When approaching rehabilitation cases for pitchers who have had ulnar collateral ligament reconstruction (UCLr, or “Tommy John surgery”), the traditional model looks something like this:
- Surgery occurs and the arm is placed in a locked brace that limits flexion/extension at the elbow
- The patient is given a stretching/mobility program and ordered to gain full flexion and full extension before doing strengthening exercises (this can vary depending on the surgeon and physical therapist, but is largely similar across the board)
- The patient begins a “throwing” program
The throwing programs prescribed for post-UCLr are often called “interval throwing programs,” and this is an example of such a program from a prominent doctor:
It’s our opinion at Driveline Baseball that this type of program has two major flaws:
- It is excessively aggressive, especially when it comes to volume
- It lacks monitoring of any kind outside of distance
Your first day throwing on this program involves two sets of “warm-up throws” and 50 total throws from 45 feet. If you split the difference on the warm-up throws and call it 15 throws each (10-20 per the document), then you are making 80 total throws on your first post-surgery throwing day!
Not surprisingly, the most common side effect of these types of programs involves debilitating soreness and setbacks due to inability to overcome the volume of the program, which delays the rehabilitation clock.
Secondly, there is no monitoring outside of distance. Pitchers going out to 180 feet on this program do so at varying angles, velocities, intent, and rest periods between their throws. This program cannot be equally effective for the MLB pitcher who sits 95 MPH in games and the 17 year old who sits 83 MPH. Either the MLB pitcher is being overtrained or the high school pitcher is being undertrained – it’s not possible that neither is happening.
Instead, we propose a different method of rehabilitation. While we very much agree with the basic steps of a hard brace, regaining flexion/extension at the elbow, and then doing strengthening exercises at the forearm and shoulder before progressing into a throwing program, how we do throwing looks a lot different.
And since it never fails that we get ridiculous comments every single time we post a video of high-intensity throwing, like this one of Kyle Zimmer as part of his rehabilitation:
I guess this article is needed!
Our article detailing “pulldown” throws goes into a bit of detail, but I’d like to expand specifically on high-intensity throwing and why we do it with our rehab cases.
A Different Timeline for Rehabilitation
We’ve recently been tasked with the rehabilitation of various high-level pitchers, both amateur and professional. In all cases, we have a standardized approach but an individualized method. What does that mean? Let’s take a look at the standardized model, and then we’ll look into how it can adapt and deviate for an individual.
The Standardized Driveline Rehabilitation Approach
How we go about rehabilitation is fairly standard, but takes many branches once we collect data. The general model looks something like this:
- Pitcher has surgery, regains full flexion/extension, does strengthening exercises for forearm/shoulder, and is cleared for throwing
- During the flexion/extension and strengthening phases, our High Performance team and Physical Therapist meet with the client to perform a full assessment, and training economy is directed at regaining hip/shoulder mobility and stability through manual therapy, mobility drilling, and strength exercises. Lower body power is highly prioritized during this phase as well, with adaptive exercises programmed so no load will happen on the shoulder or elbow.
- Cleared to Throw: Start overload, low-velocity PlyoCare force acceptance program with extensive manual therapy at shoulder. Examples include Reverse Throws, plyometric “rebounder” throws, wrist weight work, and Upward Tosses. High Performance team begins attacking the elbow via strengthening exercises and assisted manual therapy as volume goes up and eccentric training is added.
- Force Acceptance Complete: Once the force acceptance period is nearing completion, low-velocity, overloaded PlyoCare forward throws can begin – examples include the Pivot Pickoff Throw and Roll-In Throw with blue PlyoCare balls. This helps to build dynamic range of motion in a low-velocity manner with little acceleration at the joints, which keeps peak stresses down but total stress up. The body adapts significantly better to chronic stress in a repeatable kinematic model, so patterning and verbal cuing is at its highest in this phase not only to protect the arm, but to effect positive mechanical changes.
- Overload, Low-Velocity Program Complete: When the low-velocity, overloaded forward throw program is complete, postural circuit throwing generally begins, as well as baseball throwing. Note that we complete two full phases of throwing before ever picking up a baseball in our rehabilitation program. We’ll begin yellow, red, and blue PlyoCare circuit throws, examples being the Rocker Drill and Walking Windups. We’ll also play catch with overloaded baseballs like the 6, 7, and 9 oz. weighted balls at low-intensity. In all cases, we are monitoring the velocity of the throws and keeping it below a certain standard for each day to ensure we are layering stress appropriately, slowly, and in tune with the athlete’s recovery and soreness levels. In many cases, we will use the Motus mTHROW sleeve to measure dynamic range of motion at the arm, valgus stress, and arm slot changes to ensure we are on a good kinematic path to recovery. This is our “interval throwing program.”
- Interval Throwing Program Complete: With the interval throwing program complete, we will now start some basic mound work to prepare the athlete, and then have them throw at 80-90% rate of perceived exertion (RPE) off our mound with reflective markers on to capture biomechanics (kinematics and kinetics) of the athlete. From this data, we can capture angular velocities and positions that are critical for future training insights – from what we should do in the weight room, to what our physical therapists and manual therapists do, to how our Throwing Trainers prescribe reps/sets and workloads for our athlete.
