Home Posts tagged "UCL"

CSP Elite Baseball Development Podcast: The Evolution of Elbow Surgeries with Dr. Jeffrey Dugas

We're excited to welcome renowned orthopedic surgeon, Dr. Jeffrey Dugas, to the latest podcast. He shares some great insights related to the history, present, and future of elbow surgeries. Dr. Dugas is on the cutting edge of baseball sports medicine, so we're fortunate to tap into his expertise on this episode.

A special thanks to this show's sponsor, Marc Pro. Head to www.MarcPro.com and enter the coupon code CRESSEY at checkout to receive an exclusive discount on your order.

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Podcast Feedback

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And, we welcome your suggestions for future guests and questions. Just email elitebaseballpodcast@gmail.com.

Thank you for your continued support!

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CSP Elite Baseball Development Podcast: Jesus Luzardo

We're excited to welcome Oakland A's starting pitcher Jesus Luzardo to this week's podcast. He talks about his quick ascent to the big leagues, things he learned during Tommy John rehab, sacrifices needed to compete at the highest level, and the things he's working on to keep improving.

A special thanks to this show's sponsor, Athletic Greens. Head to http://www.athleticgreens.com/cressey and you'll receive a free 20-pack of Athletic Greens travel packets with your first order.

Sponsor Reminder

This episode is brought to you by Athletic Greens. It’s an all-in-one superfood supplement with 75 whole-food sourced ingredients designed to support your body’s nutrition needs across 5 critical areas of health: 1) energy, 2) immunity, 3) gut health, 4) hormonal support, and 5) healthy aging. Head to www.AthleticGreens.com/cressey and claim my special offer today - 20 FREE travel packs (valued at $79) - with your first purchase. I use this product daily myself and highly recommend it to our athletes as well. I'd encourage you to give it a shot, too - especially with this great offer.

Podcast Feedback

If you like what you hear, we'd be thrilled if you'd consider subscribing to the podcast and leaving us an iTunes review. You can do so HERE.

And, we welcome your suggestions for future guests and questions. Just email elitebaseballpodcast@gmail.com.

Thank you for your continued support!

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CSP Elite Baseball Development Podcast: Tommy John Timelines with Stan Conte

We’re excited to welcome physical therapist Stan Conte to this week’s podcast for a detailed discussion of expectations surrounding Tommy John surgery. Stan is not only an experienced clinician, but also a prolific researcher in the baseball sports medicine world. With the prevalence of ulnar collateral ligament injuries in today's game, this podcast is a must-listen.

A special thanks to this show's sponsor, Athletic Greens. Head to http://www.athleticgreens.com/cressey and you'll receive a free 20-pack of Athletic Greens travel packets with your first order.

Show Outline

  • How Stan’s career in professional baseball has evolved from the clinical setting into more research based work
  • How Stan was a part of the group that began the Health and Injury Tracking System (HITS), the first injury surveillance system in Major League Baseball
  • How the disabled list had long been utilized as more of a roster management tool than an injury prevention system
  • Why DL data is still nonetheless relied upon when analyzing medical history in pro baseball
  • What studies Stan has been a part of regarding Tommy John surgery, and how this research is shaping the way players are managed
  • How the increase in pitching velocity throughout the game of baseball has redefined the pressure put on prospects and led to throwing injuries in younger arms
  • Why no one really knows how long it takes a UCL graft to mature and what conclusions Stan has drawn from research and working alongside rehabilitating athletes
  • When the best time to begin throwing after Tommy John surgery is
  • Why having pain when throwing during Tommy John rehab is not normal and what protocols players can look to when setbacks arise
  • When flat grounds, bullpens, and simulated games should fit into a return from TJ throwing program
  • When Stan recommends the reincorporation of off speed pitchers in return to throwing programs
  • What the true success rate of UCL reconstruction surgery is
  • What common Tommy John perceptions are actually myths
  • Why the number of Tommy John revisions is rising and how long post-op are the majority of these revision surgeries occurring
  • What the difference is between UCL repair and UCL reconstruction, and when each is an option for patients
  • Despite the high success rate for pitchers with TJ surgery, why catchers see the lowest success rate from Tommy John
  • Where Stan would like to see more research done in the baseball performance industry
  • You can follow Stan on Twitter at @StanConte.

