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.

Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches used by Cressey Performance Pitchers after they Throw!

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.

Sign-up Today for our FREE Newsletter:

Understanding Elbow Pain – Part 6: Elbow Pain in Lifters

Written on June 2, 2010 at 6:26 am, by Eric Cressey

Today, I’m going to wrap up this six-part series entirely devoted to the elbow.  In case you missed the first five, check them out:

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

In this final installment, I’m going to discuss elbow issues as they pertain to a strength training population.  Even though some of the treatments for these injuries/conditioning may be very similar or even identical to what we see in a throwing population, I separate lifters because their problems are almost always soft tissue in nature.  While we may see stress fractures, ulnar nerve issues, and ulnar collateral ligament tears in throwers, we are virtually always dealing with problems with muscles and tendons in folks who are avid lifters.  What gives?

Well, it’s very simple: they grip stuff a lot more than normal folks, and also perform a ton of repetitive movements at the elbows and wrists.  This difference also makes you appreciate why we often see elbow issues in those who work on factory lines, performing the same task for hours on-end.

Why is it that all these issues present at the elbow?  You see, many of the muscles involved in gripping originate at the superomedial aspect of the forearm, particularly on the medial epicondyle:

When these structures get overused, they shorten – and as we discussed in Part 1, the zones of convergence (where tendons bunch up and create friction with one another) are where we develop some nasty soft tissue adhesions.

However, this doesn’t just happen from gripping.  Think about what happens when you put the bar in this position to back squat:

That bar wants to roll off his back, and while the majority of the weight is compressive loading, a good chunk of it becomes valgus stress that must be resisted by the flexors and pronators that attach at the medial aspect of the forearm/elbow. It’s not a whole lot different than the stress we see here; we just trade off the velocity and extreme range of motion in the throwing motion for prolonged loading in the lifting example:

As a general rule of thumb, the narrower the squatting grip, the more stress on the elbow.  Unfortunately, the wider the grip, the more shoulder problems we tend to see, as this position can chew up the biceps tendon.  The solution is to maintain as much specificity as possible with respect to one’s chosen endeavor, but find breaks from the repetition of these squatting positions by plugging in options like front squats, giant cambered bar squats, and safety squat bar squats.

For these reasons, I also look at soft tissue work on the forearms – and particularly the medial aspect – as a form of preventative maintenance.  Regardless of the soft tissue modality you select, get some work done every few months and stay on top of your stretching in the area to maintain adequate length of these tissues.

We’ll also see a fair amount of “underside” elbow pain in lifters, in most cases where the three heads of the triceps join up as a common tendon (another zone of convergence; does anyone see a pattern here?) to attach to the olecranon process.  The smaller anconeus – a weak elbow extensor – also comes in here.

Almost universally, the lifters who present with overuse injuries posteriorly are the ones who use loads of elbow-only extension movements like skullcrushers/nosebreakers/French presses/triceps extensions.  As a random aside to this, how can these movements have four different names, and not one of them begins with some Eastern European nationality?  “French” just doesn’t get it done when we have Russian good mornings, Bulgarian split squats, Romanian Deadlifts.

Anyway, we vilify leg extensions and leg curls as being non-functional and overly stressful at the knee.  The knee is the joint most similar to the elbow, yet it’s much bigger than the elbow, yet nobody contraindicates 4-5 elbow extension-only exercises per week in many routines as being inappropriate – or even excessive.  If you want to build big legs, you squat, deadlift, and lunge.  If you want to build big triceps, you bench, do weighted push-ups, overhead press, and do dips.  The absolute load is higher, but the stress is shared over multiple joints.

In just about every instance, when you drop the direct elbow extension work from someone’s program, their elbow issues resolve very quickly and they don’t miss a beat with training.

So, as you probably inferred, it’s very rarely a lack of strength that causes elbow pain in lifters.  Rather, it’s generally poor tissue quality, a lack of flexibility, and overuse of a collection of muscles that have “congested” insertion points.  Simply changing the program around, getting some soft tissue work done, and following it up with some stretching can go a long way to both prevent and address these issues.  That said, there will be cases where elbow pain may originate further up at the cervical spine or shoulder or – as I learned from a reader in the comments section of Part 5 – from an abducted ulna.  So, there is definitely no one-size-fits-all approach.

