Exploring Arm Injuries

Posted by:Coach Bleecker in Medical

We have a problem in Baseball. Arm injuries continue to rise and Baseball players, specifically pitchers, are the worst prepared athletes to step on an athletic field.  As coaches and trainers we are solely responsible for the development, health and future of our players.  It is our job to Inspire them to reach their goals and inform them on the information necessary to do so.  ASMI and all the leading researchers on the subject make it very clear, the injuries are happening when the players are young.  The ligaments and tendons are stretched over time eventually resulting in a tear.  Finally, those very same ligaments are only as strong as the muscles that surround and support themAs far as we are concerned, this entire issue boils down to one thing, asking the body to do something it isn't prepared to handle.  We are going to discuss these issues, highlight the opinions of some of the best coaches in the business and present some ways we can attack this problem collectively.

 

It’s important to first examine who is getting injured.  It’s not often you see a 16 year old pitcher that throws 72MPH on the operating table.  It’s the guys that throw hard, it’s the elites, it’s the future collegiate and professional Baseball stars of tomorrow.  We started training an interesting young prospect about 2 months ago.  He is an elite 14 year old that recently won the MVP pitcher award at the 14u WWBA this year.  Arguably the best event in the country.  He is 6’2” and weighs in at 183 lbs.  He walked in here on his evaluation day throwing 81-83 off the mound which we would consider elite in his age bracket.  He had poor, inefficient throwing patterns that placed considerable stress on his arm. He is a big kid but his body is put together poorly having scored one of the lowest FMS ratings we have ever seen.  His explosiveness and raw strength levels were poor.  His connective strength was extremely poor and his decelerators specifically were almost nonexistent.  His nutrition was terrible and he basically had no idea how to take care of himself.  He wasn’t throwing regularly even though he was getting on the mound every few weeks and pitching in a competitive environment.  As a result of all these things he experienced a lot of soreness on a regular basis.  He is an elite with a bright future in this game and he is ALSO a perfect example of someone who, without a change will be the guy most likely to end up on an operating table.  

 

WHAT HASN’T WORKED

Pitch Counts and Throwing less:  I do believe that Pitch counts at the amateur level are important simply because the players are not prepared to throw an extensive amount of pitches.  That, and the fact the in many places across the country pitchers are throwing competitively year round which I also don’t agree with.  The reason pitch counts aren’t going to solve the problem is the simple fact that many of these pitchers aren’t prepared to handle 50 pitches let alone 75 or 100.  The young man I discussed earlier was on pitch counts at every event he threw, yet still experienced pain on a regular basis.  Everyone is scared to throw right now.  Pitching too much is a problem, but not throwing enough is a bigger one.  Amateur players are throwing harder than they ever have, but because they are scared to throw and not throwing enough, they aren’t building the arm up to handle pitching in a competitive environment.  Their arm has not been trained or been used enough to withstand the forces they are producing.  Later we will go into deeper detail of what that really means and how to prevent it.  Since the Tommy John epidemic began to take Baseball by storm, at the collegiate and professional level pitchers and coaches alike have begun to “baby” the arm.  That method of injury prevention has been extremely ineffective.  This is proven by the fact that injuries have not decreased, but actually increased since the pitch count system was introduced.  Recently, Nolan Ryan one of the greatest pitcher’s in history was quoted as saying “It’s because pitchers simply don’t throw as much as we did.  When I pitched, we pitched every fourth day and guys would pitch 300 innings and it wasn’t considered a big deal.  If you don’t get on the mound and develop stamina, your risking injury”.  That was Nolan Ryan’s way of saying the same thing we are, that pitchers aren’t ready to handle the workload they are being asked to perform.

 

Rest during the competitive season: We have also noticed through countless interviews and discussions with amateur pitchers that they are constantly resting their arm for periods of time during their competitive season.  In doing so, they think they are going to stay healthy because they are resting.  I worked with a player in Pitttsburgh, Pa at the end august that is a potential high round draft prospect this year.  As a sophomore he was up to 93MPH and after his junior season his arm was hurting and the kid was tired.  Now this is a big country strong young man with a lot of muscle on his body.  At the recommendation of his pitching coach, he took a month off after his HS season ended, threw once a week in a bullpen session all summer after the break and pitched in competition roughly every other weekend during the summer.  That is about the worst possible plan I can think of and again, yet another perfect example of a kid who without change, is going to end up on an operating table.  Taking break periods during the middle of a competitive season is extremely detrimental and counterproductive to a pitcher’s health.  If you trained to Deadlift 200 lbs. 100 times on a regular basis and then took a month off and asked your body to perform, not only would you be unable to perform the task with the same ability level, you would be running the risk of injury by pushing your body beyond its capability.  Breaks are important, but understanding when to take them and the preparation necessary to get back on the mound is just as, if not more important.   

