Home Posts tagged "Tommy John Surgery" (Page 4)

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.

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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.

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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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Understanding Elbow Pain – Part 2: Pathology

In case you missed Part 1 of this series (Functional Anatomy), you can check it out HERE.

Elbow issues can be really tricky at times from a diagnostic standpoint. Someone with medial elbow pain could have pronator and/or flexor (a.k.a. Golfer’s Elbow) soft tissue issues, ulnar nerve irritation or hypermobility, ulnar collateral ligament issues, or a stress fracture of the medial epicondyle – or a combination of two or more of these factors. All of these potential issues are “condensed” into an area that might be a whopping one square inch in size. Throw lateral elbow pain (commonly extensor overuse conditions - a.k.a. "Tennis Elbow" - and bony compression issues) and posterior (underside) pain in the mix, and you’ve got a lot of other stuff to confound things.

lateralepicondyle1

To make matters more complex, it’s not an easy diagnosis. The only way to recognize soft tissue restrictions is to get in there and feel around – and even when something is detected, it takes a skilled clinician with excellent palpation skills to determine just what is “balled up” and what nerves it may affect (especially if there is referred pain).

In these situations, I’ll stick with the terms “soft tissue dysfunction” and “tendinopathy” or “tendinosis” to stay away from the diffuse and largely incorrect assumption of “elbow tendinitis.” We’re all used to hearing “Tennis Elbow” (lateral) and “Golfer’s Elbow” (medial), and to be honest, I’d actually say that these are better terms than “epicondylitis,” as issues are more degenerative (“-osis”) than inflammatory (“-itis”).

golfers

Ulnar nerve pain patterns can present at or below the elbow (pinky and ring finger tingling/numbness are common findings), and may originate as far up as the neck (e.g., thoracic outlet syndrome, brachial plexus abnormalities, rheumatologic issues, among others) and can be extremely challenging to diagnosis. A doctor may use x-rays to determine if there is some osseous contribution to nerve impingement or a MRI to check on the presence of something other than bone (such as a cyst) as the cause of the compression. Nerve conduction tests may be ordered. Manual repositioning to attempt to elicit symptoms can also give clues as to whether (and where) the nerve may be “stuck” or whether it may be tracking out of course independent of soft tissue restrictions.

Childress reported that about 16% of the population – independent of gender, age, and athletic participation – has enough genetic laxity in the supporting ligaments at the elbow to allow for asymptomatic ulnar nerve “dislocation” over the medial epicondyle during elbow flexion. In the position of elbow flexion, the ulnar nerve is most exposed (and it’s why you get the “funny bone” pain when you whack your elbow when it’s bent, but not when it’s straight). Ulnar nerve transposition surgeries has been used in symptomatic individuals who have recurrent issues in this regard, and it consists of moving the ulnar nerve from its position behind the medial epicondyle to in front of it.

ulnarnerve

An ulnar collateral ligament (UCL) issue may seem simple to diagnosis via a combination of manual testing and follow-up diagnostic imaging (there are several options, none of which are perfect), but it can actually be difficult to “separate out” in a few different capacities.

First, because the UCL attaches on medial epicondyle (albeit posteriorly), an injury may be overlooked acutely because it can be perceived as soft tissue restrictions or injuries.  The affected structures would typically be several of the wrist flexors as they attach via the common flexor tendon, or the pronator teres.

Second, partial thickness tears of the UCL can be seen in pitchers who are completely asymptomatic, so it may be an incidental finding. Moreover, we have had several guys come our way with partial thickness UCL tears who have been able to rehab and return to full function without surgery. While the UCL may be partially torn and irritated, the pain may actually be coming to “threshold” because of muscular weakness, poor flexibility, or poor tissue quality.

Medial epicondyle stress fractures can be easily diagnosed with x-rays, but outside of a younger population, they can definitely be overlooked. For instance, I had a pro baseball player – at the age of 23 – sent to us for training by his agent last year as he waiting for a medial epicondyle fracture to heal.

stressfracture

While these are the “big players” on the injury front – particularly in a throwing population – you can also see a number of other conditions, including soft tissue tears (flexor tendons, in particular), loose bodies (particularly posteriorly, where bone chips can come off the olecranon process), and calcification of ligaments. So, long story short, diagnosis can be a pain in the butt – and usually it’s a combination of multiple factors.  At a presentation last weekend, Dr. Lance Oh commented on how 47% of elbow pain cases present with subluxating medial triceps ("snapping elbow"), but this is rarely an issue by itself.

