Post by Glenn Fleisig, Ph.D. on Feb 18, 2013 13:49:12 GMT -6
I'm sorry to point out the elephant in the room, but I think the cause of pain flaring up again is overuse. It sounds like his off-season from throwing was only three weeks, and this rest was just because of the arm pain. We see too many kids coming in for elbow reconstruction surgery or arthroscopic surgery, and their stories are all the same that they are good pitchers, love pitching, and were playing nearly year-round.
I know that Spring is in the air, but you need to shut him down again and get him checked again by the sports medicine physician. After he is cleared to pitch again, you can consider whether he needs to change his mechanics. As you can tell from this forum and other venues, there are plenty of opinions on mechanics. You may wish to consider coming to ASMI for a biomechanical evaluation. In fact we just tested a different 11-year-old this morning.
Actually he did not throw from the last week in July until around the second week in October. From that point on until the first week in January, he threw alittle here and there. Since the first week in January we have been throwing 1-2 a week.
Last nights practice my son threw about 15 or so warm-ups and about half he said he had some elbow pain. We shut his throwing down, but let him have batting practice. We eventually had to shut that down as well because swinging the bat was aggravating his elbow. He is going to the sports medicine ortho tomorrow. Should I insist that the doc take x-rays of both arms? Anything else I should be having them do? My son is very bummed about this and feels like he is letting his team down. I explained to him that it is not his fault and we will get it taken care of. I admit that I am worried that this is going to be another long term healing period and that he will miss part of the season for sure
After all this time I thought I better say something.
“Last nights practice my son threw about 15 or so warm-ups and about half he said he had some elbow pain.”
The way our bodies are naturally built with the arm attached of to the side leads to intuitive supination and low arm vector (Humerus) throwing and pitching. This leads them to a mal-mechanic that has his elbow find the end of range of motion without the ability to hinge correctly just before it finds it’s end of range of motion because of forearm supination where the thumb back and up at release. It does not take very many throws or pitches to cause these problems with many youth athletes because they always start with extreme lack of fitness in their middle finger muscles and attachments (that attach right above the MCL (UCL) at the medial epicondyle) especially when they have been sedentary.
He needs to learn how to pronate his throws and pitches where the thumb is turned down and the elbow pops up at and after release.
This is best learned by having him learn how to properly crow-step instead of drop step to start his leg work then pronate the throw and finish with full 180 degree rotation of his body instead of leaving his ball leg back the way he currently performs it.
The problem exists in all youth throwers in that nobody recommends this or teaches it, even the highest learned and experienced professionals are ignorant of this technique so it never gets passed down or learned. When I get new youth or adult clients this is the first thing they learn. I get previously released (by their Dr’s) athletes all the time and they never again have these problems.
He is going to the sports medicine ortho tomorrow. Should I insist that the doc take x-rays of both arms?
This is the only way a correct comparison for abnormalities can happen. This is the method (glove and ball arm x-rays) used in the most comprehensive study ever done on youth throwing and pitching injuries done back in the mid 60’s by an orthopedic surgeon named Joel Adams where he explained the mechanism that lead to these type injuries. He determined that “ballistic hyper extension” was the culprit in all the cases he studies from intuitive forearm supination and lack of fitness to proceed.
“Anything else I should be having them do?”
He needs to learn all pronated pitches if he is going to pitch. He needs to align his shoulders, arms, hips and legs directly at his target when his glove side leg lands. He needs to have arrived his throwing arm up to driveline height (Humerus straight back, forearm slightly bent) thumb up (supinating) with the ball slightly above the elbow when his glove foot plants. He then needs to immediately raise his elbow up to start his acceleration phase so that the humerus passes close to the head and pronate the forearm with a natural hinge in the elbow.. He needs to perform middle finger overload exersises. He needs to be "sport specifically" fit to pitch, this is done with wrist weights and heavy ball throws. The bowling thing exposed his lack of fitness after a long rest (atrophy) period.
“I admit that I am worried that this is going to be another long term healing period and that he will miss part of the season for sure.”
This is OK no worries! Get his Dr’s release and make those changes!! I often make those changes as soon as pain is felt and they get immediate relief.
Last Edit: Feb 20, 2013 11:55:12 GMT -6 by dirtberry
He is going to the sports medicine ortho tomorrow. Should I insist that the doc take x-rays of both arms? Anything else I should be having them do? My son is very bummed about this and feels like he is letting his team down. I explained to him that it is not his fault and we will get it taken care of. I admit that I am worried that this is going to be another long term healing period and that he will miss part of the season for sure
I'm very glad you are taking him in to get checked. This elbow pain is not normal and not right. There is nothing that you need to tell the doctor to do. What you do need to tell him/her is what is happening with your son and then let the doc decide what kind of images are needed. If you click on my name, you can send me a private message about who the doctor is and I can check that he/she is qualified.
Don't be worried about missing a part of a season. Be satisfied that you are taking your son in to most likely fix a small problem (rest, exercise, change in mechanics) instead of ignoring it and one day having a big problem (torn ligament needing surgery).
