A New Injury Epidemic in Baseball Pitchers: Blisters

Injuries to baseball pitchers. You’re probably thinking of an assortment of shoulder and elbow pathologies. The most common ones include labral injuries of the shoulder or ulnar collateral ligament tears of the elbow requiring a Tommy John procedure.

One growing injury trend impacting pitchers at all levels, particularly in collegiate and professional baseball, is blisters. You heard that right. Blisters are causing well over several months per season of cumulative days missed at the Major League Baseball (MLB) level.

These injuries can be particularly debilitating to the throwing hand of pitchers. They can decrease performance through improper ball handling and command, and may result in an inability to throw a baseball without pain or discomfort.

Due to blisters becoming such an issue in baseball, let’s step back and quickly look at the data. Let’s review how these injuries are occurring, as well as discuss ways in which medical professionals can not only treat these injuries but work to prevent them in the first place.

 

Are Blisters in Baseball Pitchers an Epidemic?

During the 2016 and 2017 season each, approximately 190 days were missed in the MLB by pitchers due to blisters. For comparison, between 2012-2015, less than 190 days combined were missed.

So, what happened at the start of 2016?

In a recent article from “The Ringer,” former Dodgers head athletic trainer Stan Conte stated that there’s “no question that there is an increase from previous years.” He continues by stating “the million-dollar question is why. I think we all the talk about the perceived changes in the ball, that has to be on the top of the list.”

The Ringer indicated amongst their incidence data provided below, that “seam-height data” of the baseball testing they had provided from the MLB, that the seams on baseballs itself are lower now than they were before 2016. Can seam height truly dictate the incidence of blisters?

 

Why Do Blisters Occur?

Aside from the growing issue that blisters potentially pose to baseball pitchers, it’s critical for training room medical professionals to understand how to address these issues.

Blisters can form on any finger of the throwing hand of a pitcher. However, typically speaking, most blisters form on the middle finger. This is most likely due to the middle finger being the last point of contact during a fastball pitch.

In addition, these blisters can also occur more frequently on the thumb or index finger, as well. I’ve had pitchers tell me in the past that during a circle change-up pitch, they can even get contact between the nail of their index finger and the inside part of their thumb upon ball release.

Overall, blisters form due to the friction that occurs between the ball (or seam of the ball) and the end of a finger.

This repetitive load and friction that occurs with the hundreds and thousands of pitches thrown, can lead to a focal irritation and breakdown of skin.

 

How to Prevent Blisters

There are several ways in which baseball pitchers have attempted to address blisters. Mark Vinson of the Tampa Bay Rays states that “some pitchers use spray-on antiperspirant, which has been shown to help prevent sweat and reduce added moisture from sweat.”

He also recommends that pitchers place their “throwing hand into a bag of rice in between innings to help reduce moisture on their fingers” as well.

The goal of these preventative measures is to maintain integrity of the skin on the fingertip, and ultimately reduce the likelihood of “pruning” from developing from prolonged moisture that can take place from sweat.

However, once a blister has formed, it’s imperative that treatment begins quickly to avoid any potential of prolonged missed time from competition.

 

Treating Blisters in the Baseball Pitcher

The blister, whether filled with clear serous fluid or blood, can often best be addressed by having a sterile drain be applied with a needle to the affected area.

Most importantly, while the drainage should provide instantaneous relief, it’s critical that the blister be monitored to ensure that it does not open up, creating a secondary skin avulsion.

In the cases in which a “chunk” of the skin has been removed through a skin avulsion, it can cause a significant amount of missed time. This is due to basically having an “open wound” on a finger that is constantly becoming further irritated by throwing.

Outside of having a needle drain the blister, other more conservative measures include Dermabond, which is essentially like a “skin super glue” that can perform as another barrier of friction over the injured finger.

If the skin on the finger begins to open up , pitchers may have to address any potential infections that occur. Vinson states that Betadine mixed with water can be useful as “Betadine helps to clean the area, prevent infection and toughen the skin around the affected area over the long-term.”

 

Summary

It’s clear that the incidence of blisters among baseball pitchers at the Major League level is rising dramatically. The reason for this new epidemic is less clear. Is it due to the type of pitches thrown, the seams of the baseball, or other factors? We don’t have an answer.

In the meantime, it’s important for training room professionals and coaches to try to prevent blisters from occurring at all. When they inevitably do occur over the course of a season, training room staff should be educated on how to address these injuries so that the pitcher can return to the field in a pain-free manner.

Regaining Shoulder Range of Motion in Baseball Players

Regaining motion following heavy doses of high intensity throwing cannot be overlooked.

Throwing causes significant range of motion changes from eccentric stress. Any movement activity causing significant muscle damage can alter movement in the days following.

Pitchers throwing a large amount of pitches suffer significant eccentric stress, not only in the arm/shoulder but throughout the entire body. Joint distraction forces at the shoulder and elbow rapidly increase to 1–1.5 times the body mass to decelerate the arm.

Mike Reinold, in a 2008 study, showed significant decreases in shoulder internal rotation, total motion, and elbow extension following pitching in the dominant shoulder.  These changes were noted immediately post pitching and continued to exist 24 hours after.  These motion losses begin acutely but can progress into long term alterations.

Many of us in the baseball field have long known about glenohumeral internal rotation deficit (GIRD) when it comes to the throwing shoulder, but several recent studies are linking injuries to other movement loss within the glenohumeral joint.

Over 6 years, Dr. Chris Camp and others studied range of motion on all invited pitchers from one professional organization, totaling 81 pitchers followed and accounting for 132 pitcher seasons.

The authors looked at shoulder flexion, horizontal adduction, external rotation, internal rotation, as well as elbow flexion and extension in both the dominant and non-dominant arm during the pre-season.

