SLAP Injuries in the Baseball Player: Classification and Subjective Evaluation

A superior glenoid labrum injury is a common reason for shoulder pain in baseball players.

These injuries were initially explained by Dr. James Andrews in 1985 secondary to a biceps tendon origin pathology. The injury is described in that the biceps tendon exerted a traction-like force to actually “peel” the labrum off the glenoid structure, itself.

These superior labral tears, anterior to posterior (SLAP), have several different types can be stable or unstable that are under the umbrella that was previously described that result in the “peel back” etiology.

One can also back the argument that due to the high loads of eccentric contraction that occur in the late cocking phase of throwing most baseball players (pitchers in particular) have some level of a SLAP tear or superior labrum lesion that is, for the most part, asymptomatic in nature. Some SLAP tears may even be considered necessary adaptations to the throwing shoulder for baseball players.

Taking a brief look at the pathomechanics of the throwing motion and the underlying structures, one can quickly understand why the anterior portion of the labrum is under immense stress.

During throwing, particularly in late cocking phase at maximal external rotation, the humeral head will shift from a posterior to inferior direction. However, in these types of overhead athletes who likely already have anterior capsule laxity, the shoulder will have exhibit a greater willingness to shift the humeral head in a posterosuperior direction.

This directional-preference the shoulder takes subjects the superior labrum to greater load, particularly in a torsion-manner.

There’s several different types of mechanisms that can be explained by many different types of classification systems. For now, let’s take a look at the different mechanisms as described by Snyder for these types of injuries:

 

Classification of SLAP Tears

The original classification was proposed by Snyder in 1990, where he bunched SLAP tears into four primary mechanisms:

Type 1: These types of lesions are best characterized by degenerative fraying of the superior labrum with not only an intact, but stable biceps tendon. Snyder noted that this type of variant classification was present approximately 11% of the time. These types of lesions are most consistent with a rotator cuff pathology.

Type 2: These types of lesions include a detachment of the biceps anchor from the glenoid that are unstable in nature and are considered the most common variant encountered. Snyder stated that these represent 41% of all SLAP injuries.

Type 3: These types of lesions include a “buckethandle”-like tear of the superior labrum without disruption of the biceps tendon anchor. However, the bucket-handle can become mobile and become entrapped within the glenohumeral (shoulder) joint, creating a very painful clinical picture. This type of lesion is consistent with traumatic instability, in addition to a Type 4 tear.

Type 4: These types of lesions also include the “bucket handle”-like tear of the superior labrum. However, this type of tear also includes an unstable biceps tendon. It should be noted that the level of biceps involvement in this type of lesion can be extremely variable. This type of lesion is the least common variation of a SLAP tear.

 

Subjective Examination Pearls

Examination of an athlete with a SLAP tear that is pathological in nature can be very challenging. It’s likely that a patient who has sustained a SLAP lesion has another present injury. This may include a concomitant rotator cuff injury or even a Bankart lesion of the anterior labrum.

A great subjective examination is key to truly developing a great conclusion of what the patient has going on.

However, a subjective examination can become very difficult as the mechanism is often different in players. It may include a single traumatic event or can be gradual over time as part of an insidious etiology.

Amongst all athletes, the most common clinical symptom that will be apparent is anterior shoulder pain. These can lead to performance issues such as decreased control while throwing or even a decrease in throwing velocity.

The patient may also note an increase in clicking or other types of mechanical symptoms.

While certain types of labral injuries can involve concomitant instability, most SLAP tears in isolation are not unstable in nature.

Altogether, while the subjective examination can be challenging, it’s ultimately imperative to understand that these types of injuries are commonplace in baseball players. In many players, SLAP tears are asymptomatic and not a concern.

The Other Type of Shoulder Instability: Batter’s Shoulder

Several baseball injuries center around the inherent instability that the shoulder, or glenohumeral joint, provides.

The classic description of the golf ball (the humerus) sitting on the golf tee (the glenoid) is really a great description of how unstable the shoulder really is.

As described often on previous posts, throwing a baseball really isn’t good for you. This is evidenced by having over 7000 degrees of rotational motion in one’s shoulder when throwing.

