Baseball Research Review, Part II: Risk Factors for Shoulder and Elbow Injuries in Adolescent Baseball Pitchers

As RGIII and Coach Shanahan learned this past weekend, Dr. James Andrews’ advice is not something that you often want to ignore- even in the football world.

That being said, for this week’s installment of “Baseball Research Review,” we highlight one of the more poignant baseball research papers by Dr. Andrews’ group, “Risk Factors for Shoulder and Elbow Injuries in Adolescent Baseball Pitchers.” As part of the newly opened MGH Sports Performance Center, I attended a recent Mass General Orthopedics Journal Club where the Orthopedic Surgeons, Residents, Interns, Physical Therapists and a group of related baseball strength and performance specialists reviewed a few of the important articles in the field. This article highlighted the selection as one of those articles with an important message all of those in the baseball field should be readily familiar with to pass on to inquiring athletes, parents and other specialists.

Risk Factors for Shoulder and Elbow Injuries in Adolescent Baseball Pitchers
The American Journal of Sports Medicine, Volume 34, No. 6
Samuel J. Olsen II, MD, Glenn S. Fleisig,* PhD, Shouchen Dun, MS, Jeremy Loftice, and James R. Andrews, MD
From the American Sports Medicine Institute, Birmingham, Alabama

Methods
In an attempt to quantify the risk factors associated with an observed 4-fold increase in elbow surgeries performed by Dr. James Andrews from 2000-2004 versus 1994-1999 along with a 6-fold increase for high school pitchers, 90 adolescent pitchers who had elbow or shoulder surgery were surveyed and statistically compared to the results of another 45 adolescent pitchers with no such history of elbow or shoulder surgery. Survey questions included queries about injury history, playing history, preventative measures taken, and competitive habits.

Results
In comparing the non-injured and injured subgroups, the authors found that pitchers who threw more innings, games, and months were more likely to be injured. In fact, they found that those who pitched more than 8 months were 5 times more likely to be injured. Specifically, they found that individuals who pitched greater than 8 months during the year were 5 times more likely to be injured. There was a 4 time greater risk of injury for those pitching more than 80 pitches per game. Pitching despite arm fatigue yielded the greatest increase in injury rate, at a 36 times rate. Not surprisingly, pitching at 85 miles per hour or higher also increased the injury rate 2.58 times.

Authors Conclusions
Taking into account the findings of their study, the authors developed some recommendations when dealing with adolescent pitchers. The main pieces of advice they had were:
1) avoid pitching with arm fatigue
2) avoid pitching with arm pain
3) avoid pitching too much- meaning limit pitching to less than 8 months out of the year, limiting it to less than 80 pitches per game, and limit multiple showcases

Limitations
The main limitation to this study, as mentioned by the authors, is that the survey relied on the recollection of these adolescent pitchers. The numbers provide a good guide; however, I’m not sure how accurately you can predict based on rememberences from youth pitchers almost a year past. Additionally, there most definitely will be some memory bias for those who are retrospectively asked how much discomfort or pain they may have pitched through, especially if they later underwent surgery. I don’t know about you, but I can barely remember the number of pitches I threw in a given warm up a year ago, let alone trust some of these adolescent pitchers to recall despite worrying about prom dates, drivers license tests, and college applications, just to name a few. Still, the finding provide a framework to further discuss and elucidate risky pitching practices.

Show Me Strength’s Commentary

As coaches ourselves, we often get questions from parents concerned about their child’s participation, or more usually, lack there-of, in showcase type events during the “off-season” months. Parents worry that if their child does not participate in said showcase, then they will be at a severe disadvantage when it comes to college or professional recruiting. What I tell the parents, and Chad would agree, that it is way more important to stay healthy than to head down to a showcase and blow your arm out. Not only is the player not in mid-season shape when they head down to a place where the temptation to try to “light up the gun” is great, but also, they waste precious time for recuperation, recovery, and building a strength foundation for the upcoming full season. If you are good enough to be recruited by a college or drafted, more likely than not the scouts will have plenty of time to find you during your regular high school or summer season. The risk/reward is just too high. As evidenced directly by this research, participation in throwing activities for the whole year puts the athlete at a significantly increased risk of injury.

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1st Annual Cressey Performance Fall Seminar Review, Part 1

A bit belated, but we have been spending time synthesizing some the great ideas that came from @showmestrength‘s attendance of the 1st Annual Fall Seminar at Cressey Performance.  We are now excited to share Part 1 of it with the Show-Me Strength community!

