Archive for the ‘Tommy John, Arm Care & Rehab’ Category

Being injured is tough.  It raises questions in oneself such as, is it really healed? Am I going to re-injure it? Am I going to have to endure another rehab stint, or worse yet, another whole surgery?  Is my career going to end if I hurt it one more time?

All of these gnawing questions plaque every ballplayer who undergone rehab or the surgeon’s knife.  Many get over these fears once they return the mound and are assured by their pain-free performances that problems are safely in their past.  Yet, many players never fully get over this mental hurdle and face decreased performance as they hold back, protecting their body from the 100% effort that they fear will result in further injury.

Thing is, this is no way to live, and certainly no way to play.  It takes a lot of reckless abandon to sprint full speed on a hamstring that has been painfully pulled, or really try to hammer a fastball by someone on an elbow ligament that tore from the bone just a year ago.  Even years down the road from an injury these doubts still persist and can hold a player back from his true potential.  So, how do we get past these mental speedbumps and roadblocks?

This is, unfortunately a tough question to answer.  I think for many, it just takes a gradual approach building confidence in the repair bodypart, with sustained pain-free performance that will ease the mind completely.  This is the path the sensitive person would probably prefer, the guy or gal who doesn’t like to push through pain that might not be indicative of any structural damage.

I make mention of structural damage because it’s an important distinction to make in one’s rehab.  Especially after surgery, the repaired bodypart is never like it used to be, and weird, random pains are a daily occurrence, even well down the road. Thing is, they usually don’t mean a damned thing.  Speaking from experience, I had some pain in my forearm that was unrelated to my Tommy John surgery.  They told me just to keep going, because it wasn’t something worth slowing down for.  Talk to anyone who has undergone surgery, and they most likely received the same advice from their surgeon at some point.

So, some people need to see pain-free results to be convinced to allow themselves to put forth a little more potentially-injurious effort, but others just need to feel their back against the wall…

I had this conversation with my friend Zach Clark, who has enjoyed a great pro career in the Orioles system for the past 5 years.  He worries about his arm sometimes, despite being a number of years out from his last major injury.  With a guy like him, who is only a level away from the Major Leagues, he has more reason than others to protect his arm by holding back.  His career has been maintaining on his current effort level, and an injury would seriously compromise his future.  So, he has a lot to lose and not too much to gain (since he has been successful doing what he has been doing) by trying to a little harder.

But, for a guy like me, who is in post-surgical and post-collegiate limbo, I have much less to lose.  The way I see it, if I hold back to protect myself and only throw, say 88, I jeopardize my attractiveness to scouts and pro coaches.  Yet, if I throw without inhibition, I may (or may only perceive to) put my arm at greater risk.  Now, my arm is certifiably fixed, but remember we’re not talking about reality here, only perception.

Either way, for a guy in my situation with his back against the wall, it’s damned if you hold back or (perceptibly) damned if you don’t.  So, I choose to attempt to reinjure myself with each and every pitch.  Sounds reckless, right?  Well yeah, it is, but not more than any other pitch thrown by any other pitcher at full speed…

A pitcher has to have confidence in himself and his arm to throw at his maximum velocity any and every pitch if he needs to.  So, post-surgery or not, the intent needs to be to throw the shit out of the ball every single time.  Throwing the ball with such intent is what separates pitchers labeled “aggressive” and those labeled “nibblers” or “conservative.” And you don’t have to throw 100 miles per hour to throw your pitches aggressively…

So reason with yourself, and make a deal with your arm if need be.  I’ll give you an example of the deal I made with my elbow a few months ago:

Me: Elbow, I’ll make you a deal: I’m going to abuse you, and I’m going to throw each of my pitches from here on out with the intent to destroy you again.

Elbow: Whats in it for me?

Me: I’m going to give you more strengthening exercises than you could ask for, so that if you get hurt again, it’s your own fault.  I’ll ice, massage and treat you better than any of my past girlfriends.  You’re gonna be taken care of, so you better start taking care of me and my career…

Elbow: That sounds like a lot of work.  Do I have a choice?

Me: No. And f you start hurting and complaining to me, I’m gonna get angry and start throwing even harder out of frustration, because I know there’s nothing actually wrong with you, and that you’re structurally sound and plenty strong to withstand at all.

Elbow: So I should just keep my mouth shut, is what you’re saying, because you’re not gonna stop no matter what I do?

