Baseball Strength and Conditioning Programs: How Much Rotator Cuff Work is Too Much? – Part 1

Written on January 9, 2012 at 8:15 am, by Eric Cressey

I just got back from presenting in front of 3,500 coaches at the American Baseball Coaches Convention in Anaheim.  I had an absolute blast, and since I received some great feedback from many coaches in attendance after my talk, I thought I’d use the first few posts of this week to recap a few highlights of my presentation.  To start off, one statement I made that I know turned some heads was:

I think most people overtrain the rotator cuff nowadays, and they do so with the wrong exercises, anyway.

To illustrate my point, I’m going to ask a question:

Q: What is the most common complication you see in guys as they rehabilitate following a Tommy John Surgery?

A: Shoulder problems – generally right around the time they get up to 120 feet.

Huh?  Shoulder pain is a post-operative complication of an elbow surgery?  What gives?

First, I should make a very obvious point: many of these guys deal with shoulder stiffness as they get back to throwing simply because they’ve been shut down for months.  That I completely expect – but remember that it’s stiffness, and not pain.  They always throw their way out of it.

The more pressing issue is what is taking place in their rehabilitation – and more specifically, what’s taking place with the synergy between their rehabilitation and throwing program. Let me explain.

Rehabilitation following a UCL reconstruction is extensive.  While different physical therapists certainly have different approaches, it will always be incredibly heavy on rotator cuff strength and timing, as well as adequate function of the scapular stabilizers.  Guys always make huge strides on this front during rehab, but why do so many have shoulder pain when they get further out with their long tossing?  The answer is very simple:

Most people don’t appreciate that throwing a baseball IS rotator cuff training.

Your cuff is working tremendously hard to center the humeral head in the glenoid fossa.  It controls excessive external rotation and anterior instability during lay-back.

It’s fighting against distraction forces at ball release.

And, it’s controlling internal rotation and horizontal adduction during follow-through.

Simultaneously, the scapular stabilizers are working incredibly hard to appropriately position and stabilize the scapula on the rib cage in various positions so that it can provide an ideal anchor point for those rotator cuff muscles to do their job.

A post-op Tommy John thrower – and really every player going through a throwing program – has all the same demands on his arm (even if he isn’t on the mound, where stress is highest).  And, as I wrote previously in a blog about why pitchers shouldn’t throw year-round, every pitcher is always throwing with some degree of muscle damage at all times during the season (or a throwing program).

Keeping this in mind, think about the traditional Tommy John rehabilitation approach.  It is intensive work for the cuff and scapular stabilizers three times a week with the physical therapists – plus many of the same exercises in a home program for off-days.  They’re already training these areas almost every day – and then they add in 3-6 throwing sessions a week.  Wouldn’t you almost expect shoulder problems?  They are overusing it to the max!  This is a conversation I recently had with physical therapist Eric Schoenberg, and he made another great point:

Most guys – especially at higher levels – don’t have rotator cuff strength issues; they have rotator cuff timing issues.

In throwing – the single-fastest motion in all of sports – you’re better off having a cuff that fires at the right time than a cuff that fires strong, but late.  Very few rotator cuff exercise programs for healthy pitchers take that into account; rather, it’s left to those doing rehabilitation.  Likewise, most of the programs I see altogether ignore scapular stability and leave out other ways to train the cuff that are far more functional than just using bands.

Now, apply this example back to the everyday management of pitchers during the season. Pitchers are throwing much more aggressively: game appearances, bullpens, and long toss.  They need to do some rotator cuff work, but it certainly doesn’t need to be every day like so many people think.

I’ll cover how much and what kind in Part 2.  In the meantime, if you’d like to learn more about the evaluation and management of pitchers, check out Optimal Shoulder Performance.

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Shoulder Mobility Drills: How to Improve External Rotation (if you even need it)

Written on May 31, 2011 at 8:12 am, by Eric Cressey

Last summer, a college pitcher came up to Cressey Performance from the South to train for a month before his summer league got underway. He was seven months post-op on a shoulder surgery (Type 2 SLAP) and had been working his way back. Unfortunately, his arm was still bothering him a bit when he got up to see us.