This violent movement over the course of a season or career can begin to develop stress in the anterior compartment of the shoulder.

Whether this causes an injury as severe as a SLAP (superior labrum anterior to posterior) tear over time is up for debate, but it’s clear that this type of instability is the most common form in overhead throwers, such as baseball players.

When we discuss shoulder instability, we often think of this certain type. Typically, the symptoms include anterior shoulder pain, perhaps from an acute dislocation, subluxation, or a general degeneration of the anterior capsule over the course of thousands of throws.

 

Introduction: Posterior Instability in Baseball

However, in baseball players, another type of shoulder instability is unique. This phenomenon is referred to as “batter’s shoulder.”

The injury, similar to anterior instability in pitchers, occurs mostly in hitters in their front shoulder from repetitive posterior capsule stresses incurred from swinging a bat. This stress is highlighted more so by instances of swinging and missing as well as swinging at outside pitches, where the front shoulder is subject to a greater moment of adduction.

This type of posterior instability is also seen in another type of unique population: football interior lineman, whose arms are always in a position of shoulder flexion with combined adduction holding onto the opponent’s shoulder pads. Through the continued line of force produced axially through their arms, posterior shoulder problems can arise.

For the purpose of this topic, we will focus on the baseball population. This type of injury is not nearly as common as anterior shoulder instability from throwing. Not often do we see player’s heading to the injured list for “batter’s shoulder” or “posterior shoulder instability,” yet it’s important from a clinician or rehab professional’s perspective to understand the inherent risks that our athletes face.

 

Phases of Batting

Just like throwing, hitting has phases, too. Shaffer and colleagues have stated that the traditional baseball swing goes through four distinct phases. These include the wind up, pre-swing, swing, and follow-through.

While throwing a baseball may be the fastest movement in sports, hitting a baseball can generate high shoulder movement speeds too. These same authors have stated that rotational velocity at the shoulder is 937 degrees per second–still a violent, powerful movement.

 

How Does Batter’s Shoulder Work?

Once we take this great amount of force produced at the shoulder and combine that with the mass of a baseball bat, albeit a small weight (typically around 2 pounds), we can begin to see how the repetitive amount of swings can impart stress onto the shoulder.

For another way to look at the effect of hitting, think about it like this. At the higher levels of competition, hitters swing the bat hundreds of times in a 5-day span, between game swings as well as the batting practice, etc., we can compare that to the amount of throws that pitchers throw over the same 5-day stretch.

In addition, it should be recognized that pitchers throw with a 5 oz. ball and hitters must use at least a 31 oz. bat in most cases. However, while a hitter uses an object that is 6x heavier than a baseball, the rotational velocity at the shoulder during pitching is approximately 7x that of swinging a bat.

It’s also important to note that anterior shoulder instability often occurs in the throwing arm of a baseball player. Posterior instability usually occurs in the front, non-throwing shoulder, unless the player hits on the opposite side of the plate, i.e., a right-handed thrower who hits from the left side.

This type of usage and repetitive force on the front shoulder that is not used for throwing will be critical when discussing the treatment options.

 

The 500-N Elephant in the Batter’s Box

As discussed earlier, swinging and missing on an outside pitch is often considered the main mechanism in a baseball setting for developing posterior instability. Kang and colleagues have determined that this type of circumstance can generate as much as 500 Newtons of “dynamic posterior pulling force” during a swing.

While 500 N may not sound like anything significant, this amount of force represents greater than about 110 pounds of force being pulled posteriorly for your shoulder to absorb. Imagine this amount of force produced over the course of a season or even a career.

While the weight of the bat, in addition to the rotational velocity and force at the posterior shoulder is important, the angle of the shoulder plays a great role in this equation.

As the shoulder is in increased horizontal abduction from a position of approximately 90 degrees of shoulder flexion, the shoulder is going to be in more a congruent, stable position with the glenoid, which is angled at about 30 degrees away from the body.

Once the shoulder moves into greater horizontal adduction (arm crossing the body) of approximately 105 degrees, as it would be the case in swinging for an outside pitch, it’s clear that the posterior shoulder would sustain more impact in this position.

