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2017

Data-Driven Rehabilitation from Tommy John Surgery: Troy Rallings Case Study

Troy Rallings was on top of the world in 2016. He had returned for his senior season at the University of Washington, forgoing the offer the Oakland Athletics made to him after drafting him in the 36th round. While he was battling arm fatigue, he held his closer role down. Heading into the series against Stanford, Troy had a 0.91 ERA, 59.2 innings thrown (3rd highest on the team despite 0 games started), 27 appearances, with 58 strikeouts to 11 walks and 0 home runs given up. As he got into a game against the Cardinal, he felt it – the tug, the searing pain in the elbow.

(This article was written by Kyle Boddy, Director of Research and Development and Founder of Driveline Baseball)

As Troy said himself on Next Level Ballplayer:

I underwent an MRI on my elbow which revealed a significant, yet partial tear of my Ulnar Collateral Ligament aka the UCL. I was crushed, but remained hopeful. The draft was less than 3 weeks away and was now completely uncertain of what my future held. The majority of teams shied away from me after the news of me being injured was revealed. I don’t blame them. I was 22 years old and more than likely needed Tommy John surgery.

On June 11, 2016 I was drafted 666th overall by The Angels in the 22nd round and was offered “senior money” to sign, but I had to pass a physical and be cleared. I knew this was not possible. I couldn’t shake anyone’s hand, open a jar, or break an egg in my hand. So I notified the Angels that I needed time and was not going to sign or be reporting when everyone else was after the draft. For seniors who are drafted and out of amateur eligibility, the team that drafts you owns the rights to sign you until a week prior to the following years draft. There was no guarantee that the Angels would sign me later down the road, but I wanted to take my health and my future into my own hands. I bet on me.

The awards piled in; Troy would be the PAC-12 Pitcher of the Year, the Louisville Slugger and Rawlings First Team All-American Relief Pitcher, and West Coast Player of the Year. He set the single season ERA record, career appearances record, and tied the career saves record at the University of Washington. But he was looking at a torn UCL and didn’t have a lot of faith that it was getting better just by resting it.

Troy Rallings, UW

With an elbow that wasn’t getting better, Troy had to make some choices.

I spent the next month evaluating options as to how I was going to get healthy. Due to the fact that the MRI showed my UCL was not fully torn, I could have tried to go the physical therapy route along with PRP or Stem Cell injections. These are options to avoid surgery and potentially make it back in 3-4 months, however research showed the results to be hit or miss and more than half of the patients who go this route wind up getting surgery anyway. I did not have that kind of time. I sought out one of the top orthopedic surgeons in my area, Dr. Michael Shepard. His opinion was that Tommy John surgery was a viable option.

I had my TJ done on August 11, 2016. The operation itself could not be simpler.

Troy opted to have UCL reconstruction – Tommy John surgery – completed on his right elbow, on August 11th, 2016. He started to regain range of motion in his elbow and begun rudimentary strengthening programmings for his elbow. In the first week of November, Troy packed up his car in Southern California and headed to Washington to train at Driveline Baseball.

I chose this path because I had prior experience training there, but also because I had a sense of urgency in getting my arm strength and health back. I am 23 years old. In the world of professional baseball, I am an old man for a 1st year player when most US player sign between 18-21. I did not want to do the generic throwing program given out by doctors that only involves playing catch with a regular 5 oz baseball.

Lead trainer Matt Daniels and I sat down with Troy on multiple occasions, notifying him that while we had an extensive history of bringing athletes back from UCL reconstruction, we usually intervened much later in the process. Troy was barely 3 months out of surgery; the only other pitcher we had worked with at such an early phase after elbow surgery was Herbie Good (avulsion fracture). We told Troy that we would be using a very data-driven process in rehabilitation in tandem with our physical therapist (Terry Phillips, DPT) and InHealth, our manual therapist partners (Curt Rindal and Kevin Rindal), and that he should expect to be completing an unorthodox throwing program that didn’t resemble any interval throwing / return to throwing program handed out by orthopedic specialists.

Curt Rindal

Unsurprisingly, Troy was all about it.

I wanted to be a test subject for what happens when someone comes back from TJ with a brand new approach. I told myself every day I wanted to change the way our world goes about rehabbing from this surgery to help guys avoid 16-18+ month rehabs that are filled with setbacks.