Out of the 53 injuries they encountered over the 6-year period, the most significant risk factors for elbow injury were loss of shoulder external rotation and loss of shoulder flexion. Injury risk at the elbow went up 7% for each degree of external rotation loss and 9% for each degree of flexion loss.

None of the range of motion measures correlated with shoulder injuries. The study shows that altered kinematics at the shoulder have a significant effect down the kinetic chain at the elbow.

In the Camp study, the presence of an internal rotation deficit did not correlate to any increased risk of shoulder or elbow injuries.

However, the predominant overall theme remains in that pitching causes significant stresses to the arm and body, and that stress can cause significant motion losses. Motion losses are regularly tied into shoulder and arm injuries.

Regaining full overhead capacity can be much more than simply soft tissue restrictions but an easy place to start is by mobilizing the tissue around the scapula and shoulder. Gaining full overhead motion can be a combination of many factors, and it often starts at form and function when it comes to global movement.

Body and anatomical positions determine form and form dictates function.  The pelvis stuck in a poor position affects the lumbar spine which affects the thoracic spine orientation which 100% affects the scapular position which affects the shoulder.  The following list to regaining overhead motion is a good place to start but is not an exhaustive list by any means.

 

Positions – Form and Function

1. Pelvic control

Pelvic control in my opinion is the foundation of all patterns within the body.  The inability to control the pelvis stems from poor glute and abdominal motor control.

Compensation patterns result from this lack of control in the form of extended spinal positions, especially at the lumbar spine.  An over extended lumbar spine creates the rib-flair up the kinetic chain, and the rib-flair allows for false motion with overhead athletes.

Developing the ability to control the pelvis should be a priority for efficient overhead motion.  Pelvic stability should revolve around the rectus abdominus, obliques, and glute complex.  Teach and train a neutral pelvis along with anti-extension throughout the torso.

 

2. Thoracic Extension

The ability of the t-spine to extend assists in humeral flexion through efficient scapular mechanics.

A poor position places the scapula at a disadvantage.

A forward head posture with excessive rounding of the upper back drives the scapula forward into anterior tilt.

An athlete unable to extend through the t-spine will be unable to effectively upwardly rotate, and posteriorly tilt the scapula resulting in less overhead ability.

A study by Strunce in 2009 showed large increases in shoulder range of motion following thoracic spine and rib manipulations.

Although not on an athletic population, the results demonstrated the immediate benefits of positioning when it comes to the thoracic cage.

Active range of motion at the shoulder improved in flexion by 38° and improved total rotation by 30° after manual manipulation.

Results from another study by Edmonston in 2012 confirmed that extension of the thoracic spine does occur during arm flexion. The ranges of thoracic spine extension with humeral flexion was an average of 12.8 degrees, showing the importance of the kinetic chain in overhead motion.

 

3. Scapular Positioning

For the shoulder to function correctly, it relies on assistance from the scapula to get overhead.  Upward rotation and posterior tilt are significant factors in flexion.

For the arm to get a full 180 degrees of motion, the scapula must contribute 60 degrees while the glenohumeral joint handles the other 120 degrees. Without that 60 degrees, motion is compromised.

Focusing on the lower trap and serratus anterior are a good place to start as both are responsible for upward rotation, while the lower trap is key in posterior tilt.  Both are the most commonly inhibited muscles in overhead athletes due to posture, lifestyle, training methods, etc.

 

4. Soft Tissue Restrictions

Obviously, the muscles attaching to the scapula and humerus play huge roles in not only creating motion but restricting motion as well. Overactive or tight tissues limit motion.

Some muscles that have great influence on scapular positioning and subsequently on motion include the latissimus dorsi, pec major and minor, rhomboids, and levator scapula (to name a few).

Manipulating these common problem areas can go to great lengths in restoring fluid movement and positioning. However, muscles aren’t the only factor.

Capsular restrictions around the glenohumeral joint itself can factor into the equation as well.

 

Soft Tissue for Scapular Upward Rotation

 

T-Spine Extension for Overhead Athletes

 

The “overhead” in overhead athletes tells us all we need to know. The overhead position matters to throwers and being able to get there the right way is key. Don’t let flexion disappear or become a compensation pattern over the course of a long season. Keep moving efficiently for long term health when it comes to the shoulder and elbow.

 

Sources:

Camp, Christopher L., et al. “Decreased Shoulder External Rotation and Flexion Are Greater Predictors of Injury than Internal Rotation Deficits: Analysis of 132 Pitcher-Seasons in Professional Baseball.” Orthopaedic Journal of Sports Medicine, vol. 5, no. 7_suppl6, 2017, doi:10.1177/2325967117s00221.

Edmondston, Stephen, et al. “Clinical and Radiological Investigation of Thoracic Spine Extension Motion During Bilateral Arm Elevation.” Journal of Orthopaedic & Sports Physical Therapy, vol. 42, no. 10, 2012, pp. 861–869., doi:10.2519/jospt.2012.4164.

Reinold, Michael M., et al. “Changes in Shoulder and Elbow Passive Range of Motion after Pitching in Professional Baseball Players.” The American Journal of Sports Medicine, vol. 36, no. 3, 2008, pp. 523–527., doi:10.1177/0363546507308935.

Strunce, Joseph B., et al. “The Immediate Effects of Thoracic Spine and Rib Manipulation on Subjects with Primary Complaints of Shoulder Pain.” Journal of Manual & Manipulative Therapy, vol. 17, no. 4, 2009, pp. 230–236., doi:10.1179/106698109791352102.

 

How to Prevent Baseball Muscle Imbalances and Overuse Injuries

BASEBALL is a pattern overload sport, meaning the same movements are replicated thousands of times throughout a season. Since baseball is a one-sided sport, this PATTERN OVERLOAD has the tendency to create muscle imbalances, often times leading to injury and decreasing overall performance.