That’s one important note. However, there is a much more important note – and that is that many rehabilitation programs are outrageously flawed in that they only focus on strengthening and stretching the muscles acting at the elbow and wrist.

As I’ll outline in Part 3 of this series, a ton of the elbow issues we see in throwers occur secondary to issues at the glenohumeral and scapulothoracic joints. And, more significantly, not providing soft tissue work in these regions grossly ignores the unique anatomical structure of the elbow and forearm and its impact on tendon quality. If you’ve got elbow issues, make sure you’ve got someone doing good soft tissue work on you. Just to give you a little visual of what I’m thinking, I got a video of Nathaniel (Nate) Tiplady, D.C. (a great manual therapist who works out of Cressey Performance a few days a week) performing some Graston Technique® followed by Active Release ® on my forearms.  Here's the former; take note of the sound of his work on the tissues; the instruments actually give the practitioner tactile (and even audible) feedback in areas of significant restrictions.  You'll see that it is particularly valuable for covering larger surface areas (in this case, the flexors of the anteromedial aspect of the forearm):

As for the ART, you'll see that it's more focal in nature, and involves taking the tissue in question from shortened to lengthened with direct pressure.

As you can probably tell (even without seeing me sweat or hearing me curse), it doesn’t feel great while he’s doing it – but the area feels like a million bucks when he’s done.

While there is no substitute for having a qualified manual therapist work on you, using The Stick on one’s upper and lower arms can be pretty helpful.

More on that in Part 3…

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Understanding Elbow Pain – Part 1: Functional Anatomy

Today's piece kicks off a multi-part series focusing specifically on the elbow.  I'm going to start off this collection by talking about the anatomy of the elbow joint, but in appreciation of the fact that a lot of you are probably not as geeky as I am, I'll give you the Cliff's Notes version first: The elbow is the most "claustrophobic" joint in the body; there is a lot of stuff crammed into very little space.  This madness is governed not just by the joint itself, but (like we know with all joints) by the needs of the forearm/wrist and what goes on at the shoulder and neck. Even for the geeks out there, in the interest of keeping this thing "on schedule," I'm just going to focus on your pertinent information.  I would highly recommend The Athlete's Elbow to those of you interested in learning more; it's insanely detailed. Your big players on the osseous (bone) front are going to be the humerus, ulna, and radius.  At the humerus, in the context of this discussion, all you really just need to pay attention to are the medial and lateral epicondyles, as they are crucial attachment points for both tendons and ligaments (as well as sites of stress fractures in younger athletes).

elbow_labelled

Posteriorly, you'll see that olecranon process of the ulna sits right in the olecranon fossa of the humerus.  This is a pretty significant region, as it gives the elbow its "hinge" properties and prevents elbow hyperextension.  Fractures of the olecranon can occur and leave loose bodies in the joint that will prevent full elbow extension.  And, not to be overlooked is the attachment site of the triceps (via a common tendon) and anconeus on the olecranon process.

elbowxray

The "elbow" may just be a hinge to the casual observer, but in my eyes, it's important to distinguish among the humeroulnar joint (described above) and the humeroradial (pivot) and proximal radioulnar joints - which give rise to pronation and supination.

0199210896pivot-joint1

Likewise, the wrist (and the fingers, for that matter) is directly impacted in flexion/extension, radial deviation/ulnar deviation, and pronation/supination by muscles that actually attach as far "north" as the humerus.  Muscles aren't just working in one plane of motion; they're working for or against multiple motions in multiple planes.

In all, you have 16 muscles crossing the elbow.  For those counting at home, that's more than you'll find at another "hinge" joint, the knee, in spite of the fact that the knee is a much bigger joint mandating more stability.  More muscles equates to more tendons, and that's where things get interesting.

As any good manual therapist, and he'll tell you that soft tissue restrictions occur predominantly at: A.       Areas of increased friction between muscles/tendons B.       Areas where forces generated by a myofascial unit come together (termed "Zones of Convergence" by myofascial researcher Luigi Stecco): this is generally the muscle-tendon-bone "connection," as you don't typically see prominent restrictions in the mid-belly of a muscle. This is a double whammy for the muscles acting at the elbow.  In terms of A, you have many muscles in a small area.  Most folks overlook the importance of B, though: a lot of them share a common (or at least directly adjacent) attachment point.  The flexor carpi radialis, flexor carpi ulnaris, palmaris longus, and flexor digitorum superficialis all attach video the common flexor tendon on the medial epicondyle, with the pronator teres attaching just a tiny bit superiorly.  There's ball of crap #1.