Data-Driven Rehabilitation: Key Metrics

The way that we were going to handle rehabilitation for Troy was going to be significantly different than what generally exists in baseball. We were going to have a tight feedback loop between his physical and manual therapists, tying both skill and general physical preparedness into an extremely quick, centralized place. Both of his therapists worked at Driveline Baseball, and both his skill (throwing) and strength programming came from the same staff. This allowed for extremely flexible decisions to be made on a daily basis, something that is usually only afforded to professional athletes rehabilitating with their team.

Secondly, we were going to use as much data as possible to inform our decisions. This meant constant calibration of his Rate of Perceived Effort (RPE) in the weight room, manual muscle tests of his shoulder and forearm to see how Troy’s recovery and body-part specific strength was coming along, using ball velocity instead of time/distance as the interval in his throwing program, digital screening of his posture using 3D cameras, throwing kinematics as measured using a Motus mTHROW sleeve, and so much more.

The vast majority of interval throwing programs for rehabilitating pitchers look like this:interval-throwing

Aside from the fact that this is a gross amount of volume for anyone just starting the Return to Throwing phase (65 throws + warm-up throws on day 1!?), it is also incredibly non-specific and general. It does not allow for autoregulation like normal long toss programs do, and RPE is a notoriously poor metric for throwing intensity (Slenker, Limpisvasti, et al – Biomechanical comparison of the interval throwing program and baseball pitching: upper extremity loads in training and rehabilitation AJSM May 2014). At 60% of perceived effort, pitchers were generating forces of 76% and ball speeds approaching 84% of maximum intensity. Put another way: Pitchers are really bad at estimating how much effort they are expending and consistently underestimate it, which has profound implications for rehabilitation programs.

Pitchers are bad at estimating how much effort they are expending - implications for rehab!Click To Tweet

The solution is to use a radar gun and to track velocities over time, with specific markers set for the day’s throwing. Troy would throw and we would monitor his velocities of the implements thrown (more on this later), making sure they fell within a reasonable band depending on how he physically and mentally felt. We would mark this down and progress him responsibly over the length of the interval throwing program.

Back to Troy: First Things First….

Let’s get back to Troy Rallings, now that we’ve discussed the differing approach we’d be taking. Troy showed up, enthusiastic to start work but also not fully mentally recovered from the blow that was dealt to him. High Performance coach Jack Scheideman and I greeted him, talked over his on-boarding procedures, and saw him leave as he went to move into his temporary housing while training here.

Jack turned to me and said: “Holy s___, did you see that?”

“Yeah,” I responded, “He has lost at least 30 pounds.”

troy-underweight

Troy at 187 pounds – down from 215.

Said Troy:

Before I began throwing a very important issue needed to be addressed, my weight. I hadn’t been able to lift for about 6 months (3 before surgery, 3 after). I typically walk around at 210-215 lbs, yet I was a frail 187 pounds. 

We gave him a comprehensive strength training program that was heavily biased towards powerlifting and hypertrophy. While it was important for Troy to pack on as much muscle as possible, he also had to increase his overall strength totals before he could start any specific rehabilitation program. No amount of manual perturbations and fancy band work is going to solve being grossly weak.

troy-sample-strength

Sample intermediate strength program for Troy

Still limited in elbow extension, we had to program around his skill-based restrictions, which meant staying away from heavy pressing or distraction forces. No pull-ups, no heavy or fast benching, and so forth. Fortunately, through diligent work in the weight room and at the dinner table, Troy regained 25 pounds inside of 3 months while still hitting all of his mobility and stability targets.

On to Throwing: The Real Fun

Troy continued to clear his manual muscle tests, grip strength parameters, was killing it in the weight room, and his screenings were all well ahead of schedule. We checked with his therapists and they gave the green light to begin a throwing program. We decided to give Troy a week or so break in training to deload, telling him only to keep up his arm-specific rehab program and general mobility work. He would fly down to Southern California and then meet us in Anaheim at the American Baseball Coaches Association Convention (ABCA), which is the biggest amateur trade show for baseball.

And, oh yeah – Troy’s first day of throwing would be there. In front of Driveline staff, coaches, scouts, vendors, and random people walking by our already popular booth.

Here’s a still shot of Troy’s face on one of his first PlyoCare throws over the weekend:

troy-abca-day1

Troy throwing in front of Caleb, Dan, and Garrett

For weeks, Troy had been using PlyoCare balls in limited fashion – upward tosses, rebounders, and other partial throwing movements to build range of motion and isometric/eccentric strength around the shoulder, but this would be the first time he’d actually be throwing an object.