After the first few days at CP, though, he told me that his arm felt as good as it’s felt in as long as he could remember. He’d been doing a comprehensive strength and conditioning program, but the “impact” stuff for him had been soft tissue work, some Postural Restoration Institute drills, an emphasis on thoracic mobility, and manual stretching into internal rotation, horizontal adduction, and shoulder flexion. From all the rehab, his cuff was strong and scapular stabilizers were functioning reasonably well – which led me to believe that his issues were largely due to tissue shortness and/or stiffness.

This realization made me immediately wonder what he’d been doing in the previous months for mobility work for his arm – so I asked. He then demonstrated the manual stretching series that every pitcher on his team went through every day on the table with their athletic trainer. Each stretch was done for 2x20s – and two of those stretches took him into extreme external rotation and horizontal abduction. I was pretty shocked.

Me: “You’re probably not the only guy on your team rehabbing right now, huh?”

Him: “No; there are actually too many to count.”

Me: “Elbows, too, I’m sure.”

Him: “Yep.”

Want to irritate a labrum, biceps tendon, or the undersurface of the rotator cuff? Stretch a thrower into extreme external rotation and simulate the peel-back mechanism. This also increases anterior capsular laxity and likely exacerbates the internal impingement mechanism over the long-term. To reiterate, this is a bad stretch!

Want to make an acromioclavicular joint unhappy? Stretch a thrower into horizontal abduction like this (again, this is a BAD stretch that is pictured):

Want to irritate an ulnar nerve or contribute to the rupture of an ulnar collateral ligament? Make sure to apply direct pressure to the forearm during these dangerous stretches to create some valgus stress. This is a sure-fire way to make a bad stretch even worse:

These stretches are very rarely indicated in a healthy population – especially pitchers who already have a tendency toward increased external rotation. The shoulder is a delicate joint that can’t just be manhandled – and when you’re dealing with shoulders that are usually also pretty loose (both from congenital and acquired factors), you’re waiting for a problem when you include such stretches. In fact, I devoted an entire article to this: The Right Way to Stretch the Pecs.

Everyone thinks that shoulder external rotation and horizontal abduction alone account for the lay-back in the extreme cocking position.

In reality, though, this position is derived from a bunch of factors:

1. Shoulder External Rotation Range-of-Motion – and this is the kind of freaky external rotation you’ll commonly see thanks to retroversion and anterior laxity:

2. Scapular Retraction/Posterior Tilt

3. Thoracic Spine Extension/Rotation

4. Valgus Carrying Angle

So, how do you improve lay-back without risking damage to the shoulder and elbow?

1. Soft tissue work on Pec minor/major and subscapularis – Ideally, this would be performed by a qualified manual therapist – especially since you’re not going to be able to get to subscapularis yourself. However, you can use this technique to attack the pecs:

2. Exercises to improve scapular retraction/depression/posterior tilt – This could include any of a number of horizontal pulling exercises or specific lower trap/serratus anterior exercises like the forearm wall slide with band.

3. Incorporate specific thoracic spine mobility drills – In most pitchers, you want to be careful about including thoracic spine mobility drills that also encourage a lot of glenohumeral external rotation. However, when we assess a pitcher and find that he’s really lacking in this regard, there are two drills that we use with them. The first is the side-lying extension-rotation, which is a good entry level progression because the floor actually limits external rotation range-of-motion, and it’s easy to coach. I tell athletes that they should think of thoracic spine extension/rotation driving scapular retraction/depression, which in turn drives humeral external rotation (and flexion/horizontal abduction). Usually, simply putting your hands on the shoulder girdle and guiding them through the motion is the best teaching tool.

A progression on the side-lying extension-rotation is the side-lying windmill, which requires a bit more attention to detail to ensure that the range-of-motion comes from the right place. The goal is to think of moving exclusively from the thoracic spine with an appropriate scapular retraction/posterior tilt. In other words, the arm just comes along for the ride. The eyes (and head) should follow the hand wherever it goes.