Sponsor Reminder

This episode is brought to you by Athletic Greens. It’s an all-in-one superfood supplement with 75 whole-food sourced ingredients designed to support your body’s nutrition needs across 5 critical areas of health: 1) energy, 2) immunity, 3) gut health, 4) hormonal support, and 5) healthy aging. Head to www.AthleticGreens.com/cressey and claim my special offer today - 20 FREE travel packs (valued at $79) - with your first purchase. I use this product daily myself and highly recommend it to our athletes as well. I'd encourage you to give it a shot, too - especially with this great offer.

Podcast Feedback

If you like what you hear, we'd be thrilled if you'd consider subscribing to the podcast and leaving us an iTunes review. You can do so HERE.

And, we welcome your suggestions for future guests and questions. Just email elitebaseballpodcast@gmail.com.

Thank you for your continued support!

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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Looking Closer at Pitching Injuries: An Interview with Jeff Passan

Today, I'm fortunate to have an interview with Yahoo Sports baseball writer, Jeff Passan. Jeff spent the past few years traveling the country to research why arm injuries in pitchers are at an all-time high, and his efforts culminated with the recent release of The Arm. I've read it, and it's fantastic.

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EC: Why did you write this book?

JP: Originally, I wrote it because I thought maybe, just maybe, through reporting and research I could find a fix-all for elbow injuries and help rid the sport of Tommy John surgery. What I learned was that I was foolish to even conceive of that, considering people far smarter than I am have dedicated their careers to ramming dead ends. Because of that, while I still think the recoveries of Daniel Hudson and Todd Coffey are the heart of the book, I began to realize just how acute this is for children. When nearly 3 in 5 Tommy John surgeries is done on a teenager, and the rise of teenage surgeries has gone in lockstep with the ascent of the showcase circuit and desire for velocity, something is very wrong. This is a book about a lot of things. I hope amid those, the lessons to parents resonate and cause them to think twice this spring about sending their young kids especially back out for an extra inning or keeping them in the game too long.

EC: Let's stay with the teenage discussion, as I've been preaching about this problem it for a decade now! When you investigated the current state of teenage baseball, what did you find? And, what surprised you the most?

I found a wasteland of ignorance, greed and scars on the elbows of children. I always heard executives complaining off-handedly about the showcase circuit but didn't realize the pervasive grasp it has on the youth space. Major League Baseball's greatest failure was allowing a for-profit company to co-opt its pipeline. As much as Perfect Game wants to claim moral superiority and a concern for the arms of children, reality tells a different story. Showcases 11 months of the year. Radar guns trained on infielders throwing across the diamond. Out-of-control pitch counts for arms simply too young to handle the workload. And that's to say nothing of actively seeking out sub-standard players to fill out an event. The commodification of children is gross, and encouraging performance and winning over development at young ages simply reinforces some of the same principles that I fear ultimately lead to arm injuries.

EC: Many people claim these issues are isolated to just the United States, and that the Far East and Latin American are immune. They deny that arm injuries are occurring at high rates in these areas; what did you find?

At the major league level, one's ethnicity does not make him any likelier to hurt himself. The numbers are pretty flat across the board. We see with Latin American players how that manifests itself because so many spend their formative years in the minor leagues and we witness their ascent and, in unfortunate cases, injury. Japanese pitchers, on the other hand, have a reputation of clean mechanics and hard work, and while that may be true, the results are devastating. It's not just the recent study that showed 40 percent of a sample of 9- to 12-year-old Japanese children had suffered ulnar collateral ligament damage. It's what I saw first-hand: Little boys, some so young their adult teeth still weren't fully grown in, coming into a clinic especially for baseball players and being diagnosed with an arm injury. Avulsion fractures. Frayed ligaments. OCD lesions. You name it, these kids had it. And it made me wonder how the Japanese baseball culture can live with itself knowing that it's choosing blind tradition over something as fundamental as the health of children.