- Biomechanics Captured, Return to High-Intensity Throwing: With biomechanics captured and all of our trainers, therapists, and coaches signing off on the athlete returning to high-intensity throwing, we will begin that phase of our program. Most programs at this time will tell the athlete to get on the mound and start pitching, but we hold them back – we think putting an athlete on the mound who has not yet fully cut a ball loose at 100% RPE is a major mistake, and often leads to mechanical flaws and setbacks in their program. This is when we will program the famous “running throws” and get supramaximal intent from our athletes, almost always wearing a Motus mTHROW sleeve to calculate chronic and acute workloads and ensure we are not overloading our athlete. After the athlete can throw well above their pitching velocity, we will then put them on the mound, where they will both be supremely physically prepared, but also extremely psychologically confident given how their intensity has gone stepping up to this part of their rehab.
- Customized: Beyond this, rehabilitation becomes highly personalized, but at all times we are monitoring the athlete via full body biomechanics periodically, radar gun velocities daily, and Motus mTHROW sleeve readings on high-intensity or high-volume days.
The Individualized Method
So now we’ve talked about the standard model for rehabilitation – which is anything but standard in the current baseball community – but inside that model, a ton of flexibility and individuality was noted. Let’s go into a few specific situations where the rehab will change based on certain pathologies or setbacks the athlete is facing.
Body is a Mess: Additional Manual Therapy Required
We’ve had athletes in here who look like they’ve been in a car crash. In those cases, our Physical Therapist and Manual Therapists will red flag them for serious deficiencies, note it in Driveline TRAQ, and ensure that our High Performance and Throwing Trainers are all on the same page: We need to halt this athlete’s throwing program until we can resolve the issues at hand.
Some common problems we’ve seen that cause halting a program:
- Serious asymmetrical hip deficiencies
- Large lack of isometric power in internal or external rotation at the shoulder
- Very poor shoulder flexion
Body is Extremely Weak: Needs to Be Put on a Strength-Focused Program
This happens unfortunately far too often in our athletic population, which points to poor coaching in their past. Strength is vitally important for performance on the diamond, but it’s significantly more important when it comes to rehabilitation and recovery from injury! Think about it: Postural control is all about kinesthetic awareness of where your body is, the mobility/stability to get into and out of positions, and the dynamic strength to maintain those positions. If you’re lacking one-third of the equation (and if you lack strength, you usually lack mobility/stability, making it worse), then you’re asking for future injuries to occur or setbacks at the very least.
If an athlete cannot meet standards for vertical power production, it’s an automatic red flag from our High Performance team in Driveline TRAQ. Without the ability to dynamically stabilize the lead leg in the throwing motion, mechanics immediately break down and compensatory movement is found elsewhere. In a high-effort mound or running throw, the lead leg is blocking a significant multiple of the athlete’s body weight, so if the athlete can’t front squat 135 for a set of three in a controlled manner or explosively generate force in a trap-bar deadlift jump, then there’s basically no shot it’s going to happen in a more athletic, less controlled, more sport-specific environment.
In this case, the athlete will spend more of their training economy in the weight room, 4-5 times per week, and less of it throwing. They’ll also work closely with manual therapists and our coaches to ensure no mobility deficits crop up as a result of additional weight training added to their program.
Arm is Extremely Fast-Twitch: Volume Needs to Go Down
While Trevor Bauer isn’t the best example of a fast-twitch arm – quite the opposite, actually – most of our professional pitchers have high arm speed in their biomechanical assessments. This makes sense; many pro pitchers were born with genetic gifts that gave them a leg up in baseball. However, this trait, if not properly controlled for, causes a lot of problems in the rehabilitation settings. It’s also the reason for the original interval throwing program you see in the beginning of this post – medical experts for decades just defaulted on keeping intensity down to try and control for overtraining their athletes. Unfortunately, if there’s one thing you can bank on when it comes to professional pitchers in rehab, it’s the fact they don’t listen to people telling them to take it easy, especially with undefined metrics and no monitoring.
So, we’ve got an athlete who has very fast angular velocities and accelerations at the shoulder and elbow, which are predictors of high valgus stress at the elbow and distraction forces at the shoulder. What do we do? We first make sure we track their throwing in Driveline TRAQ using a Motus mTHROW sleeve; this becomes their new security blanket that they wear in addition to throwing at a radar gun at all times. Since we know the body reacts to chronic, readily-stepped stress better than it does sharp peaks and valleys in training stress, we need to keep the volume down as the intensity goes up for these fast-twitch athletes. In rehab, we may increase the number of days they throw, but reduce the number of total throws for that given day. We may also cut down on underload throwing and weighted baseball training in general, or program more low-velocity throws with heavier balls to try and keep peak stress down.
An MLB team trainer of 25+ years once told me:
I see athletes making the same mistake over and over again – they think long toss, flat grounds, and weighted baseball training is all ‘free’ training economy, and then they throw their bullpens at 60% effort. The only time they cut it loose are on game days, which is highly inappropriate. There is no specificity to their training between start days!
Since I couldn’t put it better myself, I figured I’d just quote him and let him figuratively drop the mic.
Wrapping it Up: Rehab Needs to Change
If all you got from this post is that high-intensity throwing has a place in the rehab setting, then great, that’s good enough!
What we want to reinforce is that baseball rehabilitation desperately needs two things that it doesn’t currently have, which are:
- Improved monitoring of arm/body mechanics and workload (kinematics, kinetics, chronic/acute stressors)
- Better communication between skill-specific coaches (baseball) and medical professionals (Physical Therapists, Orthopedic Surgeons, Manual Therapists)
We’re attacking it via our integrated staff training methods, technology, and Driveline TRAQ – and results have never been better both on the performance AND rehab sides.
If you’re interested in rehabilitating at Driveline Baseball, drop us a line. And if you’re a coach who wants to learn more and plan a visit, do the same. We’d love to hear from you.