Stretching: The Truth
I'm planning on a series of articles to update our readers on some of the current concepts in pitcher related injuries and diagnoses that most fans have not heard much about.
We've all had our fill of reading about pitchers with rotator cuff and glenoid labrum tears. There are some interesting trends in sportsmedicine that have lead to changes in exercise programs throughout the majors and minors in an attempt to protect pitchers from a cascade of preventable injuries most fans don't know about.
Diagnoses such as:
•GIRD: (Glenohumeral Internal Rotation Deficit...not to be confused with the stomach malady also known as GERD which Cubs fans get from watching too many losses). Pitching (both cocking phase and deceleration phase) leading to a tight or thickened posterior shoulder capsular ligament plus a loose anterior capsule and loss of internal rotation of the shoulder. Extra external rotation of the shoulder develops at the expense of internal rotation.
•Scapular Dyskinesia: Shoulder blade weakness with altered kinematics.
•Internal Impingement: Thought to be related to posterior shoulder contracture from GIRD with subsequent instability of the shoulder as the humeral head (ball of the shoulder joint) which shifts back/posteriorly and upward/superiorly). This is a different entity from subacromial or rotator cuff impingement which is more common and typically occurs from friction outside the shoulder joint.
...and finally connecting the dots, sorting out how the the injured or weakened shoulder (scapula) leads to severe strain on the elbow and tearing of the Ulnar Collateral Ligament (aka the Tommy John injury).
My attention to this topic started last summer, when I heard a remarkable interview on XM radio with renown Orthopedic Surgeon, Dr. Craig D. Morgan with hosts Jim Memolo and Rob Dibble. The focus of the interview was Stephen Strasburg's shoulder tightness and the subsequent ulnar collateral ligament elbow injury that lead to "Tommy John" reconstruction of that ligament last summer. Dr. Morgan said that he had predicted elbow problems in Strasburg by watching the way he held his shoulder.
More on how the arm bone is connected to the...after the jump.
Strasburg went on the DL July 29th last season for "shoulder inflammation and tightness." He reported right shoulder stiffness that wouldn't loosen up during his warmups on July 28. Strasburg threw just eight warmup pitches and then he was shut down.
When he went on the DL for his shoulder there was a flurry of quotes about how careful the Nats were going to be about Strasburg but at least one knowledgable person threw out a red flag even as the Nationals publicly stated that all was well and they were just being cautious:
An MRI exam taken Tuesday showed Strasburg's shoulder is "totally clean," general manager Mike Rizzo said. He's been shut down since Tuesday, resting his shoulder and getting treatment.
The Nationals have said they would end Strasburg's season when he
reaches 160 innings between the majors and minors, even if that cap were
to come in late August or early September.
White Sox Pitching Guru, Don Cooper, publically voiced his observations and concerns about Strasburg and mentioned a few ghosts from the past (also reported by ESPN and in a more detailed piece in the Washington Post), all as counterpoint to what the Nationals staff publicly said:
As he (Strasburg) loads the baseball, his elbows raise higher than
his shoulders -- forming what pitching coaches call an inverted W -- and
the back of his shoulders pinch toward one another in the "scap
loading" portion of the delivery. Such a delivery, some pitching coaches
believe, puts him at greater risk of shoulder fatigue.
Cooper called it "an upside-down arm action." One major league pitching coach
years ago told me about the exact same concern about Mark Prior -- before Prior broke down.
"The real concern is what I call an upside-down arm action," Cooper told
Sirius in the interview... Cooper compared Strasburg's issues to the
ones that disrupted the careers of former Chicago Cubs pitchers Mark Prior and Kerry Wood.
"He does something with his arm action that is difficult, in my mind, to pitch a whole lot of innings on."
What Don Cooper may have been describing could be attributed to the diagnosis Internal Impingement from posterior capsular tightening from GIRD and subsequent scapular weakness.
Strasburg was activated from the DL after 2 weeks, on August 10th.
Dr. Morgan's interview seemed like he was prescient. In fact, he's one of the leading orthopedic surgeons that have blazed the trail for almost two decades on the detective work that has lead to some of the important and relatively new concepts on shoulder and elbow injuries that are just getting better understood in the last few years. Dr. Morgan was attending the game in Philadelphia where Strasburg blew out his elbow ligament in the 5th inning on August 21st.