 

 

Baseball players often throw and swing from the same side of their bodies, because of this, muscle imbalances will inevitably occur over the course of the season if you fail to take preventative measures.

The stresses and loads specific to the game of baseball expose players to a few common biomechanical dysfunctions and muscular imbalances. Here are a few common problems that baseball players encounter, with suggestions on how to correct them.

 

WEAK SHOULDER AND SCAPULAR STABILIZERS

The key to shoulder health and throwing performance is building strong, resilient scapular and posterior shoulder muscles. 17 muscles stabilize the scapula, creating synergistic co‐contraction to stabilize the shoulder complex and guide movement.

 

 

Weakness of the scapular stabilizers and resultant bio-mechanics changes could result in:

  1. Abnormal stresses to the anterior structures of the shoulder
  2. Increased possibility of rotator cuff injuries
  3. Decreased shoulder complex neuromuscular control.

CLICK HERE for a complete J-BANDS™ routine to help build strong scapular and posterior shoulder muscles.

 

POOR THORACIC “UPPER BACK” MOBILITY

All rotational athletes need adequate thoracic spine (upper back) mobility in order to create appropriate separation during throwing motions and changes of direction.

Throwers who lack thoracic mobility, primarily rotation, often have issues with scapulo-thoracic mechanics during the pitching or throwing motion which will inevitably place stress on the anterior shoulder.

Compensatory movement patterns often occur due to lack thoracic mobility including lumbar extension (lower back arching). These poor movement patterns lead to low back pain, abdominal strains, and hip dysfunction.⠀

Here’s a quick and easy drill to maintain thoracic mobility:

 

 

TIGHT “HYPERTONIC” POSTERIOR ROTATOR CUFF

There is no doubt that baseball players and other overhead athletes get tight from throwing. Over the course of a season your muscles tend to tighten and loss of mobility ensues. The deceleration component of the throwing motion exposes the posterior rotator cuff to extreme eccentric workloads.

Simple strategies to maintain tissue and movement quality of the posterior shoulder motion can be effective and can prevent loss of motion and injury, while enhancing throwing performance. In our baseball performance programs, we recommend the use of soft tissue techniques focusing on a few key areas like the posterior rotator cuff, lats, and pecs.

 

 

POOR SCAPULAR UPWARD ROTATION

One of the biggest problems throwers face is scapular and shoulder dysfunction. More specifically, issues related to inadequate protraction and upward rotation of the scapula.

The tendency to lose shoulder and scapular mobility (primarily upward rotation) occurs due to the stress of the throwing motion disrupting the force couple between the upper trap, lower trap, and the serratus anterior. This rotation is essential to maintain proper shoulder joint centration while performing high velocity movements.

 

 

The SCAPULAR LIFT OFF is an effective drill that can be used as part of recovery or a warm-up to maintain the range of motion that we need to throw.⠀

 

 

DECREASED SHOULDER INTERNAL ROTATION

Increased external rotation is correlated with increased throwing velocity. Improving this range of motion is helpful for lighting up the radar gun. However it’s important to note that this added external rotation comes the possibility of anterior shoulder instability and a loss of internal rotation.

In many cases, throwers tend to have decreased internal rotation of the shoulder. This is often a result of excessive external rotation which is necessary for a throwing shoulder to perform at an elite level.

A small decrease in internal rotation in the throwing shoulder is normal in throwers, however if its excessive, it can become a risk factor. Glenohumeral Internal Rotation Deficit (GIRD) refers to a pathological loss of internal rotation in the throwing shoulder compared to the non-throwing shoulder. We can avoid this by preserving as much total shoulder range of motion as possible using the following techniques.

 

Cross Arm Stretch

 

Arm Circles

 

Scare Crows

 

POOR HIP MOBILITY

The hips of a thrower are subject to loss of internal rotation mobility especially in a pitcher’s front stride leg. This decrease in mobility that occurs over the course of the season can cause compensatory movement patterns as well as stress on the front of the shoulder and elbow when throwing.

To improve or maintain hip mobility here are a few of my favorite drills:

 

90/90 Hip Openers

 

Rear-Foot Elevated Hip Flexor Stretch

 

World’s Greatest Stretch

 

OVERALL MOVEMENT IMBALANCE

Because most players either throw and bat from one side exclusively, there is an obvious tendency for some sort of imbalance. You can’t perform 5,000 right-handed throws and zero left-handed throws during a season and not expect your body to compensate in one way or another.

The best way to prevent this from becoming detrimental to your development and performance is to include unilateral training techniques to improve your proprioception and body control.

Here are a few effective unilateral exercises that will help:

 

Non-Dominant Side Med Ball Throws

 

Side to Side Med Ball Slams

 

Non-Dominant Stance Leg RDL

 

Unilateral One Arm Row

 

The Three Hardest Challenges of Tommy John Rehab

My elbow hurts a lot.

My arm feels really tight.

I feel great!

It was really sore the next day.

I had nothing on it – no movement and no velocity.

It started off good, then it started to hurt.

The ball was really coming out well, no pain at all!

It just feels…dead.

If you’re a pitcher who’s gone through Tommy John surgery, you’ve probably uttered all the statements above. If you’re a rehab professional, coach or parent, you’ve probably heard them too as the pitcher(s) in your life finished up their latest throwing session.

As a coach who had two Tommy John surgeries, I know that the hardest part of both of my rehabs – and they were both hard for the same reasons – was the randomness with which the arm recovers and the mental toll it takes on you. Today as a coach, I mentor young pitchers through their own recoveries and hear the same difficulties voiced regularly. Today, we’ll discuss the mental challenges of the surgery in its various forms.