Again, these are only exercises we use with certain players who we’ve deemed deficient in external rotation. If you’re a thrower, don’t simply add these to your routine without a valid assessment from someone who is qualified to make that estimation. You could actually make the argument that this would apply to some folks in the general population who have congenital laxity as well (especially females).

4. Throw!!!!! – Pitchers gain a considerable amount of glenohumeral external rotation over the course of a competitive season simply from throwing. Sometimes, the best solution is to simply be patient. I really like long toss above all else for these folks.

In closing, there are three important things I should note:

1. You don’t want to do anything to increase valgus laxity.

2. You’re much more likely to get hurt from being “too loose” than you are from being “too tight.” When it comes to stretching the throwing shoulder, “gentle” is the name of the game – and all mobility programs should be as individualized as possible.

3. Maintaining internal rotation is a lot more important than whatever is going on with external rotation. In fact, this piece could have just as easily been named “The Two Stretches Pitchers Shouldn’t Do, Plus a Few That Only Some of Them Need.”

To learn more about testing, training, and treating throwing shoulders, check out Optimal Shoulder Performance: From Rehab to High Performance.

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

Written on May 18, 2011 at 6:22 am, by Eric Cressey

Three weeks ago, this article on pitching injuries became the single-most popular piece in EricCressey.com history:

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

In that feature, I made the following statement:

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

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

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

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

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

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

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

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

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Does a Normal Elbow Really Exist?

Written on February 9, 2011 at 8:36 am, by Eric Cressey

I’ve written quite a bit in the past about how diagnostic imaging (x-rays, MRIs, etc) doesn’t always tell the entire story, and that incidental findings are very common.  This applies to the lower back, shoulders, and knees (and surely several other joints).  The scary thing, though, is that we see these crazy structural abnormalities not just in adults, but in kids, too.  Last month, I highlighted research that showed that 64% of 14-15 year-old athletes have structural abnormalities in their knees – even without the presence of symptoms.  Just a month later, newer research is showing that the knee isn’t the only hinge joint affected; young throwers’ elbows are usually a structural mess as well.  In an American Journal of Sports Medicine study of 23 uninjured, asymptomatic high school pitchers (average age of 16), researchers found the following:

Three participants (13%) had no abnormalities. Fifteen individuals (65%) had asymmetrical anterior band ulnar collateral ligament thickening, including 4 individuals who also had mild sublime tubercle/anteromedial facet edema. Fourteen participants (61%) had posteromedial subchondral sclerosis of the ulnotrochlear articulation, including 8 (35%) with a posteromedial ulnotrochlear osteophyte, and 4 (17%) with mild posteromedial ulnotrochlear chondromalacia. Ten individuals (43%) had multiple abnormal findings in the throwing elbow.

For me, the 35% with the osteophytes (and chondromalacia) are the biggest concern.  Thickening of the ulnar collateral ligament isn’t surprising at all, but marked osseous (bone) abnormalities is a big concern.

Also, as a brief, but important aside, this study was done at the Mayo Clinic in Rochester, Minnesota – which isn’t exactly the hotbed of baseball activity that you get down in the South.  Recent research also shows that players in Southern (warm weather) climates have decreased shoulder internal rotation range of motion and external rotation strength compared to their Northern (cold weather) climate counterparts. In other words, I’ll be money that the numbers reported in this study are nothing compared to the young pitchers who are constantly abused year-round in the South.

The next time you think to yourself that all young athletes – especially throwers – can be managed the same, think again.  Every body is unique – and that’s why I’m so adamant about the importance of assessing young athletes. It’s one reason why I filmed the Everything Elbow in-service, which would be a great thing to watch if you’re someone who manages pitchers.