That wraps up this series.  Hopefully, you’ve gained insights into some of what’s rattling around inside my brain with respect to elbows.  Thanks for putting up with me for all six installments!

Please enter your email below to sign up for our FREE newsletter.

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…

Please enter your email below to sign up for our FREE newsletter.

Understanding Elbow Pain – Part 1: Functional Anatomy

Written on May 9, 2010 at 6:29 pm, by Eric Cressey

Today’s piece kicks off a multi-part series focusing specifically on the elbow.  I’m going to start off this collection by talking about the anatomy of the elbow joint, but in appreciation of the fact that a lot of you are probably not as geeky as I am, I’ll give you the Cliff’s Notes version first:

The elbow is the most “claustrophobic” joint in the body; there is a lot of stuff crammed into very little space.  This madness is governed not just by the joint itself, but (like we know with all joints) by the needs of the forearm/wrist and what goes on at the shoulder and neck.

Even for the geeks out there, in the interest of keeping this thing “on schedule,” I’m just going to focus on your pertinent information.  I would highly recommend The Athlete’s Elbow to those of you interested in learning more; it’s insanely detailed.

Your big players on the osseous (bone) front are going to be the humerus, ulna, and radius.  At the humerus, in the context of this discussion, all you really just need to pay attention to are the medial and lateral epicondyles, as they are crucial attachment points for both tendons and ligaments (as well as sites of stress fractures in younger athletes).

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

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

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

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

As any good manual therapist, and he’ll tell you that soft tissue restrictions occur predominantly at:

A.       Areas of increased friction between muscles/tendons

B.       Areas where forces generated by a myofascial unit come together (termed “Zones of Convergence” by myofascial researcher Luigi Stecco): this is generally the muscle-tendon-bone “connection,” as you don’t typically see prominent restrictions in the mid-belly of a muscle.

This is a double whammy for the muscles acting at the elbow.  In terms of A, you have many muscles in a small area.  Most folks overlook the importance of B, though: a lot of them share a common (or at least directly adjacent) attachment point.  The flexor carpi radialis, flexor carpi ulnaris, palmaris longus, and flexor digitorum superficialis all attach video the common flexor tendon on the medial epicondyle, with the pronator teres attaching just a tiny bit superiorly.  There’s ball of crap #1.

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

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

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

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

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

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

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

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

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

Related Posts

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

Click here to purchase the most comprehensive shoulder resource available today: Optimal Shoulder Performance – From Rehabilitation to High Performance.

Sign-up Today for our FREE Baseball Newsletter and Receive a Copy of the Exact Stretches
used by Cressey Performance Pitchers after they Throw!

Random Friday Thoughts: 4/24/09

Written on April 24, 2009 at 5:35 am, by Eric Cressey

1. It’s been a crazy week ever since Anna and I got engaged on Sunday.  You never truly realize how many people you know until they all try to email/call/text you at once to say congratulations.  With my cell phone and email inbox going crazy, I kind of felt like Jerry Maguire – minus the whole weird scientology and jumping on Oprah’s couch stuff.

2. On Wednesday, I got out to watch two high school games where CP athletes pitched, and then headed to Fenway to watch the Sox beat the Twins.  In Game 1, Weston High Sahil Bloom had a no-hitter through 6 2/3 innings before giving up a bloop single, and then Auburn High’s Tyler Beede threw six innings.

3. Next week, I’ll be publishing the first installment of a collection of nutrition articles from Eric Talmant.  Eric has some very forward-thinking ideas to share, and it’ll make a nice weekly addition to EricCressey.com.  Be sure to check them out.

4. I’m getting really excited for this year’s Perform Better Summits.  I’ll be speaking in Providence, RI and Long Beach, CA (there is also one in Chicago); I’d definitely encourage you to check the events out if you live in that neck of the woods.  My presentations should question the “diagnostic norms” – in much the same way that I did with this week’s newsletter.

5. Speaking of newsletters, I got several inquiries after I ran this one about the medicine ball training we do with our pitchers. In particular, folks were curious about the medicine ball we used in drills like this:

The medicine balls in question can be found HERE.

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

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

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

Have a great weekend!