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!

 

 

How to Get the Most Out of the Start of Your Baseball Offseason

This article, How to Get the Most Out of the Start of Your Baseball Offseason, was originally featured on MikeReinold.com. 

 

It’s been a long summer of baseball and it is time to start thinking about your offseason training program!

Some people think of the offseason as a time to rest, or to get away from baseball, or to do everything they can to dominate again next season. I’ve seen every spectrum of player, from the player that wants to just sit in a tree stand until February to the player that comes in to train the first day of the offseason.

Offseason training programs in baseball are now standard.  Believe it or not, this was not the case 20 years ago.  However, I think there is another golden opportunity that many players do not take advantage of at the start of the offseason.  Think of it as setting the foundation to prepare your body to get the most out of your offseason training.

Here is what I recommend and do with all my athletes at this time of year to get the most out of the start of your baseball offseason training.

 

Take Time Off From Throwing and Baseball

One of the most important aspects to the start of the baseball offseason is to take a step back and get away from baseball.  While this may seem counterintuitive, I do believe it is critical to your long term success.

For professional baseball pitchers in MLB, the start of the offseason means spending time with family, golfing, hunting, fishing, and probably taking a well deserved vacation to somewhere tropical.  It’s a long season, both physically and mentally.

I wouldn’t say that a summer of baseball is much easier for the younger baseball players, either.  Between traveling teams, tournaments, showcases, and grinding away at practice, the summer is almost as busy as the pro players!  I actually joke with some of my high school and college baseball pitchers that they can’t wait to go back to school to take a vacation from their summer baseball travel schedule!

But there are important physical benefits of taking time off as well.  Throwing a baseball is hard on your body and creates cumulative stress.  Furthermore, several studies have been published showing that the more your pitch, the greater your chances of injury:

  • Pitching for greater than 8 months out of the year results in 5x as many injuries (Olsen AJSM 06)
  • Pitching greater than 100 innings in one year results in 3x as many injuries (Fleisig AJSM 2011)
  • Pitching in showcases and travel leagues significantly correlated to increased injuries (Register-Mahlick JAT 12, Olsen AJSM 06)

I have found that my younger athletes that play a sport like soccer in the fall, tend to look better to me over time.

Sure, that is purely anecdotal.  But specializing in a very unilateral sport may actually limit some of your athletic potential, especially when you are in the certain younger age ranges where athletic development occurs.  Everything is baseball tends to be to one side.  Righties always rotate to the left when throwing and swinging, heck everyone even runs to the left around the bases!

There is plenty of time to get ready for next spring.  Take some time off in the fall and let your body heal up.  You aren’t going to forget how to pitch or lose your release point or feel.  You’ll come back stronger next season.

 

Regen Your Body

Tough travel schedule, long hours in a car, bus, or  plane, cheap hotels, bad food, lack of sleep, inconsistent schedule.  Sound familiar?  That is a baseball season.  It’s tougher than you would think on your body.

All of these factors, and more, wear down your body and it’s ability to regenerate.  The constant stress to your body is a grind that drains your energy, increases your fatigue and soreness after an outing, and lengthens the time your body needs to fully recover between outings.

In order to get all that you can out of your off season training, you need to regen your body first.  This begins with the first principle above and taking time away from throwing, but there are also other things you can do to reset and regenerate your body.  You body needs to heal and sleep and nutrition are two great things to focus on at the start of the offseason.  Here are  a few things I recommend:

  • Get on a consistent sleep schedule
  • Sleep at least 8 hours a night
  • Eat a clean diet while avoiding fast food and processed foods
  • Hydrate, hydrate, hydrate

Think of it as allowing your body to get back to neutral so you can start building on a solid foundation during the offseason.  You don’t want to start your offseason training with your body worn down.

 

Clean Up Any Past or Lingering Injuries

I’m always amazed at the amount of people that limp through a baseball season and think that taking some downtime after the season is going to cure all their aches and pains.  What happens many times is that they take time off and then start training or preparing for next season and find out they may feel better but they didn’t address their past injuries.  They still have deficits.  If you wait until you start throwing again to find this out, it’s too late.

All my athletes start the offseason out with a thorough assessment that looks at all past areas of injury, regardless of whether or not they are currently symptomatic.

Many times, strength deficits, scar tissue, fibrosis, and several imbalances are still present after an injury, even if your are playing without concern.  Your body is really good at adapting and compensating.  It will find a way to perform.  This is likely one of the reasons that the number one predictor of future injury is past injury, meaning if you strain your hamstring, you are more likely to strain it again.  You probably never adequately addressed the concern.

You have to dig deep and find the root cause of the injury as well as clean up the mess created from the injury itself.  Remember, many injuries occur due to deficits elsewhere in the body.  Sometimes that elbow soreness is coming from your shoulder, for example.  Resting at the start of the offseason is great for the elbow, but you didn’t address the cause of your elbow symptoms.