 

Ice:  I know there are a lot of different opinions on this subject so we are going to stick to the facts.  A while back I spoke to an agent with The Ballangee Group named Scott Lonergan who also happens to be a friend.  At 33 years old Scott has a pretty extensive Baseball resume.  He played professionally with the Red Sox, went into scouting with the padres, left with Jed Hoyer to help rebuild the cubs, became an agent with MVP Sports group and finally left to start The Ballangee group alongside Jeff Randazzo.  As an agent Scotts job is now to take care of his players and point them in the right direction.  We were discussing a lot of things in relation to arm health and arm care protocols.  One of the things he said was “regardless of what I may or may not think, I have to go with the science”.  There has been enough research done to clearly state that at this time, icing your arm isn’t going to keep you healthy.  Ice is used for acute injury and to reduce inflammation.  Having a sore arm after throwing isn’t an acute injury and we shouldn’t be trying to reduce inflammation by constricting the blood vessels.  That is an extremely counterproductive method of arm care.  Well get into the science more later but here is a basic overview:  After any repeated activity the fascia surrounding the arm is constricted ultimately preventing blood flow and oxygen.  Blood flow and oxygen bring healing properties and are ultimately what the arm needs to heal.  Ice makes no sense.  All it does is make the arm numb tricking us into thinking it’s healed.  It doesn’t actually help. 

 

Running Poles:  Everything we previously stated about ice, also applies to running poles. There is no literature or research on the current physiology of the sport in support of distance running.   In fact, all of the research that has been done shows that sprints, explosive movements and arm care protocols are proven to be considerably more effective.  Eric Cressey wrote a phenomenal article on the topic here:  

http://ericcressey.com/should-pitchers-distance-run-what-the-research-says

 

Multiple coaches: Our industry as a whole, needs to get on the same page.  No one is working together and the ego of trainers, High School and travel coaches clash on a daily basis.   If the employee of a business had 3 different bosses and all 3 were asking the employee to perform different tasks, without any communication between them, what would that look like?  Welcome to the life of the elite amateur Baseball player.  The player gets one thing with his trainer, is forced to do something different in high school and then the travel coach tries to change everything.  This produces 2 outcomes:

  1.  The player is seen as un-coachable because he has a system that has worked for him and doesn't want to change.
  2. The player does everything he is told and spends so much time changing he can’t figure out who he really is.

Neither one of these outcomes is a desirable one.  We must find another way.  We must change how this system operates.  The players are the ones suffering, end of story.  Egos need to get checked at the door and we all need to be more open to communication and suggestions.  How hard is it to ask a player questions?  In my opinion, everyone should take some cues from Scott Brown over at Vanderbilt.  I had the opportunity to watch him work with some of his pitchers last year and it was inspiring to watch. I was there with one of my Freshman who showcased and later committed.  The first question he asked every pitcher that walked in was “what is your plan today”.  He empowers them with information and knowledge and gives them the ability to take their development into their own hands.  THAT’S WHAT SHOULD BE HAPPENING EVERYWHERE.  Rather than forcing information down everyone’s throat, why not introduce knowledge and what they choose to do with it is on them.  By having conversations with them in that fashion, you might learn something as a coach as well.  I think we should all be learning from our players.  I know I have learned just as much from mine as they have from me.  I can tell them something, but they might feel differently.  No one knows how they feel better than the player.  Moving the coaching in this direction will allow them to succeed and fail based on their own merit and the team will probably benefit as a result.  As coaches, how many times have we told a player something 1,000 times and they still didn’t do it? If the player doesn’t buy in trying to force them doesn’t work anyway.  Let’s save all that time and try to present it to them in a way they understand. If they refuse to listen, either you didn't do a good job explaining it or they aren’t going to listen anyway.  It all comes down to mutual respect with players and the better you approach them the more likely they are to accept information. 