The American Sports Medicine Institute group (ASMI) emphasized this arm angle with injury, stating that it may increase shear forces across the shoulder joint. This evidence truly underscores the stress that the shoulder can incur.

Swinging and missing can also develop more damage to the posterior capsule of the shoulder due to the shoulder muscle’s inability to contract as it normally would with making contact with the baseball.

 

So You Have This “Batter’s Shoulder,” Huh?

The typical presentation for batter’s shoulder often involves a feeling of instability, especially after reaching for an outside pitch or simply swinging and missing.

After these moments of instability, it’s also common for athletes to feel discomfort or pain with provocative positions, such as forward shoulder flexion, adduction across the body, and internal rotation, as they all function to stress the posterior shoulder capsule.

Often, during a clinical examination, the jerk and Kim tests are very good to stress the shoulder. Tannenbaum and his colleagues have described both these special tests and Kim et. al determined that the combination of both these tests have a 97% sensitivity for posteroinferior labral lesion.

 

The normal course of action for this type of instability from a labral deficit often begins with conservative therapy. Kang described that interventions will focus on rotator cuff strengthening, scapular stabilizing, and improving generalized mobility.

In the event the patient does not improve with conservative treatment, surgery is indicated to arthroscopically repair the posterior labrum.

From here, the patient will undergo a period of protected motion, motion recovery, strengthening, plyometric training, and sport-specific training. Kang reports that patients can often progress to taking swings from live pitches at 6 months after surgery following an appropriate return to hitting program.

 

Let’s Step Out of the Batter’s Box

Kang reports that the average return to sport after surgery is approximately 6.5 months with very often, excellent outcomes, without any common significant complications.

Altogether, batter’s shoulder is very rare in the realm of musculoskeletal conditions, yet a common mechanism in a baseball population.

As a health care provider, it’s important to recognize posterior shoulder pathology and the mechanism in which it can occur. This can often occur by completing a thorough subjective history and being able to replicate the instability-provoking movements.

3 Ways Baseball Pitchers Can Use a Radar Gun to Enhance Performance

One of the simplest, yet most effective training aids for any baseball pitcher is a radar gun.

At one point in time, I was actually against having youth baseball pitchers use a radar gun too often and focus on velocity, but I actually think that there are a few great benefits.  And with recent advances in technology of radar guns, people can easily get an affordable pocket-size radar run, like the Pocket Radar, to use at home.

One of the key differentiators I see between amateur and professional baseball pitchers is often just intent.

What I mean is, our pro ball pitchers tend to throw with much more intent than our younger pitchers.  Sure, this could be that pro ball pitchers are older, bigger, and stronger.  But intent isn’t just an output of mass and strength.  It’s also an output of intensity, which is something many youth need to learn.

Even in our sports performance programs at Champion, our early focus with people new to training is developing intent when training.

So while I don’t necessarily want our amateur baseball pitchers focusing solely on velocity, I still think there are a bunch of great uses of a radar gun during training.

Here are my top 3 ways baseball pitchers can use a radar gun to enhance performance.

 

Enhance Power Development

Have you ever used a radar gun to check your velocity?  No matter what your velocity was on the first throw, what did you every time on that second throw?

Try to throw harder, right?  Of course you did, we all do!

In the motor learning world, this is a form of extrinsic feedback referred to as “knowledge of results.”  This can be used to give immediate feedback to the player to enhance technique, but also motivation.  We see this all the time, especially in athletes who are competitive in nature

We know that using external feedback and knowledge of the results in the sports performance world helps increase power output.  For example, in one study using external feedback of results was shown to help improve vertical jump performance.  In a 2014 study the Journal of Human Movement Science, it was shown that using feedback of vertical jump height performance results in an immediate increase in vertical jump performance, as well an 18% improvement in jump height over a 4-week training period.

One way that we apply this knowledge with our baseball players is with medicine ball power drills.  In this video, you can see we are using a radar gun set up to monitor the ball velocity.  The athlete is encouraged to ramp up his intensity on subsequent throws until he reaches his maximum velocity.  We’ll record this and try to improve over the course of his program, just like we would by recorded weights during his lifts.

