athletes up as much as it can help them.
I'm all for young athletes playing as many sports as possible. A rich proprioceptive environment creates an awesome foundation for future athletic development in more specific endeavors. Likewise, later on, once an athlete has specialized, there is definitely a time of year for cross training - but it definitely has to be applied correctly. What am I getting at?
[bctt tweet="The lower the movement variability in one's sport, the less bold the cross-training can be."]
To put this in context, imagine a soccer midfielder or football defensive back. Both these athletes have a ton of movement variability in their sport participation; there is a lot of change-of-direction, full-tilt sprinting, backpedaling, jumping, and a host of additional sport-specific skills. Asking one of these athletes to go out and play ultimate frisbee or beach volleyball for a change of pace isn't going to dramatically increase their injury risk.
Conversely, take the typical pro golfer or baseball pitcher into this same challenge, and it's going to be a pretty stressful event with a much higher likelihood of injury. It's not to say these athletes are soft or "delicate;" it's just that the majority of their athletic calendars take place with more specificity, and there is less movement variability to their sports challenges. With both the golf swing and pitching delivery, you want to consistently repeat your mechanics.
Invariably, during interleague play in Major League Baseball, we see an American League pitcher who gets injured running the bases or swinging at the plate. Specificity of training matters, and it takes a considerable volume of specificity to build a tolerance to competing at a high level.
This isn't just specific to amplitude of movement (range of motion). Rather, the direction and magnitude of forces need to be considered. As an example, elite swimmers have a high pain tolerance from the insane volumes they do in the pool, but get them into an ultimate frisbee game, and you're going to see some awkward movements because they aren't accustomed to ground reaction forces and moving in the frontal and transverse planes.
Just keep it in mind as you plan your cross-training activities. Just because you see NFL players dominating a game of "Tag" doesn't mean that your 51-year-old master's division swimming star is going to do as well with it.
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It's time for the August installment of this popular series, and with the Olympics in full swing, MLB season in the home stretch, and the NFL season rapidly approaching, there's plenty of material rattling around my brain.
1. Don't criticize what you don't understand.
Maybe it's just because all the aforementioned sporting events are taking simultaneously and we're on sports social media overload right now, but it seems like a lot of people are ranting and raving about high-level athletes' preparation. They're cranky about Usain Bolt's hamstrings issue and how it's being managed. They're shocked the Kerri Walsh Jennings has had so many shoulder surgeries. They're flustered about Michael Phelps using cupping. They're floored by Prince Fielder's retirement after a second cervical fusion surgery. And they're cranky because they're confident that they can do a better job in spite of the fact that they have exactly ZERO knowledge of any of these situations.
If there's one thing I've learned from a lot of work with professional and Olympic athletes over the years, it's that nothing is ever as simple as it seems. What you read in the media is usually a partial truth (if that). For instance, I know of pitchers who have gone on the disabled list with calf strains or neck stiffness when they just needed to iron out mechanics or rest up from a high workload. I've also known athletes whose performance has suffered tremendously as they tried to plow through nagging injuries. They're getting blown up on Twitter when they should be getting commended for putting the team's needs ahead of their own personal health.
The point is that if you don't have any knowledge of the unique situations, blindly criticizing athletes and their sports medicine teams is a cheap shot. And, in my eyes, it makes you look incredibly unprofessional.
I'd also add that it's important to remember that you never know who is reading your criticism. Burning that bridge because you "just had to get it off your chest" could interfere with future job possibilities, or even the opportunity to work with the athletes in question.
So, sit back, chill out, and just be a sports fan, but not a Monday Morning Quarterback. You can't rehab someone on Twitter.
2. Use the bottoms-up get-up to remind hypermobile athletes to avoid elbow hyperextension - and cue "grabbing"the floor.
I love using Turkish Get-ups with athletes for a host of reasons; this drill really trains whole-body mobility and stability and delivers a great training effect without insane external loading. That said, one thing you have to be really careful of with using get-ups is that hypermobile (loose jointed) individuals will often wind up with elbows hyperextended - both on the support and overhead arms.
With that in mind, I like the idea of using a bottoms-up Turkish get-up because it's more grip intensive and strictly mandates a more neutral wrist position. This activation of the flexors of the fingers, wrist, and elbow gets the muscles that prevent elbow hyperextension a little more "pre-tensioned," so it's a lot harder to slip into bad patterns.
The bottom arm is a bit trickier, but I have had some success with the cue, "grab the floor as if you're trying to palm a basketball." That same activation of the flexors can help to keep a slight flex in the elbow.
3. A training effect prepares you, but an education sustains you.
This morning, I woke up to this article about Cubs pitcher Jason Hammel "reinventing himself" this past offseason. Part of that process involved getting started up with Cressey Sports Performance, and we've be really cheering him on as he's put forth a career year to be a big part of the Cubs' success. As the article details, one of Jason's biggest struggles was fading in the second half of the season. This was something he and I discussed at length during his initial evaluation last November. Even though it was 8-9 months away, we started talking about in-season training approaches and how to sustain performance well into the second half of the long MLB season. Thus far, he's done a great job of it; in five starts since the All-Star Break, he's 5-0 with a 1.16 ERA.
I often tell our athletes that the training effects we deliver in the off-season gets them through the first half of the season, but it's the education we impart that should sustain them through the second half of the year. The MLB calendar spans from mid-February (spring training) all the way to early October (and even longer if a team makes the playoffs). Nothing we can do in the offseason is guaranteed to last for eight months, but education certainly can. We need to work hard to help athletes understand what is unique about their bodies so that they can be advocates for themselves - and their own best coaches.
Jason's success has been a good reminder:
[bctt tweet="Coaching isn't just about building athleticism; it's also about educating."]
4. I still don't like Olympic lifts for baseball players.
By this point, most of you have probably heard (or seen) an Armenia Olympic lifter end up with a gruesome elbow injury on the jerk portion of a clean and jerk. It was a combination valgus stress - elbow hyperextension injury - which just so happens to be the exact same kind of stresses that lead to most pitching injuries at the elbow. Keep in mind that this was on a jerk - and the valgus stress is actually magnified on a snatch because of the bar path and distance traveled prior to the attempted catch.
I've written previously at length on my feelings about the topic: Should Baseball Players Olympic Lift? I think there are much better ways to train power in a specific context and with less injury risk.
Some coaches will argue, "But this is a max attempt in the Olympics! Our technique is much better than this and we aren't taking those kind of chances!" The truth is that video doesn't lie; you see a lot of ugly Olympic lifting technique all over the 'net. And, athletes will always want to push the limits and hit personal records. Moreover, baseball players have a lot more funky presentations (valgus carrying angle, medial elbow instability, and joint hypermobility) that muddy the waters further.
Perhaps more importantly, I know of very few high level arms who Olympic lift. We've demonstrated over and over again that you can build huge arm speed without snatches, jerks, and cleans, so why take the chance?
I should reiterate: I think the Olympic lifts are absolutely fantastic for other athletes. Baseball is just a different beast.
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It's hard to believe that we're 20 installments deep on this series, but I'm glad they've been so well received and definitely plan to continue to write them. Here goes!
1. Tall athletes are usually longer term projects.
When you have a 15-year-old 6-6, 150-pound kid with size 17 shoes, you have your work cut out for you.