 

We are all hopefully looking out for the best interests of the player.  We are all important to the player’s development in Baseball and even more importantly as a young man. Let’s acknowledge that our current system is very difficult for a young man to navigate and the only person it hurts is the player.  We have to find a way to come together in the best interest of our players. 

 

The Science

ASMI is considered the leading researcher on UCL injuries in Baseball pitchers.  No one has done more research than they have although Driveline Baseball is making some HUGE strides on the development side. If you haven’t seen it already, here are some of the major risk factors they present in their positional statement on UCL injuries.

  1. Pitching on multiple teams
  2. Pitching year round
  3. Poor pitching mechanics
  4. Poor physical condition

 

Here is ASMI’s recommendation for professional players and teams looking to reduce Tommy John surgery.

1Optimize pitching mechanics to ensure using the whole body in a coordinated sequence (kinetic chain). A biomechanical analysis is recommended, as it provides objective data to the pitching coach, strength coach, and pitcher. A biomechanical analysis can also serve as a baseline for re-evaluation later in the pitcher’s career, after performance improvement or after return from injury.

2Vary speeds for each of your pitch types. This will not only reduce the overuse on the elbow, but also can be an effective strategy. The best professional pitchers pitch with a range of ball velocity, good ball movement, good control, and consistent mechanics among their pitches. The professional pitcher’s objectives are to prevent baserunners and runs, not to light up the radar gun.

3Open communication between a pitcher and his professional coaching and medical staff is paramount. The pitcher’s elbow and body are living tissue. Pitching and training create small tears in the tissue; rest, nutrition, and hydration repair the tears. A pitcher and his team should have a plan, but that plan needs to be monitored and sometimes adjusted depending on how the pitcher feels. Specifically, the pitcher should keep his trainer or coach up to date about any soreness, stiffness, and pain. That way when there is an issue, the player and team can consider rest, modified activity, or examination from the team physician to allow the elbow to heal and avert serious injury.

4The pitching coach needs to watch for signs of fatigue on the mound. This could be seen in-game as well as in bullpen sessions.

5The team trainers, coaches, medical staff, and front office must share knowledge in a holistic approach to minimize the risk of injury.

6Flat-ground throwing drills and bullpen sessions should not always be at maximum effort. Reduced effort will allow for physical fitness and technique without adding undue stress to the UCL.

7Take off at least two consecutive months each year from all throwing. During this “active rest” period, you can do other physical activities and exercises, as well as continue proper nutrition. The UCL and body need time to recover and build strength, so the concept of annual periodization should include adequate rest from pitching.

8Exercise, rest, and nutrition are vital for a pitcher’s health. Pitchers with high ball velocity are at increased risk of injury. The higher the ball velocity, the more important to follow the guidelines above.

 

Now we must interpret the information and apply it to amateur players.  Obviously optimizing pitching mechanics is important but that’s a topic for a different time.  The most important information we can take from this article is opening a line of communication with our players for starters.  After that, look for signs of fatigue on the mound.  Are they struggling to find the zone?  Did they throw 25 last inning and they are already 20 deep in this one with less than two outs?  Let’s try to remember that the health and development of our player is more important than some plastic trophy.  Number 7 and 8 are without a doubt the 2 most important things to apy attention to.  TAKE OFF AT LEAST TWO CONSECTUTIVE MONTHS EACH YEAR FROM THROWING! It’s over, done, nothing more to say!  All of the research indicates that in those two months it will give the arm an opportunity to heal and LOSE some external rotation which is a great thing.  Essentially tightening up the spring.  If you talk to any ortho, in about 2 seconds they know if your son is a pitcher.  Amateur pitchers have extremely poor internal rotation due to excessive rotation caused by repeated throwing.  Don’t believe me, call the Doctor.  During this period of time you don’t stop Baseball activity all together, just throwing a Baseball.  Contrary to popular opinion I love year round Baseball players.  At 7 years old I knew I wanted to play professional Baseball.  No one pushed me to train, no one forced me to collect Baseball cards, play Baseball video games or watch Baseball tonight.  I did those things every day because I absolutely loved it.  All my parents did was support that dream.  Kids these days are a bit different, sometimes they need to be prodded a little bit, but if it’s in their heart let em go for it.  Don’t force them to play another sport just because Joe Shmoe says it’s a good idea.  However, get them in other forms of TRAINING to increase strength and skill levels across multiple areas.  This leads into the next topic.  EXERCISE, REST and NUTRITION ARE VITAL FOR A PITCHERS HEALTH!!!  If you don’t train outside of regular Baseball activity, have poor sleeping habits and worst of all, eat empty calories all the time you run a considerably higher risk of getting injured.  If you are interested in learning more about the nutritional aspect, we will go into it in great detail later in the book.