^^^^ WOW! Still trying to absorb everything you said "dirtberry". Thanks for the response. His mechanics, for his age, are pretty darn good based on what I have seen. I have always stressed go mechanics and practice this with various drills endorsed by the NPA. Also, he was absolutely not over used last season at all, I monitored this closely. I thought pronation was natural (for the most part) and a non teach? How would I even teach this to him? Do you think the bowling thing might have set the injury off again after 15 months of no reoccurance?
“His mechanics, for his age, are pretty darn good based on what I have seen.”
If he looks like a good MLB pitcher then his traditional mechanics are terrible and will produce what they all manifest! And quicker because he is a child and they are always unfit to perform these mal-mechanics.
“I have always stressed go mechanics and practice this with various drills endorsed by the NPA.”
If you only knew? The NPA is OK with any mechanics and have been teaching the same things for ever. Their drills like the ridiculous “towel drill” that makes you perform towel snapping with great precision have nothing to do with pitching “sport specifically” in any way. They teach the injurious traditional pitching mechanics that have proven to be.
“Also, he was absolutely not over used last season at all, I monitored this closely”
I heard you from the beginning and agree with Dr.Fleisig when talking about youth pitchers with open growth plates but when these growth centers are solidified pitch counts become ridiculous in that there are non-injurious powerful mechanics that can be used meaning adult injuries and most of youth injuries are entirely mechanical in nature that worsen with any use.
“I thought pronation was natural (for the most part) and a non teach?”
It’s the opposite!!!!! Supination is natural and intuitive that all youth athletes perform. Many see after release involuntary pronation snapback from end of range of motion supination as pronation when it is not and at the wrong time. You want pronation during drive and release with the elbow freely flowing (hinging) forearm over Humerus.
“How would I even teach this to him?”
It’s easy if you know the motor skill drills and if he understands the information that has him voluntarily pronate. The wrist weight exercises allow him to work on it also proprioceptively (muscle memory) and “sport specifically”. If you are curious you can go to my U-Tube channel (dirtberry) for free and see what I do with my youth and adult clients.
“Do you think the bowling thing might have set the injury off again after 15 months of no reoccurance?”
Bowling, while it has your elbow already at full length of motion and does not slam the bones together like throwing a baseball is overly taxing on the middle finger especially at the tendon attachment at the medial epicondyle and he was for sure not fit to do so. How many fitness programs have you seen where the middle finger and it’s muscle and tendon (at the area of discomfort) attachments are taxed with an overload interval training program? I guarantee you it is none when this is the main and end of line kinetic mover where all the previous contractions from the more than 30 muscles that drive the pitching motion build up and onto this last mover.
We saw the sports medicine - ortho Doc yesterday and he diagnosed him with an inflammed inner elbow. X-rays clearly showed open growth plates as expected, but he said they looked good and does not feel that there is any tissue damage based on the exam he conducted. So no MRI at this point. Doc said that the bowling incident more than likely caused the inflammation in the elbow again after we showed him how my son was twisting his arm and flipping his wrist with a 10lb ball. He said to stop everything (throwing, batting, push ups etc etc) for two weeks, ice off and on, and one "aleve" in the morning and one before bed. After the two weeks is up, he wants me to follow the AMSI little league interval throwing program. We see him for a follow up in 4 weeks.
This is an old thread but I thought I would post an update. My son pitched the 2014 baseball season with off and on elbow pain that never got overly painful. He was not used as much as he had been in the past few years. He decided to "hang it up" after the 2014 season and basically did not throw for almost a full year. This past May he turned 14 years old and started going through puberty in late summer of 2014 while he was taking a break from the game. Anyway, last month he decided to play baseball again and was asked to play in a tournament last month. To my surprise he basically picked up from where he left off, didn't seem to miss a beat! Now the not so great part. He did pitch couple of innings and threw about 35 pitches. The inner elbow pain had returned, even after laying off a full year!! He tried out from a travel team and made it for the 2016 season and we have been playing some fall ball. He has complained a bit about the elbow again and we are working on figuring out what is going on. He began working out about a month ago. We are doing things like light dumbbell shoulder raisers, push ups, rice bucket exercises to strengthen the hands and forearms, tennis ball squeezes etc etc. He mainly only gets the elbow pain after throwing off the mound and not when playing the infield (normally plays 3B or SS). He does not play catcher at all. I am thinking it is something in his pitching mechanics, so his coach will be taking a closer look at that. I believe we can rule overuse completely out now.
"...this is the age where correcting mechanics is most important. Pitching 15 months consecutively with the "WRONG" mechanics can cause pain in the elbows and shoulders, as possibly in this case."
Most time when advice is given for a medial collateral ligament problem, the advice is limited to rest and physical therapy. I always advise an evaluation of the pitching mechanics as I believe this, along with overuse, is the culprit for causation. Without correction of mechanics and adequate rest the problem stands a good chance of coming back. Another factor is pitching while exhausted and that exhaustion can be acute or chronic and after 15 months it would most likely be chronic.