These athletes are challenging for a number of reasons:
a. Their bone growth has usually outpaced their flexibility (except in kids - usually those who haven't finished puberty - who have preserved their childhood joint laxity). This often means that they have to do a fair amount of "preliminary" work just to get into good positions to benefit from big bang exercises.
b. Their center of mass has rapidly shifted up away from their base of support, creating a constantly unstable state.
c. A longer spine is a lot harder to stabilize than a shorter one.
d. You can put 20 pounds on one of these athletes and barely notice. As a frame of reference, in the picture below, the 6-6 athlete on the left added 31 pounds between September and February (when this picture was taken) to get to approximately 200 pounds. Meanwhile, Greg Robins (the CSP coach in the middle) actually weighs more than him even though his about eight inches shorter.
e. Even if you put that 20 pounds on them, it might not be enough to have a "grounding" effect on the athlete. Unless an athlete is very gifted in terms of reactive ability (as you might see with lighter weight NBA players), you might need to add a lot more weight for them to learn how to properly load the lower extremity to create athletic movement using the stretch-shortening cycle.
f. At younger ages, they're often put in positions that don't require as much movement (first base, DH, or pitcher in baseball; center in basketball; goalie in soccer; etc.). This may rob them of crucial exposure to movement "education."
The take home points?
[bctt tweet="In tall athletes, push patience, consistency, calories, and perfect technique on fundamentals."]
2. It's not your job to have all the answers.
Earlier this week, I sent along a nutrition question to Cressey Sports Performance's first employee, Brian St. Pierre. Brian is now Director of Performance Nutrition for Precision Nutrition and a tremendous resource we have at our fingertips on everything relating to nutrition and supplementation. Within 24 hours, Brian had sent along a 244-word reply that covered his anecdotal experiences on the topic in question, along with some recommended reading in case I was interested in what the peer-reviewed evidence demonstrated.
I'd love to have all the answers, but I simply don't. As such, I refer out all the time - whether it's a question like this on the nutrition front, or sending a client to a physical therapist. Your job is to deliver the best possible outcomes for your athletes/clients, and referring out regularly usually leads to those ends - and creates learning opportunities for you via the collaborative efforts that occur during the referral.
It's not your job to have all the answers; it's your job to know where you can find them.
3. It's important to understand how much relative strength an athlete needs - and that is sport and position specific.
I'll use my experience with baseball to make this point.
Pitching is a combination of absolute and relative strength and power. From an absolute standpoint, more body weight equates to more force to push off the mound, and more momentum moving downhill; that's why gaining weight can have such a profound impact on pitching velocity.
On the other hand, from a relative strength and power standpoint, you eventually have to "accept" all the force you create. We know that there are substantial ground reaction forces taken on by the front leg, and research has demonstrated that they are (not surprisingly) directly impacted by body weight. Additionally, according to 1998 research on professional pitchers from Werner et al., at ball release, the distraction forces on the shoulder are approximately 108% of body weight. You could also make the argument that these forces are even higher now, as average fastball velocity has crept up significantly since 1998, and the subjects in that study averaged only 89mph. As is the case with body weight increases, as arm speed rises, so do shoulder distraction forces.
In hitting, "accepting" force on the front side isn't as stressful because we don't hit downhill on a mound. However, batters have to run the bases, and that's a significant relative strength challenge.
With all this in mind, you it's important to realize that some athletes need to gain weight, some athletes need to lose weight, and some athletes are good right where they are. Obviously, body composition plays into this as well, but speaking in general terms, understanding strength-to-bodyweight ratios in sport-specific contexts is really important for all strength and conditioning coaches.
4. Use upper body drivers in your lower body mobility work.
This video from Mike Robertson got me thinking a lot:
We've done quite a bit of upper body reaching in our warm-ups with drills like the lateral lunge with overhead reach, but typical, this motion has really only occurred in the sagittal plane:
Conversely, if you look at the bowler squat, the upper body reach drives hip internal rotation, adduction, and flexion on the support leg.
Moving forward, I plan to get a lot more creative with using reaching to challenge folks in the transverse and frontal planes during our warm-ups.
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Today's guest post comes from physical therapist, Eric Schoenberg. Eric is an integral part of the Elite Baseball Mentorships team.
A thought came to mind as I was considering how we can work towards reducing the incidence of injury in baseball: we need more specialists.
If we use the field of medicine as a model, the Total Knee Replacement has pretty much been mastered. Of course, there is room for improvement, but over the past 25 years, this surgery has become a massive success. The biggest reason for this is a progression of specialization:
If you need a knee replacement, you don’t go to your primary care physician. Instead, you schedule an appointment with an Orthopedic Surgeon that specializes in TKR. So, if you are a baseball player, why does it make sense to work with a “general” strength coach or physical therapist?
[bctt tweet="Every profession matures into a state of “super-specialization” as it develops."]
Strength coaches and physical therapists have a great opportunity ahead of us to move our professions forward in this manner.
The current entry point for a strength coach is minimal. Most commonly, entry into the field falls somewhere between a fitness certification and a 4-year degree. In some cases, you will see dual degrees, Master’s degrees, and the occasional PhD.
However, there is no direct path available to niche into a “baseball specialist.” Instead, we have private sector, college, and even some professional strength coaches that may have seen baseball players by chance, but have no more experience with them than any other sport. It’s not a criticism of them, though; there simply isn’t an established “curriculum” they can pursue. As a result, in most cases, highly “specialized” baseball players are being managed by “general” strength coaches.
I have to believe that this is as much of a contributing factor as any to the high incidence of injury in the baseball world. By the time these athletes make it far enough in their careers to have access to “baseball specialists,” they are often too damaged for even the experts to manage.
Here are five tips to establish yourself as a trusted resource in the baseball community:
1. Watch baseball.
Don’t just watch it for entertainment value. Study the movements. Use slow motion and rewind on your TV. Watch video online and gain a better understanding of the actions and positions unique to the sport. Once you think you have it figured out, you are only just scratching the surface. Keep studying! Start to recognize why faulty mechanics can lead to improper distribution of stress and ultimately injury. By doing this, you can pair this knowledge with your individual assessment of the athlete to create a more optimal training program.
2. Spend time on a field.
Baseball players are unique in their habits and tendencies. Gain a “feel” for the game. Understand the culture of the game. Learn how to identify with and communicate with athletes that are much younger than you. Understand that most of their time on the field is spent standing around and waiting. Educate your players on how to optimize this time to prepare mentally, hydrate, properly warm up, etc. It is not enough to say you used to play baseball 20 years ago; nobody cares. My credibility and effectiveness in managing baseball players increased 10x once I started spending time at the field as part of a team. Create an angle to quickly establish trust and common ground with the athlete and watch your results dramatically improve.
3. Understand the unique physical characteristics and demands of baseball players.
Baseball players have physical characteristics that differ from other sports. Educate yourself for the benefit of your athletes. Learn about humeral retroversion, gross extension patterns, laxity, valgus stress, dynamic stability, rotator cuff timing, etc. Work towards understanding the importance of stability of the landing leg, proper hip hinge pattern, and the importance of tri-planar single leg balance. Don’t “stretch” a guy that is already too loose. Instead, give him some stability and watch his pain go away. The baseball player’s anatomy is a long way from “neutral.” Do your best to bring them closer to the middle and not further away. For example, your ability to recognize that a baseball player should not be cued to pull their shoulder blades “down and back” because their shoulder blades are ALREADY down and back may save dozens of careers.