 

Rebalance Your Portfolio

In the financial world, the concept of rebalancing your portfolio is one of the cornerstones of sound investing.  Essentially at periodic intervals you should assess your current portfolio balance and adjust based on the performance of your assets.  As some of your stocks go up and others potentially go down, your top performers are probably taking up a very large percentage of your portfolio and skewing your balance.

By rebalancing your portfolio at the end of the year, you assure that you redistribute your assets evenly and minimize your risk.

This same concept is important for baseball training.

After a long season of wear and tear you no doubt are going to have imbalances.  This happens even if you get through the season injury-free.  I say this often, but throwing a baseball is not natural for your body.  You’ll have areas of tightness and looseness, you’ll have areas of strength and weakness.  You’ll have imbalances and asymmetries.

In my studies on professional baseball pitchers (you can find some of my published data here and here), and an article on baseball shoulder adaptations), I have found many things:

  • You will lose shoulder internal rotation and flexion (if you don’t manage this during the season)
  • Your will gain external rotation, which isn’t necessarily a good thing and needs to be addressed!
  • You will lose elbow extension
  • You will lose shoulder and scapular strength
  • You will lose overall body strength and power
  • Your posture and alignment will change

One of the most powerful things I can recommend for any baseball pitcher is that you get a thorough assessment at the end of the season.  This serves as the most important day to me in your offseason program and the cornerstone of what I do with my athletes.  We need to find out exactly how your body handled the season and adjusted over the way.  Everyone responds differently.

Without this knowledge, your just throwing a program together and hoping everything works out.  This may work one year, but it’s going to catch up to you eventually.  Probably right in the middle of next season!

 

Set a Foundation for the Start of Your Baseball Offseason Training

What is the purpose of all this?  Simply taking time off after a season isn’t enough anymore.  Simply jumping into an offseason baseball training program isn’t enough anymore.  Simply performing a baseball long toss program isn’t enough anymore.

You need to actively put yourself in the best position to succeed.  Offseason training is the norm now.  You used to be able to gain a competitive advantage by training your tail off all offseason, but your peers are doing this too.

You can set yourself apart by setting a strong foundation BEFORE your offseason training.  This is not as common and one of the biggest mistakes I see amateur baseball players make each offseason.

Set yourself apart by starting your offseason on the right path.  Take some time off, regen your body, get your past injuries evaluated, and go through a thorough assessment to find ways to maximize your bodies potential.  Do this before the start of your offseason training so you set a fantastic foundation to build upon just.  This is a big part of our baseball offseason performance training at Champion Physical Therapy and Performance.

 

 

 

The New Alternative to Tommy John Surgery – UCL Repair with Internal Brace

The baseball world has been buzzing regarding a potential new surgery to repair the Tommy John ligament, rather than the traditional reconstruction, that has the potential to reduce the time to return from surgery.

The new procedure involves repairing the damaged ligament and reinforcing it with a collagen-coated fiber tape in contrast with the traditional UCL reconstruction that involves drilling tunnels in the bone and using a graft from a tendon in your arm or leg.

UCL Repair with Augmentation and Internal Brace

 

The new UCL repair with internal brace is less invasive and offers hope that the new procedure can reduce the time it takes to return from surgery while providing similar effectiveness of the traditional procedure.

 

UCL Repair and Augmentation with Internal Brace

The following presentation by Dr. Jeff Dugas from ASMI in Birmingham, AL, discusses the procedure, early results, and what we currently know about the procedure.  Dr. Dugas is one of the pioneers of the new procedure.

The following video is just one of the many amazing presentations from the 2017 ASMI Injuries in Baseball Course, which is now available online through Elite Baseball Performance:

 

Is The New Procedure a Miracle?

The mainstream media has been calling the new UCL repair with internal brace procedure “the next miracle,” but like everything else, we need to take what we read in the media as entertainment, not fact.  The media loves to sensationalize a topic, and this is no different than what is occurring with the new procedure.

The truth is that this procedure is still new, although promising.  Results are coming in and have been satisfactory to date, but realize that very strict patient criteria has been used so far to date.  We do not have a very large sample size of higher level baseball players just yet, though they are coming.

Furthermore, we do not have long term data.  Short term data appears promising, but we have a saying in scientific research, “if you want to report good results, just look at short term data.”  We don’t know the longevity of these repairs and if they prove to be as reliable and durable as UCL reconstruction.

So until we have a larger sample of data and a longer follow up time to analyze the effectiveness, the procedure should still be considered experimental at this time.  The traditional Tommy John procedure, which is more invasive and reconstructs the UCL ligament, is still the current gold standard with decades of research supporting it’s effectiveness.

