Home Posts tagged "Tommy John Surgery" (Page 3)

Pitching Injuries: It’s Not Just What You’re Doing; It’s What You’ve Already Done

A while back, this article on pitching injuries became the single-most popular piece in EricCressey.com history:

Your Arm hurts?  Thank Your Little League, Fall Ball, and AAU Coaches

In that feature, I made the following statement:

We can do all the strength training, mobility work, and soft tissue treatments in the world and it won’t matter if they’re overused – because I’m just not smart enough to have figured out how to go back in time and change history. Worried about whether they’re throwing curveballs, or if their mechanics are perfect?  It won’t matter if they’ve already accumulated too many innings.

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

Sure enough, just yesterday, reader Paul Vajdic sent me this article from the Shreveport Times. The author interviews world-renowned orthopedic surgeon Dr. James Andrews about the crazy increase in the number of Tommy John surgeries he'd performed over the past decade.

A comment he made really jumped out at me, in light of my point from above:

""I had a kid come in, a 15-year-old from Boca Raton, (Fla.), who tore his ligament completely in two,' Andrews said. 'The interesting thing is when I X-rayed his elbow with good magnification, he has a little calcification right where the ligament attaches to the bone. We're seeing more of that now. He actually got hurt with a minor pull of the ligament when he was 10, 11, 12 years of age. That little calcification gets bigger and, initially, it won't look like anything but a sore elbow. As that matures, it becomes more prominent. It turns into an English pea-size bone piece and pulls part of the ligament off when they're young.'"

In other words, it takes repeated bouts of microtrauma over the course of many years to bring an athlete to threshold - even if they have little to no symptoms along the way.  Injury prevention starts at the youngest ages; otherwise, you're just playing from behind the 8-ball when you start training high school and college players.

In addition to walking away with the perspective that young kids need to be strictly managed with their pitch counts, I hope this makes you appreciate the value of strength and conditioning programs at young ages, too.  For more information, check out my post, The Truth About Strength Training for Kids.

We can't prevent them all, but I do think that initiatives like the IYCA High School Strength Coach Certification in conjunction with pitch count implementation and coaching education are a step in the right direction.

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Weight Training for Baseball: Featured Articles

I really enjoy writing multi-part features here at EricCressey.com because it really affords me more time to dig deep into a topic of interest to both my readers and me.  In many ways, it's like writing a book.  Here were three noteworthy features I published in 2010: Understanding Elbow Pain - Whether you were a baseball pitcher trying to prevent a Tommy John surgery or recreational weightlifter with "tennis elbow," this series had something for you. Part 1: Functional Anatomy Part 2: Pathology Part 3: Throwing Injuries Part 4: Protecting Pitchers Part 5: The Truth About Tennis Elbow Part 6: Elbow Pain in Lifters

Strategies for Correcting Bad Posture - This series was published more recently, and was extremely well received.  It's a combination of both quick programming tips and long-term modifications you can use to eliminate poor posture. Strategies for Correcting Bad Posture: Part 1 Strategies for Correcting Bad Posture: Part 2 Strategies for Correcting Bad Posture: Part 3 Strategies for Correcting Bad Posture: Part 4

A New Paradigm for Performance Testing - This two-part feature was actually an interview with Bioletic founder, Dr. Rick Cohen.  In it, we discuss the importance of testing athletes for deficiencies and strategically correcting them.  We've begun to use Bioletics more and more with our athletes, and I highly recommend their thorough and forward thinking services. A New Paradigm for Performance Testing: Part 1 A New Paradigm for Performance Testing: Part 2 I already have a few series planned for 2011, so keep an eye out for them!  In the meantime, we have two more "Best of 2010" features in store before Friday at midnight. Sign-up Today for our FREE Newsletter:
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More Than Just Pitching Mechanics: The Skinny on Stephen Strasburg’s Injury

Since a lot of folks reading this blog know me as "the baseball guy," I got quite a few email questions about the elbow injury Washington Nationals phenom Stephen Strasburg experienced the other day.  Likewise, it was the talk of Cressey Performance last Friday - and got tremendous attention in the media.  Everyone wants to know: how could this have been prevented?

strasburg

On Thursday's edition of Baseball Tonight, my buddy Curt Schilling made some excellent points about Strasburg's delivery that likely contributed to the injury over time.  Chris O'Leary has also written some great stuff about the Inverted W, which is pretty easily visualized in his delivery.

invertedw

The point I want to make, though, is that an injury like this can never, ever, ever, ever be pinned on one factor.  We have seen guys with "terrible mechanics" (I put that in quotes because I don't think there is such a thing as "perfect mechanics") pitch pain-free for their entire careers.  Likewise, we've seen guys with perfect mechanics break down.  We've seen guys with great bodies bite the big one while some guys with terrible bodies thrive.

