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The Effect of a 6-Week Weighted Ball Training Program on Baseball Pitchers

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Sports health cover pageI’m very proud to say that our first research project on the effect of baseball pitchers training with weighted balls has finally been published!  Big thanks for my coauthors Lenny Macrina, Dr. Glenn Fleisig, Kyle Aune, and Dr. James Andrews.

By now, many people have seen the results of the study.  I’ve presented the data at APTA, ASMI, PBATS, Sabermetrics Seminar, and many more as we went through the publication process.  We felt this study was very important for the game of baseball as we have seen such a large growth of interest in weighted ball programs, without a complete understand of what happens to the body.

I believe we have found the mechanism behind why throwing weighted balls enhances velocity.  It’s not a change in biomechanics, arm speed, or strength.  It’s a gain in layback.  This likely also explains why these programs are more stressful and show higher injury rates.  I’ve written a summary below, but I urge you to read the full study for all the details:

The Effect of a 6-Week Weighted Ball Training Program on Baseball Pitchers

The Effect of Weighted Ball Training on Baseball Pitchers

We performed a 6-week weighted ball training program with high school baseball pitchers.

Players gradually ramped up over the 6-weeks to include kneeling, rocker, and run-and-gun throws with balls ranging from 2oz to 32 oz.  All participants had been throwing and weight training prior to prepare for the program.  We modeled this off very commonly performed programs.  We feel that this program, if anything, is more conservative than many of the programs we have seen.  Many other programs are longer, have less of a ramp up, and include balls that are even heavier.  Also realize that throwing a heavier ball with less intensity over a longer period of time is likely more stressful on the body, it’s just physics.

The max weight, 32oz, was used for a total of 18 full effort run and gun throws.  This represents only 3% of the total balls thrown over a 6-week period.

A control group was used that did not perform the weighted ball program.

After 6 weeks, the weighted ball group did increase velocity by 3.3%.  It should be noted, though, that 8% showed no change, and 12% showed a decrease in pitch velocity. Furthermore, 67% of the control group also showed an increase in pitch velocity.

Arm speed and arm strength did not increase, and biomechanics did not change, meaning the gain in velocity was not from any of these commonly theorized reasons.  In fact, arm strength was up in the control group, suggesting that a weighted ball program may actually inhibit strength gains.

The weighted ball group showed almost a 5 degree increase in shoulder external rotation, or layback.  This has been correlated in previous studies to both velocity and stress on the arm.

The weighted ball group had a 24% injury rate.  Half of these did not occur during the study, they occurred the next season, which is an important finding.  There were no injuries in the control group.

The Road to Publication

Many people don’t know what happens in the background when conducting studies with sound methodology and peer review with a prestigious journal.  So I thought I’d share that process.

It takes weeks to months to go through a credible IRB to assure the project is designed well.  It then takes months to conduct the trials to actually acquire the data.  This has to be planned well to assure consistency and valid data.  It takes weeks to analyze the data, going back and forth with the statisticians to sort through the results to pull out the clinical implications.  It then takes months to write the manuscript, remember we are clinical researchers, mean we actually work with clients in the day!  We write these in our spare time at night and on weekends.  The manuscript is then submitted to a journal, which takes months to get back to you, they likely have hundreds on manuscripts submitted per month.  You then work with 3 peer reviewers that take a hard look and criticize the paper.  Their goal is to assure the results are reliable, valid, and without bias.  You then go back a forth a few times over several months.  At this point in time >90% of articles have been rejected, so if you’ve made it this far, congrats!  The editor now takes over and we have another back and forth to assure the results are clear and everything is in order.  The publisher then reaches out with page proofs for you to approve.  Then, magically one day, you get an email with a PDF attached and a link to the publication!

Exhausted just reading that?  Yup, me too.

It’s a LOT easier to just type away and hit publish on a blog, but so many questions are unanswered when that happens.  Was the study designed properly?  Did the procedure follow sound methodology to assure the results are valid?  Were the methods reliable?  Was there no bias from the authors?

That’s why we felt it was so important to get this data out to the scientific community in a medical journal.  Doctors, physical therapists, athletic trainers, and strength coaches need to understand the effects of weighted balls when designed injury prevent, performance enhancement, and rehabilitation programs.

Should You Use Weighted Balls?

Weighted balls are not evil.  They are not the cause of injuries.

Throwing itself is the cause.  Weighted balls just change the stress to the body.

They can be used strategically if you understand this and build a program that takes the science into account.  However, remember there’s more than velocity when it comes to pitching.  And science also tells us that there are MANY other ways to enhance velocity that are much less stressful.

Weighted balls are just another tool for us to be used with the right person, at the right time.  But that is probably less often than you think.  If you are a coach using these programs, you must understand this.  There are so many teams now just starting a generic templated program for all players.  There is a better way.

The Future of Weighted Ball Research

This study was phase one.  We wanted to look at the results of a 6-week program that is commonly performed in high school players.  This study has shown us a few very important things and has brought to attention what I believe is the primary reasons weighted balls increase velocity (and injury risk).

We have already finished phase two and phase three.  Phase two will look at the effect of different positions and ball weights on the arm, mechanics and velocity.  This study will help us understand which positions and balls to use.  Phase three will look at the immediate effect of different ball weights on the arm.

