Spare The Arm - I

As far as I know, I'll be doing a presentation on throwing injuries this fall at the American College of Sports Medicine (Mid Atlantic) conference. I'll also be looking to educate the baseball and medical communities on addressing pitchers in a truly comprehensive way; hopefully letting them understand what we're trying to accomplish at GoWags.

Below is the first of a series of writings on pitching.

Every child who is physically large or shows some baseball skill tries their hand at pitching. Many kids (hopefully) play for fun, but when it comes to pitchers advancing to higher levels of play, it's nearly impossible to perform exceptionally and stay healthy. Chronically sore arms are no fun. Careers end early and talent is wasted.

Imagine focusing relatively less on the arm in order to spare the arm. What if the rest of the entire athlete is significantly underrated as a cause of injured shoulders and elbows? Despite plenty of information and advances in sports medicine, I believe that huge gaps still exist between "prehab", rehab, and actual performance on the field.

A typical example is a 15-year old who commonly experiences mild to moderate medial elbow pain that significantly worsens at about one month into the spring season. He rests for a week, possibly takes some anti inflammatory meds, and feels better. He returns to the field and immediately reaggravates the problem.

Our athlete then winds up in the hands of a PT or trainer. Early on we do some anti-inflammatory modalities and careful loading of muscular and ligamentous structures that support the elbow and shoulder. We address shoulder ROM and scapular dynamics, culminating in the Throwers Ten routine.

Six or eight weeks after the injury, the athlete is then instructed to follow a throwing schedule that gradually increases the repetition and intensity of the very same sequence that injured him in the first place.

Treating the arm (and scapula, if we're lucky) is worthwhile to some extent. But when our athlete returns to pitching, will a stronger rotator cuff and improved glenohumeral internal rotation keep him from reinjury? Sometimes, but often not.

What else can be done to comprehensively address the athlete in order to spare the arm? Plenty. Keeping consistent with baseball form, we have 9 innings to a sore arm:

1. Have optimistic expectations.

If a young athlete has "a good arm," put him on the mound as much as the rules will allow and generally don't give it too much thought. Older, more advanced athletes, should simply follow the traditional protocol for pitchers.

The overhead throwing motion is a highly skilled total body movement which requires flexibility, strength, synchronicity, and neuromuscular control. Imagine if this repeated, maximal effort, ballistic, asymmetrical activity is inherently dangerous? What if we finally have to admit that pitching is just plain and simple not good for you?

During acceleration, the shoulder internally rotates over 7250 degrees per second - the fastest motion in all of sports. The anterior translation forces and distraction forces at the shoulder are tremendous. Tensile forces at the medial elbow (during the late cocking phase) and at the lateral elbow (during deceleration) can mangle supportive tendons, ligaments, and even nervous tissue.

A brief look at some of the data will allow two easy conclusions: (1) pitchers face a rough road because there are many ways to fall, and (2) the traditional methods for training and rehabilitation are not cutting it.

[Chart common shoulder and elbow lesions and common trunk and lower extremity movement impairments].

Almost 60% of pitchers suffer a shoulder injury each year, and at the major league level account for almost 70% of time on the disabled list (1).

Almost 90% of high level pitchers have (at least) partial thickness tears of the rotator cuff (2).

All high level pitchers develop some degree of labral tearing or fraying (3).

Pitchers develop shoulder instability and humeral torsion (an actual twisting of the bone). We're still not certain if this leads to more pathology or if this has a protective effect on the elbow and shoulder complex (4).

Pitchers exhibit scapular position changes and dyskinesis including increased upward rotation, protraction, and anterior tilt. Again it is unclear if these are protective adaptations or are predisposing factors to injury (5).

I know this is a lot of talk about the shouler for an essay about focusing less on the shoulder. But the point is that pitchers can and will develop changes to the shoulder complex. That leads us to ask what, if anything, we can do to prevent these adaptive changes from going over the threshold of symptomatic pathology?

Until we decide to do away with pitching altogether, we should seriously think about (rethink) our expectations and revise our approach to training and rehabilitating the arm of pitchers.

The next 4 entries in this series will address the 8 other interrelated "innings" to a sore arm.

Part II
2. Take lessons and accept everything they teach you.
3. Don't take lessons and overlook mechanics altogether.

Part III
4. Strength Train like a pitcher.
5. Condition Like a pitcher.

Part IV
6. ROM: warming up focus on the shoulder.
7. ROM: never static stretch.

Part V
8. Do these exercises that are a waste of time, at best.
9 Planning errors: pre season, pitch counts, fatigue, and curve balls.

Part I References:

1. Ouelette, H, Labis J, Bredella M, Palmer WE, Sheah K, Torriani M. Spectrum of shoulder injuries in the baseball pitcher. Skeletal Radiol. 2007;10:3.

2. Mazoue, CG, Andrews JR. Repair of rotator cuff tears in professional baseball players. Am J Sports Med. 2006;34:182-89.

3. Burkhart, SS, Morgan, CD, Kibler WB. The disabled throwing shoulder: spectrum of pathology: evaluation adn treatment of SLAP lesions in throwers. Arthroscopy. 2003;19:531-539.

4. Whitley, AR, Ginn, KA, Nicholson, LL, and Adams, RD. Sports participation and humeral torsion. J Orthopedic and Sports Phys Ther. 2009;39:4.

5. Thigpen, CA, Gill, T, Schneider RE, DiStefano MJ, Reinold MM, and Seitz AL. Adaptations in 3D scapula position of professional baseball pitchers over one season. Presented at the 2009 Sports Physical Therapy Section Meeting.