4. Master functional anatomy and human movement.
Understand the critical role of the scapula. Train the rotator cuff in the throwing position through the entire range of motion (especially end-range external rotation). Learn how the kinetic chain applies specifically to baseball. Hitting and throwing are highly coordinated, precisely timed, multidirectional movements. Don’t train your athletes with single joint exercises that only occur in the sagittal plane. Learn about hip/trunk separation to maximize power and explosiveness. Be able to educate the athlete on what it means to have a labral tear or understand the specifics of an ulnar nerve transposition. If you can’t explain these pathologies, then how can you minimize risk when working with these athletes? Take pride in your job on this front.
5. Be willing to respectfully challenge the “institution of baseball.”
CSP coach Tony Bonvechio wrote a blog post a while back where he warned about the dangers of the phrase “this is how I’ve always done it.” I find myself observing on a daily basis that regardless of level – little league, high school, college, pro ball – at least 80% of the player’s warm up routine is exactly the same. How can that be? We have progressed as a profession; however, kids on baseball fields across the world are all doing the same useless warm-up routine.
An example of progress is Joe Maddon and the Chicago Cubs. He softened the traditional stance of getting to the ballpark at 1pm for a 7pm game. Instead, they have created a culture that emphasizes more sleep, nutrition, and recovery and his players love him for it.
If we want different results, we have to continue to move towards a different approach. The efforts of strength coaches and physical therapists to move towards becoming baseball specialists will go a long way in helping to reach this goal.
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I thought I'd use today's post to throw out some thoughts on training the shoulders.
1. In the upper extremity, the assessments are often the solutions, too.
Imagine you're assessing an athlete, and their squat pattern is absolutely brutal. Usually, the last thing you're going to do is go right to a squat as part of their training. In other words, simply coaching it differently usually won't improve the pattern immediately. Rather, you typically need "rebuild" the pattern by working with everything from ankle and hip mobility to core control, ultimately progressing to movements that replicate the squatting pattern.
Interestingly, the upper extremity is usually the opposite in that the assessment might also be the drill you use to correct the movement. For instance, an aberrant shoulder flexion pattern like this...
...might be quickly corrected with some of these three cues on a back to wall shoulder flexion pattern.
This is also true of push-up assessments and shoulder abduction and external rotation tests we do; funky patterns are usually cleaned up quickly with some subtle cueing. This just isn't the case as much in the lower body, though. Why the difference?
My theory is that because we're weight-bearing all day, the lower extremity is potentially less responsive to the addition of good stiffness in the right places. Conversely, a little bit of stiffness in serratus anterior, lower trap, or posterior cuff seems to go a long way in quickly improving upper extremity movement. My experience with the Postural Restoration Institute also leads me to believe that creating a good zone of apposition can have lead to a more pronounced transient movement in the upper extremity than it does in the lower extremity. This is likely because the rib cage is directly involved with the shoulder girdle, whereas the relationship with the lower extremity (ribs --> spine --> pelvis) is less direct.
These differences also seem to at least partially explain why upper extremity posture is much easier to change than lower extremity positioning. It's far more common to see a scapular anterior tilt change markedly than it is to see an anterior pelvic tilt substantially reduced.
Just thinking out loud here, though. Fun stuff.
2. Anterior shoulder pain usually isn't "biceps tendinitis."
First off, true tendinitis is actually quite rare. In this landmark paper, Maffulli et al. went to great lengths to demonstrate that the overwhelming majority of the overuse tendon conditions we see are actually tendinOSIS (degenerative) and not tendinITIS (inflammatory). It may seem like wordplay, but it's actually a very important differentiation to make: if you're dealing with a biceps issue, it's probably tendinosis.
Second, if you speak with any forward thinking orthopedic shoulder specialist or rehabilitation expert, they'll tell you that there are a lot of differential diagnoses for anterior (front) shoulder pain. It could be referred pain from further up (cervical disc issues, tissue density at scalenes/sternocleidomastoid/subclavius/pec minor, or thoracic outlet syndome), rotator cuff injury or tendinopathy, anterior capsule injury, a lat strain or tendinopathy, labral pathology, nerve irritation at the shoulder itself, arthritis, a Bankart lesion, osteolysis of the distal clavicle, AC joint injury, and a host of other factors.
3. Thoracic outlet surgery really isn't a shoulder surgery.
Over the past few years, each time a professional pitcher gets thoracic outlet surgery, you see many news outlets call it "shoulder surgery." Sorry, but that really isn't the case unless you have a very expansive definition of the word "shoulder."
With this intervention, the surgeon is removing the first (top) rib to provide "clearance" for the nerves and vascular structures to pass underneath the clavicle.
Additionally, surgeons usually opt to perform a scalenectomy, where they surgically remove a portion of the anterior scalenes, which may have hypertrophied (grown) due to chronic overuse. Again, this is not a "shoulder" procedure.
Finally, more and more surgeons are also incorporating a pec minor release as part of the surgical intervention. This is because the nerve and vascular structures that may be impinged at the scalenes or first rib can also be impinged at the coracoid process of the scapular if an individual is too anterior-tilted. While the coracobrachialis and short head of the biceps both attach here, the pec minor is likely the biggest player in creating these potential problems.
This, for me, is the only time this becomes somewhat of a "shoulder" surgery - and it's an indirect relationship that doesn't truly involve the joint. We're still nowhere near the glenohumeral (ball-and-socket) joint that most people consider the true shoulder.
All that said, many people consider the "shoulder girdle" a collection of joints that includes the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic articulations. In this case, though, the media just doesn't have a clue what they're trying to describe. With that in mind, hopefully this turned into somewhat of an educational rant.
4. Medicine ball scoop tosses tend to be a better than shotputs for cranky shoulders.
Rotational medicine ball training is a big part of our baseball workouts, and it's something we try to include as an integral part of retraining throwing patterns even while guys may be rehabilitating shoulder issues. When you compare rotational shotputs with rotational scoop tosses...
...you can see that the scoop toss requires far less shoulder internal rotation and horizontal adduction, and distraction forces on the joint are far lower at ball release. The shotput is much more stressful to the joint, so it's better saved for much later on in the rehab process.
5. Adequate rotator cuff control is about sufficient strength and proper timing - in the right positions.
To have a healthy shoulder, your cuff needs to be strong and "aware" enough to do its job in the position that matters. If you think about the most shoulder problem, there is pain at some extreme: the overhead position of a press, the lay-back phase of throwing, or the bar-on-your back position in squatting. For some reason, though, the overwhelming majority of cuff strength tests take place with the arms at the sides or right at 90 degrees of elevation. Sure, these positions might give us a glimpse at strength without provoking symptoms, but they really don't speak much to functional capacity in the positions that matter.
With that in mind, I love the idea of testing rotator cuff strength and timing in the positions that matter. Here's an example:
Obviously, you can make it even more functional by going into a half-kneeling, split-stance, or standing position. The point is that there are a lot of athletes who can test pretty well in positions that don't matter, but horribly in the postures that do.
6. Pre-operative physical therapy for the shoulder is likely really underutilized.
It's not uncommon to hear about someone with an ACL tear going through a month or so of physical therapy before the surgery actually takes place. Basically, they get a head start on range-of-motion and motor control work while swelling goes down (and, in some cases, some healing of an associated MCL injury may need to occur).
I'm surprised this approach isn't utilized as much with shoulder surgeries. It wouldn't be applicable to every situation, of course, but I think that in some cases, it can be useful to have a pre-operative baseline of range-of-motion. This is particularly true in cases of chronic throwing shoulder injuries where regaining the right amount of external rotation is crucial for return to high level function. Adding in some work on cuff strength/timing, scapular control, and thoracic mobility before hopping in a sling for 4-6 weeks probably wouldn't hurt the case, either. And, as an added bonus, if this was more common, I think we'd find quite a few people who just so happen to become asymptomatic, allowing them to cancel their surgeries. It's probably wishful thinking on my part, but that's what these random thoughts articles are all about.