 

Monitor Throwing Intensity

Another great use of a radar gun for baseball training is to monitor throwing intensity.  This is important for a few situations:

  1. A player returning from an injury that wants to slowly develop load to healing tissue
  2. A player preparing for a season that wants to slowly build capacity of the arm to handle stress
  3. A player inseason that wants to manage his workload more specifically

Monitoring the number of throws performed or pitch counts during a game is important, and something that we have shown to correlate to predicting both injury and performance.  However, using the quantity of throws on its own is too simplistic.  Overuse is more of a combination of quantity and intensity.

Compare one player playing light catch for 30 throws versus another long tossing for 30 throws.  Which one do you think was more stressful on the body?

By using a radar gun, you can document and build gradual progressions more appropriately.  Distance becomes less of a factor, and intensity becomes more specific.

Here’s an example of how we use a radar gun to ramp up a throwing session.  In this video you can see a few throws that slowly ramp up to the max intensity that we want that day.  The athlete then does his best to remain right around that velocity to get his work in for the day.

 

Improve Pitching Velocity

Using a radar gun to help improve pitching velocity is probably the most obvious.  When it comes to actually training to enhance pitching velocity, it has been shown that if pitchers know the speed of their pitch during their training, the have a larger increase in velocity.

In a recent study in the Journal of Human Kinetics, it was shown that if players were able to see their throwing velocity, the players were able to enhance their velocity by 4x more than if they did not know their speed.  That’s pretty amazing to me, and based off the same mechanisms of motor learning discussed above.

Another past study compared the throwing velocity of youth when instructed to “throw the ball hard” vs the same instruction with radar gun results.  Again the study showed that simply instructing the athlete to throw the ball hard does not increase velocity as much as when they can visually see the results.

In another interesting study in tennis players, it was shown that training for 6-weeks with feedback of serve velocity had a significantly greater improvement in velocity than a group that did not know their results.  But what is most interesting, is that this same group stopped training with external feedback of their velocity and still showed that the velocity improvements were retained 6 weeks after the program.

What this could mean is that training with the knowledge of your velocity not only helps motivate you to throw harder, but perhaps also trains you to continue to do this even when external feedback is removed.

So while I don’t think amateurs players should always be focusing on enhancing their velocity, I do think there are a few good reasons why the should focus on knowing their velocity.  Just like anything else, is the focus is on what is more important, a radar gun can not only be helpful to enhance performance, but also to control and monitor workload.

 

What Radar Gun Should You Use?

There are a few options when looking at purchasing a radar gun.  As you can see from the above examples, I value the convenience of having one on me.  So I value one that is portable and easy to use.  I’ve personally been using the Pocket Radar and think it’s perfect.  We’ve compared it to the more expensive guns, and it’s always just as accurate, but so much easier to use.

The new Smart Coach model is awesome, it can connect to an app on your phone or tablet via bluetooth, or even an external display.  This is what we’ve been using at Champion and everyone has loved it.

 

 

Returning to Baseball After ACL Reconstruction

It is no secret that anterior cruciate ligament (ACL) injuries and reconstruction surgeries are very common at all levels of sports today. As a physical therapist, I rarely go more than a few days without a patient in my clinic rehabilitating from ACL reconstruction (ACLR), and many coaches have likely encountered or will encounter athletes returning from this surgery.

Though ACL injuries are infrequent in the sport of baseball, I have helped several baseball players rehab and return to play after ACLR over the past year. While most baseball coaches likely have some awareness of shoulder/elbow injuries, they may not have as much exposure or education with players returning from ACLR.

For the rehab professional, it can also be very easy to overlook the sport-specific demands of baseball players when rehabbing from ACLR.

My purpose in writing this article is to provide some insight into recent research regarding return to sport after ACLR and some points to consider when returning to baseball activities after ACLR.

 

Secondary ACL Injury Risk – The Research

One of the biggest issues with returning an athlete to sport after ACLR is risk of a secondary ACL injury, either in the same knee or on the opposite knee. New research indicates that this may be happening at an alarming rate.

I will list some statistics below and then will discuss why these findings matter and how we can improve on how we are returning these athletes to sport activities.