 

Who’s a Candidate for The New Alternative to Tommy John Surgery?

While the traditional Tommy John reconstruction will likely remain the gold standard for some time, there are some people that may be great candidates for the new alternative UCL repair with internal brace procedure.

Younger baseball players with open growth plates can not perform the traditional procedure as it involves drilling of the bones in the arm and may impact the growth plate.  Baseball players with strict timelines, such as a college or high school baseball player going into their senior year, may also be good candidates.  Other athletes, such as gymnasts, football players, and those that have had a traumatic injury to the UCL may also be good candidates.

 

Who’s NOT a Candidate?

I recently spoke with Dr. Dugas about this exact topic.  As he has gained more experience with the procedure, we’re getting better at determining who is NOT a good candidate.

It really comes down to tissue quality.  If you have been wearing your ligament down for some time with past episodes of elbow pain or even ligament sprains, the tissue quality is probably not good enough to support the repair.  In addition, if you have boney changes in your ligament, such as ossicle formation from chronic stress and past injuries, the tissue quality is likely not adequate enough to support the procedure.

In fact, Dr. Dugas told me he is going into these procedures telling the patients that they may wake up and have had the full Tommy John reconstruction.  When they get in the elbow, they may feel the tissue quality is too poor.  But with time and experience, they are finding they are doing well figuring this out based on the x-rays and MRI prior to surgery.

At this time, I am personally finding it hard to recommend this new procedure for most baseball players.  I’m never a fan of adopting newer or experimental procedures when a option with good results and reliability exists.  The traditional Tommy John procedure is still my first recommendation for players that wish to continue their career development.

I hope in the future my opinion changes, as the hope of returning pitchers to baseball sooner than a traditional Tommy John procedure is exciting.

I do believe this is just the beginning.  New procedures, techniques, and biological advancements will emerge and our management of baseball pitchers with Tommy John injuries should only continue to improve.

 

2017 ASMI Injuries in Baseball Course

ASMI Injuries in Baseball 2017EBP has just released an online version of the 2017 ASMI Injuries in Baseball Conference, featuring world renowned speakers such as Dr. James Andrews, Dr. Glenn Fleisig, Kevin Wilk, Mike Reinold, and several MLB team physicians, athletic trainers, and strength coaches.  This is the premier conference for baseball related injuries and performance enhancement, with topics detailing pitching biomechanics, baseball specific functional anatomy, clinical examination, surgical management, injury rehabilitation, and performance enhancement for baseball players.

The course contains the most cutting edge information from the leaders in baseball sports medicine, including the above presentation by Dr. Jeff Dugas.

The ASMI Injuries in Baseball Conference has been on sale this week for $100 off, but there are only a few days left to save!  The sale ends Sunday June 25th at midnight EST.  Click the button below to learn more.

 

 

ASMI Injuries in Baseball Course Now Available Online

Elite Baseball Performance is excited to announce that we have just released the exclusive online version of the 2017 ASMI Injuries in Baseball Course.  Learn from the leading experts in baseball sports medicine!

The American Sports Medicine Institute has been conducting their annual Injuries in Baseball Conference for 35 years under the direction of course co-chairmen Dr. James Andrews, Dr. Glenn Fleisig, and Kevin Wilk.  This is the longest running and most prestigious scientific conference dedicated to the care of baseball players.

The online version of the conference contains a collection of presentations from the event earlier in the year.  This is the most cutting-edge information available on on baseball injuries.

ASMI Injuries in Baseball Conference

 

2017 ASMI Injuries in Baseball Course

asmi injuries in baseball course

The 2017 course is the premier conference for baseball related injuries and performance enhancement.  

And with the online version, you can access the course at anytime, from any device, anywhere in the world with internet access!  

The course contains over 8 hours of content detailing pitching biomechanics, baseball specific functional anatomy, clinical examination, surgical management, injury rehabilitation, and performance enhancement for baseball players.​  Presenters include Glenn Fleisig, Kevin Wilk, Mike Reinold, and several MLB team physicians, athletic trainers, and strength coaches.  Topics include:

Shoulder

  • Biomechanics of the Shoulder During Pitching – Fleisig
  • Examination of the Throwing Shoulder – Jordan
  • Labral & Biceps Pathology in Throwers – Conway
  • Rehabilitation of SLAP Lesions – Macrina
  • Full & Partial Thickness Rotator Cuff Tears – Mazoue
  • Rehabilitation of Rotator Cuff Lesions – Wilk
  • Putting it All Together – Andrews

Elbow

  • Biomechanics of the Elbow During Pitching – Escamilla
  • Examination of the Throwing Elbow – Conway
  • UCL Reconstruction: Current Technique and Outcomes – Cain
  • Long Term Outcomes of UCL Reconstruction – Osbahr
  • Augmented UCL Repair with Internal Brace – Dugas
  • Rehabilitation of UCL Injuries of the Elbow – Wilk