For more information on approaches to evaluating, coaching, and programming for the shoulder, be sure to check out Sturdy Shoulder Solutions.
Have a great weekend!
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We're excited to announce our next Elite Baseball Mentorship offering: a lower-extremity course that will take place on August 21-23, 2016 at our Hudson, MA facility.
The Cressey Sports Performance Elite Baseball Mentorships provide an educational opportunity to become a trusted resource to this dramatically underserved athletic population. Through a combination of classroom presentations, practical demonstrations, case studies, video analysis, and observation of training, you’ll learn about our integrated system for performance enhancement and injury prevention and rehabilitation in baseball athletes. Cressey Sports Performance has become a trusted resource for over 100 professional players from all over the country each off-season, and this is your opportunity to experience “why” first-hand at our state-of-the-art facility.
Course Description:
The Lower Extremity Cressey Sports Performance Elite Baseball Mentorship complements our upper extremity course by introducing attendees to the most common injuries and movement impairments encountered by baseball players in a sport that combines violent extension, rotation, change-of-direction, acceleration, and top speed sprinting. Core control and lower extremity function considerations will be applied to the throwing and hitting motions.
Course Agenda:
Sunday
Morning Session: Lecture
8:30-9:00AM – Registration and Introduction (Eric Cressey)
9:00-10:00AM – Movement Impairments of the Lower Extremity and Core (Eric Schoenberg)
10:00-11:00AM – Common Injuries and their Mechanisms (Eric Cressey)
11:00-11:15AM – Break
11:15AM-12:15PM – Common Mistakes in Training and Rehabilitating the Core and Lower-Extremity (Eric Schoenberg)
12:15-1:00PM – Lunch (provided)
Afternoon Session: Lecture and Video Analysis
1:00-2:00PM – Understanding and Managing Asymmetry in Rotational Sport Athletes (Eric Cressey)
2:00-3:15PM – Video Evaluation of Throwers: Lower-Extremity Considerations for Push-off and Foot-Plant (Matt Blake)
3:15-3:30PM – Break
3:30-4:45PM – (Matt Blake) – Video Evaluation of Hitters: Lower-Extremity Demands and Sequencing
4:45-5:30PM – Case Studies and Q&A
5:30PM Reception (Dinner Provided)
Monday
Morning Session: Practical
8:00AM-10:00AM – Lower-Extremity Physical Assessment: Static and Dynamic (Eric Cressey and Eric Schoenberg)
10:00-11:30AM – Lower-Extremity Prehabilitation/Rehabilitation Exercises (Eric Cressey and Eric Schoenberg)
11:30AM-12:00PM – Lunch (on your own)
Afternoon Session: Observation at Cressey Sports Performance – 12PM-6PM*
Tuesday
Morning Session: Practical
8:00AM-9:30AM – Training Power Outside the Sagittal Plane (Eric Cressey and Eric Schoenberg)
9:30-11:00AM – Individualizing Driveline to the Pitcher (Matt Blake)
11:30AM-12:00PM – Lunch (on your own)
Afternoon Session: Observation at Cressey Sports Performance – 12PM-6PM*
* The afternoon observation sessions on Monday and Tuesday will allow attendees to see in real-time the day-to-day operation of the comprehensive baseball training programs unique to Cressey Sports Performance. This observation of live training on the CSP floor with our professional, college, and high school baseball players will allow you to experience firsthand our approaches to:
• Programming
• Proper coaching cues for optimal results
• Soft tissue techniques
• Activation and mobility drills
• Strength/power development
• Medicine ball work
• Multi-directional stability
• Metabolic conditioning
• Sprint/agility programs
• Base stealing technique
In addition, you will experience:
• Live throwing sessions
• Biomechanical video analysis using the Right View Pro system
• Movement evaluation
• Live evaluations of attendees with Eric Schoenberg
Location:
Cressey Sports Performance
577 Main St.
Suite 310
Hudson, MA 01749
Cost:
$999
No sign-ups will be accepted on the day of the event.
• No prerequisites required.
• Participants will receive a manual of notes from the event’s presentations.
• Space is extremely limited
• We are keeping the size of this seminar small so that we can make it a far more productive educational experience.
•This event will not be videotaped.
For details about travel, accommodations, and other logistics, please email cspmass@gmail.com.
Over the past year or so, Cubs pitcher Jake Arrieta has been a highly celebrated MLB athlete not only for his dominant performances (including two no-hitters) on the mound, but also for "reincarnating" his career with a new organization. Previously, Arrieta had been a member of the Baltimore Orioles organization - and while he had been a Major League regular, his performance had been relatively unremarkable. That all changed when he arrived in Chicago.
Source: Yahoo Sports
In Tom Verducci's recent piece for Sports Illustrated, Arrieta detailed that his struggles with the Orioles were heavily impacted by constant adjustments with everything from mechanics, to pitch selection, to where he stood on the rubber. He was even quoted as saying, "I pitched for years not being comfortable with anything I was doing. I was trying to be somebody else."
I'm always cautious to take everything I hear in the sports media with a grain of salt, and this blog is certainly not intended to be a criticism of anyone in the Orioles organization. However, what I can say is that this story isn't unfamiliar in the world of Major League Baseball. There is a lot of overcoaching that goes on as many coaches try to fit pitchers and hitters into specific mechanic models. In other words, rather than looking for ways to make Jake Arrieta into the best Jake Arrieta possible, some coaches look to make athletes into Greg Maddux or Nolan Ryan - and they usually wind up with Henry Rowengartner (minus the arm speed).
This "phenomenon" isn't confined to baseball, however. In his outstanding book, The End of Average, Harvard professor Todd Rose, writes: "The real difficulty is not finding new ways to distinguish talent; it is getting rid of the one dimensional blinders that prevented us from seeing it all along." Moreover, he adds, "We live in a world that demands we be the same as everyone else - only better - and reduces the American dream to a narrow yearning to be relatively better than the people around us rather than the best version of ourselves."
As Rose notes, we can extend this concept to the idea of standardized testing for students and conventional hiring procedures for new employees, both of which often overlook the brilliant individuals among us who may be wildly capable of remarkable contributions if put in the right situations. In short, pushing the "average" rarely allows anyone to demonstrate - let alone leverage - their unique potential.
This is where coaching becomes more of an art than just a science. On the pitching side of things, we know there are certain positions all successful pitchers get to in their deliveries - and there are certainly bad positions they should probably avoid to stay healthy. With that said, we have to "reconcile" this knowledge with the realization that some of these "bad positions" may help pitchers generate greater velocity, influence pitch movement, or add deception. If we try to change them - especially at the highest level - we may take away exactly what makes a pitcher successful.
You can draw parallels in a lifting environment. Some of the best deadlifters of all time pull conventional, and others use a sumo stance. Their individual anthropometry, training histories, and success to date govern the decision of how to pick heavy things up off the ground.
It's important to note, however, that it's very easy to play Monday Morning Quarterback in situations like these, as hindsight is always 20/20. Long-time CSP athlete Corey Kluber won the American League Cy Young award in 2014 in large part because he switched to a 2-seam fastball with the help of Indians pitching coaches Ruben Niebla and Mickey Calloway. And, another long-time CSP athlete, Jeremy Hazelbaker, is one of the feel-good stories of Major League Baseball after a subtle adjustment to his swing from a Midwest hitting coach, Mike Shirley, yielded huge results and put him on the Cardinals opening day roster after seven years in the minor leagues.