The packed-house day (although Hurricane Sandy promted early evacuations, not caused by Tony’s jokes) consisted of 7 tremendous talks from CP strength coaches Eric Cressey, Tony Gentilcore, Chris Howard, and Greg Robins, nutritionist Brian St. Pierre, as well as associated physical therpist Eric Schoenberg and chiropractor Nate Tiplady.

While the entire scope of the event would be too lengthy to cover fully, the hope is to highlight the overall message of the event, as well as the top lessons learned from the talks in order of presentation.

A common theme of the talks can be summarized by the quote recently offered in our last post:

“The definition of insanity is doing the same thing over and over and expecting different results” -Albert Einstein

Many emphasized the necessity of re-thinking previous methodologies, re-considering others, and keeping an open mind to new treatment and strengthening protocols. Along these lines, each of the presenters
made it very clear the need for integration, recognition, and cooperation amongst the various areas of expertise- strength, nutrition, physical and manual therapy, and medicine- in order to effect the greatest benefit to athletes. At facilities like Cressey Performance, the results acchieved speak volumes to the power of such interactions between fields of expertise.

Eric Cressey, MA, CSCS- Understanding and Managing Congenital Laxity

As commander-in-chief of Cressey Performance, Eric spoke of his experience training elite professional, college and high school baseball players as well as other clients.  Drawing from his ample client base, he spoke of “tightness” and how that presents especially in the baseball population.  “Tightness” presents for a variety of reasons- muscular shortness, protective tension, neural tension, previous injury, soft tissue restrictions, protective spasms, or issues with inadequate stiffness at adjacent joints- just to name a few.  Lots to consider when evaluating clients!  Here are some knowledge bomb highlights:

Recognizing the intricate interaction between stiffness and flexibility and it’s role in determining mobility
-NEED to assses each athlete individually
-some athletes might appear to be “stiff” but really just lack the ability to create the necessary stability within their range of motion in order to utilize their full physical range of motion

How to effectively use “stretching”
-important not to overdo stretching
-rarely does one need static stretching
-use static and dynamic stretching to “get long” but very important to lock that in with strength training

Brian St. Pierre, CSCS, CISSN- The Food Freakshow: What will you be eating into the 21st Century?

As a certified Precision Nutritionist, former CP strength coach, and one of the most inquisitive minds when it comes to sifting through current research and trends in nutrition, Brian spoke of concerns with the future of food, as well as some great general PN based guidelines to consider when advising clients.  Before you discount what he has to say below because of the picture, don’t worry, he didn’t suggest feeding them insects, just yet!

Interesting and controversial methods of food enrichment- Yum!
-algae farms for nutrition
-adding flu fighting nanotechnologies to milk
-genetically modified organisms (GMO’s)
-stem cell beef –> not too far off in the future!
-other meat substitutes “mini-livestock” a.k.a insects
-high in protein, iron and calcium
-as population grows exponentially, we may one day resort to cultivation of insects as a source of nutrients (who wouldn’t want a insect protein shake?!?)

PN guidelines to follow
-focus on lean proteins, vegetables
-be reasonable when it comes to starches and fruits, and healthy fats
-focus on WHOLE foods!
-LOW or no calorie beverages- ditch the sugar sports drinks!

Nate Tiplady, D.C.- Manual Therapy: What we know, what we don’t know and the most effective ways to get people better

Nate, utilizing his varied background  presented a great overview of many manual therapy techniques which we have found as professional baseball players help tremendously in maintaining proper range of motion, and to help clear up mobility issues which may get in our way.  Both Chad and I have utilized Nate’s expertise for arm maintenance and it is worth exploring some of these options, as outlined below, to see if they may be of use in your training plans.

from Loghmani, MT et al. Instrument-Assisted Cross-Fiber Massages Accelerates Knee Ligament Healing; J Orthop Sports Phys Ther 2009; 39(7); 506-514.

Fascial Manipulation
-utilizing treatment (applying pressure) to the connective tissue which creates a continues matrix of structural support surrounding the body

Active Release Therapy
-soft tissue/movement based massage technique
-utilizes specifically directed tension with movement patterns

Graston Technique
-patented treatment method using stainless steel instruments
-mechanical load on tissues has been shown to increase healing of tissue
(see study right which shows a comparison between MCL ligament healing with Graston (C) versus without (B) compared to a healthy ligament)

Joint Manipulation
-application of high velocity low amplitude thrust to the vertebrae or extermity joint
-goal is to restore restricted range of motion and influence surrounding structures
-not something that can be learned in a book or weekend course, so it is important to develop networks of expert professionals for clients

Finally, Nate mentioned a tremendous video about the “Healing Power of Touch” which is unfortunately a dying area.  Definitley worth a watch:

Check back for Part 2, where four more great talks will be highlighted:

Eric Schoenberg, MSPT, CSCS- Out with the Old: A new model for preventing injury and improving performance in the throwing athlete

Chris Howard, MS, NSCA-CPT, CSCS- Program Design Considerations for the Young Athlete

Greg Robins, NASM-CPT, RKC, CSCS- How Strong Does An Athlete Need To Be?