 

First: Why The Last Part of Tommy John Recovery Is The Hardest

After about month eight or nine of the recovery the pitcher is capable of doing a lot of new things that make his arm hurt, get sore, and react in new and confusing ways. The player is also pretty much done with the formal, written throwing protocol, so months 9+ end up being up to interpretation, much like one of those make-your-own-adventure books. This is because pitchers in this last phase are:

  • Throwing nearly at or just near full-speed
  • Throwing off-speed stuff again
  • Increasing frequency of bullpens
  • Beginning simulated games against live hitters
  • Getting physically stronger and doing more demanding lifts in the weight room
  • Feeling the pull that they are almost ready

Because of this, the body is getting huge doses of new things ­­– it’s not just soft-tossing grenades anymore, the pitcher is putting the same forces through his arm that tore it in the first place. He’s mixing all his pitches, and curves, sliders and changeups all make the healing ligament react and get sore.

 

 

Workouts in the weight room are crucial to returning him to game shape and warding off future injury, but as strength returns, heavier weights cause the elbow to react and get sore, sometimes painful as well. How does a pitcher balance all these things?

This question raises many, many more questions:

How much should he lift after a hard bullpen that caused a little pain? Should some exercises be omitted, altered, or used with lesser resistance?

Should bullpen pitch count increase? If so, how much?

Should rest between pens begin to decrease? If so, how much?

How much should a pitcher throw in between bullpens?

Is long-toss okay? If so, when?

Are weighted balls appropriate? If so, when?

When can a pitcher return to a game?

When can he pitch on back-to-back days in relief?

His arm hurts a LOT – is that normal? Is it torn again? How long should I wait to throw?

 

The common answer to all the above is this: it depends. It’s a very unsettling answer.

There are a million variables that can’t be addressed in the written throwing protocol. There’s just too much variation and too much throttling up and down to account for it all. The experience is similar for players but also completely and painfully unique.

If the questions above seemed confusing…imagine you’re a 19 year-old kid going through this for the first time – it’s a lot.

 

Challenge #1: Interpreting and Coping with Types of Discomfort

There are four main feelings a pitcher will experience in his recovery:

  • Pain: that sharp, stabbing feeling.
  • Soreness: that dull, burning feeling.
  • Tightness: When the arm feels constricted and doesn’t move like normal, as if the joint is swollen or needs to “pop.”
  • Deadness: a general dull, achy, fatigued feeling in which the arm just…can’t.

Which of these is worse? Pain gets a pitcher’s attention the fastest, but all are unique. Soreness often turns to pain. Tightness turns to any of them and makes throwing very uncomfortable. Deadness is demoralizing.

Some of the best advice I ever received was from Stan Conte, former head ATC of the Los Angeles Dodgers. He basically just reminded me that my arm had holes drilled in it, and that the muscles and ligaments were sliced open before being stitched back together. He explained that it would never be “normal” again, and that weird pain, sensations and unexplainable things would happen. I just had to learn to accept some of that.

When I thought of it that way, I stopped dwelling on slight pain and the little aches and soreness – those were just from my arm being, well, a lot like an old car. Old cars make lots of weird sounds and are a little bumpier, but they still drive just fine.

Pitchers who have had a surgery – any surgery – are never going to feel fresh off the assembly-line again. When they stop believing they have to feel perfect and brand new to pitch, things mentally get a lot better.

 

Challenge #2: Dealing With The Randomness of Pain 

 

What’s extra frustrating about the recovery is that there is little reason why one day is a good day and why another day is a bad day.

Sure, when a player overdoes it or does something new, the arm usually reacts in a negative – but still normal – way. However, lots of times a player will be adequately rested and has set himself up for success in his routine…just to find lots of pain and discomfort that doesn’t add up.

This – unfortunately – is also normal. It’s especially frustrating and worrisome because a player feels helpless to prevent or predict good and bad days. The follow exchange was had between myself and one of my college pitcher clients, who I have been mentoring through the last stages of his rehab in conjunction with his school coaches. It sums this point up perfectly.

 

 

Challenge #3: Expectations That Are Set Too High

Lastly, there’s this idea that every player should be back on the mound, dominating and throwing 2-5mph harder at the 12-month mark. This just isn’t reality for most pitchers. Most pitchers will feel like their old selves again somewhere between the 14 month and 24-month mark. Even when a pitcher is back in games, he often won’t reach his previous level of statistical performance until the second competitive year back…if he does so at all.

I doggy-paddled through my first season back following each surgery, struggling to keep my head above water and not get released by the team. I posted league-average ERAs in both seasons and could not locate my off-speed stuff to save my life. I got by with good velocity and a fierce will to compete. Had I not had both of those things, my career would have ended; I would not have had enough tools to get by in pro baseball.

But in year two following both surgeries, my command of all three pitches improved dramatically, and my velocity went up another tick or two. Year two was much, much better than year one. Year one was hard.

 

Tommy John Surgery: It’s a Long, Hard Road.

A lot of people take for granted just how hard it is to return from Tommy John Surgery; it’s not a guarantee for any pitcher, and the mental toll is often greater than the physical. The uncertainty, randomness, pain and daily grind will challenge even the toughest of athletes. The big challenge is staying the course and trusting that tomorrow will be better…even when today wasn’t.

 

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4 Arm Care Exercises Baseball Players Should Be Doing

 

I had another request from a subscriber to go over some arm care exercises this week. I put together a video below of 4 exercises I consistently use with our throwers during arm care days, or after a throwing session.

Don’t be the person who doesn’t do any arm care. Take it from me…I never did any, and I had Tommy John in High School, then a SLAP Tear in College.

Take the 10 extra minutes to do some arm care!

 

HERE’S WHAT’S IN THE VIDEO:

  1. Forearm Wall Slides are a great shoulder mobility exercise. This exercise works your scap protractors, and your lower traps, which assist in upward rotation. Kind of important if you throw things overhead!

✅Key Cue: Make sure you are not substituting lumbar extension to get overhead. Engage your core to keep your rib cage down.