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EC: Everyone likes to play Major League Baseball general manager on the internet, but I'm going to do you one better. I'll let you be MLB commissioner and task you with determining how to address the injury epidemic that's spanning from youth leagues all the way to MLB veterans. How do you handle it?

JP: Wow. OK. So, I'm assuming an unlimited budget here, because a lot of these things are going to take money. Let's start with the kids first. I appreciate what Pitch Smart is trying to do. I also think it's not conservative enough with the youngest kids. If baseball is injuring its youngest players -- and doctors and studies alike believe it is -- we need to focus on the two likeliest culprits: overuse and excessive maximum-effort throwing. Curb the first with lower pitch limits. It's not like 8- or 9-year-old kids need to be building toward triple-digit pitches. And in concert with that, advocate an epistemological change in how we approach youth baseball: as an apparatus for development over competition. Don't get me wrong. Competition is great. But if competitiveness in this space leads to the things that lead to an increase in injuries, we can satisfy our competitive jones elsewhere and instead emphasize developing safer development and the importance of control and command over velocity. This demands better coaching, and free coaching clinics run by MLB-trained advocates at least gives us a better chance of empowering those whose voices are critical with the necessary education.

There are so many more things in the youth space I could do, but I want to move on to the pros, because if I were in power and had carte blanche, the first thing I would do is force the 30 teams to abandon their injury-prevention fiefdoms and band resources to help start solving this problem. This is a matter of the greater good. Baseball as a sport is facing another generation of pitchers arriving with Tommy John surgery scars on their elbows, and if a team found something that could mitigate injuries, those children deserve to know. I understand the desire for a competitive advantage. I also see this as a moral imperative for baseball to do what it can to solve it. Beyond that, continuing to fund the current epidemiological studies, working hand in hand with the tech companies -- so many of which seem to have a problem getting their products to market -- and pioneering in-house research through a think tank-like establishment devoted not just to the arm but varying other ends of research. In other words, I'd throw the full weight of MLB behind this, not just monetarily but starting with the first commercial of the World Series, which is a close-up camera shot first on Matt Harvey's elbow, then Stephen Strasburg's, then Jose Fernandez's. And as the camera pans back to reveal their familiar faces, each says: "This could be you." Then some stats on year-round baseball -- oh, yeah; as commissioner, I'd shut that down and hold twice-a-year showcases at which the top prospects can show up and show off their stuff for everyone in the industry, like a combine -- and some other scary numbers and, boom: Immediate education on Tommy John surgery through people not wearing white lab coats.

EC: Thanks for joining us, Jeff! Whether you're a baseball player, coach, parent, scout, or fan, I'd strongly encourage you to  pick up a copy of The Arm.

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How Limited Shoulder Flexion Relates to Elbow Injuries in Pitchers

Today, I want to introduce you to one of the screens we do with all our throwing athletes - and what the implications of "failing" this test are.  Check out this six-minute video:

If you're looking for more information along these lines, I'd encourage you to check out one of our upcoming Elite Baseball Mentorships, with events running in both October and November.

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Training Athletes with Funky Elbows: What a Valgus Carrying Angle Means

I talk a lot about how there's a difference between simply "training baseball players" and actually training baseball players with a genuine appreciation of the unique demands they encounter - as well as their bodies' responses to those demands.  Today's post will be a great example of how you can't just throw every throwing arm into a generic program.

One of the adaptations you'll commonly see in throwers is an acquired valgus carrying angle at the elbow.  For the laymen in the crowd, take note of how the throwing arm (in this case, the right arm, which is to the left side of the picture) has a "sharper" angle: 

 

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This is an adaptation to the incredible valgus stress during the lay-back portion of throwing.

layback

While the research on the subject isn't really out there, it's widely believed that a sharper valgus carrying angle predisposes throwers to elbow injuries, particularly ulnar collateral ligament (UCL) tears.  My good friend Mike Reinold actually has a lot of very good unpublished data on the topic, too. In my eyes, this verifies that we need need to treat throwers like this with extra care in light of this increased susceptibility to injury. 