Troy would be throwing PlyoCare balls from day one, rather than exclusively baseballs. This window of adaptation for an athlete post-surgery is critical and one that almost always goes to waste when completing a normal interval throwing program. The minute you pick up a baseball, the tactile feel, the psychological stressors all come flooding back, and you very quickly revert to your primary programming. It is why changing arm action and pitching mechanics is nearly impossible through verbal coaching and throwing off a mound, even when using constraint-led programming.

Post-surgery rehabilitating pitchers have a window where their effort is intentionally limited for safety purposes, and have competition well down the road for them, eliminating time pressure. It is the perfect time to begin gradual changing of pitching mechanics, and the best way to change any ingrained ballistic mechanical pattern is to use variable weight and variable implement techniques. These concepts are decades old, pioneered by the East Germans and the Soviet sports science researchers who dominated field events (javelin, hammer, shot put, discus) for years on end with this knowledge. Dr. Anatoliy Bondarchuk wrote about it at length in his historically important texts, Transfer of Training I and II, and modern coaches like Derek Evely and Martin Bingisser have refined them over the years.

By having Troy go through our constraint-based throwing circuit using PlyoCare balls and sparingly few verbal cues, he was able to make small mechanical changes while reducing boredom of rehab days and gaining proprioceptive feel much quicker, another excellent side effect of using variable training methods.

schedule-1-troy

Matt wrote Troy’s programming while I supervised, and for ten weeks, Troy would be in the Throwing Fitness Improvement phase seen above. The weeks fleshed themselves out as Troy continued to improve in his charted velocities and manual muscle tests, as well as his metrics we started to collect using the Motus mTHROW sleeve.

During this time, we rolled out the beginning of our integrated manual therapy training methods, of which Troy was one of the first trainees to benefit. Taking a cue from elite training facilities like ALTIS (Phoenix, AZ), we decided to have an even tighter feedback loop when it came to treatment. This meant investing in our trainers to become IASTM certified in various disciplines, take Postural Restoration Institute courses, and so forth. Once every two weeks, Troy was getting a full “work-up” including IASTM on all affected areas, nerve glide work, and changing corrective exercise protocols based on these results. Every once in awhile, Troy would get extra treatment on localized areas, including the most common issue with bringing back pitchers from UCL reconstruction – forearm flexor tightness.

postural-measurement-troy

Troy would also get tight in the traps, another common side effect of starting an interval throwing program, as pitchers start to exacerbate forward head posture and “rolled forward” shoulders, as you can see above in our digital screening postural assessment as completed by the Microsoft Kinect2 and custom software.

High-Intensity: Competition Looms

As Troy completed his interval throwing program and was well ahead of schedule on velocities, we started to plan out his high intensity training period, which would start his return to the mound. Unlike most interval throwing programs, we do not recommend athletes touch a mound for bullpen work until they are well past their maximum throwing fitness marker. In Troy’s case, this meant throwing a baseball from a crow-hop in excess of 95 MPH. Throwing submaximal intent bullpens with an unsure elbow is not something we think makes sense for pitchers.

troy-high-intent

Matt worked up the twelve-week plan above (Sundays were always off). We had to make a change relatively quickly, as Troy’s ability to recover from high intensity skill-specific PlyoCare throws (from a sloped surface at high intensity into a wall) regularly kept him back, so we removed them in favor of other throwing circuits.

At 8.5 months into Troy’s rehabilitation, we gave him his first Velocity day, meaning running throws at supramaximal effort (compared to mound). I told him to take it at about 95% of RPE while we charted velocities, and I would have been happy with anything over 85 MPH at this stage, even though Troy’s fitness markers and constraint throws predicted a much, much higher competition number.

Troy threw regulation (5 oz), overload (6 oz), and underload (4 oz) balls from a running start, posting the following velocities:

  • 5 oz: 87.4 MPH, 93.4 MPH, 89.4 MPH
  • 6 oz: 84.4 MPH, 93.3 MPH, 88.2 MPH
  • 5 oz (round two): 96.4 MPH, 89.0 MPH
  • 4 oz: 90.7 MPH, 97.8 MPH, 92.4 MPH, 97.1 MPH

Troy’s Motus mTHROW elbow torque scores were consistent across the range, neither overload nor underload throws predicted higher elbow torque, and measurement of maximum external rotation (MER) was also consistent across the implements, though it was a bit low for the first session.