  1. Quadruped T-Spine Rotations are a great exercise to mobilize your upper back and thoracic spine. Having a mobile T-spine will prevent you from substituting with your lower back to rotate. Throwing a baseball is a violent rotation. Using your lower back will impact your performance and possibly your injury risk.

✅Key Cue: Keep your hips and lower back as still as possible. Follow your elbow with your eyes as you perform left and right rotation.

  1. 3-Point Contact Y Scap Raises help maintain muscular balance. You can make this exercise more difficult by lifting a dumbbell. Just be sure to maintain proper technique.

✅Key Cue: Make sure you don’t lift your arm too high. You should be able to draw a straight line from your hips through your shoulder and arm at the top of the lift.

  1. Stability Overhead Press is a great strength and endurance exercise for the posterior shoulder muscles. As you press overhead, you must stabilize as the band tries to pull you forward.

✅Key Cue: Use a lighter band. Nobody is handing out world records for stability overhead press in the gym!

Does Electrical Stimulation Speed Recovery in Baseball Players?

***Disclaimer – placing electrodes on a player (or yourself) does not come without potential risks. The potential for electrical burns and infection are a real thing that warrant, at least in our opinion, the consultation of a professional.

 

In recent years, there has been a major increase in the usage of EMS (electrical muscle stimulation) units in the baseball world. From the MLB to the high school ranks, it seems like everyone has jumped on the “ESTIM unit” bandwagon, claiming that their inclusion has dramatically improved their performance. Supporters often cite improved blood flow, delayed onset muscle soreness (DOMS), and a quicker return to performance as the key benefits.

 

How Do EMS Units Work?

EMS units work by delivering electrical pulses through multiple electrodes, which are positioned over muscle motor points or painful areas. Depending on the frequency, intensity and waveform, the target of the stimulation is either at the sensory level (lower intensity) or the muscular level (higher intensity).

The units that are important here are what most people see on social media – the ones that elicit a muscular contraction to improve peripheral fluid flow in the body. The rationale being enhanced peripheral blood flow will accelerate the removal of metabolic waste, decrease inflammation, and promote a quicker return to a player’s performance baseline. In short, it speeds the recovery process after a tough game.

 

 

What Does The Research Say About The Effectiveness of EMS Units?

Professor Nicola Maffiuletti, a leading expert on the recovery process, gave a tremendous lecture for Aspetar Sports Medicine in 2013 on EMS based on a literature review that he co-authored.

In his presentation, Maffiuletti reviewed the available research on these units, their potential mechanisms, effectiveness and practical application. Here are some of the major takeaways.

  • Only 3 of 19 studies showed that EMS was more effective than passive recovery in regards to the return of muscle strength, power, activation and contractility.
  • All the other studies were unable to detect a difference between the two in healthy active individuals, recreational sportsmen and professional athletes. EMS was found to be equally effective compared to other modalities in all but one study.
  • Voluntary contractions may be better than EMS at increasing bloodflow because people are able to contract a greater amount of muscle manually. Recruitment via EMS—even at a very high visual analogue score (how much pain you can tolerate) —can only recruit around 15% of the muscle cross-sectional area. If you have ever tried ramping up the intensity on these units, you understand that it can get pretty uncomfortable and sometimes even painful! Of that 15%, it is mostly superficial muscle fibers that are recruited. To recruit deeper fibers and increase that percentage, you would have to increase the intensity of the stimulation. This can only feasibly be accomplished by improving an individual’s tolerance via persistent exposure; something that is difficult to accomplish.
  • However, according to Maffiuletti, using higher intensities can actually create muscle fatigue: “If you increase the intensity, you are creating fatigue that is 5 times faster than a voluntary contraction.”
  • There have been many case reports of muscular dysfunction resulting from overusing EMS units. If we overuse these devices we run the potential of creating long-term issues in how the muscle fires.
  • Lactate removal is faster with active recovery than it is with EMS.
  • Perceptual recovery – defined in the studies as the point when subjective psychomotivational factors were fully restored to pre-exercise levels. Subjects were asked to quantify or rank the perceived effectiveness of recovery modalities or quantifying their perceived energy and enthusiasm. EMS has been shown to be equally or more perceptually effective as a means of recovery than passive or active recovery

Maffiuletti concluded that EMS is unlikely beneficial for improving physiological recovery compared to both passive rest (including a placebo condition in one study) and other recovery modalities. EMS is, however, likely beneficial for improving perceptual recovery compared to passive rest, and possibly beneficial for improving perceptual recovery compared to other recovery interventions.

 

STUDY: Effects of Three Recovery Protocols on Range of Motion, Heart Rate, Rating of Perceived Exertion, and Blood Lactate in Baseball Pitchers During a Simulation Game.

There is, however, one often cited study in the baseball community by Warren et al. that looked at three different modalities and their effect on a pitcher’s recovery in-between innings. The authors found that a Compex Unit (EMS product) improved blood lactate removal significantly while active and passive recovery did not. Moreover, the Compex group, as well as the active recovery group, reported a significantly lower rate of perceived exertion.

Removal of lactate, however, is a naturally occurring process that can take minutes to an hour or two depending on the specifics of the exercise. Lactate removal has not been a good indicator of recovery outside of those timelines. If we know that lactate and metabolite removal is mostly completed within an hour post exercise should it really be the target of any of our interventions? Using EMS in-between innings to reduce lactate concentration may have some merit to it, but we probably need more research before we start making drastic changes.

 

Should Baseball Players Use EMS?

There is a general lack of evidence to support the idea that EMS improves physiological recovery and return of strength or power compared to other recovery modalities (passive, rest, or otherwise).