From my perspective, I think it means more time off from throwing each off-season in order to regain passive stability, as the UCL is already stretched out more than in the normal pitcher.  Additionally, it may take longer for these athletes to regain good soft tissue quality, as the musculature at the medial elbow is likely working harder to make up for this loss of passive stability and the increased range-of-motion demands.  Another key point is that this valgus carrying angle may increase the likelihood of ulnar nerve hypermobility (snapping back and forth over the medial epicondyle during flexion/extension) or ulnar neuritis (irritation of the nerve from excessive stretch). If this nerve only has a limited number of flexion/extension cycles before it really gets irritated, then we need to use each throw wisely to put off the possibility of needing an ulnar nerve transposition surgery to set it where it needs to be.

Additionally, I think it means less aggressive throwing programs, particularly with respect to extreme long toss.  I think long toss has a ton of merit for a lot of throwers, but one concern with it is that it does increase valgus stress slightly as compared to throwing on a line at shorter distances.  With that in mind, these folks might respond better to other throwing initiatives, or simply less long toss than they otherwise might do.

From a training standpoint, we need to work to gain more active external rotation to ensure that more of the range-of-motion is occuring is at the shoulder than the elbow.  This should not be confused with simply stretching the shoulder into external rotation, which does much more harm than good in 99% of cases.  Rather, we need to educate athletes on how to get to lay-back without compensation. I like supine external rotation - an exercise I learned from physical therapist Eric Schoenberg - as a starting point.

Once we've been successful working with gravity, we'll progress this drills to prone to work against gravity, and then add in various holds at end-ranges of motion to strengthen athletes in external rotation closer to end-range.  Here's an example you can try at home:

In terms of contraindications, I can't say that it changes much as compared to what we avoid - back squats, Olympic lifts, etc. - with the rest of our throwers.  However, I think the fallout could be even more dramatic; just imagine these elbows catching a snatch overhead in the off-season after 200+ innings of wear and tear.

crazyvalgus

This picture also teaches us that one can simply be born with a more significant valgus carrying angle, but throwing during the adolescent and teenage years would make it more extreme.

Beyond training implications, for the reasons I noted above, it's also extremely important to take care of tissue quality at the common flexor tendon and pronator teres. I like a combination of instrument-assisted soft tissue mobilization and hands-on work like Active Release.

I hope this post brings to light an additional assessment and follow-up training principles you can use to give your throwers the quality training and (p)rehabilitation they need. If you're looking for more insights on training throwers, I'd highly recommend you check out our Elite Baseball Mentorships; the next course takes place on December 8-10.

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Strength and Conditioning Stuff You Should Read: 7/18/13

This week's list of recommended strength and conditioning reading (and listening) will have a heavy baseball focus.  Check out these websites:

Elite Baseball Mentorships - We've run two of these, and the feedback has been fantastic.  With that in mind, today is the early-bird registration deadline for the August 18-20 Phase 2 (no prerequisites required). We'd love to see you there!

Talking Shoulders and Elbows with Eric Cressey - This is the audio of a podcast I did for the Blue Jays Plus Podcast.  We discuss baseball injuries, player development, and a host of other topics. I come on the show at the 34-minute mark, in case you want to fast-forward to it.

EverythingElbow

The Surgery that Changed Baseball Forever - With the upcoming induction of Dr. Frank Jobe (who thought up and did the first Tommy John surgery) to the Baseball Hall of Fame, Will Carroll wrote this outstanding four-part article for Bleacher Report.  Here are the links to check out each of the articles: Part 1, Part 2, Part 3, and Part 4.

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Strength and Conditioning Stuff You Should Read: 6/3/13

It's time for this week's installment of recommended strength and conditioning reading:

Half of College Grads Are Working Jobs That Don't Require A Degree - This article ran at Forbes.com the other day, and while it doesn't speak directly to the fitness industry, I thought it drew some interesting parallels to this old two-part series of mine:

----> Is An Exercise Science Degree Really Worth It? - Part 1
----> Is An Exercise Science Degree Really Worth It? - Part 2

Functional outcomes following revision ulnar collateral ligament reconstruction in Major League Baseball pitchers - It's well documented that UCL reconstructions (Tommy John surgeries) have a very high success rate when it comes to returning to previous (or better) levels of competition.  However, they've been around long enough that surgeons are sometimes seeing the same throwers back again for a second UCL reconstruction on the same elbow. Guys like Joakim Soria and Brian Wilson are the most recognized examples of late. As would be expected, the results aren't quite as good the second time around, but there is still a solid success rate, and it's better among relief pitchers than starters.