Obviously, Troy – and I – were pumped about his numbers, but the real test would be in the days to come. How would his body respond to such a stressor? Would he be able to recover quickly enough? Sure enough, it wasn’t an issue. The next week, Troy threw yet another supramaximal day, this time at 100% RPE. At 8 months and 3 weeks post UCL reconstruction, Troy hit the following number:

troy-5oz-98

Troy’s elbow torque and maximum external rotation metrics were trending upwards in a smooth, controlled fashion, just as we programmed it in accordance with Dr. Tim Gabbett’s chronic vs. acute load research – chronic load, progressed incrementally, is protective of injury, while acute spikes in workload predict injury:

gabbet-chronic-acute-load

Rehab Cut Short: Signed by the Angels

Troy called me and had news for me.

Two days later, I got a call from the Angels asking me to fly out to Arizona to sign a contract to be a professional baseball and finish my rehab at the Angels Spring Training complex in Tempe. Less than 48 hours after that it was official. I was an Angel. I threw my first bullpen this past week. It felt amazing. After a year away from the game, I am grateful for every day I get to suit up and be back out on the field. I cannot wait to take the mound in a game here relatively soon.

While I’ll miss Troy Rallings’ energy and antics around the facility, I look forward to hearing about his work down in Tempe as he prepares for either the Rookie-Level Arizona League or Instructionals with the Angels. He has his program that he continues to follow, and has thrown bullpens in preparation for sport-specific activities.

The following video has clips from his rehab and training process, and words from Troy himself for all of you.

Troy’s success and rapid return from UCL reconstruction using a very methodical approach is one that was heavily influenced from Marcus Stroman’s return from ACL surgery, which led me to design a data-driven rehabilitation program. I will give Stroman’s medical team the closing remarks, which should turn a lightbulb on in everyone’s head who works with injured athletes.

The personalized data that the Duke team gathered on Stroman allowed him to push forward faster than he would have with a one-size-fits-all regimen. “We’ve always gone from this chronologic base — Week 6, Week 8, Week 10,” Butler says. But “chronologic protocols don’t allow for five-month comebacks from ACL reconstruction.”

The key advantage to this data-driven approach is its capacity to eliminate the therapist’s bias toward a particular timeline or sequence of exercises, allowing the athlete to progress not when his doctor estimates that his body is ready, but when his body announces it is.

“I’m in the best shape of my life,” Stroman says. “I know people say that, but I can prove it with numbers.”

Obligatory Legal/Medical Note

This article describes the methods that Troy Rallings underwent in his rehabilitation from UCL reconstruction in tandem with highly-trained therapists and specialists. The advice dispensed in this article would certainly not work for everyone. Driveline Baseball does not rehabilitate injuries remotely or give advice to anyone who is rehabilitating injuries outside of our facility. Nothing contained in this blog post is intended to be used for medical diagnosis or treatment.

Comment
3
David

Got to know Troy over the past three years, first watching him at UW while my son was a recruit and a Driveline client, then after Troy started working out at Driveline. This is a wonderful story of the depths of personal travail, starting over from scratch, and self accountability. There’s no magic in this shit. It’s all about ingenuity, adaptive management, and the brutally intense mentality required to bet on one’s self. With Troy and Driveline involved, a very solid bet in my books. Congratulations to Driveline for setting the stage for advancing return to competition protocols. And especially congratulations to Troy for having what it takes to own it all. You deserve any reward you reap from this stage of your life.

Tyler Jozwik

I am soon about to get Tommy John surgery myself, this Friday the 19th to be exact. I am 18 years old and I have since grown a strong affection for the game. My fast ball only tops at 77 mph, but I had always felt like I could achieve a lot more, and had worked towards better, realistically though I am not sure if my body type could get me anywhere but I have the determination to try. Is there any type of rehab process I could do with pylo care balls to help my rehab process and help my biomechanics to my arm path?

Driveline Baseball

No program of ours should substitute a program provided by the medical professionals that know your case. With that said, we have a Return to Throwing Program that can be shown to those medical professionals to see if/when those exercises can be implemented. They might believe it is in your best interest to not use anything from that program. They know your case better, so defer to them with your rehab questions.

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