Me: Babies often cry for attention, and I’m done babying you.  Cry all you want, no one will be listening.  I’m not gonna pitch scared anymore.  I’m giving you all the strengthening you could possibly need, so it’s just go time, no questions asked.

Elbow: I hate you, Dan.

Me: I hate you, too, but we’ll be friends again someday.

I jotted down notes about my bullpen or general throwing sessions from months 7-9.5 of my recovery.  I discovered it while cleaning my place.  I’m just rewriting what I had down, so I may or may not be able to clarify if you have any questions.

March 22 – Good, not sore

March 24 – Good, not sore

March 26 – 7 months – Good, not sore

March 28 – 15 Changeups; good, but not perfect

March 30 – 10 changeups, discomfort on 1/3 of them

April 1 – 3/4 speed; no changes, no pain, 66-71 mph. felt ok, not perfect next day

April 3 – felt good, not perfect; 45 pitches @ 3/4 (speed)

April 6 – 1st two digits had pain when pressure applied

April 9 – mid to upper 70s, little pain; felt good after 4 days off prior

April 17 – no pain! 65 pitches at 3/4

April 19 – long tossed to 240 no pain

April 21 – felt good. into low 80s maybe

April 23 – gun read 75-77. TIRED! but no pain

April 25 – 8 months – Hit 81, consistent 76-79 50/30 pitches

April 28 – long toss to 270, 45 pitches at 85%

April 30 – 30 + 45 vs hitters. 82-84. Felt good

May 2 – VERY tired from April 30.  Arm achy and slight pain, very dead. threw 70 at 2/3 speed

May 4 – flat ground, 15 curves at 50 ft. pain still, arm not recovered from previous.

May 7 – Hard pen, felt good. 80 pitches at 90%

May 9 – good long toss, felt great.

May 11 – 100% from mound, 100% changes, 50% curves (15). felt good, no pain, but knotted up on forearm after.

May 14 – 100% fast + cu, no curves. Still knot in forearm but no pain

May 16 – 45 fast-curve-change, 75-75-50% respectively. less tightness, no knot next day.

May 18 – Light pen, 30 curves

May 20 – In game, 28 pitches. 30 curves beforehand. Bicep Dead, big knot afterward.  No throw 21-24.

May 25 – In game 35 pitches, no knot after, felt good

May 27 – 70 pitch pen, 30 90% curves, felt good, bicep better

May 29 – 50 pitch, 70%, curves getting sharper!

May 31 – 60 in game; arm felt slow, but great after. 55 fb/ 5 curves. No tightness at all.

June 2 – Long toss, hard but not too many throws. Need to get intensity up and let go. Felt good next morning.

June 4 – Bullpen 20 max effort, 85-90.  Arm felt achy, some occasional pain twinges, and very dead.  Decent next day. Fatigue in bicep/tricep still, but not terrible.

Thats the whole log.  Wish I had done more of that during it all, but I was more interested in getting after it than writing it all down.  Hindsight…

By Bill Blewett

In spring training 2001, researchers from Philadelphia’s Jefferson Medical College used high-resolution sonography to examine the anterior band of the ulnar collateral ligaments of 26 major-league pitchers.

The ultra-sound tests revealed micro-tears in 69 percent of the pitching arm UCLs of these 26 pitchers, who were between the ages of 21 and 39. Calcifications, which often accompany ligament injuries, appeared in 35 percent.

“The image quality produced by sonography has dramatically improved to the point that the wear and tear that occurs in a pitcher’s arm is now visible on an ultrasound well before he experiences symptoms,” says Dr. Levon N. Nazarian, the lead author of the study.  “Our results showed that when the pitching arms of these professional baseball players were stressed, the anterior band of the UCL was thicker, was more likely to have micro-tears and calcifications, and had a greater laxity or looseness in the joint when pressure was applied.”  The extent of ligament degeneration strongly correlated with years in professional baseball.

The study, published in the journal Radiology in April 2009, provides a significant piece in the puzzle of the UCL anterior band, the troublesome piece of sinew the size of a stubby pencil that often defines the success and duration of pitching careers.

The study not only demonstrates a remarkable diagnostic tool for seeing changes in the UCL before the onset of pain or disabling injury, often resulting in Tommy John Surgery.  It also provides evidence that degradation occurs to this critical component of the throwing arm gradually over the course of a pitching career.

