We're excited to welcome Dr. Chris Ahmad, team doctor for the New York Yankees, to this week's podcast. Dr. Ahmad goes into great detail on the throwing elbow with respect to anatomy, diagnostic challenges, surgical complexities, non-operative strategies, and biological interventions. He also touches on important lessons for players, parents, and coaches who want to avoid youth baseball injuries.

A special thanks to this show's sponsor, Athletic Greens. Head to http://www.athleticgreens.com/cressey and you'll receive a free 10-pack of Athletic Greens travel packets with your first order.

Show Outline

• What makes the anatomy and function of the elbow so complex, specifically in throwing athletes
• What the biggest mistakes are both surgically and diagnostically with respect to the elbow
• Why injuries of the elbow aren’t as binary as partial and full tears and how professionals can better evaluate and understand the health of elbows in throwing populations
• How UCL calcification and injury at a young age impacts the health of baseball players as they grow and advance in their career
• What makes a Tommy John surgery successful from a surgical perspective
• How Tommy John surgery has evolved since it was first performed in 1974
• What the clinical implications are for Dr. Ahmad to perform an ulnar nerve transposition during UCL reconstruction surgery
• What variables surgeons must consider when deciding where to take a tendon graft from for UCL reconstruction
• How Dr. Ahmad manipulates grafts to ensure an elbow is strong and sturdy for his patients post-surgery
• What key things Ahmad discusses with his patients as they begin their road to recovery post-surgery
• What key benchmarks Dr. Ahmad looks for patients to progress to through the Tommy John rehab process
• Why there isn’t a true standard timeline for athletes to return to performing in games after UCL reconstruction
• Why Dr. Ahmad is an advocate for biological interventions such as PRP injections and the use of stem cells to manage elbow injuries, and what benefits these methodologies offer beyond throwing injuries
• Where the future of biological treatments is headed, and what the drawbacks and dangers of using these powerful methods can be
• Where Dr. Ahmad sees the need for more research to be done in the prevention, reconstruction, rehabilitation, and recovery of arm injuries
• Why Dr. Ahmad has worked to create a registry with Major League Baseball to collect data on injured professional ball players and how this resource will be used to find answers to questions in the field without setting up a formal study

You can follow Dr. Ahmad on Twitter at @DrChrisAhmad and on Instagram at @DrChrisAhmad. And, you can learn more about him at www.DrAhmadSportsMedicine.com. Definitely check out his books:

Baseball Sports Medicine

Skill

Understanding Tommy John Surgery

Sponsor Reminder

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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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Quite some time ago, I met a pitching coach who made a bold statement to me:

"Most Major League pitchers have terrible mechanics."

I don't know if he meant that they were mechanics that could lead to injuries, or simply mechanics that would interfere with control and velocity development, but either way, I shrugged it off.  Why?

Their mechanics are so terrible that they're in the top 0.0001% of people on the planet who play their sport.  And, they're paid extremely well to be terrible, I suppose.

Kidding aside, this comment got me to thinking about something that's been "festering" for years now, and I wanted to run it by all of you today to get your impressions on it.  In other words, this post won't be about me ranting and raving about how things should be, but rather me starting a dialogue on one potential way to get the baseball development industry to where it needs to be, as it clearly isn't there yet (as evidenced by the fact that more pitchers are getting hurt nowadays than ever before).

The way I see it, mechanics are typically labeled as "terrible" when a pitcher has:

1. Trouble throwing strikes

2. Pitching velocity considerably below what one would expect, given that pitcher's athleticism

3. Pain when throwing

4. Mechanical issues that theoretically will predispose him to injury 

In the first three cases, anyone can really make these observations.  You don't need to be trained in anything to watch the walk totals pile up, read a radar gun, or listen when a pitcher says, "It hurts."  Moreover, these issues are easier to coach because they are very measurable; pitchers cut down on their walks, throw harder, and stop having pain.

Issue #4 is the conundrum that has lead to thousands of pissing matches among pitching coaches.  When a pitcher gets hurt, everyone becomes an armchair quarterback.  The two biggest examples that come to mind are Mark Prior and Stephen Strasburg.

Prior was supposed to be one of the best of all-time before shoulder surgeries derailed his career.  After the fact, everyone was quick to pin all the issues on his mechanics.  What nobody has ever brought to light is that over the course of nine years, his injuries looked like the following (via Wikipedia):

1. Hamstrings strain (out for 2002 season)
2. Shoulder injury (on-field collision - missed three starts in 2003)
3. Achilles injury (missed two months in 2004)
4. Elbow strain (missed 15 days in 2004)
5. Elbow injury (missed one month in 2005 after being hit by line drive)
6. Rotator cuff strain (missed three months in 2006)
7. Oblique strain (missed two starts in 2006)
8. Rotator cuff strain (ended 2006 season on disabled list)
9. Shoulder surgery (missed entire 2007 season, and first half of 2008)
10. Shoulder capsule tear (out for season after May 2008)
11. Groin injury (missed last two months of 2011 season)

By my count, that is eleven injuries - but four of them were non-arm-related.  And, two of them (both early in his career) were contact injuries.  Who is to say that he isn't just a guy with a tendency toward degenerative changes on a systemic level?  How do we know one of the previous injuries didn't contribute to his arm issues later on?  How do we know what he did for preventative arm care, rehabilitation, throwing, and strength and conditioning programs? We don't have his medical records from earlier years to know if there were predisposing factors in place, either.  I could go on and on.