Arrieta's Cubs teammate Jason Hammel spent some time with us at Cressey Sports Performance this off-season and made some mechanical adjustments, and he is off to a good start with a 4-0 record and 1.85 ERA. The point is that we hear a lot more about failures than we do about success stories, and it's really easy to rant when things don't work out. Subtle adjustments that keep guys healthy and confident don't always show up on the radar - and as a result, some really important and tactful coaches from all walks of life don't always get the recognition they deserve.
So when is it right to tinker on the coaching side? And, are there commonalities among what we'd see in pitchers, lifters, and other facets of the performance world? Here are seven questions I think you need to ask to determine whether the time is right to make a change:
1. Has the athlete been injured using the approach?
If an athlete can't stay healthy, a change might be imperative.
2. Has the athlete stagnated or been ineffective with the approach?
The more an athlete struggles doing it his way, the more open he'll be to modifying an approach. Career minor leaguers will buy in a lot easier than big leaguers - and the minor leaguers definitely have much less to lose if things don't work out. Conversely, Jason Hammel already had over eight years of MLB service time before I even met him; we weren't about to drastically change things.
3. Is the athlete novice enough that a change is easy to acquire and implement?
It's a lot easier to correct a 135-pound deadlift than it is to correct a 500-pound deadlift. You're best of fixing faulty patterns before a lifter has years to accumulate volume of loading the dysfunction. This is one reason why I'd rather work with a young athlete before he has a chance to start lifting on his own; there aren't any bad patterns to "undo."
4. What's the minimum effective dose that can be applied to "test the waters" of change?
Can a "tinker" be applied instead of an "overhaul?" Switching from a 4-seam fastball to a 2-seam fastball is a lot less aggressive than switching from a 4-seam fastball to a knuckleball. And, it's probably easier to go from an ultra-wise sumo deadlift to a narrower sumo stance than it is to go all the way to a conventional set-up.
5. How can you involve the athlete in the decision-making process with respect to modifications?
The concept of cognitive dissonance tells us that people really don't like conflict and generally like to avoid it. This works hand-in-hand with the concept of confirmation bias; we like to hear information that agrees with our beliefs and actions. In their fantastic book, Decisive, Chip and Dan Heath write, “In reviewing more than 91 studies of over 8,000 participants, the researchers concluded that we are more than twice as likely to favor confirming information than dis-confirming information.” Furthermore, the Heaths note, “The confirmation bias also increased when people had previously invested a lot of time or effort in a given issue.”
How, then, can we involve our athletes and clients in the decision-making process so that they effectively feel that the necessary changes are their ideas? And, can we regularly solicit feedback along the way to emphasize that it's "their show?"
6. How can we change the situation rather than the person?
In Switch: How to Change Things When Change is Hard, another great read from the Heath brothers, the authors note that you will almost never effect quick change a person, but you can always work to change the situation that governs how a person acts. If a pitcher's velocity isn't very good in the first inning (particularly during colder times of year), there's a good chance he needs to extend his warm-up. However, many pitchers are very rigid about messing with pre-game routines. Maybe you just encourage him to do more of it inside where it's warmer, or have him wear a long-sleeve shirt until he starts sweating. Here, you're impacting his surroundings far more than his beliefs.
7. Can the change be more efficiently implemented utilizing an athlete or client's learning style?
All individuals have slightly different learning styles (one more reason "average"coaching isn't optimal). Some athletes simply need to be told what to do. Others can just observe an exercise to learn it. Finally, there are those who need to actually be put in the right position to feel and exercise and learn it that way. And, you can even break these three categories down even further with more specific visual, auditory, and kinesthetic awareness coaching cues. The more we understand individual learning styles, the more we can streamline our coaching with clear and concise direction. If a adjustment is perceived easy to understand and implement, an athlete will be far more likely to "buy in."
Closing Thoughts
On the whole, I think there is a lot of over-coaching going on in today's sports. Above all else, I think us coaches need to talk less and listen more so that athletes can be athletic. And, when a change is warranted, we need to make sure it's a tinker and not an overhaul - and it's important to give an athlete or client and ownership stake in the process.
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In a 2016 meta-analysis, researchers examined the existing body of research on latissimus dorsi and teres major strains in professional baseball pitchers. While the collective sample size was small (30 total athletes), one resounding theme was present:
Lat strains can be pain in the butt to rehabilitate.
In these studies, 29 pitchers were managed conservatively, while one pitcher required surgery for the issue. In the conservative group, the average return-to-pitching timeline was 100 days, whereas the surgical case was 140 days." Perhaps of more significance, though, the researchers noted that "five patients in the conservative group suffered from complications and/or setbacks during their treatment and rehabilitation."
We have to keep the sample sizes in these studies in mind, too. They haven't had a large pool from which to draw, and many researchers might not appreciate how different "return-to-pitching" is than "feeling like your old self." The general consensus among guys I know who have had the surgery seems to be that it's 8-10 months before you're back to feeling 100% in games.
Let's face it: if you're missing 3.5-5 months with an injury - and adding even more time to get back to 100% - you might as well just cash in an entire season. That's not only a lot of money wasted on disabled list time at the Major League level, but also a lot of lost developmental time in the minor league ranks.
To make matters worse, the rehabilitation process can be delayed because lat strain diagnoses can be somewhat challenging. According to Dr. Leon Scott, a sports medicine physician and Assistant Professor of Orthopaedics & Rehabilitation at Vanderbilt University, "Because lat strain diagnoses aren't all that simple to make, especially if a physician’s exam is limited and relies heavily on an MRI, they are often a missed diagnosis. A standard MRI may not be distal enough to capture the area of injury. Arthrogram images are an even smaller field, leading to a missed diagnosis." He also notes that in one acute lat injury he saw in the past, "With a wide field shoulder MRI, there was acute edema, hematoma seen at the bone-tendon interface. It was hard to miss." In short, ordering physicians may be trying to use a narrow imaging technique for a shoulder injury when they should be painting with a broader brush that would also pick up an upper arm injury.
Source: By Anatomography (en:Anatomography (setting page of this image)) [CC BY-SA 2.1 jp (http://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)], via Wikimedia Commons
One professional player I saw struggled with getting a definitive diagnosis that his lat strain needed surgery for two years. At first, they suspected his anterior shoulder pain was occurring because of a labral tear, but a labral "clean-up" surgery didn't change his symptoms. Perhaps more interesting, though, the surgeon didn't even see the lat tear while he was doing the arthroscopic intervention. Five months later, another surgeon went in to repair the lat - which was actually significantly detached from the bone.
The first take-home message here is that if you're a thrower and you have shoulder pain, you need to make sure that you see a sports medicine physician who sees a lot of throwing injuries. A lat strain can be a tricky diagnosis, and even the most well-intentioned physicians may not know to look for it. This is especially because it often presents as pain in the front of the shoulder, in the event of a tendinous injury. You can see this clearly demonstrated by the attachment points in the image above, but I'll take more about this later when we get to functional anatomy.
As I pondered the research article and actually discussed it with a few of my staff members, I realized that we have literally never had a lat strain happen with one of our regular clients at Cressey Sports Performance - and we see a lot of pitchers. I say this not to brag (or jinx us), but rather to just bring to light that success leaves clues - which I'll also get to later on in this article.
