In the sports domain we as coaches often times try to control as many aspects of training, practice and games that we can, in hopes to help our players develop as much as possible in the short time we have them each week. However there is one factor that we have no control over and that is injury. Many “experts” in human performance will argue that if an athlete is properly trained they will remain uninjured; however, those who understand the true demands of sport and its chaotic nature also understand that no amount of training can ever prevent injury completely. At best we can hope to reduce its likelihood.
Case point, Grace Larson. Grace is a well rounded athlete who participates in both basketball and softball. One day while playing catch she made a throw which resulted in a sharp shooting pain on the inside of her right elbow. She was in a great deal of pain and could no longer continue throwing. On 4/22/19 she came in for a rehab consultation. Any athlete sustaining a serious injury which requires a long term rehab plan is taken through a comprehensive physical evaluation, this allows for an individualized program to be created specifically for the needs of that athlete.
Upon examination it was noted that she had a lack of upward rotation of the right scapula, lack of thoracic rotation to the right, as well as a lack of external rotation of the right hip.
Upward rotation allows the the scapula to glide along the rib cage, which in turn helps the arm get into and overhead position. As we will see later in Grace's video she lacked the ability to upwardly, keeping her elbow in a low position causing it to absorb more stress than desired.
The thoracic spine (green) must be able to rotate in the transverse plain for effective loading of the shoulder prior to throwing and deceleration of the arm upon release. Lacking this to her right side she was unable to properly load the shoulder which caused her to lead the elbow during acceleration, causing high amounts of stress on the medial forearm flexor's.
Finally she lacked external rotation of the right hip, holding external rotation of the hip during throwing allows for a high amount of hip to shoulder separation to occur via the kinetic chain. Proper sequencing can help alleviate stress on the elbow as well as improve velocity.
Mechanisms of Injury
As stated earlier, injury in unpredictable and can be caused by many factors, the main three we will be touching on are insufficient strength/range of motion, inefficient mechanics and workload.
Strength and Range of Motion
Strength and ROM often go hand in hand because they actually work toward the same goal, just in different ways. It is pretty obvious how being physically weak can allow for higher chances of injury, if the body can not produce high amounts of force it’s also going to lack the ability to dissipate high amounts of force. For example if the posterior shoulder lacks the ability to decelerate the arm when throwing we will often see issues down stream in the bicep or medial elbow. To the same point if Tspine mobility is less than ideal it can reduce the amount of time the body has to slow the arm down, meaning it must dissipate force at a much higher rate leading to higher levels of stress.
Mechanics are highly individual and depend heavily on strength, ROM and anthropomorphic's (differences in limb length and muscle insertion points from person to person). This means that “good mechanics” are not cookie cutter movement patterns. Good mechanics do mean however that an athlete has efficient transfer of energy up the kinetic chain beginning at the ground and ending with ball release. If energy transfer is not effective it can cause high amounts of stress in places that are not meant to handle it, increasing chance of injury.
The last and most important piece to the puzzle of injury management and prevention. The human body only has a certain amount of energy it can expend on tasks every day. This amount of expendable energy can be thought of as our training economy. Each day we start with one dollar, if we meet our base needs of sleep and nutrition, if not we begin with even less. Each activity of our daily lives such as school, work, relationships, social aspects and general stress all take away from our available training economy. If we drain our economy to low each day or even place ourselves in the negative, we increase the likelihood of an injury or decreased performance. Proper management of workload is the number one key to remaining healthy over a long-term period.
With a medial elbow injury, the worst thing that an athlete can do is rest. This is the most common recommendation given by general medicine doctor or even physical therapists who do not have a high-level understanding of the mechanism of injury or the unique demands placed on the body during throwing. If you have or have had an elbow injury and this was the recommendation to given to your or your child, I would highly recommend that you look somewhere else, a place that can provide a structured rehab plan.
Week 1 – 6
It is important early on post injury to avoid stressing the area of injury to much because it is damaged and needs time to repair. This gives the perfect opportunity to address many of the other issues that could have been contributing factors to the injury, without stressing the medial elbow itself. For grace we looked to greatly improve hip and Tspine mobility while also improving scapular control and posterior shoulder strength.
Here are some sample "mobies" that we performed every training session
90/90 Hip Rotations
Side Lying Windmill
Quad Tspine Rotations
Prone Swimmer Hover
Week 7 – 11 (Strength)
Once resting pain has subsided and we have spent a sufficient time working on mobility and scapular control it is time to begin improving strength. It is important to re-address strength before beginning a throwing program; you wouldn’t eat a fancy dinner without setting the table first right? So why rush back into throwing when the necessary strength to prevent this injury from reoccurring a few months down the road is not established.
The main areas of strength that needed to be addressed were the forearm, bicep as well as muscles of the rotator cuff and posterior shoulder.