If our goal is to improve circulation of blood and fluid flow through a muscle contraction, then EMS seems to be less effective than alternative methods in which voluntary contractions are used. Moreover, if used inappropriately – with too much frequency and intensity – EMS may cause more harm than good.

These units are, however, potentially useful in promoting perceptual recovery, a placebo effect in which the player believes he feels strong and ready to play than perhaps he really is. In the baseball world, this may be a significant factor in returning to baseline performance. If an athlete perceives that he is more prepared to throw because of the twenty minutes of stimulation, then this may warrant its inclusion from time to time. EMS units, however, can be very expensive and it’s important to consider whether a device that provides only perceived benefits is a good use of financial resources.

Do you use EMS? Leave us a comment and tell me about your experience!

Why GIRD May Be Normal and a Lack of Internal Rotation May Not Lead to Injury

In the sports medicine world, we not only want to treat deficits the athlete presents with, but more importantly, combat the root of the problem itself. In this way, we can prevent future injuries from occurring in the first place.

If we can improve our understanding of underlying pathology and have a greater appreciation for the factors that truly cause injury, we can really make a positive impact as clinicians. Sounds good, right?

In terms of baseball players, there has been a lot of recent research that has discussed the concept of “GIRD,” or glenohumeral internal rotation deficit, and its role as a potential precursor to injuries, particularly in overhead athletes such as baseball players.

But what if this loss of internal rotation doesn’t really matter in regards to injury, and that other measures, instead, could be more important to understand if a baseball player is at an increased injury risk? Before we dive into that, let’s first take a look at exactly what GIRD is.

 

What is Glenohumeral Internal Rotation Deficit (GIRD)?

According to an older and outdated definition by Kibler, GIRD occurs when an athlete demonstrates “altered shoulder internal and external ranges of motion where internal rotation is decreased and external rotation is increased in the dominant arm when compared to the non-dominant arm.”

Since this early definition, it has become well identified in the literature that this alteration in range of motion may in fact be normal in overhead athletes, such as baseball pitchers. Mike Reinold has an article describing why GIRD may be normal.

Reinold, who has worked with 1000’s of both injured and healthy baseball players, states that he believes that “a loss of side-to-side IR is actually a normal anatomical variation in overhead athletes.”

He continues by stating that GIRD should not be considered pathological unless there is “subsequent loss of total rotational motion in the dominant arm as well.”

Other sources have attempted to define GIRD as occurring when the internal rotation deficit is greater than 20° to that of the non-dominant arm. But even this has limitations as another arbitrary figure.

This newer definition that Reinold has established, works to specific the loss of internal rotation to the athlete themselves in terms of their respective total range of motion, as opposed to an arbitrary number that may have a large standard deviation across many different overhead athletes.

 

GIRD vs. Total Range of Motion

While an athlete, especially an overhead thrower such as a baseball player, presents with limitations that reflect Reinold’s definition, how important is this loss of motion from a clinician’s perspective?

Now, am I going to worry or be alarmed by a loss of internal rotation that the athlete has with pitching over the course of the season? I suppose I may be in the event that the loss of internal rotation is not equally gained into external rotation, as the total range of motion would be negatively affected.

I’ve been taught that if the athlete has the same total motion throughout their full shoulder range with variations in internal and external rotation, then we can leave it without true intervention and move on, certainly if the athlete is asymptomatic.

On the flip side, if the athlete has lost internal rotation without a reciprocal gain of shoulder external rotation, I will certainly investigate why that may be. These limitations could be due to soft tissue limitations, bony changes into humeral retroversion, or capsular restrictions.

In particular with humeral bony retroversion, it’s critical to understand why this change exists. As young children play baseball, they compete with their respective growth plates in their humerus “open.” This is so that proper natural growth can occur, and that the bones will become longer as time progresses.

While these growth plates are open, throwing a baseball is a constant throughout the year. This continual cocking back of the arm while throwing “rotates” the humerus upon the growth plate, creating a retroversion moment of the bone over time.

This retroversion moment has even been described as “wringing out a towel” by Reinold, to explain the forces that are occurring at the humerus.

Ultimately, once the growth plates close, the retroversion is essentially sustained in that position that was allowed by throwing consistently over several years.

Because of this, baseball players have a natural, expected increase in external rotation within their dominant throwing arm compared to their other, non-dominant arm, that did not throw over the course of a childhood.

This physiological concept is a way to digest and understand the relative differences between arms in a baseball player, including the change in external rotation in the dominant arm being normal and expected anatomical variation.

 

What About Loss of External Rotation or Shoulder Flexion?

So we’ve established what GIRD is, how it can impact athletes, and the importance of both total and internal rotation shoulder range of motion. If shoulder internal rotation isn’t as important on its own, what other measurements can be performed to predict injury risk in a baseball player?

A recent article by Christopher Camp was published in September 2017 by Arthroscopy that highlighted other clinical measurements that may be greater predictors of injury than shoulder internal rotation.

The study followed one MLB team during a 6-year period and measured 81 pitchers over the course of the team’s annual physical examinations during Spring Training.

All elbow and shoulder range of motions were measured for each athlete, with a complete follow-up throughout the season to track any subsequent injuries with both days missed (DM) and re-injury status among other information recorded.

The article concluded meaningful information from the athletes over this time period that relates to the use of shoulder internal rotation measurements:

• The only independent variable that reported an increased risk of either shoulder or elbow injury was the presence of a shoulder ER 5° deficit (dominant arm external rotation was not at least 5° greater than non-dominant arm).
• Shoulder flexion deficits of 5° carried increased odds of sustaining an elbow injury.
• The presence of GIRD (defined as shoulder internal rotation deficit of greater than 20° compared to the non-dominant shoulder) did not carry an increased risk to the shoulder or elbow.


 

This study essentially found that within a large sample size of elite level baseball players, that there is decreased reliability on the use of GIRD to dictate whether a player is at increased risk of sustaining a shoulder or elbow injury.