Together these three studies will shed a lot of needed light on the use of weighted balls.

Once these papers are finalized, the important part starts.  We’ll then work on a clinical commentary paper that summarizes all of our past studies and the science of weight balls.  This will be extremely valuable, and an import resource for baseball coaches, parents, and players to read.

There are still many questions to be asked.  It’s almost impossible to answer them all, but we are lot closer to understand the true science behind baseball pitchers training with weighted balls.

Help Spread the Word

Want to help?  I hope so.  Trust me, we are very busy at Champion PT and Performance with baseball injuries.  But nothing would please me more than reducing injuries and helping baseball players take it to the next level.  How’s that for sincerity.

This info needs to get to the baseball coaches, players, and parents.  Please share and spread the word.  Thank you!

Understanding Tommy John Surgery and How to Avoid It

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Note from Mike: Today’s post is an excellent article from New York Yankees team physician, Dr. Chris Ahmad, and Frank Alexander, ATC.  We know that Tommy John injuries continue to rise. Chris and Frank have written a new book to help educate your baseball players, parents, and coaches about Tommy John injuries, and more importantly, how to avoid them.

We have an epidemic on our hands in youth baseball.  With nearly half a million participants, baseball is one of the most popular high school sports in the United States.1 Injuries to the throwing arm continue to grow every year and there is no slowing down in sight.

While there are a number of injuries that a baseball player can succumb to, the most well-known are Tommy John injuries, also known as ulnar collateral ligament (UCL) tears. Once considered a career ending injury, Dr. Frank Jobe revolutionized baseball and all of sports medicine in 1974. That summer, he performed the first UCL reconstruction on the most famous recipient – and namesake – of the surgery, Tommy John.  

UCL injuries are the most studied condition in all of orthopedic surgery and its popularity in the media has made it a preeminent sports injury.

It is estimated that 1 in 4 Major League pitchers will need Tommy John Surgery in their career. In 2000, 13 MLB pitchers had UCL reconstructions. Over a decade later, in 2012, that number had increased nearly three-fold to 32 pitchers requiring the season ending surgery.2

Unfortunately, the increasing numbers of players falling victim to UCL injuries translate to the younger levels of baseball as well.

Evidence suggests the trend has impacted adolescent athletes with a 50% increase in UCL reconstructions in high school baseball players aged 15 to 19 years old.3 In New York State alone, the volume of UCL reconstructions increased by 193% over a 10-year period.3  These younger players may feel pressures within the competitive culture in youth baseball. This may lead players to play through pain and more talented players may be told they have to throw more frequently and with greater intensity.

While there are several reasons why there are so many Tommy John injuries, research has described overuse to be the main cause of player injury.

There is a 500% increase in risk for surgery for those players that pitch more than 8 months per year and a 400% increase in risk is observed for those that throw more than 80 pitches per game.3

Not only are younger athletes enduring this big-league problem, their understanding of the injury leads many of them to want the surgery even in the absence of injury.  There are still many myths about Tommy John Surgery.

Many players see their idols in Major League Baseball have surgery and return to the field throwing harder. What the younger athletes don’t see is the painstakingly long hours that the pros put into their rehab. Mike Reinold recently had a podcast episode with several Tommy John patients to describe their experiences.

There is a common belief among players, parents, and coaches that the rehab program post-Tommy John was shorter than 1 year and allowed for a quick return to throwing.4 We are now seeing players at the higher levels of competition returning to sport around 14-16 months and the average at the Major League level is 15 months post-operatively.

The popularity of Tommy John Surgery in addition to the perceived glamor players receive upon their return is what leads the younger players to think surgery is necessary. Research from our office has shown that 51% of high school baseball players believe that they need Tommy John surgery in order to enhance their performance.4  This is in the absence of an injury – meaning, players that are healthy think they need surgery just to get better at the game of baseball.

Players should have surgery for UCL insufficiency (i.e. tear), not to improve their performance. While we want to celebrate the return of our favorite athletes to the playing field, we only hear about the successes and not much about the players that are unable to make it back. The success rates of Tommy John Surgery range between 80 – 90% and even though players make it back to the field, pitchers throw fewer innings post-operatively.2,4 Having surgery places an enormous burden on the player mentally, physically and emotionally.

As the numbers of youth athletics participants continues to rise, it may seem that elbow injuries have become a part of America’s pastime.  Leaders in the field have established guidelines for our younger players in hopes that they will remain injury free and continue a long, healthy career.

 

A Guide for Young Baseball Players

Even with the implementation of these guidelines we continue to see a rise in throwing arm injuries leading us to write our book Understanding Tommy John Surgery and How to avoid it: A Guide for Young Baseball Players.

 

Understanding Tommy John Surgery and How to Avoid It

 

Our vision for Understanding Tommy John Surgery is to help younger players better understand elbow injuries and that it is not okay to play through pain. Some warning signs may include decreased velocity, elbow tightness, and difficulty warming up.  We also discuss a number of different ways for youth baseball players to stay healthy such as keeping a log of the number of innings or pitches thrown, proper warm-ups, and sport diversification.

By allowing our players to understand their elbow and know that playing through pain is not a good idea, we may finally see a reverse in the trend of Little Leaguers being diagnosed with Big League problems.