  • A 2016 study reported approximately 1.25% of high school and college athletes will have an ACL injury.
  • 6 different studies looked at athletes returning to sport after ACLR, and the average rate of a 2nd ACL injury in these studies was roughly 30% (ranging from 25-37%)!
  • In one study, 45% of re-injuries occurred in the first 2 months after returning to sport
  • Those who returned to sport within 5 months after surgery had a re-injury rate of 100%
  • Those who returned within 9 months had a 40% re-injury rate
  • Those who waited until after 9 months had a 19% re-injury rate
  • There is a roughly 50% decrease in re-injury risk for each month that return to sport is delayed up to 9 months post-op.

Remember that there are always a number of factors involved with any injury, and these include age, gender, sport(s) played, time of year, common playing surface, genetics, previous training history, previous injury history, and many more. Even without specific context, these numbers above are very alarming, and this has become a hot topic issue in the world of sports rehabilitation.

It has become common for surgeons to release athletes to return to sport activities at 6 months post-op, despite the statistics listed above. It has been a challenge for me to convince patients to avoid early return to sport when their surgeon has given them clearance, especially when strength limitations, mobility limitations, movement deficiencies, or any of the factors listed above are still present.

So the challenge, then, is how do we get better in minimizing risk for re-injury with these athletes?

 

Reducing Risk for Secondary ACL Injury

 

First, delaying return to sport is usually a great place to start. While there may be certain pressures influencing an athlete to return by a given time, much of the research listed above speaks against simply using a given time frame to determine when an athlete should return.

Many experts are now recommending waiting at least 9 months before returning to sport, with increased time often needed depending on the status of the athlete. The short-term benefits of early return often do not outweigh the long-term risk of re-injury. It is now generally accepted that there should be specific criteria met before returning, regardless of when that is achieved. What specific criteria should be used to determine when an athlete should return to sport is a topic that deserves a separate article of its own.

One of the primary reasons why I believe we see relatively high re-injury rates is that there is often poor communication between the rehab professional and the coach who inherits the athlete who may or may not be completely ready for full return to sport. Often times there are insurance limitations at play or the rehab professional discharges the athlete early with the assumption that the athlete will continue to be compliant with a home exercise program.

As a result, athletes are often discharged from formal physical therapy before they are ready for full return to sport. This leaves them with a lack of professional oversight of their rehab program if they are unable to work with an athletic trainer in their school. Many athletes, then, either do not stay compliant with their home exercise program or are not provided with proper progression of exercises, and their home program eventually fails them.

Research has shown that movement quality can decrease within a few months of stopping supervised exercise programs in uninjured youth athletes, and we have to assume the same is true in a rehabilitation population. Ultimately, unsupervised and outdated exercise programs are not adequate in getting athletes to perform at the required level to return safely to sport.

I believe part of the solution to this problem is to have greater communication between the rehab professional and either the player’s coach and/or parent to ensure that somebody is able to supervise the athlete with their exercise program.

As a coach, if you have an athlete returning from an injury, it is crucial that you get in contact with the athlete’s medical professional to ensure that you are safely and gradually returning that athlete to play. Employing or partnering with a knowledgeable strength and conditioning coach or rehab professional can be a great way to ensure that your athletes are maximizing their development and being monitored for red flags with regard to future injury risk.

 

Return to Baseball-Specific Activities

 

One of the areas in which professional supervision may be most important is when handling return to baseball-specific activities such as throwing and hitting. It is important to remember that the athlete has likely spent an extended time away from these activities.

For many athletes, this is likely a good thing for upper extremity health and provides a great window to address issues in the upper extremity kinetic chain. As a rehab professional, it is important to ensure that proper trunk and upper extremity strength and mobility are achieved and maintained, even in the early stages of rehabilitation. This will ensure that the athlete is ready for a gradual progression of throwing activities once their knee allows them.

Once the lower body is ready for returning to throwing or hitting, it is important to allow for a gradual ramp-up in volume and intensity of these activities. Excessive early volume or intensity may predispose them to injury in other areas of the body, such as the shoulder or elbow.