EverythingElbow

(if you're interested in learning more about the injury mechanisms for UCL tears as well as my experiences working with post-op Tommy John cases, be sure to check out my Everything Elbow in-service)

Rack Hip Thrusts - This was a short, but very useful article by Ben Bruno over at T-Nation.  If you've ever had problems with the set-up on barbell hip thrusts, it's a must-read.  Plus, I found it wildly entertaining that Ben referred to the male reproductive anatomy as "tackle."

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Pitching Injuries and Performance: Understanding Stride Foot Contact and Full External Rotation

At the end of the day yesterday, I took a quick glance at my Facebook feed and was quickly drawn to a "highlight" video from a baseball strength and conditioning program.  The athletes' energy was great, and there was a ton of camaraderie.  The only problem was that if you had watched the video without first seeing the word "baseball" in the title, you would have never known it was a baseball team training. The exercises - and the way that they were/weren't coached - clearly didn't reflect the unique demands of the sport.

With that in mind, I thought I'd use today's post to quickly highlight the most important positions you need to understand when you're training throwing athletes: stride foot contact/full external rotation.

Stride foot contact occurs just before maximum external rotation takes place.  As the foot touches down, the pelvis has started rotating toward home plate while the torso is still rotated in the opposite direction to create the separation that will enhance velocity.  Maximum external rotation - or "lay-back" - signifies the end of this separation, as the energy generated in the lower extremity is already working its way up the chain.  Nissen et al. (2007) presented this tremendous diagram to illustrate the separation that takes place.  This image represents a right handed picture, where the top image is the hips, and the bottom image is the torso (right and left shoulder joint centers of rotation).

Source: Nissen et al.

Based on this image alone, you should be able to see where most oblique strains and lower back pain originate; this is ridiculous rotational stress.  Additionally, you can appreciate why hip injuries are higher in throwers than they ever have been before; it takes huge hip rotation velocities to play "catch up" so that the pelvis and thorax are squared up at maximum external rotation (if they aren't, the arm drags).  This just refers to what's happening at the lower extremity and core, though.  Let's look at the shoulder.

At full lay-back (maximum external rotation), we encounter a number of potentially traumatic and chronic injuries to the shoulder.  In a pattern known as the peel-back mechanism, the biceps tendon twists and tugs on the superior labrum. The articular side (undersurface) of the rotator cuff may impinge (internal impingement) on the posterior-superior glenoid, leading to partial thickness cuff tears. Finally, as the ball externally rotates in the socket, the humeral head tends to glide forward, putting stress on the biceps tendon and anterior ligamentous structures. 

Likewise, at the elbow, valgus stress is off the charts.  That can lead to ulnar collateral ligament tears, flexor/pronator strains, medial epicondyle stress fractures, lateral compressive injuries, ulnar nerve irritation, and a host of other isssue.  I don't expect most of you to know what much of this means (although you can learn more from Everything Elbow), but suffice it to say that it's incredibly important to train throwers to be functionally strong and mobile in these positions. 

And, this brings to light the fundamental problem with most strength and conditioning programs for overhead throwing athletes; they commonly don't even come close to training people to be "safe" in these positions. "Clean, squat, deadlift, bench, chin-up, sit-up" just doesn't cut it.  You need to be strong in single-leg stance to accept force on the front side with landing.

You need to be able to apply force in the frontal and transverse planes.

You also need to transfer this force to powerful movements.

You need to have plenty of rotary stability to effectively transfer force from the lower to upper body.

You need to be strong eccentrically in the 90/90 position.

You need to have outstanding hip mobility in multiple planes of motion.

You need to attend to soft tissue quality in areas that other athletes rarely have to consider.

