Major league baseball injuries - Part I
Three strikes and… you’re out for a year. Baseball, though a sport with minimal contact unless you’re Jose Bautista, has an alarming number of injuries. Gone are the days where players just felt shoulder or forearm soreness. Now, we hear about lat injuries, first ribectomies, and even abdominal strains. In this two-part series, I’ll break down some of the most common baseball injuries players face, the findings with each injury, and a basic outline of how to treat them.
Wait, the lat? Isn’t that in the back of the shoulder?
Enter Noah Syndergaard. Syndergaard had what doctors thought to be anterior shoulder tendonitis; however, they came to find out he had a confirmed latissimus dorsi strain.
Additionally, the Lat is very active in the pitching motion. It works eccentrically during the layback phase, when the shoulder is externally rotated, and then is used concentrically to internally rotate the shoulder during the acceleration phase. In addition, the lat connects the lower body to the upper body through the thoracolumbar fascia to help transfer force, and also helps stabilize the core.
No wonder pitchers that have high ball speed and velocity are tearing their Lats at an alarming rate.
So, the million dollar question: what can we do about this?
First, it is important to rest the player. They may not want to hear this, but players should be shut down 4-8 weeks, depending on the severity of the tear. In addition, it is important to examine the pitcher closely. After throwing, the arm is often tight, due to the repetitive motion of pitching. Look at their overhead shoulder elevation and cross body adduction, as these are two motions that often point to a tight lat that is at risk for injury.
In addition, it is important to create both dynamic stability and strength of the rotator cuff muscle. If one muscle overpowers the other, it could lead to imbalances that put the pitcher at risk. Testing lat function with shoulder internal rotation or straight arm pull downs is a good start to see if there is any reproduction of symptoms or weakness.
Lastly, it is very important to remember all injuries are not the same, and don’t progress the patient if they are not ready.
During my time with the Pittsburgh Pirates during Spring Training, we had three players go down with oblique strains. The obliques have two main responsibilities – we all know they produce rotation but they are also important for trunk stability. Pitchers use their oblique and core muscles to transfer force from their lower extremity to their shoulder, so it is no surprise that this group of muscles is key to helping a player with delivery and ball speed.
The contralateral internal oblique to the throwing arm has been found to be the most commonly injured muscle. The internal oblique is working eccentrically during the cocking phase and concentrically during the delivery phase.
Baseball is a rotational sport by nature, and if you don’t have a strong core and trunk stability, don’t be alarmed if the player all of the sudden can’t throw the ball with great velocity. It is worth mentioning that pitchers don’t just suffer from this injury, but also hitters. If a hitter makes a swing against an unexpected pitch, their mechanics can be off and thus increasing the likelihood of injury.
Like a lat strain, it is important to diagnose the injury before it becomes too late and too severe. The athlete must be fully healed before you return them to the mound, which, like a lat strain, can take 4-8 weeks depending on severity.
When rehabbing an oblique strain, it is important to also look at the full picture.
- Are their hips stiff?
- Is their lumbar spine hyperextended?
- Does the thoracic spine have enough rotation?
- Does the core have not only anti-flexion and anti extension capabilities, but also anti rotation strength?
Think about these things when you rehab a player to help them return to the mound.
I don’t think this injury needs a big tagline or a large introduction. Tommy John surgery has unfortunately become a mainstay surgery in the life of a pitcher. For those of you not familiar with baseball, this is a surgical operation in which the ulnar collateral ligament in the medial elbow is torn, and replaced with a tendon, often the palmaris longus tendon or from the hamstring.
The big question is... Why? Why does this happen?
I don’t think we can pinpoint one reason specifically, but it really is a cascade of events that often leaves the pitcher at risk. My belief; and some may disagree, is imbalances in the throwing shoulder and increases in velocity.
Let me explain. Many pitchers present with increased external rotation and decreased internal rotation – known as Glenohumeral Internal Rotation Deficit (GIRD). GIRD is NOT BAD; this is NORMAL considering the player has an equal arc of total rotational motion side to side.
However, this is not the only imbalance that needs attention. More and more research has come out that imbalances in hip and thoracic rotation, core stability, or shoulder and scapula strength and mobility all place extra strain on the elbow. Don’t believe me?
Enter Pedro Martinez, arguably one of the best MLB pitchers of all time (Sorry, Yankee fans). Without getting into too much detail, you can see there is a lot more involved than just the shoulder. Yes, you need scapular stability, mobility and strength to maintain this position and to even get your arm into the optimal position, but the legs transfer energy through the core to the shoulder. Without everything else in place, your elbow can take a beating.
Remember that quick internal rotation I told you about during the acceleration phase of the pitching motion? What muscles do you think help keep the humerus from flying off the body? The rotator cuff. The rotator cuff is crucial for dynamic stability of the scapula and shoulder, as well as eccentric control at ball release, and it’s important to not only train this muscle for strength and endurance, but also for stability.
During spring training, I saw many guys come back from the offseason “strong.” However, I would make them do a prone “T” and they couldn’t even do 3 sets of 10 before fatiguing. It’s not just about the big muscles that make you look good, it’s important to focus on an arm care program on the scapular stabilizers and rotator cuff muscles if you want to be a successful pitcher.
The second and last point I will make is increased velocity and overuse in young pitchers are undoubtedly a reason for the increased trend in Tommy John Injuries. Many teams draft guys out of high school just because they can throw over 90 mph, but don’t be surprised if he is on the DL list one year later.
With so many young athletes specializing early, there is a good chance they will be at risk for arm trouble later in their career. Coaches praise a kid for throwing fast and hard, yet, we see a breakdown later in their career. Weighted balls to increase velocity have become all the rage in some little leagues. However, without the proper tools in place, you’ve got a kid who may have set himself up for a trip to the doctor.
To summarize, baseball is such a dynamic sport, and when there is a breakdown somewhere up or down the chain, you can have an injury not just at the shoulder. When treating a baseball player, it’s important to consider the whole body, joint by joint. It’s important to cover all of your bases to prevent any kind of injury from happening again.