The point is that while we are always going to strive to clean things up - physically, mechanically, psychologically, and in terms of managing stress throughout the competitive year - there is always going to be some happenstance in sports at a high level.  As former Blue Jays general manager JP Ricciardi told me last week when we chatted at length, "you've only got so many bullets in your arm."

Strasburg used up a lot of those bullets before he ever got drafted, so it's hard to fault the Nationals at all on this front.  In fact, from this ESPN article that was published when the team thought it was a strain of the common flexor tendon and not an ulnar collateral ligament injury (requiring Tommy John surgery), "Strasburg has told the team he had a similar problem in college at San Diego State and pitched through it."  It's safe to assume that the Nationals rule out a partial UCL tear in their pre-draft MRIs, but you have to consider what a common flexor tendon injury really means.

medialepicondyle

As I wrote in in my "Understanding Elbow Pain" series (of interest: Anatomy, Pathology, Throwing Injuries, and Protecting Pitchers) the muscles that combine to form the common flexor tendon are the primary restraints - in addition to the ulnar collateral ligament - to valgus stress.  If they are weak, overused, injured, dense, fibrotic, or whatever else, more of that stress is going on that UCL - particularly if an athlete is throwing with mechanics that may increase that valgus stress (the Inverted W I noted above) - the party is going to end eventually.  Is it any surprise that this acute injury occurred just a few weeks after Strasburg dealt with a shoulder issue that put him on the disabled list for two weeks?  The body is a tremendously intricate system of checks and balances, and it bit him in the butt.

There are other factors, though.  As a great study from Olsen et al. showed, young pitchers who require surgery "significantly more months per year, games per year, innings per game, pitches per game, pitches per year, and warm-up pitches before a game. These pitchers were more frequently starting pitchers, pitched in more showcases, pitched with higher velocity, and pitched more often with arm pain and fatigue. They also used anti-inflammatory drugs and ice more frequently to prevent an injury."  And, they were also taller and heavier.

valgus

Go back through the last 12-15 years of Stephen Strasburg's life and consider just how many times he's ramped up for spring ball, summer ball, fall ball, and showcases - only so that he can shut down for a week, just to ramp right back up again to try to impress someone else.  Think of how many radar guns he's had to pitch in front of constantly for the past 5-7 years - because velocity is all that matters, right?

Stephen Strasburg's injury wasn't caused by a single factor; it was a product of many.  And, it can't be pinned on Strasburg himself, any of his coaches or trainers, or any of the scouts that watched him.  Blame it in the system that is baseball in America today.

We already knew that this system was a disaster, though.  Yet, people still keep letting their kids go to showcases in December.  Heck, arguably the biggest underclassmen prospect event of the year - the World Wood Bat Tournament in Jupiter, FL - takes places at the end of October.  When they should be resting, playing another sport, or preparing their bodies in the weight room, the absolute best prospects in the country are pitching with dead, unprepared arms just because it's a convenient time for scouts and coaches to recruit - because the season is over.

They're wasting their bullets.

Now, I'm not saying that Strasburg's injury could have been avoided in a different system - but I'd be very willing to bet that it could have been pushed much further back - potentially long enough to allow him to get through a career.  An argument to my point would be that if it wasn't for all these exposures, he wouldn't have developed - but my contention to that fact was that it is well documented that Strasburg "blew up" from a good to an extraordinary pitcher with increased throwing velocity when he made a dedicated effort to getting fit when he arrived at college.

My hope is that young pitchers will learn from this example and appreciate that taking care of one's body is just as important as showing off one's talent.

