We have treated many baseball players at Champion. One thing is for sure, throwing a baseball does take a lot of people out of shoulder mobility!

We often see this associated with pain on the inside of the elbow, so when someone is recovering from an elbow injury like Tommy John, we usually focus on the shoulder as much as the elbow.

We discuss this concept and more in this episode.

To see more episodes, subscribe and ask questions, visit mikereinold.com/askmikereinold.

#AskMikeReinold Episode 319: Baseball Pitchers with Limited Outspin

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show notes

• Teres Major: An often overlooked important muscle in throwing athletes

Transcript

Courtney:
OK Sam from California. “Hi, I am working with a left-handed pitcher who has a translocated ulnar nerve after a year. He has been doing well and is ready to pitch for the upcoming season. As a pitcher, his out-of-shoulder Very limited rotation. He has normal range of motion throughout the rest of his body. He does have limited shoulder flexion, which has improved. He continues to have intermittent medial elbow pain and mild ulnar nerve symptoms. So my The question is, is his lack of shoulder external rotation causing him to overpronate his elbow during labor and increase the tension in his elbow? Should we try to increase his glenohumeral external rotation as this could be his elbow Root cause of pain? Thank you.”

Mike Reynolds:
well done. It’s a long question, so there you go. That was wonderful.

Dave Tilly:
It moves on.

Mike Reynolds:
a good job.

Lenny McLeaner:
in one breath.

Mike Reynolds:
correct? That was wonderful. When I read this question from Sam I was like wow. Did you just describe every one of my patients for the past five years? For T, so much. Well, who wants to start? Therefore, the ulnar nerve was transposed, and there were still symptoms one year later, without external rotation. Could this be part of the reason? I have no idea. Mike, would you like to start? I think you’ve seen a lot of that lately as well. What do you think?

Mike Scaduto:
well, of course. I think this is definitely a very common presentation for our Champion patients. I would say the range of motion in the shoulder definitely has an effect on the stress on the elbow. We know that when baseball players pitch, they get nervous and get tired. When they get tight, they tend to lose overhead height, possibly some soft tissue limitation of the Latin teres major, which could also be an underlying cause of limited external rotation, and you need to move somewhere. So maybe they’re trying to throw the ball as hard as possible, and they have a little more clearance at the inside elbow. Just put a little more pressure on UCL, put a little more pressure on UCL. If they had pain on the inside of the elbow and they had a transposition of the ulnar nerve where it moved the nerve, it might sound like a UCL sprain, but maybe we never addressed the UCL during surgery. Honestly, it sounds like they might still be dealing with a UCL sprain.

Mike Reynolds:
I wonder maybe they just thought it would heal in the meantime. It’s like a mild sprain, but with a subluxed nerve or something like that, and it heals. But yes, it makes sense. I like the way you mentioned there, Mike, you have to take the motion elsewhere. In order to throw the ball, you need to lie down. So I think it’s a really good point that if your external rotation is limited, you might be putting more torque on the inside elbow to try and get more and more movement. So I think it makes sense. Len, obviously I think you’re seeing a lot of that as well. What do you think?

Lenny McLeaner:
It’s interesting to see lefties come in because you’ll stretch their left side, which is their throwing side, and then you stretch their right side, and you’re like, “Well, you should be a righty because the right side has more Better sports.” We joke about it all the time, but it’s true. They both started throwing at a much younger age, so they should get the retro needed for lieback and outspin. But I don’t know what a lefty is. It seems like all of us are born right-handed. Be upright, not because I hate you. Naturally right-handed, sorry. They’re just southpaws, but with so little gain and outspin, they end up falling apart, whether it’s the bladder or the elbow stuff. They just don’t have that kind of relaxation.

This condition and loss of flexion… We know that loss of flexion also increases the risk of elbow injury. Whether that’s secondary or primary, who knows? But throwing also makes you lose some flex. If that doesn’t recover, there’s also a higher risk of elbow pain. Camp proved it, we proved it, and I guess it’s been going on for a decade now, which is horrible. I think that’s something that needs to be addressed, and like Mike said, I think there’s an underlying issue with UCL that might need to be addressed in the future. Getting external rotation, to answer your questions, is going to be tough. These guys, you can maybe get some benefit with the soft tissues and stretch them, but that’s probably a really solid endfield, and those solid endfields don’t get much movement. Sometimes that’s what happens with those lefties, is you stretch them out and you’re like…it hits the wall. It’s just a nice rebound entry compared to righties. So it’s going to be a tricky one, but I think we’re probably going down the path of more surgery.