medialepicondyle

Ball of crap #2 occurs at the lateral epicondyle, where you have the common extensor tendon, which is shared by extensor carpi radialis brevis, extensor carpi ulnaris, supinator, extensor digitorum, and extensor digiti minimi - with the extensor carpi radialis longus attaching just superiorly on the lateral supracondylar ridge.  Ball of crap #3 can be found posteriorly, where the three heads of the triceps converge to attach on the olecranon process via a common tendon, with the much smaller anconeus running just lateral to the olecranon process. You can see both balls of crap (double flusher?) coming together here:

lateralepicondyle

Ball of crap #4 is a bit more diffuse consisting of the attachments of biceps brachii (radial tuberosity), brachioradialis (radial/styloid process), and brachialis (coronoid process of ulna) on the anterior aspect of the forearm.

distalbiceps

This last graphic demonstrates that there are a few other factors to consider in this already jam-packed area.  You've got fascia condensing things further, and you've also got a blood supply and nerve innervations - most significantly, the ulnar, median, and radial nerves - passing through here. The median nerve, for instance, passes directly through the pronator teres muscle.

Oh, and you've also got ligaments mixed in - some of which are attaching on the very same regions that tendons are attaching.  The ulnar collateral ligament attaches on the medial epicondyle in close proximity to the flexors and pronator teres, for instance.  These ligaments are heavily reliant on soft tissue function to stay healthy.  As an example, flexor carpi ulnaris is going to be your biggest "protector" of the UCL during the throwing motion.

elbow

So what's the take-home message of this functional anatomy lesson?  Well, there are several.

1. Lots of stuck is packed in a very small area.

2. When things are stuck together, they form dense, fibrotic, nasty balls of crud.

3. These gunked up muscles/tendons can impact everything from nerve function to ligamentous integrity - or they can just give out in the form of a tear or tendinopathy.

4. Diagnosis can be tricky because all the potential issues take place in a small area, and may have very similar symptoms.  Different pathologies take place in different athletic populations, too.  We'll have more on this in Understanding Elbow Pain - Part 2: Pathology.

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Why Do Some Guys Come Back to Pitch Better After Tommy John Surgery? Things I Learned from Smart People: Installment 2

shoulder-performance-dvdcover Click here to purchase the most comprehensive shoulder resource available today: Optimal Shoulder Performance - From Rehabilitation to High Performance. 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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Why Do Some Guys Come Back to Pitch Better after Tommy John Surgery?

Q: I was wondering the other day about why guys often come back from Tommy John surgery pitching better and harder than they did before.  My first thought was they can't do any upper-body strength training for months while they recover from the surgery, so they're forced to work on lower body, core, and mobility - and, in turn, come back as better conditioned athletes with more control and velocity.  Or, do you think their improved velocity and command is just an illusion made possible because we're comparing them to the way they pitched while they were hurt, but not yet "disabled?"  Or, is there another factor I'm missing altogether? I figure there's a sample-size issue -- we're just looking at the guys who make it all the way back, and ignoring the ones who don't.

A: It's an excellent question - and one I actually get quite a bit.   I'd say that it's a combination of all three.

In my eyes, an ulnar collateral ligament tear is usually an injury that speaks to YEARS of dysfunction and accumulated stress.  Guys usually have a history of elbow pain/soreness in their teenage years, some calcification on the UCL, and then it finally goes in their college/pro years.  They may have been managed conservatively (physical therapy) for a long time just because doctors don't like doing surgeries on 16-year-olds.  However, when they're 20, it becomes "acceptable" to do a Tommy John surgery.

scar

In the meantime, many of these injured pitchers will modify their deliveries to avoid the pain and end up with some crazy mechanics that leave the ball all over the place at erratic radar gun readings.  So, that can usually cover the velocity drop and control issues.  This is in stark contrast to what you'll see with serious injuries to the labrum (SLAP2 lesions), which generally give you the quick velocity drop, and eventually, loss of control - even in the absence of pain.  Elbow stuff doesn't usually directly influence velocity as quickly; a lot of guys can throw through it for years.

elbow

So, yes, we are comparing them to their pre-injury numbers.  However, there is - at least in my eyes - a better reason.