That said, I should note that my ideas in this article also draw heavily on our experiences working with a lot of frustrated pitchers who have come to work with us after the injury has occurred because they need help bouncing back. Failures (in this case, injuries) also leave clues.
Before we get to all these observations and potential countermeasures to prevent lat strains, I think it's incredibly important to discuss the functional anatomy of the latissimus dorsi and teres major. And, as an extension, we'll discuss how this functional anatomy understanding needs to be put alongside biomechanics research and anecdotal observations of injured athletes to pull together a hypothesis for the "perfect storm" of lat injury risk.
Functional Anatomy
The latissimus dorsi is a big muscle with huge functional implications.
It attaches on the thoracolumbar fascia (lower back) and runs all the way up to the intertubercular groove of the humerus (front of the upper arm). This is why it has to be considered as a differential diagnosis for anterior shoulder pain in throwers - alongside everything from biceps and rotator cuff tendinopathy or tears, to labral injuries, to anterior capsule injuries, to thoracic outlet syndrome.
As an interesting aside, there are a number of anatomical variants present along this lengthy anatomical course. In a small percentage of people, the lat actually attaches on the ilium (top of the pelvis). In just under half of individuals, it has a direct attachment on the scapula. The number of costal (rib) and vertebral attachments also varies from person to person.
Everyone knows about the functions of the lat at the shoulder - extension, adduction, internal rotation, and horizontal abduction - but in consideration of this expansive functional anatomy profile, we have to appreciate that it has several other key roles to consider.
Lat is a key core stabilizer - to the point that it can be heavily overused and pull athletes into a "gross extension" pattern. Notice the big anterior pelvis tilt and lordosis here - but also take note of the position of humeral extension (and the indirect effects on forward head posture).
Given its attachment on the scapula in some individuals - and the indirect impacts of "crossing" the scapular region - the lat also contributes to scapular depression.
Finally, it's been theorized that an aberrant, extension-biased posture would interfere with optimal diaphragmatic function (via loss of the zone of apposition). Because the lat is also an accessory respiratory (inhalation) muscle, you could say that it has to pick up the slack for a problem it actually helps create! My favorable experiences with the Postural Restoration Institute and my own anecdotal observations definitely support this theory.
Source: www.PosturalRestoration.com
For all intents and purposes, you can view teres major as a "mini-lat." It shares the same scapula-to-humerus functional relationship and actions, but doesn't impact the rib cage or lumbar spine directly.
Implications for Throwers
By appreciating the functional anatomy of the lat, we can recognize just how vital it is to throwing a baseball hard. In short, it connects the lower body to the upper body to allow for force transfer that ultimately leads to arm speed and ball velocity.
Not surprisingly, a 1987 study from Gowan et al. observed that lat recruitment during the acceleration phase of throwing was substantially higher in professional pitchers than in amateurs. Not surprisingly, experienced, accomplished athletes know how to use big-boy muscles (prime movers) to do big-boy jobs (accelerate the arm, which is the fastest motion in all of sports). The amateur pitchers actually continued to heavily rely on smaller, stabilizing muscles - the rotator cuff, biceps, and posterior deltoid - during acceleration. That's not a safe or effective long-term strategy.
This is likely why we rarely see lat strains in younger athletes; you probably have to throw 90mph+ to effectively "use" the lat, and muscles that don't get used usually don't get strained. The younger kids are more likely to have rotator cuff pain, irritation of the long head of the biceps tendon, or proximal humeral growth plate issues.
There's a bit more to "lat overuse" than just the acceleration phase of throwing, though. During the lay-back (extreme cocking, or maximum external rotation) portion of throwing, the lat and teres major are two of several muscles (including notables like subscapularis pectoralis major) that are working eccentrically to prevent the humerus (upper arm) from flying off the body.
This eccentric pre-stretch also helps to store elastic energy that is subsequently released during the acceleration phase to create ball velocity. Most muscle strains occur - whether it's acutely or chronically - as muscles and tendons are stretched during the eccentric phase of activity. Hamstrings strains usually occur at the terminal swing phase of sprinting. Middle-aged men rupture Achilles tendons when they land on dorsiflexed ankles - where the calves are maximally stretched. The lats and teres major are the most overstretched at this lay-back phase of throwing.
On a chronic note, repeated exposures to aggressive eccentric stress can lead to muscle shortening. Reinold et al (2012) demonstrated this with respect to elbow extension and shoulder internal rotation. My experience has been that pitchers who trend toward the "tight" end of the continuum also lose shoulder flexion and "true" external rotation over the course of the season. As I describe in the video below, this is very likely related to stiffness or shortness in the lats - and the research has demonstrated that it is associated with an increased risk of elbow injuries in pitchers.
Beyond just the specific roles of the lats during the throwing motion, we have to also appreciate that they're heavily overused during daily life because of their roles as core stabilizers and accessory respiratory muscles. And, given that we don't spend a lot of time in our daily lives with our arms overhead and shoulders externally rotated, they aren't afforded a whole lot of length throughout the day. Take a chronically shortened muscle, overuse it, and then throw it into the fastest motion in all of sports, and you've got a recipe for strains. However, you can't throw hard without it. Hence, this Tweet from me a few years ago:
Having established the injury mechanisms, it's important to also consider why lat strains in throwers take so long to rehabilitate. I see four primary reasons that differentiate lat strains from just "any other muscle strain:"
First, as we noted earlier, early diagnosis may not happen. This can occur because the athlete just ignores the issue as normal soreness, or they manage it as "biceps tendonitis." Or, a physician may not recognize that a lat injury could create anterior shoulder symptoms. Finally, a typical MRI might just miss the injury altogether. All these factors can potentially lead athletes down the wrong rehabilitation path.
Second, my experience has been that many of these injuries are far more chronic than they are traumatic. More often than not, when you dig deeper into the history of a pitcher who has a lat strain, he's thrown through some kind of extended soreness/discomfort for weeks, months, or years. Eventually, it becomes too much to stand and begins to significantly interfere with pitching performance. Given that the issue developed over an extended period of time, it isn't going to go away overnight.
Third, as I discussed in my functional anatomy musings earlier, the lats are heavily involved in multiple planes of motion. I've theorized in the past about how muscles that play crucial roles in multiple plans are more likely to be stubborn rehabilitation projects:
Pull a quad (rectus femoris), and you’ll usually bounce back really quickly. Pull an oblique and it’s much more stubborn. What’s the difference? The rectus femoris is really all about the sagittal plane, whereas the obliques have a big role in controlling excessive motion in the sagittal, frontal, and transverse planes. The more complex the job of the muscle, the more significant the injury – and the longer the rehab. Hamstrings have roles outside the sagittal plane and can be equally stubborn, too.
Fourth, the proximal humerus (upper arm) area really seems to scar down faster than almost any other region in the body - and this is particularly true of throwing shoulders because of the eccentric stress pitchers encounter. There are 17 muscles that attach to the scapula, and most of these structures cross the glenohumeral (ball-and-socket) joint. Perhaps more significantly, eight of these tendons attach in close proximity to the insertion of the latissimus dorsi and teres major. Throw eight tendons in a very small area that experiences a lot of eccentric stress, and you'll wind up with a gritty, fibrotic mess eventually.
Injury Risks
Whether it's a chronic or traumatic onset lat issue in a pitcher, one theme always seems to hold true: symptoms emerge after a dramatic increase in throwing stress.
