Care and Maintenance of Baseball Players Arms David S. Roskin, PT Duke University Sports Medicine Durham, NC 27710

Baseball Throwing: The most violent activity you can do with the arm in sports Throwing is similar among various sports, including football, javelin, water polo, tennis serve, and volleyball serve/spike and freestyle swimming stroke but nothing equals the demands of baseball throwing In order to care for baseball players and minimize injury potential, a thorough understanding of: the necessary range of motion, strength and biomechanics required to throw safely, is needed

Baseball Throw The most challenging shoulder and elbow activity in all of sport secondary to the angular velocities generated (Fleisig et.al., 1989)

Velocity Demands at the Shoulder and Elbow Shoulder internal rotation: 7500 deg/sec +/-1000 deg Stephen Strasburg: 8000 deg/sec vs. Tom Brady: 2300 deg/sec 2300 deg/sec is velocity at elbow in baseball Torque of elbow in maximal external rotation (MER) of shoulder is higher than the load the ulnar collateral ligament can withstand

First (Consideration) Things First: Posture Stretch weakness defined by middle/lower trapezius positioned in elongation at rest (Kendall) weak backside; tight frontside Cues: Sit as you stand Feedback: “SIT UP”!!! on screensaver

Scapula (Shoulder Blade) is Foundation for Shoulder Health Injured shoulder presents similar to poor posture Shoulder Blade is tilted, protracted and rotated upward (can’t throw correctly) Upper Traps-culprit Analogy: Mansion on a bad foundation

2nd Consideration: Range of Motion Isolated glenohumeral elevation (IGHE) between 105-115 degrees (how the shoulder blade moves on the arm) Clinically 120-140 degrees External Rotation (ER)

Range of Motion Continued Clinically 60-70 degrees of Internal Rotation (IR) *Theory: If you don’t have this, brain knows it needs to get to the target and the next best place is Tommy John region (overpronation)

Conventional Wisdom Cross Body Adduction Tight posterior capsule that needs stretched out (McClure et al 2007) Standing Vertebral Stretch

Not A Fan “Sleeper Stretch”-impinges on the rotator cuff and is for the most part really uncomfortable Stretching at 90/90 should be avoided unless really tight: Will get this motion in cocking position with throwing ( medical term: acquired laxity) Stretching a shoulder that doesn’t need stretched leads to instability (cuff/labral tears)

How To Achieve-Breathing 90/90 hip lift with balloon (carries over to throwing…e.g. inhale (diaphragm) when cocking and exhale (obliques) when accelerating) Manual release of subclavius muscle

3rd Consideration-How to Strength Train According to Phases of Throw Deceleration Acceleration

Deceleration Most violent phase Distraction force at the shoulder is 1:1 with body weight Labral injuries: secondary to eccentric load of biceps Loose bodies of the elbow

Decelerators: Training the “Backside” (Muscles that Slow Down and Stabilize) Supraspinatus Infraspinatus and teres minor Posterior deltoid Rhomboids, middle and lower trapezius Biceps Wrist extensors

Core Strength for Arms of a Thrower: Decelerators/Stabilizers Train eccentrically/negatively (as the muscle lengthens) Rotator Cuff: supraspinatus (2 and 10 o’clock position) Infraspinatus/Teres Minor

Scapular Stabilizers (Cools et al 2007) Horizontal Abduction- “Ts” (target middle traps) Prone Extension-“Arrows” (target rhomboids)

Decelerators/Stabilizers Continued Seated row (target middle traps) Prone scapular plane elevation- “Ys” (need to be careful with this one) {target lower traps}

Often Overlooked Stabilizer Lateral head of the triceps (has attachment to the shoulder blade)

Protection for UCL/Tommy John Biceps curls-slows elbow in deceleration Forearm pronation/supination Wrist curls

Acceleration Ball moves forward- starts with IR of the humerus. Up to 8,000 deg/s. Impingement Rotator cuff tears Medial epicondylitis: gripping ball to tight

Accelerators: Training the “Frontside” Anterior Deltoid Pectoralis Major Latissimus Dorsi Teres Major Long head of the Triceps Anconeus Wrist flexors

Accelerators “Lat” pull downs Triceps extension

Accelerator’s Continued Anterior deltoid-Front Raises (careful not to add too much weight-overloads the cuff and the biceps) “Modified” (Neutral/Towel) Bench Press

Upper Extremity Plyometrics Baseball throwers rely on stretch shortening cycle for arm speed and power. Enhance neuromuscular coordination and muscle recruitment.