Ligaments and tendons are cable-like bundles of collagen fibers.  As with any cable, breaking one strand will make it imperceptibly weaker.  It is not until a significant portion of the strands break that the ligament becomes significantly weaker, more compliant, more susceptible to complete failure.

There is anecdotal evidence that this weakened condition results in a diminished maximum velocity of the fastball. The UCL anterior band is the cable that transmits the torque of internal rotation from the humerus bone in the upper arm to the ulna bone in the forearm. The 5-m.p.h. fall-off in fastball velocity that typically occurs at the end of a career or before a UCL injury becomes acute is the likely result of weakening of this ligament.

An indication of this condition is instability of the elbow joint.  The Jefferson College study showed that when stress was applied, the joint space in the pitching elbows of the 26 subjects measured 4.2 mm on average, significantly greater than that of the pitcher’s non-pitching arm, which averaged 3 mm.

A compliant tendon, one that stretches more easily, is like a slipping clutch on a dragster.  The rotational acceleration of the arm is indeed dragster-like.  In the internal-rotation phase of the pitch, the forearm’s angular velocity exceeds 7,000 degrees/second, the equivalent of 1,200 rpm.  It accelerates to this velocity in just 0.03 second, placing huge stress on the UCL.

Ligaments and tendons are elastic.  For example, biomechanical studies have shown that the elasticity of the Achilles tendon in humans and similar tendons in animals provides storage and return of energy with each stride while running. Like all elastic materials, ligaments and tendons have a strain limit. Once a collagen fiber stretches beyond 105% of its normal length, it is likely to break.

The science of how ligaments and tendons heal indicates that the damage of broken fibers is not completely reversible. Though the human body produces new connective tissue for repair, it does not organize the tissue of tendons and ligaments into the original structure of long bundles of fibers.  The healing rarely creates a structure that is equal to its original strength and elasticity.

One implication of the irreversibility of ligament damage is that that there is only a finite number of strain-limit pitches in an arm.  That number may vary with the thickness of the ligament the pitcher has been given by the genetic dice-roll; with individual differences in pitching mechanics, strength, and flexibility; and with the cumulative number of maximal-effort pitches thrown. Pitchers who exceed this strain limit too frequently eventually suffer the cumulative result of broken fibers that leads to Tommy John surgery.

Though the sonography study brings good news — that UCL degeneration can now be measured before it becomes critical, the bad news remains: there are few practical options for preventing the degeneration, short of not pitching.  Here are some possibilities:

Proper wrist extension. Some pitchers begin the acceleration phase with the wrist locked at zero degrees of flexion.  This produces greater stress on the UCL than does extending the wrist during acceleration.  By extending the wrist 30 to 40 degrees (angled toward the back of the hand, as shown in the photo above), as most pitchers do, the ball is about 5% percent closer to the elbow on a fastball grip, reducing the resistance to acceleration by the same percentage.  The wrist flexes later, transferring momentum just before release.

Light- and heavy-ball training protocols.  Throwing a 6-ounce baseball places 20 percent more stress on the UCL than the standard 5-ounce baseball.  If maximal effort is applied with the heavy ball in this light-then-heavy routine, the additional stress could hasten degeneration of the UCL.

Lighter baseballs for young players. This concept has been presented in scientific papers by Dr. Glenn Fleisig of the American Sports Medicine Institute, a prominent research scientist.  Throwing a 4-ounce baseball would reduce the stress on young elbows by 20 percent.  There is precedent for this lighter-for-younger approach in another throwing sport.  The men’s shot put increases from 8 to 12 to 16 pounds from middle school to high school to college.

Fewer maximal-effort fastballs.  This may be the least practical path to UCL preservation, because the gatekeepers to professional baseball are armed with radar guns.  No one is likely to ascend to the majors by pitching the way they did a century ago — by throwing high heat only when there were base runners.  There are many major leaguers who have succeeded, however, by dialing back on fastball velocity.

*Bill Blewett is writing a book exploring pitching velocity including its history, how it is produced, and what we can do to manage, increase and further understand it.  The book will analyze the latest research to gain a better understanding of the elusive act of throwing 90+ mph and the implications that throwing hard has on the human body.*

By Steve Eagerton, Pitcher & Tommy John Patient @ Jacksonville University

The most painful part of coming back from my experience with Tommy John was restoring my range of motion. I was removed from a semi hard cast at two weeks post op., and the next day I started range of motion exercises.  It took me about 5 weeks to get full range of motion with my therapist moving my arm and almost 8 weeks to get full range of motion on my own. I literally thought my elbow would explode some days- it hurt so bad.  Of all the people I know who underwent Tommy John, I seem to have had the most pain. I think maybe it was because I had a lot of scar tissue, or maybe I am just a sissy (just kidding!).