And last but certainly not least,

Tony Gentilcore, CSCS, CPT- Deep Squats: Are They Worth It?

Rethinking Common Post-Game Recovery Protocol by Chad Rodgers

“Here’s to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They’re not fond of rules, and they have no respect for the status quo. You can quote them, disagree with them, glorify and vilify them. About the only thing you can’t do is ignore them because they change things. They push the human race forward. And while some may see them as crazy, we see genius. Because the people who are crazy enough to think they can change the world, are the ones who do.” Steve Jobs

 

The point of this article is to act a little bit like the people in this quote by Mr. Jobs. I want to challenge some of the status quo in the baseball world. I’d like for pitcher’s to stop doing what everyone else does, and start doing what works when it comes to their development.

Pitchers young and old continue to get injured at alarming rates. They continue to get sore for long time periods, complain of stiffness, and are often not truly ready for the next time that they take the hill.

“Insanity is doing the same thing over and over and expecting different results.” Albert Einstein 

I’ve seen this over and over in many different forms throughout my career both as a player, instructor, and coach.

It’s not uncommon to see players do things or act in a certain way that might be comfortable, normal, or accepted in their group of peers or teammates.

I always have the conversation with every pitcher that I encounter about how they recover from their outings. It doesn’t matter if the person is one of my high school pitching clients or a fellow professional ballplayer, the discussion with the ones who are always experiencing the same issues and complaining of the same things often goes like this…..

Me- Hey man. I was wondering what you like to do after you pitch to recover and feel good as soon as possible. Thoughts?

Sore/unsuccessful pitcher- I don’t know. Sometimes I ice of it hurts or if I threw a lot.

Me- Does that make it feel better?

Sore/unsuccessful pitcher- I’m not sure. I think it takes away inflammation. If its extra sore I’ll take some Ibuprofen.

Me- What about getting bloodflow or range of motion back into your arm?

Sore/unsuccessful pitcher- Well for that I run to flush my arm out. That helps with recovery I think.

Me- Does it?

Sore/unsuccessful pitcher- Well I see everyone else running and icing….

Me- Gotcha

Not such a smart idea now, huh?

The conversation with a super successful player is always different. I won’t bore you with another dialogue rundown, but the 2 points they always make known are……..

1.) They know what works for them. Everyones different, and no two routines are alike.

2.) They are open minded only if it will benefit their progress.

Although I haven’t reached my ultimate goal of getting to the big leagues, I feel like in the grand scheme of things as a pitcher, I’ve been pretty successful because these two traits are always constant.

Here’s what works for me when it comes to post-game (immediately after game) recovery

FIRST- Replenish calories on a large scale and replenish lost liquids.

There’s plenty of times where I come out of the game so amped up that eating is the last thing on my mind, but then I’ll catch myself and remember that it’s just another day and I have to stick to my routine. I try to have a diesel protien shake loaded with everything good with a focus on calories. Then I crush a heavy dinner with a focus on meat, veggies, and a carb source like sweet potatoes, baked potato, rice, or quinoa. I realize that this isnt always possible, but the main goal is always calories and hydration.

Obviously your plan will change a bit if you have a few pounds to lose, but replenishing nutrients is still a must.

– After your post-pitching meal is a good time to take your vitamins! I stick to a multi, fish oil capsules, and vitamin d.

SECOND- Getting some bloodflow back to my pitching arm.

1.) I do something on the very light side for shoulder exercises. The two I like the best are external rotations with light tubing in a scapular plane and light dynamic stabiliations. I learned these from my strength coach, Eric Cressey, who understands the way of the shoulder better than anyone I know. I just try to make sure I don’t overdo it after the game, as my main goal is to get some extra blood back into my arm.

2.) I try and get a trainer or teammate to help me with some light soft tissue, or I’ll do some rolling on my own. Check out more specific strategies in my soft tissue troubleshooting post here.

THIRD- Get range where you need or have lost range.