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Long Toss: Don’t Skip Steps in Your Throwing Program

Written on January 16, 2011 at 2:19 pm, by Eric Cressey

My good buddy Alan Jaeger has gone to great lengths to bring long tossing to the baseball world.  I discussed why I really like it and what some of the most common long toss mistakes are in two previous posts:

Making the Case for Long Toss in a Throwing Program
The Top 4 Long Toss Mistakes

However, one thing I didn’t discuss in those previous blogs was the status quo – which is essentially that long toss distances should not exceed 90-120 feet.  These seemingly arbitrary numbers are actually based on some research discussing where a pitcher’s release point changes and the throwing motion becomes less and less like what we see on the mound.  Alan looked further into the origins of the “120 foot rule,” and informed me that these programs began in the late 1980s/early 1990s and were based on “post-surgery experience” of a few rehabilitation specialists.

Yes, we’re basing modern performance-based throwing programs for healthy pitchers on 20+ year-old return-to-throwing programs that were created for injured pitchers.  It seems ridiculous to even consider this; it’s like only recommending body weight glute bridges to a football player looking to improve his pro agility time because you used them with a football player who had knee or low back pain.  It might be part of the equation, but it doesn’t improve performance or protect against all injuries.  Let’s look further at how this applies to a throwing context, though.

A huge chunk of pitching injuries – including all those that fall under the internal impingement spectrum (SLAP tears, undersurface cuff tears, and bicipital tendinosis), medial elbow pain (ulnar nerve irritation/hypermobility, ulnar collateral ligament tears, and flexor/pronator strains), and even lateral compressive stress (younger pitchers, usually) occur during the extreme cocking phase of throwing.  That looks like this:

It’s in this position were you get the peel back mechanism and posterior-superior impingement on the glenoid by the supra- and infraspinatus.  And, it’s where you get crazy valgus stress (the equivalent of 40 pounds pulling down on the hand) at the elbow – which not only stresses the medial structures with tensile force, but also creates lateral compressive forces.

In other words, if guys are hurt, this is the most common spot in their delivery that they will typically hurt.

So, logically, the rehabilitation specialists try to keep them away from full ROM to make the surgical/rehab outcomes success – and you simply won’t get full range of motion (ROM) playing catch at 60-120 feet.

Effectively, you can probably look at the “progression” like this:

Step 1: 60-120 ft: Low ROM, Low Stress
Step 2: 120+ ft: Medium ROM, Medium Stress
Step 3: 240+ ft: High ROM, Medium Stress
Step 4: Mound Work: High ROM, High Stress

In other words, in the typical throwing program – from high school all the way up to the professional ranks – pitchers skip steps 2 and 3.  To me, this is like using jump rope to prepare for full speed sprinting.  The ROM and ground reaction forces (stress) just don’t come close to the “end” activity.

Only problem?  Not everyone is rehabbing.  We’re actually trying to get guys better.

Long Toss.  Far.  You’ll thank me later.

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Weight Training for Baseball: Featured Articles

Written on December 29, 2010 at 7:24 am, by Eric Cressey

I really enjoy writing multi-part features here at EricCressey.com because it really affords me more time to dig deep into a topic of interest to both my readers and me.  In many ways, it’s like writing a book.  Here were three noteworthy features I published in 2010:

Understanding Elbow Pain - Whether you were a baseball pitcher trying to prevent a Tommy John surgery or recreational weightlifter with “tennis elbow,” this series had something for you.

Part 1: Functional Anatomy
Part 2: Pathology
Part 3: Throwing Injuries
Part 4: Protecting Pitchers
Part 5: The Truth About Tennis Elbow
Part 6: Elbow Pain in Lifters

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

Strategies for Correcting Bad Posture: Part 1
Strategies for Correcting Bad Posture: Part 2
Strategies for Correcting Bad Posture: Part 3
Strategies for Correcting Bad Posture: Part 4

A New Paradigm for Performance Testing – This two-part feature was actually an interview with Bioletic founder, Dr. Rick Cohen.  In it, we discuss the importance of testing athletes for deficiencies and strategically correcting them.  We’ve begun to use Bioletics more and more with our athletes, and I highly recommend their thorough and forward thinking services.

A New Paradigm for Performance Testing: Part 1
A New Paradigm for Performance Testing: Part 2

I already have a few series planned for 2011, so keep an eye out for them!  In the meantime, we have two more “Best of 2010″ features in store before Friday at midnight.