If you’d like to learn more and join in our efforts you can visit Dr. Ahmad’s website and get your own copy of Understanding Tommy John Surgery and How to avoid it. If you or a family member has a baseball related elbow injury, Dr. Ahmad will happily review the images with you as a free service and is available to all baseball players across the nation. You can learn more at his website!

 

References

 

  1. Saper, MG, Pierpoint, LA, Liu, W., et al. (2018). Epidemiology of shoulder and elbow injuries among United States high school players. American Journal of Sports Medicine, 46(1), 37-43.
  2. Erickson, BJ (2015) The epidemic of Tommy John Surgery: the role of the orthopedic surgeon. American Journal of Orthopedics, 44(1), E36-E37.
  3. Hodgins, JL, Vitale, M, Arons, RR, & Ahmad, CS. (2016). Epidemiology of medial ulnar collateral ligament reconstruction A 10-year study in New York State. American Journal of Sports Medicine, 44(3), 729-734.
  4. Ahmad, CS, Grantham, WJ & Griewe, RM (2012) Public perceptions of Tommy John Surgery, The Physician and Sportsmedicine, 40(2), 64-72.

Keys to Effectively Stretching the Forearm

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Sometimes you do something and don’t even realize what it means when you do it.

I’ve always been complimented by my athletes and patients about how I stretch their forearms.  They tend to gravitate to me for a stretch.  Perhaps it’s because I’ve worked with so many baseball players with stiff forearms, but apparently my technique feels more effective to people.

As with everything else, I do put a lot of thought into my technique to stretch the forearm.  The issue I think I see with people is that they are solely focused on wrist flexion and extension, and miss the majority of the stretch this way.

I wanted to share a quick video demonstrating how I stretch stretch the forearm.  Not rocket science, but paying attention to the little details will surely help you stretch the forearm more effectively.

These same concepts can be applied if you are performed a forearm stretch on yourself.

 

Keys to Effectively Stretching the Forearm

Essentially what it comes down to is assuring you:

  • Lock out the elbow
  • Bring the wrist into flexion or extension
  • Also include pronation or supination
  • Assure that you are including all the fingers
  • Assure that the finger joints are not flexing, extend them too

Hope this helps you more effectively stretch the forearm!  Let me know what you think and if you do something different.

 

 

The Keys to Tommy John Rehabilitation

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The latest Inner Circle webinar recording on the Keys to Tommy John Rehabilitation is now available.

The Keys to Tommy John Rehabilitation

Keys to Tommy John RehabilitationThis month’s Inner Circle webinar was on The Keys to Tommy John Rehabilitation.  in this presentation, I overview what I feel are the most important concepts to understand when rehabbing from UCL reconstruction surgery, or Tommy John Surgery.  If you follow these key principles, the rehabilitation process will go smoothly and you can maximize your chances of returning to full competition.  These principles are the perfect complement to the rehabilitation protocol following Tommy John surgery, giving you more details on the most important concepts.

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

5 Reasons Why There Are So Many MLB Tommy John Injuries

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The baseball season is only a few weeks old and we’ve already seen an impressive amount of MLB pitchers need Tommy John surgery.  This pace could lead to a record breaking amount of injured pitchers.  While many have speculated about the causes of this rise, I wanted to share my perspective as someone that has worked with 1000’s of healthy and injured players from Little League to Major League Baseball.

Injuries Are Higher in the First Month of Season

It’s probably not going to be as bad as we think.  The big league trends have been studied and have shown that MLB injuries are higher in the first month of the season.  I feel like every year at this time we all comment on how Tommy John surgeries are on the rise and will reach new records.  Over the course of the season, this tends to slow down and even out.

baseball injury rates

Looking at the amount of Tommy John surgeries over the last decade, the number per year is fairly consistent, especially if you consider 2012 an anomaly.  Sports Illustrated showed a nice graph of this recently.  Perhaps this year does show another trend upward.  But I wouldn’t be surprised if we saw a slow down and ended up right around 20 Tommy John’s this season.

Also, realize that many of the Tommy John injuries in spring training were well know by the player and team.  They likely had issues the prior year and were hoping the offseason would help, which isn’t really the case with Tommy John injuries.  This also inflates the number of TJ’s early in the year.

So just because it’s a surprise to you doesn’t mean it was a surprise to them.  If you have surgery in October, you are going to miss the entire next season.  Many take the chance and know that surgery next spring training likely won’t impact their return date significantly, so why not give rest and rehab a try?  More on this in the next point.

Preparation for the Season

So considering that injuries are higher during the first month of the season, what could be the reason for this?  I think there are probably two reasons why we see so many Tommy John surgeries near the beginning of the season: 1) poor preparation, and 2) lingering issues.

I think a big factor is preparation for the season.  Over the last two decades we have improved offseason strength and conditioning.  I don’t think it is that players are sitting around on the couch all offseason.  Rather, I think it has more to do with their throwing programs.

There are two ends of the spectrum, the established player that knows that they have a spot on the roster, and the player trying to make the team.  For the player trying to make the team, they need to show up on day one of camp ready to go and ready to impress.  This requires more throwing in the offseason and a more aggressive progression, knowing that roster cuts are just a week or two away.  These players also tend to throw through soreness, fatigue, and tightness in spring training and avoid the training room like the plague.