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Ulnar Collateral Ligament Injuries in Quarterbacks vs. Pitchers

Here's an interesting study on the incidence of ulnar collateral ligament (UCL) injuries in professional football quarterbacks.  With only ten reported cases between 1994 and 2008, it's obviously (and not surprisingly) much lower than the rates we see in professional baseball players.  This is right in line with what I discussed in Weighted Baseballs: Safe and Effective or Stupid and Dangerous?

Bengals Seahawks Football However, what is very interesting to me is that 9/10 cases were treated non-operatively; in other words, Tommy John surgery is much less prescribed in football quarterbacks than baseball pitchers - meaning that the quarterbacks respond better to conservative treatment. What's up with that?  They are the same injuries - and presumably the same rehabilitation programs. In my eyes, it's due to the sheer nature of the stress we see in a baseball pitch in comparison to a football throw.  As a quarterback, you can probably "get by" with a slightly insufficient UCL if you have adequate muscular strength, flexibility, and tissue quality.  While this is still the case in some baseball pitchers, the stresses on the passive structure (UCL) are still markedly higher on each throw, meaning that your chances of getting by conservatively are probably slightly poorer.

elbow

I'm sure that the nature of the sporting year plays into this as well.  Football quarterbacks never attempt to throw year-round, so there isn't a rush to return to throwing.  There are, however, a lot of stupid baseball pitchers who think that they can pitch year-round, so kids often "jump the gun" on their throwing programs and make things worse before they can heal completely. That said, we've still worked with a lot of pitchers who have been able to come back and throw completely pain-free after being diagnosed with a partial UCL tear and undergoing conservative treatment (physical therapy).  It's an individual thing. Related Posts Understanding Elbow Pain - Part 3: Throwing Injuries Understanding Elbow Pain - Part 4: Protecting Pitchers Please enter your email below to sign up for our FREE newsletter.
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Three Years of Cressey Performance: The Right Reasons and the Right Way

Though a somewhat "normal" day at the gym, yesterday marked Cressey Performance's three-year anniversary. While my business partner's blog post yesterday did an excellent job of doling out "thank yous" to a lot of the important people who have been so involved in our success - from clients to parents, coaches, interns, and significant others - I wanted to add my own two cents on the matter today.  More than anything, I really wanted to highlight a sentence that illustrates what makes me the most proud about where CP has been, where it is, and where it's going.

We've done this for the right reasons, and we've done it the right way.

newcp21 I read a business development blog post by Chris McCombs the other day where he wrote something that really hit home for me.  When he was talking about how he decides to accept or reject a new project/opportunity, here is one of his guidelines: "Only Take on Projects That Are In Line With My Current Values and Fulfill Me Beyond Just The Money - A project must fulfill me in some way BESIDE just money...too many people spend their life JUST chasing a buck; to me, that's no way to live.  For me, the money must be there, but it should fulfill me personally, be fun, help a lot of people, and build and be in line with my current brand and brand equity." Back in 2007, I had a tough decision to make.  My online consulting business had really taken off, and the Maximum Strength book deal was in the works.  My other products - Magnificent Mobility, The Ultimate Off-Season Training Manual, and Building the Efficient Athlete - were selling well and getting great reviews, and I'd just had a study published in the Journal of Strength and Conditioning Research.  This website was growing exponentially in popularity, and I had just wrapped up my first year on the Perform Better tour - so lots of doors were opening for me on the seminar front to present all over the world - and I could have stayed home and just written all day, every day. I was getting really crunched for time, as I was already training clients 8-13 hours per day, seven days per week, as my in-person clientele had rapidly grown. My phone rang off the hook for about three weeks after Lincoln-Sudbury won a baseball state championship after I'd trained several of their guys, and one of my athletes was named state player of the year.  And, after being featured on the front page of the Boston Globe with a nipple so hard I could cut diamonds, I was in demand as a t-shirt model (okay, not really - but it made for an awesome blog post, The School of Hard Nipples).