For a recent athlete of mine, we spent an extended period of time performing plyoball throwing drills followed by light flat ground throwing before he got anywhere near the mound just to ensure that he was able to build tolerance for throwing again. This also allowed for gradual progression of loading his surgical knee prior to performing high intensity throwing on a mound. As a coach, you cannot assume that the athlete is ready to return to max effort throwing activities just because the knee appears to be ready for it.

On that same note, specific drill work is a great way to introduce the athlete to baseball activities, but they should be performed with gradual progression of intensity and difficulty. This can allow a player to begin to feel comfortable with position-specific activities before their full return to play. Again, this is where input from an informed professional can be an excellent way to ensure that you are maximizing what you can do with the athlete without exposing them to unnecessary risk.

This is also an excellent time to assess how other parts of the kinetic chain may be impacting throwing or hitting mechanics. Athletes with ACL injury are likely to display limitations with ankle mobility, hip mobility, lower extremity strength, and possibly even trunk stability or mobility issues if these have not been areas of focus throughout their rehab process. While these areas may have been deemed adequate to perform basic strengthening exercises or running/plyometric progressions, they may provide barriers to adequate performance with throwing or hitting.

 

Closing Thoughts

While there is a relatively large amount of research in return to sport after ACL reconstruction, I am unaware of any that relates specifically to baseball players. I hope to see future research investigating short-term or long-term changes in throwing or hitting mechanics in athletes with previous ACLR history.

These topics discussed above are only a small number of issues that need to be taken into account when returning athletes to baseball after ACLR surgery and there are numerous others that could be discussed as well.

While I work full-time in an outpatient physical therapy clinic, I have made it my goal to partner with local programs and facilities to try to assist with topics such as this to ensure that athletes, coaches, and parents can be better educated about how to safely and effectively return to baseball activities while minimizing risk for future injuries.

For any coaches or facility owners who may read this, I encourage you to partner with a rehab professional or knowledgeable strength and conditioning professional to ensure that you are promoting proper health and wellbeing of your players.

 

Sources:

Stanley, et al. Sex differences in the incidence of anterior cruciate ligament, medial collateral ligament, and meniscal injuries in collegiate and high school sports: 2009-2010 through 2013-2014. Am J Sports Med, 2016 Jun;44(6):1565-72. doi: 10.1177/0363546516630927.

Grindem, et al. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med, 2016 Jul;50(13):804-8. doi: 10.1136/bjsports-2016-096031.

Goerger BM, et al. Anterior cruciate ligament injury alters preinjury lower extremity biomechanics in the injured and uninjured leg: the JUMP-ACL study. Br J Sports Med, 2015 Feb;49(3):188-95. doi: 10.1136/bjsports-2013-092982.

Sugimoto, et al. Compliance with neuromuscular training and anterior cruciate ligament injury risk reduction in female athletes: a meta-analysis. J Athl Train, 2012 Nov-Dec;47(6):714-23. doi: 10.4085/1062-6050-47.6.10.

Padua DA, et al. Retention of movement pattern changes after a lower extremity injury prevention program is affected by program duration. Am J Sports Med. 2012;40:300–306. doi: 10.1177/0363546511425474.

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.

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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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.

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.

The Dynamic Neuromuscular Stabilization Approach To Arm Care

Dynamic Neuromuscular Stabilization (DNS) is a method of training stability and movement of the arm and body. Not only does it help with longevity and health of the arm, but also with movement and functionality of the kinetic energy system. DNS is revolutionizing rehabilitation, and its principles can be directly applied to pitching.

The function and position of the diaphragm is foundational to DNS. Dr. Hans Lindgren’s previous article on diaphragmatic function and intra-abdominal pressure (IAP) called “Core Stability From the Inside Out” exposes the importance of this mechanism.  IAP is the foundation for which the spine is stabilized and forces are efficiently transferred throughout the body.

Joint centration is the other main tenet of DNS.  Joint centration is defined as the ideal loading of a joint in a neutral position that enables:

  • Optimal loading
  • Ideal balance between agonistic and antagonistic muscles
  • Generation of maximum muscle power

Joint Centration is a position in which the joint surfaces are in maximum contact and the ligaments and capsule have low tension. In this position, all muscles around the joint can most effectively be activated. Symmetrical activation of the muscles around any joint is the hallmark of ideal function without injury. When disturbed, there can be catastrophic joint injury (ie ACL tear) or more low level chronic injuries such as: forms of tendonitis, ligament strains, and spinal disc herniation’s to name a few. DNS exercises emphasize joint centration at all times regardless of the position being used to exercise.