I’m not sure if this is fixable, though creating a more unbiased and proactive medical department may be a start.  Players shouldn’t fear coming into the training room, but many do.  It is the organizations job to assure players that treatment is preventative with the goal of staying on the field and enhancing performance.  This education starts in player development.

The established player, especially the veterans, may be trying to save some bullets and start throwing a little later, and ramp up a little slower.  I actually like this approach as the goal is to pitch all the way through October.  This is where spring training may need to be evaluated.

Spring training usually begins with several bullpens and live batting practice in the first week.  Some teams will throw up to 5 pens and live BP’s in 10 days.  The starters would then start pitching every 5th day for 1-2 innings.  That represents a huge jump, and then a huge slow down.

This was always my least favorite week of the year, and I think most of the pitchers agreed.  Guys arms were hanging every year. Players go from a casual offseason progression to an excessive amount of high intensity pitches in a short amount of time.  It is a grind.  This approach may be necessary for some, but I’ve talked to many MLB pitchers that disagree.  There are reasons for this progression that range from tradition, to roster decisions, to simply a lack of time to prepare all the pitchers.

I was always a fan of pitchers coming to camp a little early to ease into this progression.  Pitchers do not need to work through a “dead arm.”  That is just silly.  The goal is to avoid the dead arm.

I also feel that many players have been dealing with elbow issues in past seasons and hope that a good offseason will heal them up.  Realize that although it may come as a surprise to you when you hear of a MLB pitcher needing Tommy John surgery, many times both the team and the player have been following their elbow symptoms and trying to avoid the surgery.  They give it a good offseason but come to camp and still have symptoms.

Velocities are Increasing

Another interesting trend that we are seeing is a large jump in average velocity in MLB.  We know that velocity is one the factors that is associated with Tommy John injuries.  A recent article by Travis Sawchik of TribeLive noted the trend in MLB towards higher velocity.  In 2008, the average fastball in MLB was 90.8 MPH, in 2013 the average fastball was 92.0 MPH.  in 2003, Bill Wagner was the only MLB pitcher to throw 25 pitches over the speed of 100 MPH.  In 2013, there were 8.

Take this with a grain of salt as I tried to look at this myself using Pitch/FX data, but my data shows almost a 1 MPH increase in velocity from 2007 to 2013.  More interesting is that there has been a near linear increase in velocity each year (with the exception of 2010, as 2009 saw a large jump).  On average, as you can see with the straight line, velocity is trending upward each year.

Average MLB Fastball Velocity

When I was a kid playing Little League we would all wish we could throw 90 MPH.  90 MPH is close to unemployed now.

This comes down to simple physics.  F = M*A.  Force equals mass times acceleration.  If the trend in velocity continues to rise, the trend in Tommy John injuries will also continue to rise and pitchers will be experiencing these injuries earlier in the career.

Teams still want to draft for velocity, which isn’t surprising, we just need to realize that these guys are going to break down faster.  That is OK, just don’t be shocked when the 26 year olds all start getting Tommy John instead of the 32 year olds.

What Goes Around Comes Around

Tommy John InjuriesWe are starting to see the results of what these kids did 10 years ago.  The excessive pitching from youth and high school baseball is catching up.  There is a lifespan on your ligament.  Many kids are injuring themselves as kids and may not even know it.  Remember that week your elbow was soreness in High School?  Yup, that may have been the beginning.

In addition to avoiding overuse, which has repetitively been proved to be the #1 factor in youth pitching injuries, youth pitchers need to proactively manage their soreness and injuries.  Don’t ignore your symptoms, get them worked on by a physical therapist.

My friend Dr. Glenn Fleisig from the American Sports Medicine Institute said this to me once: “If you give a kid a pack of cigarettes in Little League, they probably aren’t going to get cancer right away, but they may down the road.”  What we do to our arms as youth carries over to our career.

If you ask a lot of MLB pitchers about a decade ago what position they played in Little League and High School baseball, many would have said shortstop or center field.  If you asked that same question now there is no doubt in my mind that most pitched throughout their youth.  We are specializing early.  You could argue that this creates a better pitcher, and I bet it does, however they are breaking down earlier.  Just like velocity, it is a trade off.  (photo credit)

Pushing Past Our Physiological Limits

MLB pitching injuriesSimilar to the overuse and early specialization we have seen in pitchers, we are now seeing a large trend towards focusing on velocity at an early age.  I get it, velocity is what gets you drafted.  Perhaps that is the actually problem.

However, I feel like we are excessively trying to push pitchers past their physiological limits to develop velocity.  But at what cost?  It is not advisable for youth players to begin aggressive long toss and weighted ball programs that are not customized to their unique body and goals.  Yet this is exactly what we are seeing.  Kids do not want to wait to grow, develop, get strong, and perfect their mechanics, they want velocity now.

So they start aggressive long toss and weighted ball programs on a weak frame, before their body matures, and with poor mechanics.

I am not against long toss and weighted balls, I am against the sloppy use of these training techniques.  These are tools in a system that absolutely must be customized for each player.

We are seeing a trend towards being too aggressive.  If throwing a 6 oz overweight ball has been shown to increase velocity, than throwing a 2 lb overweight ball will increase it even more!  If long tossing to 180 feet has been shown to increase velocity, then throwing to 300 feet will increase it more!  Realize there is always a diminishing return with a huge rise in risk.  I’ve written about this when discussing baseball long toss programs and the concept of the minimum viable exercise (your should read these both).

There are ways to safely and effectively increase velocity that do not require you to excessive push past your physiological limits.  I’ve written about this in the past and if you are a parent, coach or athlete you should read this article about how baseball players can enhance performance while reducing injuries.

To summarize, I don’t think Tommy John injury rates in general are going to slow down, as I don’t think any of the above factors are going to change anytime soon.  If what I wrote above is correct, we should see Tommy John surgies increase even more over the next decade.  Remember, what we are seeing now is the summation of the last 10+ years of players career.  At the MLB level, the damage is already done.

So focusing our attention on reducing MLB Tommy John injuries is likely the wrong approach.  The focus needs to be earlier.

I hate seeing all the articles in the media asking about why injuries continue to rise despite the greater focus on injury prevention.  It’s not the medical teams fault.  It’s not the strength coach’s fault.  It’s not the players fault.  It’s the culture of baseball right now.

8 Keys to Tommy John Rehabilitation

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Tommy John Surgery

With the baseball season almost officially in full swing, we are starting to see several players needing UCL reconstruction, or Tommy John surgery.  We know that injuries are most common in the first month of the baseball season.

For those unfortunate to have injured their elbow, sorry to hear that.  But luckily Tommy John surgery is fairly successful.  With the right Tommy John rehabilitation, your should be able to return to pitching with minimal complications.

Knowledge is power, so in order to recover as best as possible, I want to education you on what I consider the keys to Tommy John rehabilitation.  You should probably go back and read my past article on the 5 Myths of Tommy John Surgery as well.  Follow these keys and put yourself in the best position to succeed.

Avoid Loss of Elbow Motion

elbow extension tommy johnOne of the most common complications following Tommy John surgery is loss of elbow motion, especially elbow extension.  The elbow is a very congruent joint, there isn’t a lot of empty space and room for error.  So anytime you have surgery and scar tissue formation, you risk the chance of losing motion.  The problem is, once you get behind with motion, you end up being behind for a long time.  This can slow down your return to throwing.

Over the years we have progressed our rehabilitation program to focus on restoring full extension of the elbow a little faster.  My goal is to have full elbow extension by 3-4 weeks if possible.

The key to this is early rehabilitation and finding a skilled physical therapist with experience in Tommy John rehab.  Despite the media coverage that this surgery receives, in the grand scheme of things it is a relatively rare surgery so many therapists have never worked with one.  A skilled therapist will know when to push and when to back off, you want them guiding you through this process.

It still amazes me that in this day and age, there are still surgeons who do not emphasize early rehabilitation.  Take it upon yourself and make sure you don’t get behind with your motion.

Work on Imbalances During the Early Phases

manual therapy tommy johnI tell my athletes undergoing UCL reconstruction that there are three phases of Tommy John rehabilitation – The Boring Phase, The Monotonous Phase, and the Fun Phase when you get back to advanced exercises and eventually throwing.

To break this down, the first 4-6 weeks are focused on recovering from the surgery, reducing your pain and swelling, restoring your motion, and starting basic exercises.

The next two months consist of building back your strength, mobility, and stability.  This involves shoulder program exercises and using those little dumbbells, slowly progressing week by week,  Think of this phase as laying the foundation for more advanced exercises.  It gets really monotonous laying those bricks down, but without them you are not going to have a good outcome or maximize your potential.

This is where I see most rehabilitation programs miss a huge opportunity to work on the some of the imbalances that likely led to you needing Tommy John surgery.  These often include issues with your posture, core stability, and alignment of your scapula.  This is a great time to work on those long standing soft tissue restrictions of the throwing arm.  Manual therapy here is key.

Throwing a baseball places a lot of stress on your UCL ligament.  But I often wonder if it is restrictions in your soft tissue, mobility, and strength from the shoulder, scapula, trunk, and core that placing the extra strain on your elbow that led to the injury.  Use this time to get back to neutral so that way when you are ready to start throwing, you have put yourself in the best position to succeed.

Focus on the Shoulder and Scapula

Most of my athletes are amazed at how much my focus of rehabilitation is on the shoulder, scapula, trunk, core, and legs, and NOT the elbow.  Don’t get me wrong, we do plenty of elbow work.  The flexor carpi ulnaris and flexor digitorum superficialis muscles of the forearm lay directly over the UCL ligament and have been shown to provide 24% of the dynamic stability of the joint.

But the emphasis of any throwing athlete is often on the shoulder and scapula.

Think of the throwing motion as a wave of energy transferring from your legs, through your core, and eventually down your arm to the ball.  Any restrictions or deficiencies in mobility, strength, or stability will cause an inefficient transfer of energy and often times your elbow takes that extra load.  Most of the predisposing factors to injuring your UCL involve reduced strength and alterations in shoulder motion.

Integrate Core and Lower Body Training

Similar to emphasis on the shoulder and scapula, to really achieve optimal performance when you come back from Tommy John surgery, you must integrate proper core and lower body training.  The above comments on the kinetic chain are applicable here too.

The days of just doing some treatments on the elbow and a few exercises for the shoulder are over.  Proper rehabilitation programs must include attention to the core and legs to reach peak performance.

It’s Not Just About Strength

kinetic chain tommy johnWe’ve talked a lot about working the elbow, shoulder scapula, trunk, core, and lower body.  Most people, however, take this to mean get these areas strong by performing strengthening exercises.  That is absolutely true and important.  However, throwing strength on top of all your past problems is only going to mask your real issues.

Equal attention must also be spent on restoring mobility and dynamic stability.

To throw a ball effectively, you must be strong and stable.  Throwers tend to have laxity in their joints that allow them to bend and stretch further than most.  This is extremely effective in making you a better pitcher with more velocity on your fastball.  But it is also the reason why throwers get injured.

So we know that the joints of the elbow and shoulder have some underlying inherent instability.  The must have pristine dynamic stability to counteract this.

Dynamic stability is simply your muscles ability to contract at the right time and intensity to stabilize your arm, and essentially prevent your arm from flying off your body.  This is trainable, but it is difficult to do on your own.  We perform a series of progressively advanced exercises to enhance your neuromuscular control and maximize your muscles’ ability to dynamically stabilize.

Don’t Skip or Rush Steps in the Progression

One of the flaws that I often see in athletes that come to me from a consult, but are rehabilitating elsewhere, is the expectation that the rehabilitation progression is simply a protocol and based on time.  I often here, “It is week 16 and my doctor said I can start throwing.”

OK, sounds good, on the inside your UCL ligament is healed enough to throw in the doctor’s mind.  But are you “ready” to throw?

What I mean is, do you look good on my examination?  Did you restore your motion?  Do you move well?  Did you restore your strength? Do you exhibit proper dynamic stabilization?

Most importantly I always review their rehab program to date and assure that have went through the proper sequence.  If you haven’t done the right program to date to prepare yourself to throw, you aren’t picking up a ball with me.  I don’t care how weeks ago you had Tommy John surgery.

Use Your Throwing Program to Work on Your Mechanics

release pointI think there are 3 main reasons you injure your UCL.  The number one factor is overuse.  The more you throw, the more stress you put on your ligament.  I also think improper physical preparation can also lead to UCL injuries.  But don’t forget that your pitching mechanics have a large impact on your chances of hurting your ligament as well.

There are many mechanical faults that have been scientifically proven to increase stress on your UCL, such as throwing with and inverted W.

If you are serious about pitching, you need three key consultants on your team to help you achieve your goal, a physical therapist, a strength coach, and a pitching coach.  Together, this team covers all your major bases for a strong and healthy return.

Your throwing progression is going to be long.  Initially, I like you to just worry about throwing and playing catch, and NOT your mechanics.  But this switch flips once we get closer to pitching and throwing off a mound.  Create good habits early and work with a pitching coach on some of the mechanical factors that may have led to your Tommy John injury in the first place.

Follow a Slow and Gradual Throwing Progression

Many times people have a really good comeback from Tommy John surgery during the rehab process, but have issues during their throwing program.  Here is an important thing to consider:

There are going to be bumps in the road.

I usually see these bumps at the transition points such as when you start long toss, or when you start throwing off a mound.  Any time you have a jump in intensity or volume, this may occur.  These are common and expected.  If you put in the proper effort and progression to date, you have put yourself in position to successfully deal with these events.

The key is to avoid a roller-coaster progression of speeding-up, slowing-down, and speeding-up again.  A slow and gradual progression is always best.

I’m going to let you in on a very super secret that most doctors and therapists do not want you to know.  Your are probably going to feel great about 1-2 months into your throwing program and think you can throw 100 mph.

Resist this urge.  You are not ready and you will flare up your elbow (or even shoulder).

Please, please, please do not rush back to returning to pitching, especially for the youth and parents reading this.  Yes, our research has shown that pitchers return to throwing at 9-12 months following surgery.  Realize there are a large variety of people in a study like this.  Many of my MLB pitchers have return in 10-11 months, especially the veterans.  There are a lot of factors in determining this return date.

But I do not even feel good about a veteran all-star returning at 9 months after Tommy John surgery, let alone a 16 year old.  For the youth and even collegiate pitchers, a good timeframe to shoot for is 12 months.  Do it right the first time.

SEE ALSO: Watch my full presentation on the Keys to Tommy John Rehabilitation

With the right care and attention, UCL reconstruction surgery can have a really good outcome.  Follow these 8 keys to Tommy John Rehabilitation and you’ll be back on the mound in no time.

5 Myths of Tommy John Surgery

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One the big topics at the 2014 ASMI Injuries in Baseball course this year was our evolving understanding of the outcomes follow UCL reconstruction, better known as Tommy John surgery.  As each year goes by, we have more data on the results of people who have previously had Tommy John surgery since Dr. Frank Jobe first performed the procedure.

Dr. James Andrews and Dr. Frank Jobe

Dr. James Andrews and Dr. Frank Jobe

Over the last few years we have seen very important outcomes studies from Dr. James Andrews, who undeniably performs the most Tommy John surgeries of anyone in the world.  In 2010 they published the short term 2-year results of 1281 athletes over a 19 year period.  More recently, they have presented their results on 256 people with at least 10 years follow up, meaning that they all had surgery at least 10 years ago.

Based on the information we have obtained from these landmark studies, we now know more about the outcomes of Tommy John surgery.  However, has some of the public perceptions around Tommy John remained true or has our opinions been swayed by sensationalized media reports?

Dr. Chris Ahmad, of the New York Yankees, recently released a paper asking players, coaches, and parents about their perceptions regarding Tommy John surgery.  The authors report:

  • 28% of players and 20% of coaches believed that performance would be enhanced by having Tommy John surgery.
  • 23% youth, 32% HS, 53% of college pitchers, 33% of coaches, and 36% of parents believed velocity increases after Tommy John  surgery.  (I polled my followers on Twitter and Facebook yesterday too and I would say the majority do believe that velocity increases after Tommy John surgery)
  • 24% of players, 20% of coaches, and 44% of parents believed that return would occur in less than 9 months.

And get ready for the most shocking one:

  • 33% of coaches, 37% of parents, 51% of high school athletes, and 26% of collegiate athletes believed that Tommy John surgery should be performed on players without elbow injury to enhance performance.

That is absolutely crazy!

Based on Dr. Ahmad’s study and recent research on this topic, I wanted to discuss many of these perceptions to help people understand that many of these are myths.

Here are 5 myths of Tommy John surgery that any player, coach, or parent needs to fully understand.

Everyone Returns From Tommy John Surgery

If 37% of parents and 51% of high school athletes believe that they should have Tommy John surgery even if they don’t have an elbow injury, then the assumptions must be that every returns to throwing, so why not?

Well, first off, Major League Baseball disagrees.  Stan Conte, the Head Athletic Trainer of the Los Angeles Dodgers, presenting interesting data at the 2014 ASMI Injuries in Baseball Course.

SEE ALSO: Presentations from the ASMI Injuries in Baseball Course can be seen at RehabWebinars.com

He noted that 16% of all professional baseball pitchers, both Major and Minor League combined, have had Tommy John Surgery, and 25% of Major League Baseball pitchers have undergone Tommy John Surgery.  So if Tommy John surgery was a slam dunk, that number would be closer to 100%.

According to both the short term and long term Dr. Andrews studies, 83% of pitchers return to play at the same level or higher.  83% is a really good result, but it is not 100%.

Simply put, no one wants Tommy John surgery unless they need it.  Returning from surgery is not guaranteed.

There are No Complications with Tommy John Surgery

Tommy John Surgery

Tommy John Surgery

While I would certainly agree that complications can be kept to a minimum with good surgery and rehabilitation, don’t forget that Tommy John surgery does not always go smoothly and can have complications.

In the above mentioned study perform by Dr. Cain and Dr. Andrews, they noted that 20% of all the procedures performed by Dr. Andrews had complications, though 16% were considered not major complications.  These can range from issues with your ulnar nerve, to infection, to even failure of the graft.

Keep in mind that this rate of complication was reported by the surgeon that is considered the best at this procedure and performs the most Tommy John surgeries.

No surgery is 100% perfect, there will always be some complications.

Recovery From Tommy John Surgery is Quick and Easy

The false sense of comfort that the general public has adopted over the years also implies that the general assumption is that recovery from surgery is quick and easy.  Again, Dr. Ahmad reported that 44% of parents believe their child can return to pitching in less than 9 months.

In general, we have always said that return to play takes 9-12 months.  This was based on past studies that showed this range was common.  I must admit that I have seen a mild trend in baseball with people attempting to come back quick, closer to the 9 month range.

Results from Dr. Andrews’ studies have shown the average time to competition has been 11.6 months.

There are a lot of factors involved with deciding when a safe return to play show happen with each individual.  These include your age, level of play, timing of the surgery, and how well your rehab has gone to date.  I honestly don’t remember the last time I have had someone return at 9 months.  Some of the elite level MLB players that I have worked with have returned around 10.5-11.5 months after surgery, but I really don’t recommend that for younger players.

I personally am going to stop citing the 9-12 month range, as I feel that may bring some false hope and information to many people.  I am personally going to start simply saying Tommy John recover is 1 year.  I may individualize this for each person, but as a rule of thumb, I think elite level players returning around 11 months and amateurs around 12 months is probably in the athletes’ best interest.

Assume going into surgery that it is going to be 12 months before you return to competition.

Velocity Improves After Tommy John Surgery

Of all the myths discussed so far, I think the myth that velocity increases after surgery is likely the most important to dispel.  This fact has been sensationalized in the media for years.

Two preliminary research projects have recently been conducted that looked at MLB pitchers velocity before and after having Tommy John Surgery.  Rebecca Fishbein presented a report at the 2013 Sabermetrics meeting in Boston.  She analyzed the average velocity of 44 MLB pitchers before and after undergoing Tommy John surgery between 2007 and 2011.

She reported no significant difference with velocity after surgery (she actually found a mild 0.875 mph decrease in velocity, though this was not significant).  Stan Conte reported a similar finding at the 2014 ASMI Injuries in Baseball Course in 32 pitchers from 2007 to 2012.  In Stan’s study, there again was no significant difference in velocity before and after surgery (he also found a 0.79 mph drop in velocity, but again not statistically significant).

I personally have seen many players increase their velocity after surgery, but the important point here is that on average, velocity does not change.  There are many reasons why it may go up in some people.  Perhaps they were pitching with a deficient ligament or in pain for several years, perhaps they never worked out before surgery, or perhaps the hit a big growth spurt while rehabbing.

Despite popular belief, velocity has not been shown to go up in MLB pitchers after Tommy John surgery.

All Tommy John Rehabilitation is the Same

Tommy John Rehabilitation

Tommy John Rehabilitation

This last myth is personal one for me!  Baseball pitchers are such unique athletes that to truly get the best outcomes, you really need to work with a person that has extensive experience.  There are many subtleties and things to watch out for that could easily slow down the rehab process if you aren’t on the look out.

I have spent my entire career working with baseball players and I can tell you I continue to learn more and more about what makes them unique every year.  Just when you think you have figured out something, someone comes around and amazes you with what they can do with their body.

Tommy John rehabilitation requires the understanding of the unique attributes of the baseball pitcher, the unique nature of how these injuries occur, and knowledge of the stress involved while throwing during the recovery.  Anyone can follow a protocol, it is understanding how to individualize the protocol to each person to avoid speeding up and slowing down the program like a roller coaster.

Losing range of motion is going to be a problem, assuring the ulnar nerve isn’t stressed is an issue, gradually progressing activities to make sure the ligament is ready to start throwing is always important, and controlling strength and conditioning workloads while progressing a throwing program takes skill and experience.

Everyone rehabbing after Tommy John surgery is going to have some bad days and even bad weeks.  It is how these periods are handled that will assure you return to competition safely and effectively.

Summary

In summary, 83% of people undergoing Tommy John surgery have been shown to return to play at the same level or higher, without an increase in velocity, in 11.6 months [Click Here to Tweet].

Tommy John surgery is not a slam dunk, so the best strategy is ALWAYS to avoid surgery as much as possible.  While this isn’t always possible, programs should be built that work on enhancing performance AND reducing injuries in baseball players.

SEE ALSO: How Baseball Players Can Enhance Performance While Reducing Injuries

Despite popular belief, if you have Tommy John surgery you are not guaranteed to return to your previous level without complications, and rehab is not a quick and easy process that results in improved velocity.

Are We Putting Our Kids at Risk for Youth Baseball Injuries?

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Over the years I haven’t been shy about discussing the rise in youth baseball injuries and some of my thoughts regarding how to reduce the amount of pitching injuries.  I have written about the reason there are so many youth pitching injuries and presented my tips on reducing youth baseball injuries.

In the past, I have stated that the real reason that the amount of youth throwing injuries is rising is not because they are throwing more curveballs, or pitching with poor mechanics, or performing too aggressive long toss programs, or any of the other proposed claims.  They may be involved, but I simplified my response and said that the real reason why there are so many youth baseball injuries is due to abuse.

Notice I didn’t say “overuse,” I said “abuse.”

Are Youth Baseball Injuries from Overuse or Abuse?

youth baseball injuries

There is a big difference between overuse and abuse.  Overuse implies that the athlete is simply throwing too much, which is often in fact accurate.  To date, there have been excellent studies from the American Sports Medicine Institute that has shown that the primary factors that correlate to injury in youth baseball are related to overuse.  (Photo by Edwin Martinez1)

Specifically, the more you pitch, the more you raise your chances of getting hurt.  This includes factors such as:

  • Pitching competitively for more than 8 months of the year
  • Pitching on back-to-back days
  • Pitching for more than one game in the same day.
  • Pitching for more than one team during the same season
  • Pitching and also playing catcher on the same team

To combat this, both Little League Baseball and USA Baseball have provided pitch count rules and guidelines to follow.

Are We Following the Guidelines to Reduce Youth Baseball Injuries?

However, abuse is when our parents and coaches simply neglect the stated pitch count guidelines and youth safety information that has been provided for our youth athletes.

You may recall that I wrote about a study that polled 95 youth baseball coaches regarding youth pitch count rules.  The results indicated that 57% of questions regarding the rules were answered incorrectly, essentially stating that the coaches did not understand the rules.  27% of coaches admitted to not following the safety guidelines, however only 53% of coaches felt that other coaches in the league followed the safety guidelines.  Furthermore, 19% of coaches reported that they pitched a player while having a sore or fatigued shoulder or elbow.

Keep in mind that these are only the coaches that admitted to not following the rules!

Early results from an AOSSM sponsored study of over 700 pitchers around the country between the ages of 9 and 18 have started to surface.  One-third of the pitchers reported having a pitching-related injury in the past 12 months, seven out of 10 reported significant arm tiredness in the past 12 months, and nearly 40 percent reported significant arm pain within the past 12 months.

More importantly, the study was able to quantify the percentage of youth baseball pitchers that were performing activities that have been correlated to increase injury risk:

  • 40% pitched in a league without pitch counts or limits
  • 13% of pitchers pitched competitively for more than 8 months of the year
  • 57% pitched on back-to-back days
  • 19% pitched more than one game in the same day.
  • Nearly 33% of these pitchers pitched for more than one team during the same season
  • 10% also played catcher on the same team

The results of the study demonstrate that quite a large percentage of youth baseball players are putting themselves at risk.

The Key to Reducing Youth Baseball Injuries May Be Awareness

The first step in injury prevention is awareness.  We now know several factors that correlate to injury.  We now have rules and guidelines that have been designed with this information in mind.   We now know the percentage of coaches that understand and are actually following these rules.  We now know how many players are putting themselves at risk.

This is a lot of information.  Now it is time to start promoting this information and raising awareness.  Who is with me and how are you going to help promote this information to help reduce youth baseball injuries?

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