The article also reports that the use of shoulder external rotation and flexion measurements may be more indicative of the risk of shoulder and elbow injuries, respectively.

Ultimately, I believe that as a profession we need to be able to look at solid clinical research such as this, utilizing a group of clinicians that actually treat baseball players, to make more effective conclusions about the health and status of the athletes we work with.

 

Final Thoughts on GIRD and Moving Forward

I believe in physical therapy and rehab in general, there’s a lot of buzzwords, hot topics, and just outdated information.

I think that GIRD is just one of the concepts that while important in the proper context, such as the loss of external rotation that occurs in conjunction with the loss of internal rotation (total range of motion loss), on itself does not hold as much merit as it receives in textbooks and other resources.

The article by Camp truly demonstrates that there are other factors to consider when attempting to understand a baseball player’s injury or their potential likelihood of injury.

It’s also important to note that these clinicians did not need to use diagnostic ultrasound or other fancy systems or equipment to predict an injury, rather using their clinical judgment and embracing the basics to interpret the findings.

I’m certainly not dismissing the concept of GIRD, but I think it’s important to consider the other deficits that may be present before concluding an athlete is at increased risk for injury. Every baseball pitcher is unique in their own appearance, mechanics, and even measurements that can all be seen as healthy and asymptomatic.

Being able to be a communicator with the athletes we treat about their arm using sound evidence-based research and experience will not only allow the athlete to build their rapport and confidence in you as a clinician, but facilitate a relationship that allows you to prevent injuries and truly achieve our ultimate aforementioned goal more effectively: getting to the root of a problem before it causes injury.

2 Key Subscapularis Arm Care Exercises for Baseball Players

The subscapularis is a muscle that is often neglected when talking about arm care exercises for baseball players.

The subscapularis is a rotator cuff muscle that attaches from the inside of your shoulder blade/scapula and wraps underneath to the front part of your shoulder. It can be placed at a mechanical disadvantage with poor mechanics.

 

It contracts to protect your shoulder from excessive external rotation (layback) late in the throwing motion. There are also larger muscles that contribute to the velocity of the throw that are involved to provide stability (pectoralis major and the latissimus dorsi) in this layback position.

If the shoulder isn’t trained specific to the movement pattern, type of contraction, and position the arm needs to be in to accept these forces, you’re leaving yourself open to injury.

I often see exercises done by throwing athletes with bands or tubing that are nonspecific and do not prepare the shoulder for the forces that are placed on it during maximal external rotation.

Performing any tubing or band exercise does have a potentially positive effect for any throwing athlete, but there are simple things and pivotal positions that athletes should include that can make exercises for the rotator cuff so much better.

The rotator cuff’s primary role is to keep the humerus centered in the socket, resist distraction, and contribute to the ligamentous stability of the glenohumeral joint to prevent excessive anterior and posterior translation of the humeral head.

If the shoulder moves too much in the socket during the throwing motion in either direction that can contribute to instability and injury.

Knowing what a muscle’s role is in the throwing motion and what types of contractions it goes through should be the guiding principle in which exercises are chosen and how they’re performed. There is an extremely delicate balance that must be maintained when training a rotator cuff.

These factors are often overlooked and not included in most arm care routines and training regimens, even in professional baseball. My personal experience in professional baseball with injury, anterior subluxation requiring surgical correction, incomplete recovery, and 17 years of clinical experience working with throwing athletes has forced me to evaluate the effectiveness of rotator cuff exercises.

The posterior rotator cuff is often the prominent focus of in therapy for shoulder athletes, and rightfully so. But the subscapularis is a pivotal muscle for the throwing athlete but it is often neglected in therapy and training situations.

Below are two joint and contraction specific subscapularis exercises that we utilize and often include in our throwers’ corrective exercise programs. These videos give great detail as to the “why” behind certain exercises are chosen.

 

 

If you want to have a long-playing career, or even a healthy throwing season, you should implement these 2 exercises into your arm care routine and be sure to focus on your subscapularis.

Safe Implementation of a Baseball Interval Throwing Program

Whether it be a pitcher or outfielder rehabbing from shoulder or elbow surgery or injury, no greater sense of joy and excitement overwhelms them than the first day they can throw a baseball.

For some, it is the highlight of last three to four months of hard work, dedication and determination to return to the sport they love and have grown up playing. For others, especially rehabilitation specialists such as physical therapists and athletic trainers, it can be the scariest.

The first time our throwers start throwing, we always have that one question in the back of our mind…will they reinjure themselves?

Although, we would never return someone to throwing without physician clearance, a satisfactory clinical exam, a battery of plyometric testing and proper screening of pitching mechanics, the possibility of re-injury exists.

Before you start the throwing program that has been prescribed, it is important to consider some key components for the program to be properly executed.

Lastly, effective education and communication must be approached for a thrower to fully return to a competitive state.

Key Components to Address Before Starting A Throwing Program

Over the last few years with adolescent baseball injuries on the rise, there have been many throwing programs available for free on the internet developed by baseball coaches and rehabilitation specialists on how to return to throwing following an injury or surgery.

This can be concerning since key variables and questions may not be addressed in these programs. It is critical to analyze the who, what, when, where, why, and how.

Common Questions About Interval Throwing Programs

The Who, What, and When

  • Who should I be throwing with?
  • What types of pitches should I throw? Are my mechanics okay?
  • How do I monitor my mechanics changes?
  • How many days a week should I throw?
  • How many days should I rest?

The Where, Why, and How

  • How far should I throw?
  • How hard should I throw?
  • How am I going to monitor my velocity?
  • Should I throw from the mound or flat ground?
  • Can I complete multiple sets in one day?
  • Should I throw on a line, crow hop or arc my throws?
  • If I experience pain, what should I do? Continue or stop?