The concept of DNS is based on the scientific principles of developmental kinesiology. Meaning, all positions used for exercise in DNS are the same positions every human-being will advance through in the first year of life. If the baby develops normally, and the right environment is present, the correct activation of all muscles helps to form the joint surfaces and skeleton. This has enormous implications for baseball pitchers. If the development is not ideal then performance and arm health can be drastically altered later in life.

Revolutionizing Arm Care: The DNS Approach

As a baby develops, they must use their body as efficiently as possible which means proper joint centration, intra-abdominal pressure, and global stabilization.  There are phases for development of the stabilization function that are:

  1. 0 – 4.5 months (Sagittal stabilization)
  2. From 4.5 months (Extremity function differentiation within global patterns)
  3. From 8 months (Development of locomotor function)

For example, at 3 months of development in the prone position (on the stomach), the baby starts to integrate all the muscles involved in scapular stabilization. This is a complex strategy that involves many muscles, including some away from the shoulder girdle. Correct diaphragm position and IAP is a prerequisite for activation of key scapular stabilizers such as serratus anterior. Using closed chain exercises (elbow or hand support) is imperative for establishing the correct stabilization around the shoulder. This allows the muscles to be pulled from the opposite direction. Said differently, because the distal segment is now fixed (elbow) all the muscles around the shoulder reverse their direction of pull. Traditional rehabilitation exercises often neglect this function.

You can learn more about DNS and the stages of developmental kinesiology.  Also, if you’re interested in taking a DNS course you can check to see if they’re coming to your area.

The function of the scapula during the throwing motion is to allow 3-dimensional movement as well as coactivation of the muscles around the scapula to allow functional stabilization throughout the ranges of motion.  Dr. W Ben Kibler was one of the first to discuss scapular dyskinesis.  Kibler has shown that dysfunctional scapular movement can possibly lead to injury if not addressed, which is incredibly prevalent in the overuse community of baseball. He was also one of the first people to start talking about the importance of the entire kinetic chain as it relates to arm injuries.

Most injuries in baseball are non-contact which means that injuries occur because of stress overload, which can be from repetitive overuse, poor mechanics, or both. If not a biomechanical issue, often improper stabilization of the shoulder girdle can be found in both shoulder and elbow injuries.

Kibler has shown that patients with scapular dyskinesis will demonstrate:

  • Medial or inferomedial scapular border prominence (winging)
  • Early scapular elevation or shrugging on arm elevation
  • Rapid downward rotation on lowering of the arm

To assess scapular dyskinesis we will demonstrate a couple of DNS tests.

The 4-point rock test

Start on your hands and knees, rock back and forth several times and observe for any fatiguing or lack of stabilization in the scapula or hips.

What to look for:

  • Hand support (improper support on outside of palms)
  • Gradual winging of scapula
  • Medial border of scapula more than 2.5 – 3 inches away from spine.

Shoulder abduction test

The shoulder abduction test is where you raise your arms from the side all the way up and bring them down in a controlled manner.

What to look for:

  • Early activation of the scapula before 90 degrees of abduction
  • Clunking or popping of the scapula during abduction
  • Rapid downward rotation upon lowering of arm

These strategies can be used for rehabbing an injury, improving performance, and they’re a great warm up because it neurologically wakes up the muscles that hold the scapula in a good position.

Now let’s dig into a few of the exercises that really set this technique apart. We’re going to start with only a few to leave you with to master. The first exercise is called the…

5-7.5 Month Uprighting

You’ll start on your side laying on your shoulder with your arm directly out in front of you. Next, you’ll drive pressure into the ground with your elbow and bring your upper half off the ground trying not to bend too much at the torso. Slowly lower your body back down using the muscles around your scapula.

Repeat this process 8-10 reps in a situation where you’re trying to strengthen those muscles and 3-4 reps when you’re just warming up before throwing or exercises.