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I was exhausted and stressed - but absolutely, positively, "living the dream" that I'd always wanted. To make matters a bit more interesting, I had just started dating a great girl (now my fiancee) who I really had a good feeling was "the one" after about three months.  The work days, however, were insanely long and I was worried that I'd screw up a good thing by not spending enough time with her. Every business development coach out there would have seen a "simple" answer to all my problems: stop training people in person.  Just write, consult, make DVDs, and give seminars.  It would have cut my hours by 80% and still allowed me to earn a pretty good living - and enjoy plenty of free time.  There was a huge problem with that, though; as Chris wrote, it wouldn't "fulfill me personally, be fun, help a lot of people, and build and be in line with my current brand and brand equity."  I like doing evaluations, writing programs, coaching, sweating, training with my guys, cranking up the music, helping people get to where they want to be, collaborating with and learning from other professionals, and watching my athletes compete - whether it's at some high school field or at Fenway Park.  Giving that up wasn't an option; I guess I'd have just been a crappy business coaching client, as I would have been stubborn as an ass on giving that up.

stubborn

Fortunately for me, Pete Dupuis, my roommate from my freshman year of college, had just finished his MBA and was in the midst of a job search.  And, during that MBA, he'd started to train with me and packed on a ton of strength and muscle mass - making him realize and truly appreciate the value in what I was doing (especially since he was and is a goalie in a very competitive soccer league).  Pete had also met and become friends with a ton of my clients - and taken a genuine interest in my baseball focus, as a lifelong Red Sox fan.  Almost daily, Pete would encourage me to do my own thing and let him handle all the business stuff for me. Simultaneously, Tony Gentilcore was ready for a change of scenery on the work front.  Having been Tony's roommate and training partner for almost two years at that point, I knew he was a genuinely great guy, that he'd read everything on my bookshelf, and that he could coach his butt off and "walk the walk."  He, too, had met a lot of my clients - so there was continuity from the get-go. So, on July 13, 2007, Cressey Performance was born.  Here is what we started with.

first-picture

Boatloads of renovations and equipment additions later, it wound up looking like this.

cressey-performance-1

Of course, we outgrew and demolished this space after about nine months and moved three miles east to a facility twice the size.  And, we've continued to grow right up to this day; June was our busiest month ever, and July should be busier.  We've got regular weekly clients who come from four states (MA, NH, CT, RI), and in the baseball off-season, I have college and pro guys who come from the likes of OH, AZ, CA, SC, NC, GA, FL, and VA.  And, we had 33 applicants for this summer's internships.

To be very candid, though, I don't consider myself a very good "businessman."  No offense to Pete or Tony, either, but I don't think they even come close to the textbook definition of the word, either.  We just try to be good dudes. "We've done this for the right reasons, and we've done it the right way."

We don't allocate a certain percentage of our monthly revenues to advertising.  In fact, we haven't spent a single penny on advertising - unless you count charitable donations to causes that are of significance to us.

We don't search high and low for new revenue streams to push on our clients.  In fact, if I get one more MonaVie sales pitch, I'm going to suplex whoever delivered it right off our loading dock.  Rather, we bust our butts to set clients up for success in any way possible - and trust that those efforts will lead to referrals and "allegiance" to Cressey Performance.  We ask what they want from us and modify our plans accordingly.  It's what led to us bringing in manual therapy, a pitching cage, and, of course, pitching coach/court jester Matt Blake's timeless antics.

Along those same lines, we don't measure our success based on revenue numbers; we measure it based on client results.  In three years of seeing LOADS of baseball players non-stop, we've only had three arm surgeries: one shoulder and two elbow.  All three were athletes who came to us with existing injuries, and in each case, we kept them afloat as long as we could and trained them through their entire rehabilitation.  I don't want to toot our own horn, but this is a remarkable statistic in a population where over 57% of pitchers suffer some form of shoulder injury during each competitive season - and that doesn't even include  elbows!  And, our statistics don't even count literally dozens of players who have come to us after a doctor has told them they needed surgery, but we've helped them avoid these procedures.  The college scholarships, draft picks, state titles, individual honors, and personal bests in the gym are all fantastic, but I'm most proud of saying that we've dedicated ourselves to keeping athletes healthy so that they can enjoy the sports they love.

The same goes for our non-competitive athlete clients.  The fat loss and strength gains they experience are awesome and quantifiable, but beyond that (and more qualitatively), I love knowing that they're training pain-free and are going to be able to enjoy exercise and reap the benefits of training for a long time.