When it comes to the forearm, wrist curls and loaded end range pronation/supination rotations will strengthen the muscles of the forearm in full ROM’s.
The bicep is often one of the most under looked areas of strength development for throwers, especially eccentric strength. Eccentric muscle action is the lengthening of a muscle, so in this case when the elbow extends leading up to release of the ball, the bicep is needed to decelerate the forearm otherwise hyperextension of the elbow can occur, leading to unnecessary strain on the elbow.
Also lumping the rotator cuff and posterior shoulder into one category is advantageous because we train movement patterns not individual muscles. A healthy shoulder with proper ROM and strength will be able to move through retraction (blade pinching back), protraction (blade wrapping around the ribs gliding forward), upward rotation (tip of the blade rotating into the arm pit) and depression (tip of the blade retracting down and back toward the spine). Therefore it is important to load these positions and build strength through the entire ROM.
Here are some sample exercises that help to strengthen muscles of the posterior shoulder as while working through high transfer patterns
Week 12 – 20 (Return to Throwing)
After a sufficient baseline of strength is returned the athlete is now ready to begin throwing again. The most difficult aspect of the return to throwing is managing workload. In a good return to throwing program the athlete will continue to lift, improving overall strength, however it is important to regulate the volume and intensity of the lifting program because as discussed earlier, an athlete only has so much training economy to distribute between throwing, lifting and their day to day lives.
The first day back throwing was mainly focused on getting video and a few metrics to establish a baseline.
Above we see what grace looked like post strength rehab but before the beginning of the throwing program. Before breaking down her mechanics it is important to establish some characteristics of high level throwers. #1: The ball moves with a slowly increasing momentum from the moment of hand break up until release. 2# They create tremendous amounts of hip to shoulder separation. When looking at her arm action a few things stand out immediately. First, she reaches the ball away from her body early and begins supination (Palm Up), of the throwing hand. This causes a break in the momentum at an incorrect time, meaning that she will be forced to maximally accelerate the ball forward from almost a dead stop, this is why maintaining small momentum is key; it allows for energy to be most efficiently transferred up the kinetic chain from the ground. The other thing you will notice in the second video is the lack of horizontal shoulder abduction (scapular loading). The lack of scapular loading is not the problem itself, however what it causes further up the kinetic chain is. When the shoulder cannot be held in retraction during forward rotation of the torso, it will prematurely horizontally adduct which causes the elbow to lead in front of the body. In doing so nearly all the energy which was transferred up the kinetic chain is dissipated.
Pivot Pick – The pivot pick is the number one utilized throwing drill for all of our athletes, this drill helps teach the player passive shoulder loading as well as improves proprioception of the arm spiral by removing the lower half. By placing the athlete in a counter rotated position it also helps teach proper sequencing through exaggerated hip to shoulder separation.
In the second video we can see she does a much better job a keeping her shoulder loaded longer which allows her lower body to accelerate longer, in turn proving more energy to transfer up the kinetic chain.
Walk in Throw – The walk in throw places the athlete in a pre-internally rotated hip constraint, meaning that the athlete must feel proper arm path, create hip to shoulder separation, as well as have proper timing of the arm. Some athletes have correct arm paths but poor timing, meaning they struggle to have their arm in a position that they can accelerate it from quickly. Poor timing also results in improper sequencing. Grace specifically needed to work on both timing and hip to shoulder separation so this was what I would consider the single most important drill she performed during her arm repatterning.
In the second video we see a dramatic increase in the amount of lay-back the arm achieves prior to acceleration. The increased lay-back can be attributed to increased hip to shoulder separation as well improved timing of the arm. The body will protect itself from injury, so often times it will not allow itself to get into high stress positions due to risk. But now that the arm is in a safe position to be accelerated, the body allows deeper lay-back.
Turn Throw – The turn throw teaches athletes what it feels like to aggressively rotate their lower half while also allowing their torso to say closed as the scap passively loads. Grace immediately understood the concept of separation after performing this drill for a few weeks. Her lower body action shows what high level sequencing should look like, while there is still improvement yet to be desired with her shoulder load.
The aggressiveness, and smoothness of the turn speak for themselves
Throwing is one of the most complex tasks in all of sports, for an athlete to improve their throwing velocity takes a consistent effort of improving strength, mobility and mechanics. Doing all of those things is quite challenging, but adding recovering from an injury in the mix makes things a whole lot more complicated. The dedication of coming 3 - 4 times a week and even weekends isn't for most but for those who choose to make the sacrifices, you can and will make improvement just as Grace did.
After - Enjoy
Although it was not recorded on video, grace ended up topping out at 60.1 MPH to close her throwing rehab program, even improving beyond her pre-injury top velo. I wanted to close by saying that I couldn't be more proud of the consistent work and determined attitude that grace showed up to the facility with everyday. It was an absolutely pleasure to be apart of her recovery journey, and we at Tcats cannot wait to see where life takes her.