The issue is that our sample size is one (Mark Prior) because you'll never see this exact collection of issues in any other player again.  It's impossible to separate out all these factors because all issues are unique.  And, it's one reason why you'll never see me sitting in the peanut gallery criticizing some teams for having injured players; we don't have sufficient information to know exactly why a player got hurt - and chances are, the medical staff on those teams don't even have all the information they'd like to have, either.

Strasburg has been labeled the best prospect of all-time by many, and rightfully so; his stuff is filthy and he's had the success to back it up.  Of course, the second he had Tommy John surgery, all the mechanics nazis came out of their caves and started berating the entire Washington Nationals organization for not fixing the issue (an Inverted W) proactively to try to prevent the injury.  Everybody is Johnny Brassballs on the internet.

To that end, I'll just propose the following questions:

1. Did Strasburg not do just fine with respect to issues 1-3 in my list above?

2. Would you want to be the one to screw with the best prospect of all-time and potentially ruin exactly what makes him effective?

3. Do we really know what the health of his elbow was when the Nationals drafted him?

4. Do we know what his arm care, throwing, and strength and conditioning programs were like before and after being drafted?

There are simply too many questions one can ask with any injury, and simply calling mechanics the only contributing factor does a complex issue a disservice - especially since young athletes are growing up with more and more physical dysfunction even before they have mastered their "mature" mechanics.

The Inverted W theory is incredibly sound; Chris O'Leary did a tremendous job of making his case - and we certainly work to coach throwers out of this flaw - but two undeniable facts remain.  First, a lot of guys still throw with the Inverted W and don't have significant arm issues (or any whatsoever).  They may have adequate mobility and stability in the right places (more on this below) to get by, or perhaps they have just managed their pitch counts and innings appropriately to avoid reaching threshold.  I suspect that you might also find that many of these throwers can make up for this "presumed fault" with a quick arm combined with a little extra congenital ligamentous laxity, or subtle tinkering with some other component of their timing.

Second, a lot of guys who don't have an Inverted W still wind up with elbow or shoulder injuries. Good research studies bring issues like these to light, and nobody has really gotten a crew of inverted W guys and non-inverted W guys together to follow injury rates over an extended period of time while accounting for variables such as training programs, pitch counts, and pitch selection (e.g., sliders vs. curveballs). We don't know if some of these other factors are actually more problematic than the mechanics themselves, as it's impossible to control all these factors simultaneously in a research format.

As such, here we have my first set of questions:

Don't you think that pitching coaches need to make a dedicated effort to understand research methods so that they can truly appreciate the multifactorial nature of injuries?  And, more importantly, wouldn't learning to read research help them to understand which mechanical issues are the true problem?  

The Inverted W is certainly an issue, but there are many more to keep in mind. Just my opinion: I think the baseball industry would be much better off if pitching coaches read a lot more research.

Now, let's move on to my second question.  First, though, I want to return to the Inverted W example again. I have not met more than a few pitching coaches who can explain exactly what structures are affected by this mechanical flaw because they don't understand what functionally is taking place at the shoulder and elbow.  They don't understand that excessive glenohumeral (shoulder) horizontal abduction, extension, and external rotation can all lead to anterior glide of the humerus, creating more anterior instability and leading to injuries to the anterior glenohumeral ligaments and labrum.  Meanwhile, the biceps tendon picks up the slack as a crucial anterior stabilizer.  They also don't appreciate how these issues are exacerbated by poor rotator cuff function and faulty scapular stabilization patterns.  And, they don't appreciate that these issues are commonly present even in throwers who don't demonstrate an Inverted W pattern.

At the elbow, they also can't explain why, specifically, the Inverted W can lead to problems. They don't understand that the timing issue created by the "deep" set-up leads to greater valgus stress at lay-back because the arm lags.  They can't explain why some players have medial issues (UCL injuries, ulnar nerve irritation, flexor/pronator strains, and medial epicondyle stress fractures) while other players have lateral issues (little league elbow, osteochondritis dissecans of radial capitellum) from the same mechanical flaws.  They can't explain why a slider thrown from an Inverted W position would be more harmful than a curveball.

I can explain it to you - and I can explain it to my athletes so that they understand, too. I've also met a lot of medical professionals who can clearly outline how and why these structures are injured, but we aren't the ones coaching the pitchers on the mounds.  The pitching coaches are the ones in those trenches.

To that end, I propose my second set of questions:

Don't you think pitching coaches ought to make an effort to learn functional anatomy in order to understand not just what gets injured, but how those injuries occur?  Wouldn't it give them a more thorough understanding of how to manage their pitchers, from mechanical tinkering, to pitch selection, to throwing volume?  And, wouldn't it give them a more valid perspective from which to contribute to pitchers' arm care programs in conjunction with rehabilitation professionals and strength and conditioning coaches? 

The problem with just saying "his mechanics suck" is that it amounts to applying a theory to a sample size of one.  That's not good research.  Additionally, this assertion is almost always taking place without a fundamental understanding of that pitcher's functional anatomy.  It amounts to coaching blind.

To reiterate, this was not a post intended to belittle anyone, but rather to bring to light two areas in which motivated pitching coaches could study extensively in order to really separate themselves from the pack.  Additionally, I believe wholeheartedly in what Chris O'Leary put forth with his Inverted W writings; I just used it as one example of a mechanical flaw that must be considered as part of a comprehensive approach to managing pitchers.

With that said, I'd love to hear your opinions on these two sets of questions in the comments section below. Thanks in advance for your contributions.

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