We don't penny-pinch during our slowest times of the month (late March through mid-May - the high school baseball season).  We see it as an opportunity to do more staff continuing education, renovate the facilities, and get out to watch a lot of baseball and support our athletes.  And, we adjust our hours to open up on Sundays and stay later on weeknights during the baseball season to make it easier for athletes to get in-season training in whenever they can.  If a pitcher wants to come in and get his arm stretched out before or after an outing, he stops by and we do it for him - but don't charge him a penny for it.  It's about setting people up for success.

We don't try to just "factory line" as many clients through our facility as possible with everyone on the same program.  You might walk into CP and see 20 different clients on 20 different programs - because a 16-year old pitcher with crazy congenital laxity is going to have a markedly different set of needs than a 16-year-old linebacker with shoulder mobility so bad that he needs help putting a jacket on.  One program on one dry erase board for hundreds of athletes isn't training; it's babysitting.

Taking this a step further, we don't boot clients out after a certain amount of time.  Clients take as long as needed to complete the day's program. And, when they're done (or before they even begin), loads of our clients spend time hanging out in the office just shooting the breeze and enjoying the environment.  As an example, Toronto Blue Jays Organizational Pitcher of the Year Tim Collins spends a minimum of five hours a day at CP all off-season.

collins_stride

Tim has sold girl scout cookies for the daughter of one of our clients, and he's been our back-up front desk guy when Pete is out of town.  Yesterday, he was back to visit on his all-star break - and he said hello to every client he saw - and remembered them by name.  If you're a 15-year-old up-and-coming baseball pitcher, how cool is it to get that kind of greeting when you walk into the office?  Well, at CP, kids get that greeting from 10-15 pro guys all the time.  And, if they're lucky, they might even get to throw on a bobsled helmet and join these pro guys in a rave to Miley Cyrus, apparently.

At least once a week, I get an email from an up-and-coming coach asking for advice about starting a facility.  When I get these emails, I now think about how Rachel Cosgrove recently mentioned that more than 80% of fitness coaches leave the industry within the first year. In most cases, this happens because these people never should have entered the fitness industry in the first place - because their intentions (money) were all wrong.  They usually leave under the assumption that they could never make a living training people, but in reality, these folks are going to have a hard time making a living in any occupation that requires genuinely caring about what you do and the people with whom you work, and being willing to hang your hat on the results you produce.

ec-bk

As such, the first advice, in a general sense, is obvious: do it for the right reasons, and do it the right way.  Sure, making a living is essential, but only open a facility because it would fulfill you "personally, be fun, help a lot of people, and build and be in line" with who you are and what your values are - which together constitute your "brand." Making the move to start up this business was one of the most daunting decisions I have ever had to make, and all the efforts toward actually getting the business started were equally challenging.  However, in the end, it has been more rewarding both personally and professionally than I could have ever possibly imagined.

Thank you very much to all of you - clients/customers, parents, EricCressey.com readers, seminar attendees, and professional colleagues - for all your support over the past three years.  We couldn't have done it without you - and look forward to many more years of doing things for the right reasons and in the right way.

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Mobilizing the Throwing Shoulder: The Do and Don’t

Q: I recently opened up my own place to train athletes, and wanted to thank you for all of the knowledge you have passed along, as it has been a big factor in designing my own training philosophy.  The majority of my athletes are baseball and football players in the high school and collegiate level, and I had question for you regarding my baseball players specifically. Nearly every player I work with (and for the most part every pitcher I have worked with), has tight shoulders due to over-use, being imbalanced, and weak.  I have them performing a ton of upper back work in comparison to pressing movements, rotator cuff work, sleeper stretches, and myofascial release.  It helps greatly, but they still seem to never get back to a full range of motion or an actual natural throwing motion.  Because of this, I was wondering what you thought about adding in shoulder dislocations using a dowel rod or broomstick to help with shoulder mobility. Because the players I work with are either in college because of their ability to play baseball, or have a chance at being drafted or getting a good college scholarship from their arms, I want to make sure that everything I do makes them better instead of hurting them in the long run for what looks like a quick fix when they are with me. I'd love to hear any thoughts you might have on helping increase shoulder mobility and the shoulder dislocation exercise, in particular.