 

Now let’s discuss how we can improve the health and performance of pitchers everywhere.  Conventional Baseball training emphasizes an adequate training of muscle fibres, of cardiovascular conditioning and neuromuscular coordination.  However, most Baseball related injuries are due to overload that occurs within elements of the bodies wide fascial net, which are then loaded beyond their prepared capacity. UCL injuries are a prime example of this very thing.  This tensional network of fibrous tissue includes ligaments and tendons. Fibroblasts continually but slowly adapt the morphology of these tissues to repeatedly applied challenging loading stimulations.  Principles of a fascia oriented training approach MUST be introduced to Baseball.  This includes utilization of elastic recoil, preparatory counter movement, slow and dynamic stretching, as well as rehydration practices and proprioceptive refinement.  This method of training should be introduced on a regular basis to Baseball players in order to develop a more resilient fascial body.

 

Whenever a football player is unable to take the field because of recurrent knee pain, a tennis star gives up early in a match due to shoulder problems, or a sprinter limps across the finish line with a torn Achilles tendon, the problem is most often neither in the musculature nor the skeleton.  Instead, it is the structure of the connective tissue – ligaments, tendons, joint capsules, etc. – that have been loaded beyond their prepared capacity. (Renstrom and Johnson, 1985; Hyman and Rodeo, 2000; Counsel and Breidahl, 2010).  The same exact thing is occurring in the UCL of Baseball pitchers and as a result, Tommy John surgeries continue to rise. According to ASMI and all the leading researchers in the game, we know that UCL injuries happen over time as opposed to one isolated throw.  The UCL stretches repeatedly like a rubber band and develops micro tears that ultimately lead to the partial or full tear of the ligament. Due to the repetitive nature of pitching a baseball and the stress levels placed on the UCL during the process, it is paramount that the Baseball community begins to understand the importance of training protocols that build the connective and fascial strength necessary to handle the workload they experience.  The only way to prevent these injuries from occurring is the continued education of coaches and players.  Especially at the amateur level, pitchers MUST throw more, pitch less and MUST build up the connective strength to handle the workload they are going to experience.  Here is a deeper look into the fascia we are attempting to train.

 

Fascia has been described as a body of wide tensional network, which consists of all fibrous collagenous soft connective tissues, whose fibrous architecture is dominantly shaped by tensional strain rather than compression.  This continuous network envelops and connects all muscles and organs.  Think of a spider web that surrounds the entire body.  It is important to understand, that the local architecture of this network adapts to the specific history of previous strain loading demands (Blechschmidt, 1978: Chaitow, 1988).  According to the widely accepted SAID principle the body will Specifically Adapt to Imposed Demands.  We are simply not asking our pitchers to prepare properly. 

 

Focusing on training the fascial network should become a necessary protocol in the development of Baseball pitchers.  If the fascial body is well trained to become optimally elastic and resilient, then it may be relied upon to perform effectively and at the same time offer a CONSIDERABLY higher degree of injury prevention to the UCL in pitchers. Baseball training at all levels is generally focused on the classic triad of muscular strength, cardiovascular conditioning and neuromuscular coordination.  Most Baseball pitchers lift weights, run poles and do conditioning work based on plyometrics.  Alternative physical training activities like Pilates and yoga take the connective tissue work into account, but that certainly isn’t enough when specifically looking to build connective strength in one problematic ligament. 

 

         Connective tissue is amazing in its adaptability.  When regularly put under increasing yet physiological strain, the inherent fibroblasts adjust their matrix remodeling activity such that the tissue architecture better meets demand.  Recent studies have confirmed (Arampatzis et al., 2010) that in order to yield adaptation effects in human tendons, the strain magnitude applied should exceed the value that occurs during habitual activities.  These studies provide evidence of the existence of a threshold or set point at the applied strain magnitude at which the transduction of the mechanical stimulus influences tensional homeostasis of the tendons.

Ok we get it, this stuff is important.  Now what do we do?