1.) Light static stretching only on areas that tend to lose range of motion (ROM). For example, I tend to lose some mobility in my throwing elbow from a supination point of view (opening up palm to sky). Some pitchers simply lose extension, but I’ve needed to focus more precisely on the supination of my forearm, as it tends to get junked up. Shoulder wise, I simply check to make sure my internal rotation hasn’t gone by the wayside with a nice easy sleeper stretch (NO CRANKING INTO A FULL ON STRETCH!!! VERY IMPORTANT). Once checked, if it’s a bit tight, I’ll do a bit more soft tissue and then check it again.

I follow the same protocol for for my hips and hamstrings. For my hips, I like to check them with a lying knee to knee stretch, and with my hamstrings, an easy band hamstring stretching on the ground. If tight, more soft tissue!

So in a nutshell, that’s what I do after each outing. Be your own judge as to how much or how little works for you. For me, it varies on how much I’ve thrown, what the conditions were like. Was it hot? Cold? How much did I sweat? How did I feel in the game? Before the game? After the game?

All these questions will guide you to your own customized post pitching routine. My advice is to continue to soak up information and techniques that work for you. Do not under any circumstances think you have it figured out. Do not go along with what is the norm just because your teammates do that. Let them be average.

 “I will persist until I succeed. I was not delivered into this world into defeat, nor does failure course in my veins.  I am not a sheep waiting to be prodded by my shepherd.  I am lion and I refuse to talk, to walk, to sleep with the sheep. The slaughterhouse of failure is not my destiny.  I will persist until I succeed.” ~ Og Mandino

Soft Tissue Troubleshooting For Pitchers (Part 2) by Chad Rodgers

In Soft Tissue Troubleshooting For Pitchers (Part 1), I ran through a few areas in the upper body where we as pitchers tend to get knotted up, then outlined some solutions to combat those soft tissue restrictions. Here in Part 2, I will do the same, but for areas in the lower body that tend to give pitchers trouble as the season wears on.

First, lets just pose a scenario where someone asks me to look at a professional pitcher’s delivery. Then, after watching, that person asked me what parts of that pitcher’s lower half I believed would become the most restricted, knotted up, or troublesome from a soft tissue standpoint throughout the season.

After thinking about how I would answer, I believe the first thing I would say is that I really didn’t need to see that video to give an appropriate answer. The questions I would ask them instead would be, 1.) Was this pitcher wearing cleats in the video? 2.) Did this pitcher participate in a full spring training? 3.) Has this pitcher already logged a ton of innings or appearances at the time of this video?

You might be wondering where I’m going with this, but coming from someone who has been to 6 spring trainings and pitched in parts of 7 professional seasons, I believe that from my experiences as well as discussions with fellow teammates about our aches and pains, I could cite at least a few areas in the lower body that tend to get aggravated at different stages of the season. Here are some…

1.) Bottoms of the feet– Often pitchers go entire off-seasons without putting on cleats. We train hard all winter in bare feet or minimalist footwear, and are happy campers when we finally get to finally move around without baseball spikes. Then, once spring training or spring practice rolls around, we are suddenly wearing spikes all the time again. Our feet start to get crammed up again, and as a result the arches of our feet get weak and sore. Heres a quick fix!

Tool– Batting cage ball- Sore Spot– Arches of feet

Find the meat of your foot and roll the pain away. I always tend to try and find the sorest spot and just hold the ball there with added pressure until the soreness subsides. After rolling for a bit, walk around without shoes. You should notice an appreciable difference.

2.) Shins, Shin Splints, or Medial Tibial Stress Syndrome (for the geeks)- Working our way up the chain, this area is a common problem amongst pro ball players coming back to spring training where we #1 Start wearing cleats again for a good part of the day #2 Stand around in sub-par posture most of the day shagging batting practice, and #3 Run absurd amounts (often in cleats) after standing around with sub-par posture. In my opinion and experience, this is a recipe to turn super strong and athletic pitchers into sore, immobile, and dysfunctional pitchers. Here is a way to help maintain decent soft tissue on the both sides of that tibia.

Tool– Rolling Stick or Tiger Tail– Sore Spot– Calves, Shins

Forget the ultrasound, ice, or lovey dovey massage. If you want to feel better, you’re going to need to get in on that calf and around your shins. Have one of these rolling sticks or Tiger Tails handy to roll up along your calf and alongside your shins to get that crap outta there. It’s gonna hurt, but the pain is temporary. You’ll feel better after a few min of this focused soft tissue work. Pair this with a little static calf stretching and you’re golden.