Rehabilitation and Performance

  • Training for the Scapulothoracic Joint & Thoracic Spine – Paine
  • Plyometric Training for the Thrower: Techniques & Evidence – Escamilla
  • Oblique Injuries In Baseball – Conte
  • Training the Core – Crenshaw
  • Breathing Exercises to Enhance Rehab & Performance – Crenshaw
  • Interval Throwing Programs Revisited: Where Are We Today – Axe
  • Extending Throwing Programs for the Thrower Following UCL Surgery – Porterfield
  • Effects of 6-Week Weighted Ball Throwing Program on Velocity & Arm Stress – Reinold

Youth Baseball

  • Update on Risk Factors in Youth Baseball Pitchers – Jordan
  • Longitudinal Changes in Pitching Mechanics from Youth to High School – Fleisig
  • Impact of Youth Baseball on MLB – Reed

Softball

  • Pain History & Pitching Mechanics in Collegiate Softball – Oliver

 

Save $100 Off Now Through Sunday June 25th at Midnight EST

To celebrate the launch of the program, we are offering it for $100 off the regular price of $299.  You can purchase the program for only $199 now through Sunday June 25th at midnight EST.  Click the button below to learn more and purchase now!

 

Pullover Variations to Improve Overhead Stability in Throwers

When working with overhead athletes, optimal positioning and function of the shoulder complex is vital for sustained performance. Whether you’re a high school outfielder or major league pitcher optimal development and function of the serratus anterior and the deep abdominals are a must for meeting the demands of an overhead sport like baseball. This brings us to the Kettlebell Pullover; this exercise is an underutilized yet effective movement that baseball players can add into their performance and rehabilitation programs.

Why should we use them?

With these exercise variations, we are achieving many things. First, the person will have to stabilize their anterior core while moving their arms in space (AKA proximal stability promoting distal mobility). This allows us to see the person’s ability to reach a full squat both passively (through hip flexion on the floor) as well as actively (reaching a full squat position).

The exercises posted below are challenging the individual to go overhead while maintaining the pelvis and rib cage over one another. This can help achieve proper scapular upward rotation, scapular posterior tilt, and protraction of the scapula.

One of the other benefits is it can be modified to fit the movement ability of each person.  As shown below these exercises follow a developmental sequence of supine to half or tall kneeling to standing.

This is a general progression of positions I may follow with a person who has limited movement experience and needs to better solidify their overhead capabilities.

Kettlebell Pullover Variations for Throwers

Progression 1: Supine

The follow supine exercise can be progressed from bilateral to unilateral, and feet on the ground transitioning to a 90/90 position without wall support.

Supine Kettlebell Pullover

 

Supine Single Arm Kettlebell Pullover

 

Supine Bottoms Up Single Arm Kettlebell Pullover

 

Progression 2: Kneeling

The following exercises progress from half kneeling or tall kneeling, can be performed bilateral or unilateral, and can go from a light band to a light Kettlebell.

Tall Kneeling Bilateral Band Pullover

 

Half Kneeling Single Arm Kettlebell Pullover

 

Progression 3: Standing

Lastly, we can progress to the standing position, with or without the squat. 

Kettlebell Goblet Squat with Heartbeat to Pullover

 

Application to Strength Training

These exercises are beneficial for the overhead athlete in both the warm up and during the workout itself. These exercises teach the client how to keep their pelvis and rib cage aligned, which will then carry over to relearning a more optimal overhead mechanical pattern.

When progressed appropriately it can also be a challenging anterior core exercise because the person has to resist excessive lumbar extension while their arms begin to move overhead.

Application to Rehabilitation

Many times patients come to us with hip and shoulder pains that can be traced back to overuse of the latissimus dorsi and underuse of the deep abdominal muscles, serratus anterior along with an anteriorly tilted pelvis. When we begin to balance out these opposing forces, we then see better outcomes in our patient population.

These exercises are a good starting point to slowly and safely reintroduce the overhead pattern in various non-threatening positions. Many times a patient is highly guarded after experiencing shoulder soreness or an injury. Putting them in these positions allows the therapist to tap into the person’s nervous system and make a positive change towards the patient relearning a more optimal overhead movement sequence.

Finally, it gives us a global view of the person we are working with. Can they do the task we want or do they need an excessive amount of extension strategies to get into the squat position or to get their arms fully overhead?

How to Program

Start with 2-4 sets of 4-6 breaths either in the warm up or as filler in between exercises is a great place to begin implementing this exercise.

  1. Reach your arms long to the ceiling throughout the motion
  2. Inhale to start the motion and exhale as you bring the Kettlebell down towards the floor
  3. Slightly bring your belt buckle towards your chin while maintaining your low back on the floor