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

Written on September 23, 2013 at 8:34 am, by Eric Cressey

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  My good friend Mike Reinold actually has a lot of very good unpublished data on the topic, too.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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  • John

    Other than snatches, what other movements are potentially risky for a lifter who has this?

    Also, is there anything that can be done to reverse the adaptation if it’s been made (in non pitchers)?

  • http://www.GoToBALL.org Ted Browne

    Should one ever do these first drills with very light (i.e. 2 1/2 lbs) weights?

  • http://ericcressey.com Eric Cressey

    Ted,

    Eventually, yes. Improving active ROM first is the important point.

  • http://richthetrainer.tv RW Roberts

    As usual, great article. I have assess and correct… it’s perfect. Thank you!

    I think diet has a huge effect on rebuilding cartilage and reversing damage. We often don’t get into that until we age but think what we can do with that while young.

  • Nolan Bruce

    If there any way to do some soft tissue quality work like above without a partner?

  • Nolan Bruce

    Is *

  • http://www.sportsmedres.org Stephen Thomaqs, PhD, ATC

    Eric,

    I wonder if pitchers that don’t have as much humeral retroversion are the ones presenting with an excessive carrying angle. With limited retroversion the players are inherently lacking external rotation so to make up for it they develop an elbow adaptation (bony and soft tissue). Just some food for thought!

  • http://ericcressey.com Eric Cressey

    Nolan,

    Nothing is as good as a skilled manual therapist, but using the Stick can help:

    https://www.youtube.com/watch?v=qf242YcKjM0

  • http://ericcressey.com Eric Cressey

    Stephen,

    Absolutely.  I would have brought it up, but didn’t want to deviate too much from the points at hand. That said, the second pitcher pictured actually had very little retroversion.  That said, I’ve definitely seen others who had both significant retroversion and an exaggerated valgus carrying angle.

  • http://www.sportsmedres.org Stephen Thomaqs, PhD, ATC

    Eric,

    How are you measuring retroversion on the pitchers? I have used ultrasound previously for research purposes but I know there is a clinical measure (http://www.mikereinold.com/2010/03/measuring-humeral-retroversion.html) floating around but it in a small study we did at spring training the clinical measure did not accurately measure the amount of retroversion. It actually didn’t even come close. I think the clinical technique is actually measuring posterior tightness and not retroversion. As you move in crossbody adduction you put more tension on the posterior structures (capsule and cuff). To release this tension the arm will begin to externally rotate thereby increasing the angle.

  • http://ericcressey.com Eric Cressey

    Stephen,

    My feeling is that you work to make total motion symmetrical, then measure the internal rotation deficit that’s present.  There’s your retroversion.

  • http://ericcressey.com Eric Cressey

    John,

    I’d be careful with back squats, too.

    This is not reversable.

  • Joe

    Can deadlifts and pull-ups/chins, stress the ucl?

  • http://ericcressey.com Eric Cressey

    Joe,

    Anything can stress it, but the biggest issue with these exercises is that gripping can cause the flexor tendon to pull on the medial epicondyle, which is also the attachment point of the UCL. Additionally, if an athlete is hypermobile and allows the elbow to hyperextend, that can be a problem as well.

  • Brent Schwarz

    You mentioned guys with subluxation of the ulnar nerve–what do you recommend for management of those throwers, in terms of warm up/recovery/training?


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