When I watched Strasburg pitch I told my wife in the first inning ... I told my wife he would be on an operating table within a week. Was I wrong?"
"I could see that his right shoulder was down compared to his right (probably a misquote and should be "compared to his left"), which means he has muscle weakness. That's the No. 1 cause of the Tommy John ligament injuries. It's all preventable."
"All elbow problems originate from the shoulder," Morgan told MLB.com
In a nutshell, Dr. Morgan's observation that Strasburg's shoulder action upon coming off of the DL showed weakness would fall into the category of what is being called Scapular Dyskinesia (the absolute experts on this are Drs. Kibler, Burkhart and Morgan). Although additional factors can make the situation more complex, the weakness often comes as a secondary phenomon from loss of internal rotation (GIRD) because it's the opposite rotational direction that pitchers need to gain velocity (external rotation which can develop in several ways including bone adaptation during growth known as humeral retroversion) but that increased external rotation (where a pitcher archs his shoulder back to cock his arm) often comes at a price. The loss of internal rotation (thought to be related to thickening of the posterior shoulder joint capsule) leads to some adverse compensatory shoulder and trunk muscle actions including forward scapular (shoulder blade) posture.
So when we hear that a pitcher is dropping his arm slot or has altered his follow-through, it should be a big red flag. I certainly recall those concerns being voiced at times regarding Carlos Zambrano. Subsequent elbow problems can develop because of the altered slot might be related to scapular weakness and GIRD (so an MRI not showing a rotator cuff or labral tear is good news but just might not be the end point of what they should be focusing on).
Many of the MLB teams throughout their minor league systems have instituted preventative exercises to keep pitchers from losing internal rotation. The one exercise in these programs is best known as the "sleeper stretch". A study by Dr. Lintner of the Astros from 2007 looking at 85 professional pitchers in their organization showed that the group on the stretching program after 3 years showed the most gains in internal rotation, so it's not a short term solution but more of a philosophical and organizational adaptation. In the XM interview that I referred to with Dr. Morgan, he mentioned that he has data that the internal rotation and scapular strengthening exercises have dramatically decreased the number of pitching injuries in one or two organizations that he's working with, after a three year period from when they were instituted.
I plan on following up this introduction to the topic with a series that will go into more detail on the individual diagnoses including info from articles from the orthopedic surgeons that have done some of the heavy lifting on this knowledge. The relevant literature includes articles from team orthopedic surgeons from the Astros (Dr. Lintner, who one of my partners, Dr. Sunil Dedhia, did his sportsmedicine fellowship with), Rays (Dr. Andrews), Rangers (Dr. Meister), Rockies (Dr. Noonan), Diamondbacks (Dr. Lee), Angels/A's (Dr. Yokum) and several other clubs. I'm hoping to get an interview out of one of the Cubs trainers at the major or minor league level as I get farther into this process.
Here's a link to a listing of the orthopedic surgeons associated with individual MLB teams.
Did I forget to mention the Rob Dibble lost his broadcasting job as color analyst with the Nationals over his comments on Strasburg? Talk about how deeply ingrained old school thinking is, coming from a 1990's pitcher who's relief pitching career was cut also short by injury to his pitching arm. It's all about advancing the understanding of anatomy and pathologic conditions and then getting the correlating hypothesis proved by analysis of data. Thank you Dr. Morgan. Back in Rob Dibble's day, which isn't all that long ago, pitchers did have to suck it up until their arms fell off, and about all that doctors could offer back then was cortisone and duct tape (former Cubs from Ernie Broglio to Chad Fox say "hello").
"So for me, a little bit has to be put back on Strasburg here," Dibble said.
"OK, you throw a pitch, it bothers your arm, and you immediately call
out the manager and the trainer? Suck it up, kid. This is your
profession. You chose to be a baseball player. You can't have the
cavalry come in and save your butt every time you feel a little stiff
shoulder, sore elbow. ... Stop crying, go out there and pitch. Period."
We all know "there's no crying in baseball", but clearly there have been major medical advances here. The beauty of this topic though is that the advances are more about correct stretching techniques and (hopefully) less about surgery.
So it seems that Mark Prior and Kerry Wood might have had Hall of Fame careers had medical research been twenty years ahead of their time. Just another case of Cubbery.
Next stop...GIRD (Glenohumeral Internal Rotation Defecit). Pre-test (pop quiz) included in this link.