Mike Reynolds:
Wow. For me, I think you did it. I think one of the things that people don’t appreciate if you don’t treat a lot of baseball players is that lefties do look different and you shouldn’t expect lefties to be the same as righties. So that’s a very good point. I wish there were more published studies that draw a line between left-handers and right-handers, but in the end, the number of subjects in the left-hander studies was small. So it’s hard to tell them apart, but they’re definitely different. I don’t know if that’s glenoid direction, scapular direction, thoracic direction, but it’s definitely part of it. I’m going to offer a more optimistic view than Len’s. I think actually Len is right, but a little more optimistic. Just because the shoulder flexion is so bad, I think we see it every day on Champion’s hands, if we do soft tissue work on the back muscles or even the subscap, they can get 10, 20 degrees of external rotation in one session. Just by desensitizing it and trying to redo some of the pitch to keep that flexibility going and then I think that takes a lot of pressure off the inner elbow.

Students know we made it this week. Some of you did the measurements for me because I measured this guy 10 times at a time just to keep a record of his mobility. So I really like how you lost the flexion of the shoulder. For me, that showed me lat teres major, maybe even some subscap, with some nervousness and I think some optimism. But you are right. If you still have ulnar nerve symptoms like Lenny said, you still have inner elbow pain and may even have other issues.

But I always like to say that. I don’t think it’s fair to say what we should do for this person right now because their range of activities is limited. So I think our first goal is, let’s maximize the range of motion, bring back his overhead flexion and see if that increases his back and then see if that takes the pressure off the medial elbow. If so, boom, you’re good to go. If not, like Lenny said, we may have to fix more of what’s going on. But Sam, I think you’ve done a really good job of putting all of this together, it’s the next level of thought process. So kudos to you, I think that’s really good. Wish to focus on some of the things we talked about, but I don’t know. I think we nailed that episode. Anyone have anything else they want to add or… I think we’re done pretty quickly.

Lenny McLeaner:
I think it would add an adequate throwing scheme for him as well. A lot of times it’s like we just wing it and let him start throwing the ball around, so you have to step it up. And then also mechanically, what does it look like when they throw something? Did they open up really early, hang it, no good mechanics? There’s a lot of other stuff you can check out, too, Sam. But I’m pulling some old data, which is unpublished data, and it blows my mind. That’s probably why we didn’t publish it. We have 220 right-handed pitches and only 76 left-handed pitches. So you can see doing these studies, which were done on the Tampa Bay Rays court over a period of time, we didn’t see any difference. I was shocked. 131 with 130 outside. These are professional baseball players with a 90-degree outreach. Their total motion is 183, and their pronation is also symmetrical; the way we measured it during spring training, Kevin and I. So I was shocked when I pulled it and found out that we didn’t publish it and it was put in a file to be published. But there are 220 righties and 76 lefties. Again, it’s over, but I’m surprised lefties have so much stats. Again, these are Major League Baseball, so they come into the pros, and maybe that’s the difference. I guess they have a motion.

Mike Reynolds:
Well said, maybe they just filter themselves out. I do think that’s part of it, but I’m also wondering if the standard deviation is different. I bet right-handers have a larger standard deviation.

Lenny McLeaner:
They are 9.6 right-handed and 9.2 left-handed, the difference is very small.

Mike Reynolds:
Wow, that’s great.

Lenny McLeaner:
I know.

Mike Reynolds:
interesting. I think you are right. I wonder if this is optional. If you make it big, it’s because you have a good range of motion. This is so much fun. So I also wanted to say Sam, maybe to answer the other part of your question about “Should you work with external rotation?” Like Lenny said there, you have to measure. So measure the internal and external rotation on both sides, put them together to calculate the total range, and you’ll see. If the total range is the same, then you probably know they’ve maximized their range of motion. But my guess is in this guy, based on the experiences we’ve seen with all the guys with shoulder flex and ER tightness, I’d guess they’d have a reduced total range of motion and probably external rotation.

So taking a step back, we never focus on capsules first. These guys, if the shoulder flexion is limited, for me it’s almost always a lat teres, a little subscap, work on those three, recover that motion and give the ligaments some room to breathe when you throw, Hope this does the trick. But if you don’t restore it and just start a throwing program and try to throw through it, it’s like you’re just banging your head against the wall, right? You still have that thorn by your side. So be sure to work hard. Great stuff, great research analysis by Lenny. I think Lenny is our Lou now that there’s ARCOS data on the Hack Out podcast. Lou Stagner.

With the batting game. sorry. Anyway, if you know, you know. But anyway, I appreciate the question, Sam. If you have a question like that, go to mikereinold.com, click on the podcast link, you can ask, and we’ll see you in the next episode. Thank you so much.