Plyos For Rotator Cuff One handed throws can reach velocity levels of up to 1,200 to 1,500 deg/s

Plyometrics For Larger Muscles Good exercise for trunk accelerators (abdominal, hips); Can perform either kneeling or standing

Isokinetics (Accomodating Resistance) Accommodates to resistance delivered by the player and gives the same amount of force back throughout the entire ROM (rotator cuff) Nice adjunct to training Instant feedback to both therapist/thrower Works at different speeds/provides specificity to baseball (500 deg/s)

Isokinetics Continued Biceps/Triceps

Dynamic Stabilizing “Gizmos” Body Blade for rotator cuff stability BOING: elbow stabilizer

Exercises to AVOID!! Lateral Raise: The main culprit (lever arm is too long, usually use too much weight, impinges on the cuff Upright Row: Impinges on the cuff, not functional unless your job is taking groceries out of a car trunk or shopping cart

No-No’s/Impingers Continued “Empty Can”: Not functional, impinges on the rotator cuff Overhead Press: Impinges on cuff/biceps-a baseball weighs between 5 and 5.25 ounces

No-No’s (Stretches Anterior Capsule) “Lat” Pulls (behind the neck): Can injure the neck but also stretches anterior capsule Dips: Stretches anterior capsule

Last but not least… Regular bench press: puts too much pressure on the anterior capsule Shoulder Shrugs: Target-Upper Traps

(Joint forces and torques) Final Consideration: Throwing Mechanics Improper Mechanics Increased Stress (Joint forces and torques) Increased Risk of Injury

Biomechanical Analysis Phases Events Wind up Balance Stride Foot contact Arm cocking Maximum external rotation Arm Acceleration Maximum internal rotation ease Arm Deceleration Ball Release Follow Through

Biomechanical Analysis Improper Mechanics Early/Late Arm rotation  Shoulder anterior force  Shoulder proximal force  Elbow medial force  Elbow varus torque Foot placement Shoulder anterior force Shoulder rotation Leading with the elbow

Drills for Throwers Using mirror for visual feedback

Wall drill Protects thrower from getting too much horizontal abduction in cocking phase

Frontside Drill Teaches direction

Power Position Teaches loading the backside. 65% of body weight should be on stance leg at the end of stride

Position at Foot Contact (FC) Baseball Pitch ASMI, 1994 Bat Toss Shea Stadium, 2000

Interval Throwing Programs (ITP) LONG TOSS: Throwing from short to longer distances MOUND: Throwing off mound with progression from fastballs/change-ups to breaking balls

ITP Continued Goal of ITP: The thrower will be prepared for the workload encountered during competion without risk for injury. Long toss with pitchers up to 120 feet, then mound; infielders 150 feet; outfielders 180 feet ITP usually start at 50% intensity but thrower’s sometime have flawed ability to estimate effort (Fleisig et al 1996)

ITP Continued Rehab/care cannot reproduce the speed or the joint forces generated during throwing. The only way to mimic the forces of a baseball throw is to actually throw a baseball.

Do not forget!! Abdominals LE exercises Back extensor strength Agility Drills Run, run, run

Pain Management Medications per MD Iontophoresis InterX Ice/heat Joint mobilizations “No pain, no gain…………no good!!! Can’t chase pain

Between MDs, PT, ATC, patient, coach, and family Team Effort Between MDs, PT, ATC, patient, coach, and family

Thank you