These key components all need to be addressed because implementing a throwing program without proper supervision and knowledge of that program can be doing more harm than good.

If you do not know the answers to ANY of those questions, you need to ask!  Your doctor and rehabilitation specialist should be able to answer those questions and customized their answer to your unique injury and situation.

For those of us who work in the clinic, we wish we could go outside and throw with our throwers. However, that is not always practical due to limited space, time management with other patients and lastly, insurance.

As rehab specialists, we hope to keep our throwers to the very last day of their rehab. However, insurance does not always allow this due to a limited number of patient visits.

In these cases, what do we do? There have been many times where throwers have been given throwing programs with no direction or insight on how to initiate or complete the program.

Interval throwing programs are an essential part, if not the most important part of the rehabilitation process and should not be overlooked by any means.

It’s what allows us to find out if our throwers are ready for advancement in rehab or if they can return to sport.

Would we allow an ACL patient to initiate running without proper supervision or guidance? How about a soccer player with a sprained ankle? Would we allow them to initiate agility training without first assessing isolated linear and lateral movements?

We know that return to play outcomes are much higher in ACL patient’s when supervised rehabilitation occurs. Why are we not doing the same for our throwers?

These questions must be addressed and the interval throwing program must be supervised at all times.

Players must be monitored so that velocity, volume, mechanics and pain can all be addressed if the thrower has questions, concerns or incidents arise during the program.

Ways to Safely Implement an Interval Throwing Program

The best way to make sure that all of this occurs is through education and communication.

We need to sit down with our throwers and their parents/guardians to educate and direct them on the throwing program itself, how to initiate it and what to do if they have questions or concerns.

The more detail and direction we can provide will ultimately lead to our goal of a safe return and their goal of returning to baseball.

We also need to make sure that there is always an open line of communication between our throwers, their parents/guardians (if the thrower is an adolescent) and the rehab specialist.

Our athletes must know that they can contact us any time if questions or concerns come up so that we can properly guide and educate them through the process. Injuries take a toll on our throwers not only physically, but emotionally and psychologically.

Telling a baseball player that he or she cannot throw can be one of the most disappointing things they could hear.

It is our job to make sure that we provide the highest quality of care to get them back to throwing quickly but most importantly, safely.

The last thing that we would ever want to happen is to have one of our throwers reinjure themselves due to something so simple such as improper guidance, which could have easily been prevented through proper education and communication.

The interval throwing program is something that must never be overlooked or taken lightly. It is such an important part of the rehab process that allows throwers to stress the surgically repaired or injured tissue in a safe and controlled manner.

It also allows our throwers to become more confident as they move throughout the throwing program and their overall rehab.

Most importantly, it gives us the objective information that we have been waiting to find out for the last few months which is, are they ready to return?

Before starting an Interval Throwing Program, it is important to consider the key components of that throwing program by analyzing the who, what, where, when, why, and how. Lastly, effective education and communication can go a long way for the athlete.

Evidence-Based Inseason Arm Care for Baseball Players

Recently the American Sports Medicine Institute published some fantastic research identifying specific changes in pitchers that may increase risk of an arm injury during the baseball season.

The most important changes have been linked to range of motion in the throwing arm.  At our facility, we identify three changes in measurement as red flags while in season: decreased shoulder flexion, decreased shoulder internal rotation and increasing shoulder external rotation.

We have adopted specific mobility and stability exercises as part of an arm care system that draws heavily on this research.  I will outline how we progress through our most common exercises that drives the best results for players.

 

How to Prevent Loss of Shoulder Flexion

Pitchers will acquire a heavy workload on the lats and low back muscles during the year, especially at the start of the baseball season.  Stiffness in these muscles will contribute to loss of shoulder flexion and the ability to fully reach overhead.

We have players start with lat soft tissue mobilization for 1-2 sets of 10, and then follow with lat isometric liftoffs for 1 set of 5 for 5 second holds.

 

How to Prevent Loss of Shoulder Internal Rotation

More people are now familiar with the concept of pitchers losing shoulder internal rotation from throwing.

This can happen for a variety of reasons, including chronic bony changes in mature throwers over time, and acute changes to the rotator cuff and trunk muscles in pitchers during the season.

This article will not detail the total motion concept, and if you are unfamiliar I would urge you to read articles by ASMI that are readily available online.  Mike Reinold has an excellent article about GIRD and loss of internal rotation in baseball players.

We mandate that all players at our facility have a plan for pre- and post-throwing to prevent negative long-term changes in shoulder range of motion.  Here you will see how we target the posterior shoulder to accomplish this.

We have players start with posterior shoulder mobilization for 1-2 sets of 10, and then follow with the cross-body rotation stretch for 1 set of 10.

How to Prevent Excessive Increase of Shoulder External Rotation

Rapid increases in shoulder external rotation have been linked with increased risk of injury in throwers.  This change in external rotation is also correlated with throwing harder, so we should not be surprised by the link between the two.  So how can we encourage our athletes to throw hard while reducing injury risk?

We use data from a recent ASMI weighted ball study that demonstrated an increase of more than 5 degrees of shoulder external rotation during a throwing program is correlated with a risk of arm injury.

Motor control of end-range external rotation and trunk position often decreases with workload and fatigue in our experience.  As a result, we prescribe two of the following exercises to maintain motor control in the layback phase of throwing.

We have players start with half kneeling cuff stabilization for 2-3 sets of 3 for 5 second holds, and then follow with external rotation oscillations for 2-3 sets of 15.

The cuff stabilization drill allows the coach or clinician to progressively load the shoulder based on feel and comfort for each player.

There seems to be a gap in the baseball world between recommendations from research and real-world implementation with players.  I hope this article will provide some ideas for fitness and medical providers to connect the dots and help reduce the epidemic of arm injuries currently plaguing baseball!