overhead-shoulder-dislocation-1overhead-shoulder-dislocation-2

A: First off, thank you very much for your kind words and continued support. Unfortunately, to be blunt, I think it would be a terrible idea and you would undoubtedly make a lot of shoulders (and potentially elbows) worse. Most pitchers will have increased external rotation (ER) on their dominant side, and as such, increased anterior instability.  If you just crank them into external rotation and/or horizontal abduction, you will exacerbate that anterior instability.  Think about what happens in the apprehension-relocation test at the shoulder; the relocation posteriorly pushes the humerus to relieve symptoms by taking away anterior instability. We are extremely careful with who we select for exercises to increase external rotation, and it is in the small minority.  Most pitchers gain ~5 degrees of external rotation over the course of the competitive season, as it is.  If we are going to have them do mobilizations to increase ER, it's only after we've measured their total motion (IR+ER) as asymmetrical and determined that they need ER (a sign is ER that is less on the dominant shoulder).  And, any exercises we provide on this front are done in conjunction with concurrent scapular stabilization and thoracic spine extension/rotation - as you'd see in a side-lying extension-rotation drill.

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.

aroldis-chapman-mechanics

While we're on the topic, be careful about universally recommending sleeper stretches.  There is going to be a decent chunk of your baseball players that don't need it at all.  In particular, if you have a congenitally lax (ultra hypermobile) athlete (high score on Beighton laxity test), a sleeper stretch will really irritate the anterior shoulder capsule and/or biceps tendon. These players don't really need to be stretched into IR; they just need loads of stability training.  You'll find that these guys become more and more common at higher levels, as congenital laxity serves as a sort of "natural selection" to succeed for some people.  So, universally prescribing the sleeper stretch becomes more and more of a problem as you deal with more and more advanced players and could be jacking up multi-million dollar arms.  You'll even find guys who can gain 10-20 degrees of internal rotation in a matter of 30 seconds  - without any shoulder mobilizations - just with the appropriate breathing patterns.  It just doesn't work for everyone.  Honestly, the only way to know is to assess; each pitcher is unique. The obvious question then becomes "why are you seeing shoulder "tightness.?"  Is it postural?  Is it an actual range of motion you've assessed?  Is it guarding/apprehension in certain positions?  And, what is a "natural throwing motion?" They said Mark Prior had "perfect mechanics" and he has been injured his entire career.

mark-prior

What is "natural" is not what is "effective" in many cases, so you have to appreciate that throwing is an unnatural motion that may be necessary for generating velocity, creating deception, and optimizing movement on a certain pitch. It might seem like shameless self-promotion, but I would highly recommend that you pick up the DVD set Mike Reinold and I recently released: Optimal Shoulder Performance.

shoulder-performance-dvdcover

It covers all of this information in great detail, plus a ton more.  Baseball players - and particularly pitchers - are a unique population as a whole, and within that population, each one is unique. I'd also strongly encourage you to check out Mike Reinold's webinar, "Assessing Asymmetry in Overhead Athletes: Does Asymmetry Mean Pathology?"  It's available through the Advanced CEU online store. Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!
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The Fascial Knock on Distance Running for Pitchers

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.

at-2e-cover

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):

050413_waterrunning_vmed_2pwidec

Here is one guy (and a good looking one, at that) in multiple vectors in a matter of seconds:

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.

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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.

stressfracture

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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Understanding Elbow Pain – Part 6: Elbow Pain in Lifters

Today, I'm going to wrap up this six-part series entirely devoted to the elbow.  In case you missed the first five, check them out: Part 1: Functional Anatomy Part 2: Pathology Part 3: Throwing Injuries Part 4: Protecting Pitchers Part 5: The Truth About Tennis Elbow In this final installment, I'm going to discuss elbow issues as they pertain to a strength training population.  Even though some of the treatments for these injuries/conditioning may be very similar or even identical to what we see in a throwing population, I separate lifters because their problems are almost always soft tissue in nature.  While we may see stress fractures, ulnar nerve issues, and ulnar collateral ligament tears in throwers, we are virtually always dealing with problems with muscles and tendons in folks who are avid lifters.  What gives? Well, it's very simple: they grip stuff a lot more than normal folks, and also perform a ton of repetitive movements at the elbows and wrists.  This difference also makes you appreciate why we often see elbow issues in those who work on factory lines, performing the same task for hours on-end. Why is it that all these issues present at the elbow?  You see, many of the muscles involved in gripping originate at the superomedial aspect of the forearm, particularly on the medial epicondyle:

medialepicondyle

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:

hammer-back-squat2

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:

wagner2

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.

lying_triceps_extension_5314_7

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!