They are often lazy and inconsistent with their training and arm care before they get hurt.  Quite often, you'll see an ACL reconstruction leg coming back and being stronger than the uninjured side long-term.  The same thing can happen with a Tommy John.  The rehab is crazy long, so guys have time to learn arm care as religion and - as you noted - focus on athletic qualities that are often partially or entirely "squeezed out" by competing demands.

I remember talking with Curt Schilling along these lines - although it was with respect to his shoulder.  He had a shoulder surgery in 1995, and it made him "religious" about arm care.  His best years came years after that even though he'd gotten older.

curt-schilling1

So, usually, the guys who wind up throwing harder are just the ones who were lazy in the first place and were finally forced into actually taking care of their bodies.  The guys who DO take good care of their arms and wind up tearing UCLs rarely come back throwing harder, and to be frank, probably have a lower chance of returning to their former selves than their lazy counterparts.

Of course, this obviously excludes issues with the graft type (autograft or allograft), graft site (Palmaris longus, hamstrings, or another site), surgeon's abilities, physical therapy, athlete motivation, strength and conditioning, and return-to-throwing progression.

To learn more about assessment and management of the throwing elbow, check out my Everything Elbow In-Service video.

Sign-up Today for our FREE Baseball Newsletter and Receive Instant Access to a 47-minute Presentation from Eric Cressey on Individualizing the Management of Overhead Athletes!

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Random Friday Thoughts: 4/24/09

1. It's been a crazy week ever since Anna and I got engaged on Sunday.  You never truly realize how many people you know until they all try to email/call/text you at once to say congratulations.  With my cell phone and email inbox going crazy, I kind of felt like Jerry Maguire - minus the whole weird scientology and jumping on Oprah's couch stuff. 2. On Wednesday, I got out to watch two high school games where CP athletes pitched, and then headed to Fenway to watch the Sox beat the Twins.  In Game 1, Weston High Sahil Bloom had a no-hitter through 6 2/3 innings before giving up a bloop single, and then Auburn High's Tyler Beede threw six innings. 3. Next week, I'll be publishing the first installment of a collection of nutrition articles from Eric Talmant.  Eric has some very forward-thinking ideas to share, and it'll make a nice weekly addition to EricCressey.com.  Be sure to check them out. 4. I'm getting really excited for this year's Perform Better Summits.  I'll be speaking in Providence, RI and Long Beach, CA (there is also one in Chicago); I'd definitely encourage you to check the events out if you live in that neck of the woods.  My presentations should question the "diagnostic norms" - in much the same way that I did with this week's newsletter. 5. Speaking of newsletters, I got several inquiries after I ran this one about the medicine ball training we do with our pitchers. In particular, folks were curious about the medicine ball we used in drills like this:

The medicine balls in question can be found HERE.

6. I've written quite a bit in the past about how a glenohumeral internal rotation deficit can be one contributing factor (among others) to medial elbow injuries in overhead throwing athletes.  The other day, someone asked me if I had any scientific evidence to support this idea.  The answer would be a resounding YES.

Very simply, if you lack internal rotation, you'll go to the elbow to "regain" that lost range-of-motion.  It's the same reason that ankle mobility deficits can lead to knee pain, and hip mobility deficits can lead to knee and lower back pain.

7. I don't really "get" how this whole Delicious bookmarking thing works, but Jon Boyle (who helps out with the blog) recommended I start sending him recommendations of good stuff I've read.  You can find some of my recommended reading/viewing off to the right-hand side of the page.  If there are books you recommend I check out, by all means, please post suggestions in the comments to these blogs; I'm always looking for new reading material.

Have a great weekend!

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A Good Rule of Thumb for Working with Injured Pitchers

If you have a pitcher athlete with good shoulder ROM (normal GIRD and symmetrical total motion), sufficient thoracic spine mobility, good scapular stability, and adequate tissue quality who has rehabbed and long-tossed pain-free, but has shoulder/elbow pain when he gets back on the mound, CHECK THE HIPS! Staying closed and flying open will be your two most common culprits; this cannot be seen in a doctor's office!  Changing lead leg positioning is a quick way to indirectly (and negatively) impact the position of the arm.  Guys who stay closed have to throw across their body, and guys who fly open often have problems with the arm trailing too far behind (out of the scapular plane). For more information, check out the Optimal Shoulder Performance DVD Set. 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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Can Little Leaguers Strength Train?

