Grace Larson 20 Week UCL Rehab
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.