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Understanding Elbow Pain – Part 4: Protecting Pitchers

This is Part 4 of a series specifically devoted to elbow pain in athletes.  Be sure to check out Part 1, Part 2, and Part 3 if you haven't already. As I presented in Part 3 of this series, there is absolutely nothing healthy about throwing a baseball, as the body is being contorted to extreme positions as the arm accelerates in the fastest motion ever recorded in sports.  These outrageous demands warrant a multi-faceted approach to protecting pitchers from injury.  In my eyes, this approach consists of four categories, and that's what I'll cover today. 1. Avoiding Injurious Pitching Mechanics Let me preface this section by saying that I do not believe there is a single mechanical model that governs how one should pitch.  Everyone is different, and those unique traits have to be taken into consideration in determining what is or isn't considered potentially harmful.  For instance, only a tiny fraction of the population could ever even dream about pitching like Tim Lincecum because of ideal blend of congenital laxity and reactive ability he possesses.

lincecum

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:

magnuson-collins

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.

While we can never expect all pitcher to fit the same mechanical model, we can look to the research (a great 2002 study from Werner et al. is an excellent place to start) to educate us about certain factors that predispose pitchers to increased elbow stress.  To start, leading with the elbow too much  increases valgus stress by about 2.5N per degree of horizontal adduction that the arm must travel.  The problem with this is that every successful pitcher you'll ever see leads with the elbow to some degree, so it becomes an issue of "how much" and "when." Getting to maximal external rotation too early also increases valgus stress on the elbow.  According to Fleisig et al. (1995), the typical thrower is going to have about 67 degrees of shoulder external rotation at stride foot contact.  The more external rotation there is, the more elbow stress you'll see.  Unfortunately, this is one contributing factor to one's velocity, so these results must be intepreted cautiously.  If you take away that external rotation, you may take away a few miles per hour.  Again, the same goes for horizontal abduction. Lower extremity sequencing problems can also wreak havoc on an elbow.  Pitchers who fly open early tend to let their arm lag behind their body, increasing valgus stress in the process and making it harder to get good contribution from the lower half. Likewise, guys who stay closed and throw across their body can wind up with medial elbow issues.  If a pitcher maxes out his shoulder internal rotation and scapular protraction in coming across his body, the only choice to continue getting that range of motion is the elbow.  If you create more range of motion, you have to slow down more range of motion. This last point kicks off a brief, but important discussion.  Many pitchers stay closed to improve deception.  Others use it to help them get movement on sinkers.

brandon-webb

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!

2. Avoiding Acute and Chronic Overuse One of our high school kids threw 188 pitches in a game last week.  I'd like to think that I'm pretty good at what I do, but nothing I can do to keep a kid healthy if his coach asks him to do that time and time again. Acutely, fatigued pitchers put more stress on their arms.  There is less trunk tilt at ball release as the lower body gets more tired.  And, the usually elbow drops. "The next thing you know, there's money missing off the dresser, and your daughter's knocked up. I've seen it a hundred times." Gold star to those of you who caught that movie reference, but kidding aside, just about every case of elbow pain we see who comes through our door has been mismanaged in terms of pitch count - either acutely, chronically, or both.  They think they can pitch year-round.  They blow money on showcases.  They play on three teams team at a time.  They throw bullpens with their teams and with their private pitching instructors.  The research is out there and the answer is very clear: there is only so much stress an arm - especially a skeletally immature arm - can take.

littleleague5

3. Being Chronically Physically Prepared to Pitch This is the topic of which I've written the most on this site, and it encompasses everything I've written with respect to strength training for pitchers and targeted flexibility work, not to mention my absolute hatred for distance running for pitchers.  Long story short, throwing a baseball is an action that takes its toll on the body; if you aren't functionally fit to pitch, you're just asking for an injury. 4. Being Acutely Physically Prepared to Pitch This is a very overlooked component of not only staying healthy, but also performing at a high level.  I'm amazed at how many young pitchers just "show and go" when it comes to pitching.  That is, they get to the field and just go right to throwing.  In other words, they throw to warm up. We teach our athletes, "You warm up to throw; you don't throw to warm up."  I've spent the last 57 paragraphs (give or take a few) outlining how incredibly stressful the throwing motion is, yet some kids can't wait to jump right into it before getting their body temperature up, optimizing joint range-of-motion, activating key neuromuscular connections, or doing anything that even vaguely resembles an appropriate "rest to exercise" transition.  We encourage athletes to go through 8-10 dynamic flexibility drills followed by some easy sprinting progressions before they ever pick up a ball.