Bear

Start on your hands and knees just like the 4-point rock test with your hands under your shoulders and knees under your hips. Next, raise your knees about 5 to 6 inches off the ground. You’ll be supporting your weight while stabilizing at your hips and your shoulders. Now while staying as balanced as possible, lift one hand or foot (either side) off the ground 1 inch and hold it there for 15 seconds. Alternate until you run through all 4 extremities, or you can just hold the normal bear starting position. The important part is to feel the stabilization in the shoulder blades and the hips.

Again, this can be performed in a strengthening or in a warm-up setting and reps/sets should be done appropriately.

In conclusion, there are several different approaches to stabilizing the scapula. We believe a strategy that utilizes development kinesiology principles is the most effective. Many different developmental positions could be used; however, certain positions have a greater influence on the shoulder blade than others. Every exercise is a snapshot of the developmental sequence and will always be seen in the normal developing child. If the correct IAP and joint centration is maintained throughout the exercise, then the CNS will be able to proportionately activate all the muscles around the shoulder blade. Training and rehabilitation techniques that focus solely on individual muscles (ex. rotator cuff) may not create the most ideal stabilization strategy around the shoulder. These principles are revolutionizing how we assess and treat the throwing athlete.

Although this article has focused on assessment and treatment, the principles can also be used for biomechanical evaluation of the pitcher.

This article was co-written by Tyler White, co-founder of Gestalt Performance.

References:

  • Kibler, Ben W., and John McMullen. “Scapular dyskinesis and its relation to shoulder pain.” Journal of the American Academy of Orthopaedic Surgeons11.2 (2003): 142-151.
  • Burkhart, Stephen S., Craig D. Morgan, and W. Ben Kibler. “The disabled throwing shoulder: spectrum of pathology Part III: The SICK scapula, scapular dyskinesis, the kinetic chain, and rehabilitation.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 19.6 (2003): 641-661.
  • Burkhart, Stephen S., Craig D. Morgan, and W. Ben Kibler. “The disabled throwing shoulder: spectrum of pathology Part I: pathoanatomy and biomechanics.” Arthroscopy: The Journal of Arthroscopic & Related Surgery19.4 (2003): 404-420.
  • Wilk, Kevin E., Leonard C. Macrina, and Michael M. Reinold. “Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability.” North American journal of sports physical therapy: NAJSPT 1.1 (2006): 16.
  • Frank, Clare, Alena Kobesova, and Pavel Kolar. “Dynamic neuromuscular stabilization & sports rehabilitation.” International journal of sports physical therapy 8.1 (2013): 62.

Download our Free Arm Care Program for Baseball Players

One of the foundational pillars of any program for baseball players is an arm care program. Yet, this is often one of the most neglected areas I’ve seen. Many collegiate baseball players, let alone high school and youth baseball players, have never performed an appropriate arm care program.

Here’s a simple fact… If you are a baseball player, you must be performing an arm care program. All the big leaguers do, why aren’t you?

More importantly, if you are performing a strength training program, getting pitching lessons, or participating in a long toss or weighted ball program and do NOT perform an arm care program, your priorities are reversed.

I always say, you are focusing on the frosting before you’ve baked your cake.

But I get it, some people have never heard of an arm care program and some people do not have access to a good one.

Well, I want to change that.

Our mission here at Elite Baseball Performance is to advance the game of baseball through trustworthy and scientifically proven information and programs.

Download the the EBP Arm Care Program for FREE

EBP Reinold Throwers Arm Care ProgramI want every baseball player in the world to perform an appropriate arm care program, that’s why I am giving mine away for free here at EBP.

I’ve developed this program over the course of two decades based on the science of throwing a baseball and the science behind exercise selection. This is the foundational program that we have used at Champion PT and Performance on everyone from Little League pitchers to Cy Young winners. Sure, the programs we do with our athletes in person are far more comprehensive, but I consider this to be the mandatory foundational program you should be performing.

In exchange, I only ask for your help spreading the word. Please share this page with all your friends, teammates, coaches, parents, and anyone else that wants to help baseball players enhance their performance while reducing their chance for injury!

Start performing this today and you will be well ahead of the curve. Countless big leaguers perform this exact program, get it here for free today!