These demands are really just the tip of the iceberg, though, as you have to see how all the pieces fit together with respect to throwing and hitting demands at various times of year.  Training for baseball isn't as simple as doing the football strength and conditioning program and then showing up for baseball practice; there are far more unique challenges when dealing with any rotational sport, particularly those that also integrate overhead throwing.  Watch the sport, talk to the players, appreciate the demands, and evaluate each individual before you try to write the program; otherwise, you're simply fitting athletes to existing programs.

For more insights like these, I'd encourage you to check out one of our Elite Baseball Mentorships; we have two of these events scheduled for this fall.

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Why Baseball Players Shouldn’t Olympic Lift

I've been very outspoken in the past about how I am completely against the inclusion of Olympic lifts in baseball strength and conditioning programs because of injury risk and the fact that I don't believe the carryover in power development is as good as many folks think.  I've taken a lot of heat for it, too, as it's essentially blasphemy for a strength and conditioning coach to not think the Olympic lifts are a "Holy Grail" of performance enhancement.

Truth be told, I think there is merit to the Olympic lifts for a lot of athletes and general fitness folks.  However, baseball players aren't like most athletes or general fitness folks.  They have far more joint laxity, and it's a key trait that helps to make them successful in their sport.  While I hate to ever bring additional attention to an extremely unfortunately event, a weightlifting injury that occurs in this year's Olympics reminded me of just one reason why I don't include the Olympic lifts with our throwers.  Please keep in mind that while this isn't the most "gruesome" lifting injury video you'll see, some folks might find it disturbing (if you want to see the more gruesome "after" photo, read this article).  If you're one of those folks, don't push play (Cliff's notes: he dislocates his elbow).

Now, without knowing for sure what the official diagnosis is, an elbow dislocation could mean two things.  First, it could have been elbow hyperextension; I doubt that's the case, as the elbow appears to be slightly flexed when it "buckles."  Second - and more likely - we're talking about a valgus stress injury; not the joint angle below, which is approximately 20-30 degrees of elbow flexion:

You know what's remarkably coincidental about that elbow flexion angle?  It's where you do a valgus stress test to assess the integrity of the ulnar collateral ligament.

I don't know for sure if Sa Jae-hyouk is going to have a Tommy John surgery, but I can't say that I would be surprised if it does occur.  And, he certainly wouldn't be the first Olympic lifter to have one.

Now, I want to bring up a few important items.

1. I think this essentially kills the "they're safe for baseball players if it's in good form" argument that some folks throw out there.  For those who might not know, this was a gold medalist in Beijing in 2008, and he was expected to medal at this year's Olympics, too.  I suspect he knows a few things about proper Olympic lifting technique.

2. According to research from Bigliani et al, 61% of pitchers and 47% of position players at the professional levels had sulcus signs (measure of instability) in their throwing shoulders.  And, 89% of the pitchers and 100% of the position players ALSO had it in their non-throwing shoulders, meaning that this is the way that they were born, not just something they acquired from throwing. I've never met an accomplished male Olympic lifter with a sulcus sign, though, which tells me that laxity is virtually non-existent in this athletic population, particularly in comparison with baseball players.  We need to fit the exercises to the athlete, not the athlete to the exercises.  

3. The obvious next question for most folks is "what about cleans and high pulls?" With cleans, the wrist and elbow stresses are even more problematic than with snatches, and there is also the issue of direct trauma to the acromioclavicular joint on the catch phase.  Plus, when folks hang clean, the distraction forces on the lowering component of the lift (assuming no drop) can be a big issue in "loose" shoulders and elbows.  High pulls are a bit better, but all of the aggressive shrugging under load with minimal scapular upward rotation can really interfere with the improvements to scapular stability that we're trying to make with our overhead throwing athletes.

4. For those curious about what I meant with respect to the power carryover from linear modalities (like Olympic lifts) not being great to rotational sports, check out this recently published research study from Lehman et al. You'll see that it backs up what I'd proposed from my anecdotal experience back in 2010; that is, power development is very plane specific.  Get to doing your med ball work!

This is one case where the injury prevention battle isn't just about adding the right exercises; it's about taking some away, too.  

With all that said, I hope you'll join me in keeping Sa Jae-hyouk in your thoughts and send him good vibes for a speedy recovery and quick return to competition.

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