Layout 1

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!

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Understanding Elbow Pain – Part 3: Pitching Injuries

In case you missed them, check out Part 1 (Functional Anatomy) and Part 2 (Pathology) of this series from last week.  With that housekeeping out of the way, let's move forward to today's focus: elbow injuries in throwing athletes.  I work with a ton of baseball players and I know we have a lot of not only players, but parents of up-and-coming baseball stars that read this blog - so it's a topic that is near and dear to my heart.  While my primary focus within the paragraphs that follow will be baseball, keep in mind that the many these issues can also be seen in other overhead athletes.  They just tend to be more prevalent and magnified in a baseball population. Obviously, in dealing with loads of baseball guys, I see a lot of elbow issues come through my door.  The overwhelming majority of those folks are medial elbow pain, but we also see a fair amount of lateral elbow pain. What's interesting, though, is that in a baseball population, most of these issues are purely mechanical pain; that is, the discomfort is usually only present with throwing, as it is tough to reproduce the velocities and joint positions present during overhead (or sidearm/submarine) throwing.

bradford

The question, logically, is why do some throwers break down medially while others break down laterally, or even posteriorly? In other to understand why, we first have to appreciate the demands of throwing.  And, that appreciation pretty much always leads back to the valgus and extension forces (termed valgus-extension overload by many) that combine to wreak havoc on an elbow during throwing. At late cocking - where maximal external rotation (or "lay-back") occurs - there is a tremendous valgus force of 64Nm on the elbow, according to Fleisig et al.

wagner

As Morrey et al. determined, the ulnar collateral ligament (UCL) "takes on" approximately 54% of this valgus force - meaning that it's assuming about 35Nm of force on each pitch.  This is all well and good - until you realize that in cadaveric models, the UCL fails at 32Nm.

huh

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.

williem

Keep in mind that it isn't just the UCL that's stressed in this lay-back position.  Obviously, the flexor-pronator mass takes a ton of abuse in transitioning from cocking to acceleration.  It's also a tremendously vulnerable position for the ulnar nerve as it tracks through some tricky territory.  That just speaks to the medial side of things; there is more to consider laterally.

You see, the same valgus force that can wreak havoc medially also applies approximately 500N on the radioulnar joint during the late cocking phase of throwing; that's about one-third of the total stress on the elbow.  In this case, a picture is worth a thousand words:

compressive-forces

So, the same forces can cause a thrower to break down in multiple areas both medially and laterally!  What usually separate the medial from the lateral folks? Let me ask you this: when was the last time you saw an 8-year old rupture his ACL?  Never. Now, when was the last time you saw an 8-year-old break a bone?  Happens all the time. This same line of reasoning can be applied to the pitching elbow.  The path of least resistance - or the area of incomplete development - will generally break down first.  As such, in a younger population, we generally see more lateral, compression-type injuries to the bones. These are your growth plate issues and Little League Elbows, usually.

llelbow

As athletes mature and the bones become sturdier, we get more muscle/tendon, ligament, and nerve issues on the medial side. This isn't always the case, of course; you'll see young kids with medial elbow pain, and experienced throwers with lateral issues as well. It generally holds pretty true, though. The issues at the cocking-to-acceleration transition would be bad enough by themselves, but there is actually another important injury mechanism to consider: elbow extension.

stlouiscardinalsvcoloradorockiesj69qqmqog8ll

This lateral area also takes on about 800N of force at the moment arm deceleration begins with elbow extended out in front as posteromedial impingement occurs between the ulna and the olecranon fossa of the humerus.  This bone-on-bone contact at high velocities (greater than 2,000 degrees/second) can lead to fractures and loose bodies within the joint. This wraps up the causative factors with respect to elbow pain in throwers - but I need to now go into further detail on the specific physical preparation and mechanical factors one needs to consider to avoid allowing these issues to come to fruition.  Stay tuned for Part 4.

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