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Managing Sidearm and Submarine Pitchers

Written on September 1, 2010 at 5:43 am, by Eric Cressey

Q: I just saw your post about Strasberg and pitching injuries.  This may be hopelessly naive, but – do “submarine” throwers face the same perils?  I’m old enough to remember Kent Telkulve, so it made me think.  It seems as though I see a fair number of throws from SS and 3B positions that appear somewhat submarine-like in motion, so the technique wouldn’t be completely unknown. Thoughts?

A: In short, the answer would be “yes,” they do face the same perils.

If you actually slow things down and example joint angles, you’ll see that the shoulder and elbow positioning most of these guys get to is very similar to what you see in more overhand throwers.  The difference is in how much lateral trunk tilt they have; the more trunk tilt, the lower the release point.

The primary difference you’ll see is that sidearm/submarine throwers will typically break down at the elbow a lot more than the shoulder.  Aguinaldo and Chambers found that sidearm throwers had significantly higher elbow valgus torques than overhand throwers. It’s not surprising, given that they do tend to lead with the elbow a bit more.

Position players who throw more sidearm can largely get away with it because a) they don’t have anywhere near the volume of throwing in a single outing or a season that pitchers do, and b) they aren’t throwing off a mound.  We know that just stepping up onto the elevated mound dramatically increases arm stress.

So, what are the practical applications of knowing the demands are, for the most part, very similar?

First, spend a considerable amount more time focusing on core stability and working to iron out excessive right-left asymmetries that arise secondary to all the lateral trunk tilt.  In other words, worry as much about the spine as you do about the arm.

Second, I’d put an even greater emphasis on soft tissue work at the medial elbow – particularly on the common flexor tendon (the muscles that join to create this tendon protect the ulnar collateral ligament from excessive valgus stress).

Third, as is usually the case, use these guys as relievers to keep their throwing volume lower while still maximizing their utility.

Other than that, manage them as if you would any other pitcher – which should always be a tremendously individualized process, anyway!

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More Than Just Pitching Mechanics: The Skinny on Stephen Strasburg’s Injury

Written on August 29, 2010 at 11:45 am, by Eric Cressey

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

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

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

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

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

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

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

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

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

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

They’re wasting their bullets.

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

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

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Ulnar Collateral Ligament Injuries in Quarterbacks vs. Pitchers

Written on July 26, 2010 at 5:39 am, by Eric Cressey

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

However, what is very interesting to me is that 9/10 cases were treated non-operatively; in other words, Tommy John surgery is much less prescribed in football quarterbacks than baseball pitchers – meaning that the quarterbacks respond better to conservative treatment.

What’s up with that?  They are the same injuries – and presumably the same rehabilitation programs.

In my eyes, it’s due to the sheer nature of the stress we see in a baseball pitch in comparison to a football throw.  As a quarterback, you can probably “get by” with a slightly insufficient UCL if you have adequate muscular strength, flexibility, and tissue quality.  While this is still the case in some baseball pitchers, the stresses on the passive structure (UCL) are still markedly higher on each throw, meaning that your chances of getting by conservatively are probably slightly poorer.

I’m sure that the nature of the sporting year plays into this as well.  Football quarterbacks never attempt to throw year-round, so there isn’t a rush to return to throwing.  There are, however, a lot of stupid baseball pitchers who think that they can pitch year-round, so kids often “jump the gun” on their throwing programs and make things worse before they can heal completely.

That said, we’ve still worked with a lot of pitchers who have been able to come back and throw completely pain-free after being diagnosed with a partial UCL tear and undergoing conservative treatment (physical therapy).  It’s an individual thing.

Related Posts

Understanding Elbow Pain – Part 3: Throwing Injuries
Understanding Elbow Pain – Part 4: Protecting Pitchers

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Understanding Elbow Pain – Part 2: Pathology

Written on May 12, 2010 at 6:16 am, by Eric Cressey

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.

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”).

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.

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.

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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