On multiple occasions, I've seen lat strains that have come about because a reliever pitcher was moved into the starting rotation without a gradual increase in pitch count.
In other instances, the lat got cranky after a big velocity jump in a single off-season. This is usually the case in a high school kid who jumps from 84 to 94mph in a single winter. As my friend Derek Johnson, the pitching coach for the Milwaukee Brewers has said, the "arm is writing checks the butt can't cash."
Sometimes, it may come about after a single outing with an abnormally high pitch count. The pitcher just can't bounce back in time for the next start, and the subsequent start becomes the straw that breaks the camel's back. y experience has been that when you throw the typical "high arm speed" (90mph+) high school pitcher out for back-to-back outings of 100+ pitches - even on a seven-day rotation - things often start to head down the wrong path. This doesn't happen nearly as frequently in the college game, and I think this speaks to the fact that there is clearly something really important that's occurring in terms of work capacity and/or strength improvements for pitchers in the 16-19 age range.
Finally, lat issues seem to be particularly common when you see high school and college starters switch from a 7-day rotation to a 5-day rotation when they enter professional baseball. It isn't as much of a dramatic increase in stress as it is a significant loss in recovery time or capacity. I've heard many guys over the years say that they have to learn to pitch with only 90% of what they're typicaly capable.
Movement Quality
Beyond just the increase in throwing stress, there are a few things I've found to be common in the lat strain pitchers I've seen in recent years.
1. The lower traps can't keep up with the lat.
The lower traps are very important for providing posterior tilt (slight tipping back) of the scapula and assisting in upward rotation. These two functions make it essential for a pitcher to get his scapula in the right position during the lay-back phase of throwing.
Conversely, the lat has more of a "gross" depression effect on the scapula; it pulls it down, but doesn't contribute to posterior tilting or upward rotation. This might help with an adult rotator cuff pain patient who has an aggressive scapular elevation (shrug) substitution pattern, but it's actually problematic for a thrower who is trying to get his scapula up and around the rib cage to make sure that the ball-on-socket congruency is "flush" when it really matters:
As such, you can say that the lat and lower trap "compete" for scapular control - and the lat has a big advantage because of its cross-sectional area and multiple attachment points. It's also much easier to train and strengthen - even if it's accidentally.
To this end, we'll often hear throwers cued "down and back" during their arm care drills. The intention - improving posterior tilt via lower trap activation - is really good, but the outcome usually isn't. Unless athletes are actually put in a position of posterior tilt where they can actually feel the lower traps working, they don't get it. Instead, they pull further down into scapular depression, which feeds the lat-dominant strategy. This is why we teach almost all our throwers to differentiate between depression and posterior tilt on their first day in the gym.
2. The rotator cuff can't keep up with the lat.
As I noted earlier, the lat has numerous functional roles at the shoulder. Because the attachment point of the lat is on the shaft of the humerus and not the ball, the lat really can't have any direct control on the positioning of the ball in the socket. In fact, it actually indirectly destabilizes the throwing shoulder because it contributes to an anterior (forward) gliding of the ball on the socket during the lay-back phase of throwing. This anterior glide is counteracted by the rotator cuff musculature.
Whenever we evaluate movement, we have to consider both osteokinematics (gross movements - flexion, extension, etc. - of bones at joints) and arthrokinematics (subtle movements - rolling, rocking, gliding, etc. - of bones at joint surfaces).
To paraphrase something that physical therapist Shirley Sahrmann has noted many times, whenever you see a strained or overworked muscle, look for a dysfunctional synergist. In this case, the synergists to the lat and teres major are the rotator cuff muscles. We just rarely consider lat strains as a consequence of rotator cuff weakness because it's usually the biceps tendon, labrum, capsule, or rotator cuff itself that winds up cranky before the lat starts barking.
3. Guys usually have a history of doing a lot of lat dominant lifting.
In a baseball population, throwing is lat dominant. Breathing is lat dominant. Core stabilization is lat dominant. When you add in a lot of lat dominant lifting to the mix - particularly during the in-season period - things don't usually go well. I'm just going to put this out there:
[bctt tweet="I've never met a high-level thrower who had weak lats."]
I'm speaking with respect to both relative and absolute measures. Relatively speaking, I've never looked at a guy and said, "Well, if he added 50 pounds to his best weighted chin-up, he'd definitely throw harder and be healthier. His rotator cuff and lower traps are too strong." Absolutely speaking, I have yet to see any research examining the relationship between lat strength and throwing velocity. I'm very confident that there is a point of diminishing returns where getting stronger doesn't help add any more velocity. Moreover, it may actually interfere with improvements - and increase susceptibility to injury. This includes elbow irritation, as heavy weighted pull-ups and chin-ups are brutal on the medial elbow in lifters who don't even throw a baseball for a living.
Just like you don't have to squat 800 pounds to have an elite vertical jump - but you probably won't jump high if you only squat 200 pounds - your lats just need to be strong enough to throw hard.
Also worthy of mention is the fact that exercises like deadlifts, farmer's walks, and dumbbell lunges, and any other drill where weights are held in the hands are actually very lat intensive. With the arms at the sides, the lats are almost fully shortened - and the lat is working hard as a core stabilizer against appreciable external loading.
The take-home message is that you really have to critically examine your entire strength training program for how much lat-dominant work your athletes are doing. My rule of thumb is that an athlete has to have full shoulder flexion and great cuff strength to "earn the right" to do pull-ups in his off-season programming, and we don't use any pull-ups or pulldowns with in-season programs. We can accomplish everything we need with horizontal pulling variations.
4. Guys usually accumulated a lot of innings or appearances without much, if any, manual therapy
NASCARs require more upkeep that ordinary automobiles. If you're going to push a car to its limits, you better plan on changing the oil and tires more frequently. The same goes for a high level throwing arm. Manual therapy is a game-changer for maintaining or improving range-of-motion and bouncing back between outings.
The lats and teres major get pushed really hard during the throwing motion, and it's important to do regular routine manual therapy maintenance to keep them "supple" with a variety of soft tissue approaches. I've seen athletes that responded really well to cupping, some to Graston Technique, some to Active Release Technique, some to dry needling, and others to more traditional massage. Everyone is different - but everyone needs it.
Also worth of note, trigger points in the latissimus dorsi may actually relate to discomfort in other regions. Chris Howard, massage therapist at Cressey Sports Performance – MA, notes:
“Trigger points in the latissimus dorsi can refer pain and discomfort to the medial and inferior border of the scapula extending to the posterior shoulder, medial triceps region and down to the pinky and ring finger. Trigger points not only cause pain, but can also mimic nerve symptoms by causing numbness and tingling in their referral zone. Of particular interest to this article is the fact that trigger points, regardless of whether they are active or latent, have the ability to alter muscle activation patterns. In other words, once trigger points are present in muscles of the shoulder girdle, the normal activation pattern is altered, which can lead to abuse of some of the smaller muscles.”
5. Guys have insufficient anterior core control.
The stiffer (or shorter) your lats are, the more you need to have great anterior (front) core control to prevent this from happening:
When the core control isn't present, the lats are never really challenged to approach their end range - which is full shoulder flexion. Learning to add some good stiffness to lock the ribs to the pelvis during overhead motion obviously protects the lower back, but it also has the added benefit of making lats "healthier."
