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.
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.
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.
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.
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 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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Anyone interested in strengthening the core and shoulder musculature should be performing some type of row variation as part of their workouts. The row is a pulling movement which involves flexing the elbow, extending the shoulder, and pulling the shoulder blade back, also known as retraction. The row challenges the muscles of the upper back (trapezius, rhomboids, and erector spinae) as well as muscles of the core and low back. Also, when performed in various standing positions, this exercise can train the entire kinetic chain from the lower body, through the trunk, to the upper body.
It is common for the row to be performed seated with the use of exercise machines. This is fine for those first learning the movement pattern. However, seated machine rows do little to challenge the core or lower body musculature. There are much better options for athletes, those with a history of injury, and those looking to take their workouts to the next level.
If absolute strength is the goal, heavy barbell or dumbbell bent over rows are the best options. However, these row variations require coaching and practice to perfect proper technique. Performing heavy rows with improper technique makes one susceptible to low back or shoulder injury. Again, there are better options, especially for those with a history of injury and looks to train in a more specific fashion. Try the following five row variations and see which ones work best for you.
Standing 1-Arm High Cable Row
Set up a cable system with the cable positioned slightly above the level of the head. Stand in a lunge position with the left foot in front of the right. The majority of body weight should be on the front leg with the knee bent approximately 45 degrees. Start with a palm down grip with the right arm extended out in front. To begin the movement, pull the cable, bending at the elbow, straight back towards the trunk while maintaining a neutral spine. Be sure to emphasize scapular retraction which refers to pulling the shoulder blade back and slightly down. Also, avoid shrugging the shoulders or arching the low back.
This exercise challenges the core by activating the trunk musculature to resist rotation as the arm and scapula produce the row movement. This makes the 1-arm high cable row a good option for those who are looking to train anti-rotational trunk muscle endurance. This high-cable position and lunge stance set-up have also been shown to result in favorable muscle activation patterns of the lower and upper trapezius. This is important for overhead athletes or those with a history of shoulder problems.
Cable Lawnmower Pull
This exercise begins with the trunk flexed and rotated to the opposite side of the exercising arm. The hand of the exercising arm starts at the level of the opposite knee. To begin the movement, the trunk is rotated toward the exercising arm while extending the hip and trunk to a vertical position. The exercise ends with the arm at waist level with the shoulder blade retracted as if placing the elbow in the back pocket. Pause for 1 or 2 seconds then slowly reverse the movement returning to the starting position.
The lawnmower pull is a multi-joint functional exercise performed in a diagonal pattern replicating many movements in sport. The exercise incorporates the transfer of force from the lower body through the trunk to the upper body. It has been shown to activate the trapezius and serratus anterior muscles at low to moderate levels. These muscles are important for maintaining shoulder health in overhead athletes (i.e., baseball players) and those with a history of shoulder pain. The exercise can be performed with a cable system, resistance band, or dumbbell.
1-Arm Band Rotational Row
Set up a resistance band anchored at approximately waist to belly button level. Position the front leg with the foot facing towards the anchored band. The rear leg will begin facing the same direction but must be free to pivot once the exercise commences. The right arm begins extended and the majority of body weight begins on the left leg. The movement occurs with the simultaneous coordination of an upper-body row, trunk rotation, and weight shift to the rear leg. Pause in the end position for 1 to 2 seconds before reversing the movement in a slow and controlled fashion.
This row variation is ideal for rotational athletes such as baseball players. It incorporates the coordinated activity of the lower body, trunk, and upper body. Controlling the eccentric, or negative, part of the exercise is important. This exercise also teaches weight transfer and weight acceptable from the rear to lead leg and vice versa. Be sure to perform the exercise from both sides to avoid reinforcing any side to side asymmetries which are common in athletes.
Suspension Trainer Row
Anchor a suspension trainer, such as a TRX, in an overhead position. Grasp both handles with the arms extended. Position the feet in front of the body spread slightly wider than shoulder-width apart. Your body should be maintained in a neutral position with your head, trunk, and legs forming a straight line. Perform the row movement and pause at the top position for 1 to 2 seconds before returning to the start position in a slow and controlled fashion. Maintain the trunk in a rigid position throughout the exercise. To increase the challenge of this exercise position your feet further away from your upper body to assume a more inverted position.
The inverted position assumed in the suspension trainer row elicits high activation of the abdominals, latissimus dorsi, upper back muscles, and hip extensor muscles (glutes and hamstrings). This exercise produces lower levels of lumbar spine muscle activity due to lower spine loads incurred from the suspended position. These factors make the suspension trainer or inverted row a good option for patients with a history of low back pain.
Dumbbell Renegade Row
Hold two dumbbells and assume a push-up position with the feet spread slightly wider than shoulder-width apart. Align the head, trunk, and lower body in a straight line and maintain this position throughout the exercise. Initiate a row with one arm while maintaining stability through the trunk and lower body. Control the descent of the load back to the floor. Be sure to alternate sides with each repetition. Light loads are recommended when first learning this exercise.
The push-up position utilized in the renegade row increases challenges to the abdominal musculature. Furthermore, 1-arm row variations have been shown to elicit great oblique abdominal muscle activity compared to rows performed with both arms simultaneously. This is a more advanced row variation so it may be best to start with cable or suspension rows before embarking on the renegade row.
There are many variations to the row exercise and I have described only five. For beginners, it is best to start with cable row variations and suspension trainer rows. The lawnmower pull and rotational row are more complex movements which require total body coordination. Thus, these exercises are more challenging to master. To really challenge the core and shoulder stability, the renegade row is a higher level option. The most important points are that you choose the most appropriate variation for your level of training and that your technique is as close to perfect as possible.
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Fenwick CM, Brown SH, McGill SM. Comparison of different rowing exercises: Trunk muscle activation and lumbar spine motion, load, and stiffness. J Strength Cond Res. 2009;23(5):1408-1417.
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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.
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.