Major League Baseball Injuries: Part II
In my recent article, I discussed three injuries that are common in the Major League Baseball athlete today. Check that article if you need a refresher on anatomy and a description of each injury! In this article, I am going to outline treatments to use for MLB athlete injuries, and things to keep in mind when working with a pitcher or player.
First things first . . . evaluate the athlete!
As mentioned previously, the lat is an important muscle in the throwing motion. During the layback motion, the lat acts eccentrically to stabilize the anterior glenohumeral joint, and acts concentrically during the acceleration phase to internally rotate the arm. Additionally, it connects the upper body to the lower body through the thoracolumbar fascia to help transfer force and helps to stabilize the core. Can’t you tell how important this muscle is?
So, what happens when the muscle is strained or torn? First things first, do not let the player throw. Would you have a soccer player with a hamstring strain run? No! The player needs to be shut down possibly for 4-8 weeks depending on the severity of the injury. After they pass clinical tests and start them on a gradual throwing program to retrain their arm to throwing.
One clinical pearl I have taken from Mike Reinold, an expert in the baseball realm, is “let distance dictate your intensity.” Don’t start throwing darts at 60 feet. It takes time to build up the endurance of throwing, and you don’t want to apply stress to a muscle that is not fully healed otherwise you are at an increased risk of reinjury.
So where do we start? It is important to cover all your bases when looking at a thrower’s shoulder. The lat attaches in the front of the shoulder, and pain in the anterior part of the shoulder can be mistaken for biceps tendonitis when really the source of the pain is coming from the lat.
In addition, the lat is a core stabilizer. When the muscle is overactive, it leads to muscle shortening — in which you can see pelvic anterior tilt, excessive lumbar lordosis, loss of external rotation, and scapular depression.
With a loss of external rotation due to a tight lat, a pitcher will try to find other ways to get their arm into the layback position . . . often through hyperextension of their lumbar spine, or worse through their elbow. What also resists lumbar hyperextension? The obliques — I hope you are catching on here.
Also, if a pitcher is tight, you will see a loss of shoulder flexion which can lead to an increased risk of injury. Thus, it is important to clear up any soft tissue or mobility restrictions. I personally like foam rolling or using mobility balls to clear up both the lat and the teres minor, another muscle that tends to be overdeveloped in a pitcher and has an effect on scapulohumeral motion.
Balance out the imbalances
Next, since the lat is such a dominant muscle, it is important to lessen any imbalances in the throwing shoulder. A pitcher will always be asymmetrical to the other side due to the nature of the sport, but the shoulder needs support from the rotator cuff, scapular stabilizers, and core to assist with the throwing motion.
The lower trapezius is important for posterior tilting of the scapula along with upward rotation, and this helps decrease excessive scapular depression from the dominant lat muscle. I use a prone 1-arm trap raise, as I find this is the easiest exercise to perform initially to teach a player how to engage this muscle.
Also, the lat may need to overwork due to a relatively weak rotator cuff. It’s not enough to train this muscle for strength, doing mindless 3x10, train it for endurance and dynamic stabilization. Yes, it needs to be strong, but it also works most of the day and strength is not enough.
Lastly, as stated earlier, the more anterior pelvic tilt you have due to a tight lat, the weaker the anterior core is. What else is a part of the anterior core? The oblique. I’m not saying this is a cause and effect relationship, but you should be mindful of both when rehabbing a player or pitcher. However, doing situps and crunches should not be your first treatment for either injury.
Anterior core training is essential to resist excessive lumbar extension, control excessive rotation (which could lead to an oblique strain), and helps with hip mobility. Deadbugs, Kettlebell Squats, Chops and Lifts, and TRX Fallouts are excellent ways to challenge anterior core control and rotary stability.
Speaking of the core, let’s transition into the oblique. I won’t go into the specific anatomy twice, but it has important implications during the pitching motion. It works in conjunction with the lat to help transfer forces from the lower extremity to the upper extremity. However, the oblique has a more crucial role in rotation than the lat, and it’s an area that can affect any position player.
Athletes have a lot of power in their hips and are stronger than ever. With increased bat speed and pitching velocity, there can be an increased torque during rotation and the oblique can be the scapegoat. There are many different theories of oblique strains, and I think it’s again a multifactorial injury. Are your hips mobile enough? Is your anterior core strong enough to resist lumbar extension? Is your core compensating too much due to reduced mobility above or below it?
Again, like the lat it is important to clear up any mobility or soft tissue restrictions. The hips need to externally rotate, but internal rotation on the lead leg is also crucial for a pitcher. Without this mobility the core can work on overdrive.
In addition, the obliques attach to not only the pelvis, but also the lower ribs which has an effect on thoracic positioning. Too much stiffness in the abs can pull down on the rib cage, preventing thoracic extension and rotation. Thus, improving thoracic mobility through foam roller thoracic extensions or quadruped rotations are excellent ways to free up any limitations.
In the initial stages of the injury, I think it’s important to not do any significant core work because you are going to place too much stress on an already irritated area. Within a couple of weeks, you can begin light isometrics then progressing to exercises that again resist lumbar hyperextension, and train rotary stability and overall spinal stiffness. I am a huge fan of Palloff Presses, Half Kneeling Cable Lifts and Chops, RKC Planks, side planks, and kettlebell carries. Core exercises work hand in hand with hip mobility, and often times I see greater hip mobility following core activation.
As you can see, back, hip, and abdominal injuries can occur in baseball pitchers. However, Million Dollar Arm wasn’t named just for a tag line — arm injuries are still the primary injury that pitchers and position players face. What may just be elbow tendonitis can turn into full fledged Tommy John surgery.
I believe elbow injuries are a secondary issue, and that the main cause of the problem are issues at the glenohumeral or scapulothoracic joint. Just like the former two injuries, it is important to maintain increase soft tissue mobility in the elbow and forearm muscles, rotator cuff, teres major, and lat.
Remember, any restrictions in the throwing arm can throw off the pitching mechanics.
Mobility or stability . . . that is the question!
Also, mobility needs to be balanced with stability. Because of the excessive external rotation all baseball players have, this requires greater dynamic stabilization requirements from the surrounding musculature. The rotator cuff and scapular upward rotators and protractors are all important muscles to maintain good scapulothoracic control during throwing. If the active restraints are strong, the passive restraints don’t have to work as hard. Muscles to target will include the serratus anterior, middle and lower trapezius, rotator cuff muscles, subscapularis,
Exercises I love are the prone “T”, Prone “Y”, Prone ‘W”, 90/90 ER/IR, Sidelying External Rotation, Wall Slides, Prone Horizontal Abduction with ER, and Half Kneeling 90/90 Isometric Hold. As mentioned early, the rotator cuff does not only need to be strong, but it needs to create dynamic stability and needs to fire at the right time. Manual perturbations to to the arm at a 90/90 position or even during different phases of the throwing motion are excellent techniques to challenge the rotator cuff dynamically.
Know the player and know the mechanics
If you’re still with me, you can see that there are many injuries to which baseball players can succumb. Just like with every patient, it is important to look at the entire body and not just the painful body part.
The body is a kinetic chain, and looking at the joint above and below the joint of interest will take you far with not only this patient population, but for every other patient that walks into your door.
Knowledge is power, and knowing details about the demands on a baseball player is crucial to fully rehabilitate them back to the mound.
So batter up!