3.) Lead Hip- This pertains to the final question I asked about the professional pitcher in the scenario mentioned at the beginning of this post. It’s no mystery that pitching is one of the most violent motions in all of sports. Not only is it violent, but it’s repetitively violent. The same joints, muscles, tendons and ligaments take a beating. When we look closer at a pitcher’s delivery, we can see precisely which areas those are. When it comes to a pitcher’s lower half, I would argue that the lead hip (hip closest to home plate throughout delivery) is the most important area to narrow in on for the most soft tissue maintenance.

Tool– Batting Cage Ball- Sore Spot- Outside of Lead Hip

For right-handed pitchers, cross your left leg over the right and roll over the tight fascia in your glute and outside hip on the left side. Opposite for lefties of course. This position is beneficial because it allows all your weight to sink into to the ball, ensuring you free some of that junked up soft tissue to allow for better hip internal rotation lost from driving through that front side so aggressively while pitching.

When it comes to being a healthy pitcher, the things that first come to mind are proper mechanics, strength, flexibility, mobility, and shoulder/elbow health. Still, one of the most important pieces to the puzzle, soft tissue, often gets overlooked. In professional baseball it is seen by some as weak, coddling, or pampering, all labels you want to avoid. Still, so many pitchers tend to break down over the year, many of them which could have been prevented with diligent soft tissue maintenance. If you are a pitcher, do yourself a favor and add some of these techniques to your program or routine. You can thank me later!

Soft Tissue Troubleshooting For Pitchers by Chad Rodgers (Part 1)

Getting sore, in my opinion, is the worst part about pitching. Actually, I digress, it’s a fact. There is nothing worse than pitching your tail off for your team, then waking up the next morning with your arm feeling like it got run over by a truck. It’s a humbling feeling to say the least. There are undoubtedly countless variables that go into the fact that you are sore from pitching. The first being the most obvious in that human beings weren’t designed to be able to throw an object overhead at incredible velocities. There are many others to consider as well. Here are just a few….

– Proper post-game recovery/cool-down (I’ll touch on this soon)

– Optimal sleep-something professional baseball players either get too much or too little of

– Proper nutrition/hydration- fried chicken and beer? If it didn’t work for the Red sox, it wont work for you.

– Good soft tissue quality- Soft whaaattttttt? Ya dude, you can’t just roll out of bed and expect to be ready to throw everyday.

Some can get away with doing the bare minimum for a while, but eventually, if you aren’t careful, improper arm care will catch up to you. There’s this piece that many of us miss when wondering why the heck we get so friggin knotted up and sore in our throwing arm. It’s called soft tissue quality! When we throw at peak velocity, incredible strain is put on both our shoulder and elbow to try and hang on for the ride through your delivery. Somehow, your body will find a way to stabilize the arm to do the amazing things that it’s capable of. As an unwelcomed side effect though, the muscles around the shoulder and elbow joints take a beating each time you throw. “GREAAAT. So that’s why I wake up feeling like I got into a car wreck?” Yep!

So now what? Here are a few select areas where pitchers tend to get the most sore, and some tools and strategies for breaking up some of that junk from the night before.

SORE SPOT-Posterior Shoulder-TOOL-Batting Cage Ball

Just about every baseball player has one of these balls collecting cobwebs in the garage somewhere. When I do this, I try and find the spots the back of  my shoulder that are the most sore, then allow your bodyweight slowly relax into the ball. I’ll hold it there for a good 30 seconds or however long it takes for the pain to subside.

SORE SPOT- Extensor and Flexor Muscles around the Elbow-TOOL-Tiger Tail Stick

This bad boy can iron out some sore spots alright. Its never pleasant when having someone roll over a knot, but stick it thru the pain, and you’ll thank me later. Grab a partner for added leverage and force. Also, add a bit of extension (extend elbow palm up) and supination (roll palm open, turning back of hand to face the ground) when getting the flexors rolled on to help open the area up a bit.

SORE SPOT-Upper Trap-TOOL-Thera Cane or Batting Cage Ball

Ever feel like you have a pinball permenatly lodged in your trap from pitching? My bet is, if you pitch a ton, you sometimes do. We can get this are to chill out a bit with a couple easy techniques. This upper trap area, in particular, I like to apply consistent, hard pressure, until that knot either releases or calms down. Both the Thera Cane and batting cage ball are effective tools.

The fact is, most of us can’t afford a deep tissue massage after each time we pitch to eliminate the soreness from our arms. We do however, truly need quality soft tissue to maintain optimal arm health throughout the season. There are plenty of ways to accomplish this both inexpensively, and effectively. The techniques demonstrated above will get you started on the road to feeling better. This is just the tip of the iceberg though. I’ll be back soon to show you more cool ways to get you back on the mound feeling good.