Q: Mr. Cressey, I was given your name and website from my massage therapist, who is a big fan of yours. I was wondering what your opinion is about when a child should start muscle strength training (not weight training) for baseball? I have a 10-year old son who pitches and I always worry about his shoulder since I have had to have surgery on both of mine. He is playing up in age so he is pitching from 50 feet and pitches a consistent 48 mph. I always ice him down after for 30 minutes, but what do you recommend him to do to prevent injuries? A: This is a great question, and the timing is actually perfect (as I'll explain in the last paragraph). In a nutshell, assuming good supervision, I'd start as early as possible. While most of our work is with athletes in the 13+ age range, we run a group of 9-12 year olds every Saturday morning at Cressey Performance. There is a lot you can to with kids at that age to foster future success - but, more importantly, have fun. It was actually started by popular demand of some of the kids who had older brothers in our program; they wanted to jump in on the fun. Now, we look at it as a feeder program of sorts; by teaching things effectively early-on and exposing them to a wide variety of movements, it makes it easier for them to become athletes down the road. We work on squat technique and/or deadlift technique, with the majority of the time aimed at just keep them moving by performing various circuits that include things like jumping jacks, med ball throws, lunges, and wheelbarrow medleys, etc. We also have tug-o-war battles and SUMO wrestling where we have them grab onto a SWISS ball and try to maneuver each other outside of a circle. All in all, we have fun while at the same time improving their motor skills. That is what's most important. I don't want the kids to dread coming to the gym, which is what I think happens when trainers and parents start taking it too seriously. There's going to come a time when things will get more specialized, but ages 9-12 isn't that time. Truth be told, kids nowadays are more untrained and unprepared than ever - yet they have more opportunities that ever to participate in spite of the fact that they are preparing less. It's one of several reasons that youth sports injuries are at astronomical rates. As perhaps the best example, you can now see glenohumeral internal rotation deficit (GIRD) in little leaguers, as this study shows. The GIRD isn’t the problem; that’s a natural by-product of throwing. The problem is that kids throw enough to acquire this structural and flexibility anomaly, but have no idea how to manage it to stay healthy. So, in a nutshell, find someone who understands kids both developmentally and psychologically - and make it fun for him. Looking for someone affiliated with the IYCA (www.iyca.org) would be a good start. Also, among the products out there, Paul Reddick's stuff is a great start if you're looking for things to do with up-and-coming baseball players.

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Training around Elbow Issues in Overhead Athletes

We see a lot of baseball players, so a lot of these guys come to use with elbow problems. In most cases, the doctors they’ve seen have said, flat-out, “NO LIFTING WEIGHTS.” This drives me nuts for a variety of reasons: 1. They’ve still got two good legs, one good arm, and a bunch of core musculature that needs to be strong and functional. 2. This recommendation implicitly means “Stay away from personal trainers and strength coaches.” It’s probably due to the fact that there are a lot of bonehead personal trainers out there who could do more harm than good, but the truth is that these services comprise more than just lifting weights. We do a lot of mobility and activation work and self-myofascial release on the foam roller. Collectively, #1 and #2 demonstrate that this blanket recommendation includes an insanely ignorant omission, as the majority of elbow problems can be attributed to mobility and strength deficits at the shoulder. You can train a shoulder a thousand different ways without even involving elbow motion – let alone challenging it sufficiently to cause a problem. In fact, I'd estimate that you could prevent 90% of elbow problems in baseball guys if we simply taught all of them how to sleeper stretch in their early teenage years: I'd strongly encourage you to check out this article I wrote, where I go over the common mistakes folks make when performing the sleeper stretch. 3. This recommendation flat-out ignores the specific nature of the overwhelming majority of elbow problems in throwing athletes. Let me elaborate.. In my estimation, 95% of baseball players with elbow pain couldn’t elicit their pain in a weight room if they wanted to; seriously! The reason is that this elbow pain is typically mechanical in nature; that is, it’s only aggravated by specific activities (in their case, throwing). Believe it or not, I have had guys do everything from pull-ups, to dumbbell bench presses, to rows, to push-ups, to grip work just days out from elbow surgery. It isn’t true in every case, but it’s definitely the majority. And, they can all get diesel in the lower body during this time period. Some great related reading for you: Inefficiency vs. Pathology Lay Back to Throw Gas

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Inefficency vs. Pathology

In Newsletter 95, I wrote about how pathologies often don’t become symptomatic until inefficiencies get to be too bad. Here is a perfect example of a guy who has basically learned how to work around a pathology to remain competitive at a high level. New Twist Keeps Dickey’s Career Afloat You can bet that he’s got a lot of efficiency working in his favor. Thanks, Paul Vajdic, for passing this along!
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