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Pitching Injuries: Why It's Important to Fix the "What" and the "How"

Pitching Injuries, Elbow Pain, Physical Therapy
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Added on September 13, 2016


Article by Matt Lesniak/Director of Outcomes and Clinical Programs.

To anyone who is a baseball fan and follows an MLB team, the site of Stephen Strasburg walking off of the mound last Thursday September 7th with obvious elbow pain is both reminiscent and saddening. His history of repeated elbow injury is one which won't easily be forgotten by Washington National supporters or by healthcare professionals who treat these injuries. Strasburg was drafted in 2009 by the Nationals with high expectations. While his performance on the field has delivered on those expectations time and time again, his inability to stay on the field has been as mesmerizing as his 100-mph fastball.

Strasburg's injury history is expansive. It started with shoulder soreness in July 2010, then a month later he tore the Ulnar Collateral Ligament (UCL) in his throwing elbow. He underwent reconstructive surgery, Tommy John Surgery, and returned toward the end of the 2011 season and pitched under his notorious innings-limit in 2012. A shoulder muscle strain sent him to the disabled list in 2013, and he underwent a surgery in the offseason to remove more spurs from his elbow. He missed significant time in the 2015 season with shoulder and oblique muscle strains. Most recently in 2016 he first spent time on the disabled list for an upper back strain in July, then for elbow soreness in August, followed by him leaving the game on September 7th with elbow pain. He has been diagnosed with a strain of the flexor-pronator muscle group located on the medial forearm and is now seeing further specialists for second opinions.

As someone who loves the game of baseball and loves rehabilitating athletes back to their top form, I cannot help but empathize for Strasburg. I do not think that there is any underlying "weakness" to his joints or tissues that some impassioned fans might suggest on sports radio. I don't think he got anything but top-notch treatment from the Nationals' franchise. After all, his surgeon is world-renowned, the trainers and therapists for the Nationals are highly skilled, and the team tried to protect his susceptibility for re-injury by limiting his exposure when coming back from the initial elbow reconstruction. So why does Strasburg continue to have a difficult time staying healthy?

The answer is multifactorial, as there are many things to consider when dealing with injuries like this. The first thing that everyone should appreciate is how ultra fine the line is between being able to pitch safely and exceeding the joints' or tissues' physical structural limits; In addition to the deceleration phase of the pitch yielding a force equal one's body weight that acts to pull the shoulder out of its socket, data from biomechanical studies and cadaveric studies imply that every pitch creates enough torque on the elbow to tear the UCL. With the injury slope being that slippery, all factors of injury should be explored. There are 3 main factors for overuse injuries: predisposing factors, precipitating factors, and perpetuating factors. Predisposing factors are any conditioning factor that an individual can illicit to cope with stress. For pitchers this encompasses many things but essentially it comes down to their anatomy and biology: their muscle strength, joint range of motion, flexibility, inherent tissue strength, skeletal structure, nutrition, etc. These are the types of things that are treated clinically through surgery, therapy, diet, exercise. Perpetuating factors are any factor that maintains the disabling symptoms. This is a big fancy way of describing the "volume" of activity, or how much of it one engages in. The often overlooked factor for baseball pitchers is the precipitating factor, or the catalyst for injury. Without there being direct trauma, the catalyst for pitching injuries is pitching and the different variables that go along with pitching such as velocity, pitch types, pitch type distribution, and pitch mechanics.

While advances in evaluation and treatment of these athletes are profound, there still remain head-scratchers like Strasburg's case. He received optimal treatment for his predisposing factors through his surgeries and rehab. He was protected about the perpetuating injury factor in his innings limitation. Yet nothing was done for the precipitating factors. By all means this is not an indictment of Strasburg or the Nationals. After all, doing so is a precarious idea at best. Studies have shown that the faster a pitcher pitches, the higher the torque values act at the shoulder and elbow, and that injured pitchers have thrown on average with higher velocity and with more distribution of their pitches being high-velocity than non-injured pitchers. However, asking a pitcher to throw his fastball slower is an obvious competitive disadvantage and an easy way to find oneself looking for a new job.

What about pitching mechanics? This is what I like to talk to my patients about as the "How" of the injury, and I make my point that is as important as treating the "What" of the injury. The case of Strasburg is an excellent talking point. Strasburg has long been thought to have pitching mechanics that put him at higher risk of injury. There is an abundance of data from 3-dimensional biomechanics laboratories that describe how differences in mechanics can affect the torques experienced the shoulder and elbow. However through the eyes of this observer, one thing that has remained consistent since 2010 is Strasburg's throwing delivery. In regards to his elbow, first it was the ligament (2010), then the underlying bone (2013), then the muscle/tendon structures that were reported on his injury rap sheet. In other words, different structures took their turns at trying to absorb the high torques and stresses that his delivery was applying to his elbow. The perfect adjunct to treatment of those structures, the "What," would be to analyze and correct any flaws in his movement that contribute to it, the "How" of the injury.

Either medical management hasn't come far enough to see what is staring at us in the face in this scenario or, more likely, for specialized athletes of this caliber who have honed their ability and have being doing so in a particular way for years if not decades, it is darn near impossible to change. This I believe is the case for Strasburg. He found a way to throw a baseball 100 miles per hour and repeated exactly the way he did so to the point where neuromuscularly that throwing pattern is as automatic as a knee-jerk reflex. His precipitating factor for injury is set. The "How" of his injuries is set. Any subsequent tissue that is brought past its physiological limit is just another "What" to his injury history.

I wish Stephen Strasburg the best of luck and I hope he can rebound from his latest ailment and come back better than ever. I respect both his athleticism and his mental toughness in coming back from various injuries. I mean no malicious or insulting intent.

Rather I want to point his case out so that athletes, parents, and coaches can learn from it. If your athlete or son or daughter has a throwing injury, please don't overlook it. As benign as it may seem, it may be the signal that his or her body is starting to feel the effects of throwing with too much volume, and/or bad mechanics, and/or that his body doesn't have the physical tools necessary to withstand what his participation is presently asking of it. He may have faulty throwing mechanics that may lead to further injuries down the road. What starts out as Little League Elbow as a 13 year old, may turn into a UCL rupture requiring Tommy John at 20 or 21. Please recognize this and seek out treatment from your health providers who are keyed into this.

What to do if you or your son or daughter has a throwing injury:

·R.I.C.E. Rest, Ice, Compression, and Elevation is a standard treatment response for acute pain and injury.

·It is most beneficial when applied within the initial 5-7 days after the injury.

·Abstain from all forms of throwing (and yes that includes pitching) until being seen and cleared to resume by a physician.

·Seek the evaluation of a physician who is trained and skilled in sports medicine.

·Inquire about and seek treatment from a physical therapist that is skilled in sports medicine and the mechanics of throwing and pitching.

·Do not try to return to playing and throwing too soon. If you have any doubt then that means you shouldn't be playing.

For further information about baseball injuries, pitch limits, innings limits, and for a risk analysis profile for you or your athlete's risk of a pitching injury please visit these sites:







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