Spare the Arm 5: Choices

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This 5-part series is about not missing the forest for the trees when it comes to injury prevention and training of pitchers. Focusing on the shoulder and elbow "trees" often causes neglect of the "forest" of relevant factors throughout the rest of the body. This installment explores some areas not directly related to anatomy and physiology at all.

Planning

I'm not going to give you a structured and straightforward evidence-based decision tree on not doing stupid things. The majority of shoulder and elbow injuries are due to the same thing that causes injuries in softball and judo and shuffle board and tight rope walking over Niagara Falls.

Whatever happens, it's not his fault.

The root of this multisport epidemic is non-organic (i.e. mental), and should be labeled Stupid Choices Syndrome (SCS). SCS is closely related to Common Sense Deficit Disorder (CSDD) and Too Much Too Soon Syndrome (TMTS), not to be confused with Teenage Mutant Ninja Turtles (TMNT).

These clinical diagnoses are especially prevalent in young men and may also be passed down genetically from overzealous parents. Whatever the case, shift the blame onto the syndrome and off the behavior of the athlete (and parents). Here's an actual clinical picture of a young man suffering with SCS:

Now of course all injuries are not due to taking on too much too soon or doing stupid things. But when they are, please don't feel bad. I've been stupid with you. The ulnar collateral ligament of my right elbow is an excellent case study in SCS.

During grad school I appeared to pitch in a Twilight League game after one whole week of preparation. I made it two innings. A few years later, without warming up, much less training my body to throw hard, I attempted to throw out a runner tagging for home plate. Last fall I tried to beat Bret Wagner in a walnut throwing contest in my backyard, and prior to that separated my right AC joint falling off my mountain bike.

All of these injuries and re-injuries resulted in elbow pain when throwing, and none of them were the "fault" of my UCL. My scapular stability and core rotational strength and hip range of motion were certainly not to blame. I've since self-diagnosed myself with a pretty cut and dry case of SCS, but many times the clinical picture is much less clear:

If you love baseball and try to pitch 11 months out of the year, you're diagnosed.

If you take a few months off like you should and then expect to gun the ball on a cold day in March, you're diagnosed.

If you're a player or coach who stretches the truth about pitch- and Ibuprofen counts, because it's the playoffs - you're diagnosed.

If you throw very hard and love to prove it at pitching "showcases" and especially at the local fair "Guess Your Velocity" game...

If you think you can get away with sitting 16 hours per day at school/work and in the car and on the X-box and not perform regular hip, scapula, and thoracic mobility work - you're diagnosed.

If you think it takes weeks and not months to condition your body to max out and withstand repeatedly throwing as hard as possible...

If your arm is sore and you always want to blame it on the curve balls you threw as a 12 year old, you're diagnosed.

As I wrote about here, curve balls don't injure developing arms. Pitching injures developing arms (1, 2). The factors strongest associated with injury in adolescents pitchers have nothing to do with pitch type or stretching routine or technical delivery technique. Instead, the primary risks include pitching more than eight months out of the year, often throwing more than 80 pitches per game, participating in "showcases", pitching with arm pain and fatigue, and frequently using anti-inflammatory drugs and ice (2).

- the.arm.is.not.a.robot -

And again I say prepare your entire body to throw. For example, my SCS resulted in tremendous strain to the UCL. Had I allowed sufficient time for the supportive elbow, wrist, shoulder, and scapular muscles to be conditioned for their role of significantly unloading the UCL, it likely would have been capable of handling the strain (3).

My advice to not do something stupid seems pretty obvious until you consider that SCS truly is a common diagnoses, and then it's very hard to steer out of a rut once you've been injured. As listed in part one of this series, the chance of the arm surviving to even get to the point of high level pitching (much less succeeding) is slim, even when you don't do something stupid (4, 5, 6).

So now that you're going to try not to catch SCS, I'm going to ask that you don't do something ignorant in your training. While the right conditioning can be extremely beneficial for pitchers, training sometimes gets a bad "rap" because many of us trainer type people have difficulty remembering that working out is not the end, but only a means to an end (lots of Ks and/or Ws).

We must take extra precaution to make sure the cost/benefit ratio is in check. Is it worth the time and risk involved for a high level pitcher to perform power cleans and heavy overhead presses? I don't think it is. Does the potential payoff justify the time and risk involved to perform some form of deadlifts and plyometrics? I think so. This type of cost/benefit analysis is critical for fitting the training to the individual athlete and not vice-versa.

And of course, when it comes to training, there is a ton of Misinformation Disorder and Just Plain Bad Idea Disease going around:

If you think muscle confusion, P90-X, and Cross Fit are good, pitching specific off season training programs - you're diagnosed. [Although the lower body plyo portion of P90-X does have merit.]

If you think that upright rows and dumbbell kickbacks are great exercises and needed for isolating the anterior deltiod and long head of the triceps...

If you think that pitchers must avoid all overhead exercise and yet persist in benching three times per week...

If you think that a handful of wimpy rubber tubing exercises are the key to safely decelerating an arm that the entire body has accelerated to over 7200 degrees per second...(7)

If you think jogging is a good way to condition your legs to repeatedly, explosively accelerate and decelerate the body and won't negatively effect peak power production...(8, 9).
David Wells errored a little too much on the safe side of overdoing cardio.



If you think you can pitch for a number of years without routinely revisiting corrective stretching and strengthening exercises...

Train like a baseball player for total body strength and power. Perform specific corrective stretches that will counter the asymmetries that pitching creates, and warm up well with rotational total body activities as outlined here.

In the spring, be patient and allow time to taper into throwing gradually. During the season, resist the urge to pitch the best players too frequently for too long, and to cover it up with Advil. Make sure the body gets an off season from actual throwing to focus on other sports or at least a period of hard cross training.

These are the things that spare the arm.

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1. Fleisig GS, Kingsley DS, Loftice JW, Dinnen KP, Ranganathan R, Dun S, Escamilla RF, Andrews JR.Kinetic comparison among the fastball, curveball, change-up, and slider in collegiate baseball pitchers. Am J Sports Med 2006;34(3):423-30.

2. Olsen SJ, Fleisig GS, Dun S, Loftice J, Andrews JR. Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. Am J Sports Med 2006;34(6):905-12.

3. Fleisig GS, Andrews JR, Dillman CJ, Escamilla RF. Kinetics of baseball pitching with implications about injury mechanisms. Am J Sports Med 1995;23(2):233-9.

4. 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.

5. 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.

6. Conte S, Requa RK, Garrick JG. Disability days in major league baseball. Am J Sports Med 2001;29:431-6.

7. Fleisig GS, Barrentine SW, Zheng N, Escamilla RF, Andrews JR. Kinematic and kinetic comparison of baseball pitching among various levels of development. J Biomechanics 1999;32:1371-5.

8. McCarthy JP, Agre JC, Graf BK, Pozniak MA, Vailas AC. Compatability of adaptive responses with combining strength and endurance training. Med Sci Sports Exerc 1995;27:429-36.

9. Bell GJ, Syrotuik D, Martin TP, Burnham R, Quinney HA. Effect of concurrent strength and endurance training on skeletal muscle properties and hormone concentrations in humans. Eur J Appl Physiol 2000;81:418-27.