6. They turn all rowing motions into lat dominant movements.
Rather than reinvent the wheel on this point, check out this detailed rowing technique video I filmed a while back. In particular, points #1, #2, #4, and #6 are the most common findings in a very lat-dominant individual. I'd encourage you to watch the entire video, though, as it's not uncommon to see multiple mistakes at a time:
7. Guys have lost shoulder flexion.
If a muscle is fundamentally short, it's going to be more likely to strain. These are usually the ones who have failed miserably on points 1-6 over an extended period of time.
Prevention
Several years ago, in the heart of the ACL prevention program craze, Mike Boyle made a bold statement, "ACL injury prevention is just good training." In short, if you teach athletes to move well with comprehensive, well-rounded programming and solid coaching to ensure good training technique, you're going to markedly reduce the incidence of ACL injuries. I couldn't agree more - and I'd argue that lat strain prevention training in pitchers is just good training, too.
1. Maintain tissue quality with regular manual therapy, and complement it with daily foam rolling.
2. Make athletes earn the right to do pull-ups.
3. Don’t do pull-ups/pulldowns during the season.
4. Make sure that the rotator cuff, lower trap, and anterior core are strong enough to keep up with the lats.
5. Be cognizant of overdoing it on drills like deadlifts, farmers walks, and DB lunges/split squats. These are all great exercises that can have their place, but anything done to excess can be a problem.
6. Ensure appropriate training technique. Specifically, don't overuse the lats when you aren't supposed to use them at all.
7. Closely monitor athletes who have seen dramatic jumps in pitching velocity or workload - and avoid building up pitch counts too quickly.
8. Constantly solicit feedback from pitchers so that mild lat soreness is discovered before it can become a full blown injury.
Obviously, once an athlete already has a teres major or lat strain, things are a lot hairier. That's really the point of the article, though: as always, prevention is the absolute best treatment.
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Today, I'm fortunate to have an interview with Yahoo Sports baseball writer, Jeff Passan. Jeff spent the past few years traveling the country to research why arm injuries in pitchers are at an all-time high, and his efforts culminated with the recent release of The Arm. I've read it, and it's fantastic.
EC: Why did you write this book?
JP: Originally, I wrote it because I thought maybe, just maybe, through reporting and research I could find a fix-all for elbow injuries and help rid the sport of Tommy John surgery. What I learned was that I was foolish to even conceive of that, considering people far smarter than I am have dedicated their careers to ramming dead ends. Because of that, while I still think the recoveries of Daniel Hudson and Todd Coffey are the heart of the book, I began to realize just how acute this is for children. When nearly 3 in 5 Tommy John surgeries is done on a teenager, and the rise of teenage surgeries has gone in lockstep with the ascent of the showcase circuit and desire for velocity, something is very wrong. This is a book about a lot of things. I hope amid those, the lessons to parents resonate and cause them to think twice this spring about sending their young kids especially back out for an extra inning or keeping them in the game too long.
EC: Let's stay with the teenage discussion, as I've been preaching about this problem it for a decade now! When you investigated the current state of teenage baseball, what did you find? And, what surprised you the most?
I found a wasteland of ignorance, greed and scars on the elbows of children. I always heard executives complaining off-handedly about the showcase circuit but didn't realize the pervasive grasp it has on the youth space. Major League Baseball's greatest failure was allowing a for-profit company to co-opt its pipeline. As much as Perfect Game wants to claim moral superiority and a concern for the arms of children, reality tells a different story. Showcases 11 months of the year. Radar guns trained on infielders throwing across the diamond. Out-of-control pitch counts for arms simply too young to handle the workload. And that's to say nothing of actively seeking out sub-standard players to fill out an event. The commodification of children is gross, and encouraging performance and winning over development at young ages simply reinforces some of the same principles that I fear ultimately lead to arm injuries.
EC: Many people claim these issues are isolated to just the United States, and that the Far East and Latin American are immune. They deny that arm injuries are occurring at high rates in these areas; what did you find?
At the major league level, one's ethnicity does not make him any likelier to hurt himself. The numbers are pretty flat across the board. We see with Latin American players how that manifests itself because so many spend their formative years in the minor leagues and we witness their ascent and, in unfortunate cases, injury. Japanese pitchers, on the other hand, have a reputation of clean mechanics and hard work, and while that may be true, the results are devastating. It's not just the recent study that showed 40 percent of a sample of 9- to 12-year-old Japanese children had suffered ulnar collateral ligament damage. It's what I saw first-hand: Little boys, some so young their adult teeth still weren't fully grown in, coming into a clinic especially for baseball players and being diagnosed with an arm injury. Avulsion fractures. Frayed ligaments. OCD lesions. You name it, these kids had it. And it made me wonder how the Japanese baseball culture can live with itself knowing that it's choosing blind tradition over something as fundamental as the health of children.
EC: Everyone likes to play Major League Baseball general manager on the internet, but I'm going to do you one better. I'll let you be MLB commissioner and task you with determining how to address the injury epidemic that's spanning from youth leagues all the way to MLB veterans. How do you handle it?
JP: Wow. OK. So, I'm assuming an unlimited budget here, because a lot of these things are going to take money. Let's start with the kids first. I appreciate what Pitch Smart is trying to do. I also think it's not conservative enough with the youngest kids. If baseball is injuring its youngest players -- and doctors and studies alike believe it is -- we need to focus on the two likeliest culprits: overuse and excessive maximum-effort throwing. Curb the first with lower pitch limits. It's not like 8- or 9-year-old kids need to be building toward triple-digit pitches. And in concert with that, advocate an epistemological change in how we approach youth baseball: as an apparatus for development over competition. Don't get me wrong. Competition is great. But if competitiveness in this space leads to the things that lead to an increase in injuries, we can satisfy our competitive jones elsewhere and instead emphasize developing safer development and the importance of control and command over velocity. This demands better coaching, and free coaching clinics run by MLB-trained advocates at least gives us a better chance of empowering those whose voices are critical with the necessary education.
There are so many more things in the youth space I could do, but I want to move on to the pros, because if I were in power and had carte blanche, the first thing I would do is force the 30 teams to abandon their injury-prevention fiefdoms and band resources to help start solving this problem. This is a matter of the greater good. Baseball as a sport is facing another generation of pitchers arriving with Tommy John surgery scars on their elbows, and if a team found something that could mitigate injuries, those children deserve to know. I understand the desire for a competitive advantage. I also see this as a moral imperative for baseball to do what it can to solve it. Beyond that, continuing to fund the current epidemiological studies, working hand in hand with the tech companies -- so many of which seem to have a problem getting their products to market -- and pioneering in-house research through a think tank-like establishment devoted not just to the arm but varying other ends of research. In other words, I'd throw the full weight of MLB behind this, not just monetarily but starting with the first commercial of the World Series, which is a close-up camera shot first on Matt Harvey's elbow, then Stephen Strasburg's, then Jose Fernandez's. And as the camera pans back to reveal their familiar faces, each says: "This could be you." Then some stats on year-round baseball -- oh, yeah; as commissioner, I'd shut that down and hold twice-a-year showcases at which the top prospects can show up and show off their stuff for everyone in the industry, like a combine -- and some other scary numbers and, boom: Immediate education on Tommy John surgery through people not wearing white lab coats.
EC: Thanks for joining us, Jeff! Whether you're a baseball player, coach, parent, scout, or fan, I'd strongly encourage you to pick up a copy of The Arm.
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Happy Monday, folks. I hope everyone had a great weekend. We brought our twin daughters to their first MLB game yesterday, and they did surprisingly well, behaving through all nine innings! Hopefully, this momentum carries over into the rest of the week. Here's some good strength and conditioning reading to get the ball rolling:
