Abdominal Oblique Injuries in Rotational Sports

Abdominal oblique injuries, also known as side strains, are common in rotational sports such as baseball, tennis, golf, and track and field.  These injuries are characterized by a sudden, sharp onset of pain near or on the side of the rib cage.  The injury usually occurs during some type of rotational sports movement such as swinging a bat, club or racket; or throwing a ball.

Trunk rotation plays an important role in generating and transferring power during sport.  It is through the trunk or core, that forces are transferred from the lower body to the shoulder and arms. Activities such as throwing and swinging require the core muscles to both stabilize the trunk and create force in order to transfer power to the upper body.

Anatomy of the Abdominal Oblique Muscles

The core includes the thoracolumbar, abdominal, pelvic, and hip musculature.  These muscle groups provide trunk stability to allow integrated limb movements, such as throwing and swinging, to occur. The abdominal core muscles include the rectus abdominis, transversus abdominis, internal oblique and external oblique.  Most abdominal injuries occur in the internal and external oblique muscles.  Less commonly, injuries can occur to the intercostal muscles between the ribs themselves.

The Role of the Oblique Muscles in Sport

The internal and external oblique muscles are responsible for flexion and rotation of the trunk, as well as providing trunk stabilization during complex sports movements.    Poor mobility of the hips or thoracic spine can contribute to excessive stress and compensation through the trunk musculature during swinging or throwing.  Rehabilitation often addresses hip mobility with manual therapy techniques performed by the physical therapist.  An imbalance between right and left side oblique muscles are also common is in sports such as golf and baseball.  This may place excessive forces through the lead side oblique musculature.  Finally, the large forces generated by lower body muscles (quadriceps and hamstrings) may overpower the weaker core musculature leading to injury during explosive sports movements.

The incidence of Abdominal Oblique Injuries in Baseball

A 2010 study in the American Journal of Sports Medicine investigated the incidence and trends of abdominal injuries in professional baseball players.  From 1991 through 2010, abdominal strains accounted for approximately 5% of all injuries in Major League Baseball.   Nearly half of these injuries occurred in pitchers.   These injuries occurred most often during the early part of the season.

In both pitchers and position players, the majority of injuries occurred on the side opposite to their throwing arm.  Pitchers missed, on average 35 days on the disabled list, while position players missed 26 days on average.  Players who receive steroid or PRP injections have been shown to miss more time from injury.   More than 1 out of every 10 sustained a re-injury during their career.  Most of these re-injuries occurred during the same or the following season.   As a result of these injury trends, many MLB teams have increased their focus on preemptive core and trunk strengthening exercises for all players.

Closing Thoughts

The incidence of abdominal oblique injuries is on the rise in rotational sports such as baseball and golf.   These injuries can result in substantial loss of playing time.  Proper training can prevent abdominal oblique injuries from occurring.  In a few weeks, I will post an article describing exercises which can help reduce the risk of sustaining an injury.  These exercises can also be part of a comprehensive rehabilitation program to safely return an injured athlete back to sport.

References

  1. Camp CL, Conte S, Cohen SB, et al. Epidemiology and impact of abdominal oblique injuries in major and minor league baseball. Orthop J Sport Med. 2015;5(3):1-8. doi:10.1177/2325967117694025.
  2. Conte SA, Thompson MM, Marks MA, Dines JS. Abdominal muscle strains in professional baseball. Am J Sports Med. 2010;40(3):650-656. doi:10.1177/0363546511433030.
  3. Nealon AR, Kountouris A, Cook JL. Side strain in sport: A narrative review of pathomechanics, diagnosis, imaging and management for the clinician. J Sci Med Sport. 2017;20:261-266.

Baseball Stretching Drill to Restore Range of Motion between Innings

Baseball players will lose range of motion in their throwing shoulder and elbow following a pitching session.  This loss of range of motion becomes cumulative over the course of a season.   Range of motion deficits have been shown to increase the risk of arm injury in baseball players.  Baseball stretching routines performed over the course of a season can help reduce this risk.  Also, stretching drills during baseball games, or between innings, is another method to combat muscle tightness and loss of range of motion in baseball pitchers.

The two-out drill has been developed by researchers from the California State University in Sacramento, and world-renowned orthopaedic surgeon Dr. James Andrews.   These seven baseball stretching exercises can be performed in approximately one minute between innings.  During game situations, the drill is initiated after two outs have been recorded and prior to the pitcher taking the mound each inning.   Performing this drill has been shown to restore professional baseball pitchers shoulder range of motion back to pre-pitching levels.   The seven baseball stretching exercises are described below with a video to follow.

Baseball Stretching: The Two-Out Drill

  1. Internal rotation stretch. Place the non-throwing hand on top of the throwing elbow with the non- throwing forearm resting on top of the throwing forearm. The non-throwing arm is then used to produce an internal rotation stretch in the throwing shoulder by rotating the forearms down towards the ground. This stretch is held for 3 seconds and is repeated twice with approximately 1 to 2 seconds of rest between stretches.  Be sure to stay tall during the stretch and avoid holding your breath.
  2. Elbow extension stretch. Extend the throwing elbow with the forearm tuned up. With the opposite hand, pull the throwing hand so that the wrist is extended back. This stretch is held for 3 seconds and is repeated twice with approximately 1 to 2 seconds of rest between stretches.  Be sure to stay tall during the stretch and avoid holding your breath.
  3. Big arm circles. Perform big arm circles clockwise and counterclockwise for 5 repetitions each way.  Make the circles as big and fast but comfortable, with an emphasis on increasing range of motion.  Be sure to stay tall during the exercise.
  4. Small arm circles. Perform small, tight arm circles clockwise and counterclockwise. Movement is fast but at a comfortable pace.  Perform 5 circles forward, and 5 circles in reverse.
  5. Forearm touch. With the arms up out to the side and elbows bent, move the elbows in so the elbows and forearms touch.  Next, move the arms in the opposite direction until a mild stretch is felt in the front of the shoulders or chest.  Repeat 5 times continuously.
  6. 90/90 IR and ER. Begin with the arms up out to the side and elbows bent. Internally and externally rotate the shoulders as far as possible at a fast but comfortable pace. Repeat 5 times continuously.  Be sure to stay tall and breathe during the exercise.
  7. Trunk Rotation. Begin with the arms fully extended and out to the side.  Rotate your arms and trunk from side to side, through a full range of motion, to the left and then back to the right. Movement is fast but at a comfortable pace.  Repeat 5 times continuously.

Closing Thoughts

Performing the two-out drill with two outs will allow adequate time to prepare the throwing shoulder for the subsequent inning.  This may be a practical and effective means to preserve shoulder range of motion throughout the course of a baseball game.  Rest and avoiding excessive throwing is undoubtedly the most important factor related to reducing risk for arm injuries in baseball players.  However, the two-out drill may help maintain shoulder flexibility during a game, and perhaps over the course of a season.  Maintaining shoulder range of motion is just one small piece to minimizing risk for injury in baseball players.

References

  1. Escamilla RF, Yamashiro K, Mikla T, Collins J, Lieppman K, Andrews JR. Effects of a short-duration stretching drill after pitching on elbow and shoulder range of motion in professional baseball pitchers. Am J Sports Med. 2016;45(3):692-700. doi:10.1177/0363546516671943.
  2. Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523-527. doi:10.1177/0363546507308935.
  3. Wilk KE, Macrina LC, Fleisig GS, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329-335. doi:10.1177/0363546510384223.
  4. Wilk KE, Macrina LC, Fleisig GS, et al. Deficits in glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers: A prospective study. Am J Sports Med. 2014;42(9):2075-2081. doi:10.1177/0363546514538

 

 

5 Arm Care Stretching Exercises for Baseball Players

The unique demand of throwing a baseball places a great deal of stress on the bones, muscles, and soft tissues of the arm.  Therefore, shoulder and elbow injuries are common amongst baseball players of all ages.  Repetitive throwing leads to adaptations in the bony structure and muscles around the shoulder.  Some of these adaptations are believed to be necessary in order to perform at a high level.  Other changes, specifically those related to muscle tightness, can increase the risk of sustaining an elbow or shoulder injury.   Therefore, it is important for baseball players, coaches, and parents to understand the rationale and best methods for stretching the muscles of the arm in overhead athletes.

Range of Motion in the Baseball Pitcher

The amount of shoulder external and internal rotation range of motion receives a great deal of attention in overhead athletes.  Repetitive throwing during a youth athlete’s period of peak growth induces adaptive changes to the structure of the upper arm bone.  The middle portion of the arm bone actually rotates backward in relation to the upper end of the bone or head of the humerus.  This is termed retroversion and it is believed to be a necessary and beneficial adaptation.  Retroversion of the humerus allows the baseball player to achieve greater amounts of shoulder external rotation, or layback, during the arm cocking phase of throwing.

Retroversion of the humerus will cause an increase in the amount of shoulder external rotation but a decrease in the amount of available internal rotation.  Again, this is believed to be a necessary adaption to improve performance.  Research suggests that the total arc of internal and external rotation range of motion is what becomes important.  The total arc of motion between the throwing and non-throwing shoulder should be within 5 degrees of each other (shown in the illustration below).  When greater discrepancies in the total arc of motion are present, stretching exercises should be performed to improve symmetry between sides.

Image result for total arc motion

The Basics of Stretching for Baseball Players

Baseball players have been shown to lose range of motion throughout the course of a single game and over the course of a season.  This loss of range of motion and flexibility typically occurs in the shoulder and elbow musculature.  Common muscles prone to tightness in baseball players include the rotator cuff, lattisimus dorsi, pectoralis major and minor, biceps, and triceps.  A regular stretching routine, performed 3-5 times per week, can help restore lost range of motion.  Also, a basic 10-minute stretching routine may potentially improve performance and decrease risk for an arm injury.  The stretching exercises presented here are a few baseball players should be familiar with.

Five Arm Stretching Exercises for Baseball Players

  1.  Cross-Body Stretch: This stretch addresses the posterior shoulder muscles which are prone tightness in overhead athletes.  The infraspinatus, teres major, and teres minor muscles can become shortened from repetitive throwing.  This stretch is performed lying on the involved side with hips and knees bent.  The involved shoulder and elbow are positioned in 90 degrees of flexion.  The hand of the uninvolved arm grasps the elbow of the involved arm and gently pulls it across the body.  Once a mild stretch is felt on the outside or back of the shoulder, this position is held for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.

  1. Sleeper Stretch: The cross-body stretch has been shown to be superior to the sleeper stretch for improving shoulder range of motion in young baseball players.  However, the sleeper stretch is probably the more popular of the two stretches.  For this stretch, the same starting position as the cross body stretch is assumed.  However, with the sleeper stretch, the wrist and forearm of the involved arm are gently moved down towards the table.  Once a mild stretch is felt on the outside or back of the shoulder, this position is held for approximately 30 seconds.  The stretch is typically performed 2-3 times each session.   For most athletes, both the sleeper and cross-body stretch do not need to be performed.  My personal experience, and the best available evidence, suggests the cross-body stretch is the most beneficial for improving range of motion.

  1. Bench T-Spine Mobilization: Extension of the upper back is necessary to achieve the arm cocking position needed for throwing.  Without adequate extension of the spine, unnecessary stress will be placed on the shoulder or elbow.  This stretch also provides a nice stretch to the lattisimus dorsi and triceps muscles which can also limit overhead mobility. The exercise begins by assuming a kneeling position facing a bench.  Place your elbows on the bench in front of you holding a PVC pipe or dowel with the palms facing up.  Sit back, pushing your buttocks towards your heels, keeping your spine relaxed, until you feel a stretch in your upper back.  Be sure to engage your abdominal muscles to prevent excessive arching of the low back.  (I could have done a better job of this in the video below).  For an added stretch you can bend your elbows further past your head.  Hold this position briefly, and exhale fully.  Reverse the motion to return to the start and repeat 6-8 repetitins.

  1. Thoracic Spine Windmill: This is a great dynamic mobility drill to restore thoracic spine rotation and improve the flexibility of the lattisimus and pectoral muscles.  Begin on your side with both arms outstretched in front of you.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.   Reach forward with your top hand and then complete a large circular windmill motion as you rotate your entire upper body.  Keep reaching as if you were attempting to lengthen your entire arm.  Follow your hand with your eyes to ensure proper thoracic spine and rib cage movement.  The top knee and leg should remain in contact with the foam roll throughout the exercise.  We generally perform 6-8 repetitions on each side.

  1. Side-Lying IR/ER: This is a more advanced dynamic mobility exercise targeting the thoracic spine, rib cage, lattisimus dorsi, and pectoral muscles.  Start in a side-lying position with the arm to be stretched on top.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.  Initiate the movement by reaching with the lower arm up towards the sky.  Hold this position, reaching upwards, throughout the drill.  The arm to be stretched is then placed overhead with the thumb pointing down towards the floor.  Exhale fully at the top and then reverse the movement by bringing the arm down to the side.  As the arm is lowered the thumb position changes so it is pointing down towards the back pocket.  It is important that both elbows remain fully straight during the drill.  We generally perform 6-8 repetitions on each side.

Closing Thoughts

These five stretching and mobility drills address typical muscle flexibility problems baseball players present with.  As always, an individualized approach is always superior to ready-made one-size fits all programs.  Building arm strength through resistance training is also important for improved performance and resiliency in the baseball player.   Before engaging in any exercise program, those with a history of arm problems or those currently experiencing pain should first be evaluated by a physician, physical therapist, or athletic trainer.  Some players may require additional arm care strategies such as passive stretching and soft tissue mobilization techniques.

 References

  1. Bailey LB, Thigpen CA, Hawkins RJ, Beattie PF, Shanley E. Effectiveness of manual therapy and stretching for baseball players with shoulder range of motion deficits. Sport Heal A Multidiscip Approach. 2017;9(3):230-237. doi:10.1177/1941738117702835.
  2. Hibberd EE, Oyama S, Myers JB. Increase in humeral retrotorsion accounts for age-related increase in glenohumeral internal rotation deficit in youth and adolescent baseball players. Am J Sports Med. 2014;42(4):851-858. doi:10.1177/0363546513519325.
  3. Keller RA, De Giacomo AF, Neumann JA, Limpisvasti O, Tibone JE. Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: A meta-analysis and systematic review. Sport Heal A Multidiscip Approach. 2018;Online:1-8. doi:10.1177/1941738118756577.
  4. Mine K, Nakayama T, Milanese S, Grimmer K. Effectiveness of stretching on posterior shoulder tightness and glenohumeral internal-rotation deficit: A systematic review of randomized controlled trials. J Sport Rehabil. 2017;26:294-305.

Little League Elbow: 5 Things Parents and Coaches Should Know

Little League elbow is an overuse injury affecting the inside part of the overhead athlete’s elbow.  The injury occurs in youth athletes 8 to 13 years old with open growth plates.  In these youth baseball players, the growth plate is much weaker than the ligaments and muscles surrounding it.  Once the growth plates fuse, athletes are more likely to injure soft tissues such as the ulnar collateral ligament (UCL).  Little League elbow is most common in baseball pitchers but can also occur in any position player, softball players, or tennis players.

During the late cocking and acceleration phases of throwing, the shoulder and elbow are subjected to very high forces.  The repetitive stress of throwing can lead to pain, swelling, and tenderness in this area.  The youth baseball player may also show signs of decreased throwing velocity and accuracy.   If untreated, there is a small chance for early growth plate closure or fracture, which could require surgery.  Little League elbow will often heal completely with 2 to 4 months of rest and an individualized physical therapy program.  Below are 5 things parents and coaches should know to prevent Little League elbow in youth baseball players.

#1: Elbow injuries are more common in those who play year-round

 The repetitive stress of throwing a baseball subjects the growing elbow to excessive forces.  The growing bones of youth athletes need time away from throwing.  Youth baseball players should take 3 to 4 months off from throwing each year.  This period should be devoted to playing other sports in order to develop overall athleticism.  This is also the ideal time to perform resistance exercise to build strength in the lower body, core, and arm.  Players who throw year-round or in multiple leagues are often plagued by arm fatigue.  Throwing with fatigue is the number one risk factor for shoulder and elbow injury in youth baseball players.

 #2: Little League elbow is common in both pitchers and catchers

 A 2004 study in the American Journal of Bone and Joint Surgery found 70% of youth catchers demonstrate signs of Little League elbow on x-rays.  In comparison, 63% of pitchers demonstrated these findings. Approximately half of these pitchers and catchers complained of elbow pain.  The other half were not experiencing pain.  However, catchers complained of elbow soreness more often than pitchers. During a game, catchers and pitchers may perform an almost equal number of throws.  Also, catchers often throw from a squat or semi-squat position.  Without the ability to generate force from the lower body, this position may place additional stress on the catchers elbow.  It may be advantageous for catchers to throw from a standing position whenever possible.  In any case, parents and coaches should closely monitor catchers and pitchers during the course of a season.  Any signs of altered throwing or complaints of pain by the athlete should prompt a medical evaluation.

#3: Taller players are more likely to develop Little League elbow

Overall height and a recent increase in growth have been shown to be risk factors for developing Little League elbow.  During the growth spurt it is believed that the rate of bone length growth exceeds the rate of bone strength development.  Therefore, the growing bone and growth plate may be more susceptible to those who are experiencing rapid changes in height.   Taller players are also more likely to throw at greater velocities which subject the elbow to greater stress.  Therefore, the stress associated with these developmental factors, along with throwing excessively at increased velocities, may predispose the taller baseball player to elbow injury.  Parents and coaches should keep a close eye on these taller players and be on the lookout for any early warning signs of arm pain or fatigue.

#4:  Little League elbow is more common in players working with private coaches

A recent study investigating Little League players in the United States found two factors associated with positive elbow MRI findings.  These two factors were year-round play and working with a private coach.   Additionally, a history of arm pain was also associated with year-round play and working with a private coach.  This is not to say that youth baseball players should not work with private coaches.  Private coaches can be instrumental in improving throwing mechanics thus potentially improving performance and reducing injury risk.  However, working with pitching coaches can contribute to throwing excessively or even year-round.   Baseball players should be encouraged to work with coaches to improve their skills and love for the game.  However, it is extremely important that these players get ample rest from throwing so they do not jeopardize their long-term playing career.

#5: Strengthening and stretching exercise can reduce the risk for developing elbow injuries

Muscle imbalances and poor movement patterns during and following growth spurts predispose youth athletes to overuse injuries such as Little League elbow. Modifiable risk factors for injury relate to improving shoulder flexibility and total arm strength.  A recent study in the American Journal of Sports Medicine showed youth baseball players can significantly reduce their risk for elbow injury by engaging in a regular stretching and strengthening program.  These exercises should target the trunk and arm musculature to address factors shown to be associated with injury risk.  Strengthening the shoulder blade and rotator cuff muscles us often emphasized in overhead athletes.  Athletes should be instructed in individualized programs based on their own unique needs.  There is no one size fits all program for baseball players.   Below are a few exercises which are useful for some overhead athletes.

Closing Thoughts

Little League elbow is becoming increasingly more common as youth baseball players are throwing more often and at greater velocities.  It is more important than ever for parents and coaches to closely monitor all youth baseball players for excessive amounts of throwing and the early signs of arm fatigue.  Also, pitchers, catchers, taller players, and those with private coaches may be at an increased risk for injury thus requiring close observation.  Youth baseball players who adhere to regular stretching and strengthening exercise can reduce their risk for injury.  Therefore, preventing Little League elbow requires a team approach involving the player, parents, coaches, trainers, and the medical staff.

 References

  1. Hang DW, Chao CM, Hang Y. A clinical and roentgenographic study of Little League elbow. Am J Sports Med. 2004;32(1):79-84. doi:10.1177/0095399703258674.
  2. doi:10.1177/2325967114566788.
  3. Pennock AT, Pytiak A, Stearns P, et al. Preseason assessment of radiographic abnormalities in elbows of Little League baseball players. J Bone Jt Surg. 2016;98:761-767.
  4. Sakata J, Nakamura E, Suzuki T, et al. Efficacy of a prevention program for medial elbow injuries in youth baseball players. Am J Sports Med. 2017; Published:1-10. doi:10.1177/0363546517738003.
  5. Yukutake T, Kuwata M, Yamada M. A preseason checklist for predicting elbow injury in Little League baseball players. Orthop J Sports Med. 2015;3(1):1-7.

Little League Shoulder: 5 Things Coaches and Parents Should Know

Little League shoulder is an overuse condition that affects the upper arm growth plate in the throwing arm of skeletally immature youth baseball players.  The image above (A) shows widening of the upper arm growth plate in a young athlete diagnosed with Little League shoulder.  The condition is characterized by generalized shoulder or upper arm pain during throwing.  In more severe cases, Little League shoulder may cause pain with activities of daily living or at rest.

Little League shoulder is treated with a period of rest, physical therapy, and programs to improve strength and throwing mechanics.  Premature closure and fractures of the growth plate have been reported in association with Little League shoulder but these are extremely rare complications.  Most will eventually ‘‘outgrow’’ the condition spontaneously with normal growth plate closure.  However, some continue to experience pain during the preadolescent or adolescent years which may considerably limit participation.

Little League shoulder most commonly occurs in youth overhead athletes between the ages of 11 and 16 years.  Thirteen years is the most common age at which players move out of Little League and to a larger diamond.  This requires a longer distance for pitches to cross home plate.  Therefore this is the period where coaches and parents should most closely monitor youth athletes for early signs of pain.  Below are five key considerations for returning injured youth baseball players back to play safely.

#1 Little League Shoulder is Occurring with Increasing Frequency

The increasing frequency of Little League shoulder is due to overuse and throwing with arm fatigue.  This trend is likely due to greater numbers of youth pitchers participating in competitive leagues and doing so at increasingly younger ages.   Increased velocity of pitches thrown, as compared with previous decades, is also a likely contributor.  Year-round participation, participation on multiple teams in a season, the influence of private pitching coaches, and ‘‘showcase’’ events all contribute to increasing stress to the skeletally immature athlete.  It is imperative that coaches and parents monitor players in accordance with Little League pitch count recommendations.  It is also strongly recommended that players take at least 3 to 4 months per year off from throwing.

#2 Little League Shoulder Treatment Always Includes Rest from Throwing

Baseball Phases of Throwing

During the late portion of the arm-cocking phase of throwing, there are considerable rotational forces acting on the shoulder. These forces can deform the cartilage of the growth plate and play a role in the development of Little League shoulder.  The only way to remove these stresses and allow for healing is to stop throwing.  The longer players throw with arm pain, the longer resolution of symptoms will take.  Therefore, the initial treatment plan for Little League shoulder always consists of cessation of throwing.   This period typically lasts 2 to 4 months.    Pain usually resolves within the first 1 to 2 months of rest.  However, premature return to throwing often leads to recurrence of symptoms.  It has been estimated that approximately 25% of injured players will experience a recurrence of pain within 6 months of resuming throwing.

#3 Early Physical Therapy Should be Prescribed

Physical therapy treatment is initiated early to normalize shoulder range of motion and to begin a progressive strengthening program. Differences in side-to-side shoulder rotation ROM is believed to contribute to shoulder pain in the youth baseball player.  These asymmetries have also been associated with a recurrence of Little League Shoulder.  Therefore, it is important that youth athletes with Little League Shoulder are evaluated and treated by a physical therapist in order to address these risk factors.  The cross body stretch targets posterior shoulder tightness which contributes to loss of motion in overhead athletes.

Posterior Shoulder Stretch
Cross Body Stretch

Strengthening the rotator cuff and shoulder blade muscles is important to build arm strength while resting from throwing.  Weakness of the rotator cuff muscles has been shown to be a risk factor for shoulder and elbow injury in adolescent pitchers.  Youth baseball players should demonstrate full pain-free strength of the rotator cuff muscles before throwing is resumed.  Sidelying external rotation and prone horizontal abduction exercises target the posterior rotator cuff muscles which are often weak in young throwers.  It is also important for athletes to strengthen the lower body and core musculature.  Weakness in these areas will result in increased stress transferred to the throwing arm.

#4 Throwing Programs Should be Undertaken after Arm Strength is Developed

Structured interval throwing programs allow for a safe transition back to play.  These programs are designed to replicate game conditions in a progressive and safe manner.  Because individual differences exist, these programs must be tailored to the injured athlete’s physical and emotional needs.  Omitting or rushing throwing programs often leads to recurrence of symptoms and delayed return to play.  Also, long toss throwing should be used judiciously due to increased rotational forces imposed on the healing growth plate.  Communication between the medical team and coaching staff is important to ensure the success of interval throwing programs.

#5 Flaws in Pitching Mechanics Should be Corrected Before Returning to Play

Before returning to unrestricted play, injured athletes should have their throwing mechanics assessed by a coach.  In particular, the rate of trunk and pelvis rotation during the acceleration phase of throwing has been linked to shoulder injuries in youth baseball players.  Hip-to-shoulder separation refers to the position of the hips relative to shoulder just prior to the front foot contacting the ground.  Under ideal pitching mechanics, the hips are facing home plate and the shoulder continues to face towards third base in a right-handed pitcher.  This allows for the optimal transfer of force from the core to the throwing arm.  As fatigue increases, the hips and shoulder begin to rotate in unison resulting in an open hip-to-shoulder separation.   This loss of force transfer and power generation results in increased stress placed upon the shoulder and elbow.  This flaw should be correctedto reduce shoulder stress in the youth overhead athlete.

Closing Thoughts

Little League shoulder usually resolves with 3-4 months of rest but symptom recurrence may occur.  It is important to not rush youth athletes back to throwing before range of motion and strength are normalized.  Correcting any pitching mechanic flaws and a progressive throwing program is also required before unrestricted return to play.  Even after returning to play, close monitoring of athletes for at least 1 year is recommended to ensure prevention of recurrence. Finally, current guidelines regarding pitch counts, rest, and activity modification should continue to be emphasized for long-term health.

References

  1. Harada M, Takahara M, Maruyama M, et al. Outcome of conservative treatment for Little League shoulder in young baseball players: Factors related to incomplete return to baseball and recurrence of pain. J Shoulder Elbow Surg. 2018;27:1-9.
  2. Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the presentation, management, and outcomes of little league shoulder. Am J Sports Med. 2016;44(6):8-11.
  3. Sabick MB, Kim Y, Torry MR, Keirns MA, Hawkins RJ, Frcs C. Biomechanics of the shoulder in youth baseball pitchers implications for the development of proximal humeral epiphysiolysis and humeral retroversion. Am J Sports Med. 2005;33(11):1716-1722.

Strengthen the Shoulder to Manage Elbow Pain

Are you experiencing lingering elbow pain?  Have you experienced elbow pain in the past and are unsure why?  Weakness of the shoulder muscles and stiffness in your upper back or neck might be underlying problems contributing to these elbow injuries.  Shoulder weakness and upper back stiffness are common in athletes (baseball players, tennis players, and swimmers) and most of the general population.  Our sedentary lifestyles and less than optimal exercise programs are likely strong contributors to elbow pain.

Tennis Elbow Pain and Shoulder Weakness

Tennis elbow, also known as lateral epicondylitis, is a common tendon disorder which occurs in both tennis players and the general population.  These individualls describe pain on the outside of the elbow aggravated by gripping or lifting activities.  Local treatment to the elbow is often unsuccessful or leads to only temporary improvements.  Common treatments which often produce minimal lasting benefits include medications, injections, braces, ultrasound, laser, or electrical stimulation.  Often, muscle weakness at the elbow and neighboring regions of the body are contributing to the onset and persistence of elbow pain.  Research suggests there is an association between posture and shoulder muscle weakness in those with tennis elbow.

Recent research shows a link between tennis elbow and muscle strength of the serratus anterior, lower trapezius, and middle trapezius.  Poor scapular muscle and rotator cuff strength is linked to tennis elbow in both non-athletes and athletes (i.e., tennis players).  These muscles are important for orienting and positioning the shoulder blade during functional activities involving the arm.  Poor strength or endurance of these muscles can result in overload to the elbow and wrist muscles.  Strengthening the scapular stabilizers is an important part of rehabilitation for patients with tennis elbow.   Targeting the middle and lower trapezius muscles using dumbbells lying in the prone position is an excellent starting point.

Baseball Players with Poor Posture & Shoulder Weakness are at an Increased Risk for Elbow Injury

Youth baseball players, ages 6 to 12, with a flexed or rounded upper back are 2.5 times more likely to sustain an elbow injury.  Exercises which restore mobility in the thoracic spine and strengthen the muscles of the shoulder blade are important to address these problems.  Loss of mobility in the thoracic spine from a rounded back position will limit a baseball player’s ability to achieve the late cocking phase of throwing.  Often, these athletes will compensate at the shoulder and elbow in order to achieve the cocked position.  Over time, the increased forces at the elbow will over stress the soft tissue and bony structures leading to injury and pain.

Scapular muscle and rotator cuff weakness is associated with throwing-related elbow and shoulder pain in youth baseball players.  Also, baseball players with ulnar collateral ligament injuries show decreased strength of the infraspinatus and subscapularis.   Similarly, weakness of the supraspinatus muscle is linked to serious arm injury in high school baseball players.  These rotator cuff muscles stabilize the shoulder joint during throwing.  Weakness at the shoulder will increase stress further down the chain at the elbow.  Baseball players should be performing regular arm care exercises which target the scapula and rotator cuff muscles.  Examples of these exercises include shoulder external rotation and diagonal patterns with a band or dumbbell.

Closing Thoughts

Strengthening the shoulder muscles is an integral component of rehabilitation from elbow injury.  Perhaps, more importantly these exercises can reduce the risk of elbow injury before pain starts.  Strengthening exercises for the elbow and wrist are also important considerations.  However, the shoulder and upper back region is often neglected when it comes to improving elbow function.   This is one reason why elbow inuries and pain often persist longer than expected.   Human movement is more complex than isolated muscles or joints.  Therefore, exercise programs should integrate the entire body in order to restore or optimize function.   Give these 5 exercises a try and let us know how you make out.

References

  1. Bhatt JB, Glaser R, Chavez A, Yung E. Middle and lower trapezius strengthening for the management of lateral epicondylalgia: A case report. J Orthop Sport Phys Ther. 2013;43(11):841-847. doi:10.2519/jospt.2013.4659.
  2. Day JM, Bush H, Nitz AJ, Uhl TL. Scapular muscle performance in individuals with lateral epicondylalgia. J Orthop Sport Phys Ther. 2015;45(5):414-425. doi:10.2519/jospt.2015.5290.
  3. Garrison JC, Johnston C, Conway JE. Baseball players with ulnar collateral tears demonstrate decreased rotator cuff strength compared to healthy controls. Int J Sport Phyiscal Ther. 2015;10(4):476-482.
  4. Lucado AM, Kolber MJ, Cheng SM, Echternach JL. Upper extremity strength characteristics in female recreational tennis players with and without lateral epicondylalgia. J Orthop Sport Phys Ther. 2012;42(12):1025-1032. doi:10.2519/jospt.2012.4095.
  5. Trakis JE, Mchugh MP, Caracciolo PA, Busclacco L, Mullaney M, Nicholas SJ. Muscle strength and range of motion in adolescent pitchers with throwing related pain. Am J Sports Med. 2008;36(11):2173-2178.
  6. Tyler TF, Mullaney MJ, Mirabella MR, Nicholas SJ, Mchugh MP. Risk factors for shoulder and elbow injuries in high school baseball pitchers: The role of preseason strength and range of motion. Am J Sports Med. 2014;42(8):1993-1999. doi:10.1177/0363546514535070.

Serratus Anterior: 3 Exercises to Improve Overhead Mobility

The serratus anterior is a key muscle involved with the performance of many overhead movements such as throwing a baseball, serving in tennis, and pressing a barbell overhead.   The serratus anterior muscle spans from the upper 8 ribs along the side of the trunk up to the inner border of the shoulder blade.  This muscle assists with rotating the shoulder blade (scapula) upwards and tilting it backward in order to position the shoulder and arm for optimal overhead function.  Along with thoracic spine extension mobility, these scapular movements are often ignored as important components of overhead function.  The serratus anterior is also the primary muscle which protracts the scapula during upper extremity function.  This involves the scapula moving forward along the rib cage such as when punching in boxing.

The Serratus Anterior and Overhead Function in Athletes

Individuals with shoulder problems demonstrate decreased upward rotation of the scapula, decreased posterior tilt of the scapula, and increased activity of the upper trapezius muscle.  In particular, swimmers and baseball pitchers commonly present with a pattern of decreased serratus anterior activation and increased activation of the upper trapezius.  This alteration in muscle patterns leads to compensatory movements, decreased overhead range of motion, and increased stress to other structures such as the rotator cuff and elbow joint.

The serratus anterior functions to upwardly rotate and posteriorly tilt the scapula
Assessing strength of the serratus anterior

Exercises which combine scapular upward rotation, posterior tilt and protraction are ideal to activate the serratus anterior.  It is also advantageous to include closed chain exercises where the hand is fixed to a surface or weight bearing through the floor or a wall.  Finally, exercises performed with the arm elevated above the shoulder or eye level elicit greater activation of the serratus compared to exercises performed at or below shoulder level.  Wall slide and bear crawl variations fulfill these criteria which are optimal to train the serratus anterior in overhead function.

 Wall Slide with Foam Roll

Begin with your forearms resting on a foam roller against the wall placed just below shoulder height.  Protract the shoulder blades by pushing the upper back away from the wall to activate the serratus anterior.  Next, “roll” the forearms up the wall in a controlled manner to approximately eye level or slightly higher, making sure you don’t lose protraction.  Return back to the starting point in a controlled manner and repeat for the desired number of repetitions.

Serratus Anterior Wall Walks with Band

Begin by wrapping a resistance band around your wrists and pulling your wrists apart. Your forearms should remain parallel and take the form of the number “11” throughout the exercise.  Protract the shoulder blades by pushing the upper back away from the wall to activate the serratus anterior. Then, “walk” the forearms up the wall in a controlled manner to approximately eye level or slightly higher, making sure you don’t lose protraction.  Return back to starting point in a controlled manner and repeat for the desired number of repetitions.

Bear Crawl

Assume an all-4’s position with the hands in front, shoulder-width apart, feet behind the hips and up in the air.  The knees should remain elevated from the floor so you are stabilized by 4 points of contact.  Begin by pushing the back up towards the sky to protract the scapula and activate the serratus anterior.  Crawl forward starting with your right hand and your left foot following with the left hand and the right foot.  After each step, pause briefly to exhale. Take four steps or more depending on space, then turn around and bear crawl back.

Closing Thoughts

Building a foundation of strength targeting the scapular muscles is crucial for overhead athletes.  This foundation should include movements which facilitate activation of the serratus anterior through scapular upward rotation, posterior tilt, and protraction.  These exercises can be included as part of a strength training session warm-up or part of a regular arm care program.   Overhead athletes, such as baseball players and swimmers, should particularly include exercises targeting the serratus anterior as part of their year-round strength and conditioning program.

 

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5 Thoracic Mobilization Drills to Improve Overhead Mobility

The position and mobility of the thoracic spine directly affects the amount of overhead shoulder movement available.   A more erect and mobile thoracic spine and rib cage will result in greater overhead range of motion.  A slouched posture or stiffness in the thoracic spine and rib cage will result in a loss of range of motion reaching overhead.   Excessive thoracic kyphosis, or a slouched posture, may alter the position of the shoulder blade and impair muscle activation patterns both of which contribute to limited overhead function and shoulder pain.

Approximately 15 degrees of thoracic spine extension mobility is required for full overhead motion when lifting both arms such as when performing a barbell overhead press. Full 1-arm elevation requires approximately 9 degrees of thoracic extension.  Thoracic spine rotation is also crucial for rotational sports such as baseball where a large amount of power is transferred through the trunk.   A baseball pitcher who lacks thoracic spine rotation will compensate by increasing movement and stress through the shoulder and elbow joints.

Strength is foundational for optimal shoulder health but thoracic spine mobility is often a neglected area when athletes attempt to maximize their overhead shoulder function.  Therefore, exercises targeting thoracic spine extension and rotation mobility should be included in any rehabilitation or performance enhancement program seeking to optimize shoulder function.  Instead of jumping to restore shoulder mobility with bands and balls, try these thoracic spine mobility exercises first.

Bench T-Spine Mobilization

This is my favorite exercise for restoring thoracic spine extension.  It also provides a nice stretch to the lattisimus dorsi muscle which can also limit overhead mobility. The exercise begins by assuming a kneeling position facing a bench.  Place your elbows on the bench in front of you holding a PVC pipe or dowel with the palms facing up.  Sit back, pushing your buttocks towards your heels, keeping your spine relaxed, until you feel a stretch in your upper back.  For an added stretch you can bend your elbows further past your head.  Hold this position, and exhale fully.  Reverse the motion to return to the start and repeat the desired number of repetitions.

Thoracic Extension + Rotation (Reach Backs)

Begin this exercise by sitting back on your heels, face down, with one hand behind your head and the opposite forearm resting on the ground in front of you.  This position minimizes available movement in the low back and maximizes movement to the upper back.   From this position rotate your elbow up to the sky while exhaling.   The opposite forearm remains in contact with the ground.  Return to the starting position and repeat for the desired number of repetitions before switching to the opposite side.

Foam Roll Thoracic Extension Mobilization

This exercise can be a challenge to perform correctly.  Most end up extending through the lumbar spine and not the thoracic spine.  Begin in a lying position over a foam roll.  Place the hands behind the neck supporting, but not pulling on, the neck.  Raise the buttocks off the ground and roll the upper back up and down the foam roll.  Identify a sensitive, stiff, or tender area and then drop the buttocks down to the ground.  From this position perform small extension movements by lifting the elbows up towards the ceiling.  Be careful not to overextend at the lower back.

Thoracic Spine Windmill

This is my “go to” exercise to restore thoracic spine rotation.  Begin on your side with both arms outstretched in front of you.  Place a foam roll under your top leg with the knee and hip bent to 90 degrees.  The bottom knee and hip remain extended throughout the exercise.   Reach forward with your top hand and then complete a large circular windmill motion as you rotate your entire upper body.  Keep reaching as if you were attempting to lengthen your entire arm.  Follow your hand with your eyes to ensure proper thoracic spine and rib cage movement.  The top knee and leg should remain in contact with the foam roll throughout the exercise.  Perform the desired number of repetitions and then repeat on the opposite side.

Standing Thoracic Rotation Mobilization

The standing rotation exercise is ideal to incorporate into a pre-workout dynamic warm-up.  From a standing semi-squat position place one arm between your thighs just above the knees.  This position will block unwanted hip and pelvic movement.  Next, rotate the body upwards towards the sky by following your open hand with your eyes.  At the top of the movement, exhale before returning to the starting position.  Perform the desired number of reps and then repeat on the opposite side.

Closing Thoughts

After performing these mobility drills it is important to work on strength and endurance of the thoracic muscles.  Also, manual therapy to the thoracic spine and rib cage has been shown to accelerate recovery and reduce shoulder pain immediately and for up to 1 year.  Maintaining or improving thoracic spine mobility is imperative for any active individual who regularly functions overhead.  Manual therapy, mobility drills, and strength/endurance exercise targeting the thoracic spine can lead to significant gains in overhead function for athletes and the general population.  These 5 mobility drills can be easily integrated into any pre-workout warm-up routine or as part of a home exercise program.

Youth Baseball Pitching Injuries on The Rise

Youth baseball pitching injuries are on the rise. The world-renowned Dr. James Andrews describes the increase in injury rates as an epidemic (ESPN interview).  His research shows 5% of youth pitchers will sustain at least one serious elbow or shoulder injury which will require surgery or end their career. Historically, throwing breaking pitches at a young age was cited as the major risk factor for these types of injuries. However, the latest research shows arm fatigue, not breaking pitches, is the primary reason for the sharp rise in youth pitching injuries.

Should Youth Pitchers Throw Curveballs?

Dr. Andrews and his team at the American Sports Medicine Institute (ASMI) in Birmingham, Alabama tracked 481 youth baseball pitchers (ages 9 to 14) for ten years. Pitchers were interviewed annually to determine the incidence of serious injury and to track pitching volume and pitch type. Serious injury was defined as those requiring surgery or ended an athlete’s career. Pitching more than 100 innings in a year significantly increased the risk of a serious elbow or shoulder injury by 3.5 times. Throwing curveballs before the age of 13 did not significantly increase the risk of injury.

Throwing with Arm Fatigue

Another 2006 study at ASMI identified the following risk factors for shoulder or elbow surgery in youth baseball pitchers:

  • Pitching 8 or more months per calendar year (5 times more likely to sustain a serious injury)
  • Throwing 80 or more pitches per appearance (3.8 times more likely)
  • Throwing velocities greater than 85 mph (2.5 times more likely)
  • Regularly pitching with arm fatigue (36 times more likely)

Research from the Journal of Strength and Conditioning Research found throwing accuracy and arm soreness to be closely associated with arm fatigue. Throwing velocity is more closely associated with generalized fatigue. Therefore, youth athletes should be closely monitored by coaches and training staff to gauge arm fatigue and throwing-induced injury risk. Throwing accuracy, and not velocity, is probably the more important variable to monitor in order to reduce injury risk. Also, regularly communicating with athletes about arm soreness is crucual  to reduce the risk of youth baseball pitching injuries.

Conclusion: Youth Baseball Pitching Injuries

Parents and coaches should closely monitor youth pitchers for signs of arm fatigue and soreness and discourage throwing year round. A minimum of 2-3 months without throwing is recommended (more from Dr. Andrews). During this active recovery period, athletes should work on other baseball skills along with aspects of strength and conditioning to improve their long-term athletic development. The off-season is the ideal time for an athlete to work with a strength coach to develop strength and power.  Contrary to popular belief, throwing breaking pitches is not associated with youth baseball injuries. The Stop Sports Injuries website has posted some other valuable youth baseball pitching injury prevention tips here.

References

  1. Fleisig, G. S., Andrews, J. R., Cutter, G. R., Weber, A., Loftice, J., Mcmichael, C., … Lyman, S. (2011). Risk of serious injury for young baseball pitchers: A 10-year prospective study. The American Journal of Sports Medicine, 39(2), 253–257. http://doi.org/10.1177/0363546510384224
  2. Olsen, S. J., Fleisig, G. S., Dun, S., Loftice, J., & Andrews, J. R. (2006). Risk factors for shoulder and elbow injuries in adolescent baseball pitchers. The American Journal of Sports Medicine, 34(6), 905–12. http://doi.org/10.1177/0363546505284188
  3. Freeston, J., Adams, R., Ferdinands, R., & Rooney, K. (2014). Indicators of throwing arm fatigue in elite adolescent male baseball players: A randomized crossover trial. Journal of Strength & Conditioning Research, 28(8), 2115–2120.