Full range of motion for me, using my left arm as a guide, was 0-147 degrees. I think the first day I reached 20-88°. We tried to increase the ROM about 10° a week. I got full extension pretty quick, within about 3 weeks, but I made shorter strides in gaining flexion.

For TJ patients, I recommend making sure you keep it moving outside of rehab because if not you won’t progress as quickly. For the first week or two I was so sore that I would just keep my arm immobile on non-rehab days. Eventually I realized I needed to move it, even if just a little, to keep it from stiffening up.

I just want those who think they are hurting a lot while trying to reach full ROM just to know you aren’t the only one, and to grind it out.

The pictures come courtesy of Steve Eagerton, and they are simply amazing.  I have absolutely no idea what is going on in any of those pictures.  Surgeons are incredible.

Probably the most difficult facet of the recovery process has been me, in my head, wondering if I have plateaued, and whether or not I will continue to improve in the coming months.

I remember the first time I threw off the mound.  It was timed so that I started in Florida, during our spring break trip, and I can recall my 3rd bullpen session, which I threw on the side at the University of Miami.  That day I felt really fresh, and was confident in my arm after having two mound sessions already under my belt.

So I did my 45 throws or whatever at 60 feet, and I remember feeling like I was popping the ball.  It was on a line, and it had a nice crisp sound, and I was just pleased as shit about it.

3 or 4 weeks later, I was still doing largely the same routine, but throwing with more intensity.  I felt like it was time to get out the radar gun.  I was throwing 75%, so I figured I should be around 70 with very little effort.  So I start throwing, and they start shouting back my velocities…

64.  62.  61.  64.  Really?  So now I try to throw a little harder.  64.  64. 63.  What?  I just muscled up and its still only 64?  This is ridiculous.  Thing was, I didn’t feel like I was throwing 75%, I felt like I was throwing 100%.  It was the hardest I had thrown in 6 months, and it looked and felt like I would never again throw a ball over 65 mph.  Not happy. Read the rest of this entry »

One of my readers here wanted to share his throwing program with everyone.  It’s unique; I haven’t seen one like his and like I have said before, every player and doctor are different and it’s always interesting to see how the same surgery is handled in different ways.  He left this to me as a comment, but I figured I’d do one better and post it.

This is actually a really nice idea, sharing each person’s surgery information.  If anyone out there is interested in doing any writing, or sending me anything that they think would benefit the tommy john community, please hit me with an email.  I’ve posted my thoughts, maybe we can post yours…

*Understand also that this, and any program posted here, is for reference only, and one should always consult a doctor before starting or altering a rehabilitation protocol*

The following is all courtesy of Steve Eagerton, so I want to send a big thank you out to him for providing this to all of us.  I wish him all the best in his recovery, and it’s easy to tell that he is strongly in control of his rehab, which is great.

I thought I would leave my throwing program on here my Dr was Dr. Jordan out of Tallahassee, FL FSU team doctor has well as several other team doctors. I have been following this and am starting week 5’s throwing this week. I don’t follow this to the letter more than anything just listen to your arm. The first 6 weeks are not about velocity at all the DR has stressed just tossing. The Dr actually cleared me to start tossing @ 16 weeks and not at 4 months. My 1st day of throwing was August 16th. I am a 21yrs old RHP pitcher at Jacksonville University redshirt sophmore.

Week 1 @ 4 months
Tossing 50ft 25 throws every other day

Week 2
Tossing 50ft 25 throws daily Read the rest of this entry »

Time makes fools of us all.

At 8.5 months I thought I was ready to pitch in games. I thought I was ready to get back in front of scouts at 10.5 months.  Not so fast.

I don’t know where the time went, but my smooth and swift cruise through rehab got choppy, eventually slowing me down to an idle this summer.   Read the rest of this entry »

The following six exercises are prescribed to any ballplayer with elbow pain.  Be it tendinitis, UCL strains, sprains, or surgery, these forearm exercises are the ones that strengthen the whole forearm and ward off future elbow problems.  To the untrained thrower doing this prehab can also add a few MPHs, as the forearm and hand are the last mechanical parts in the delivery of a throw.  Today is the perfect time to start doing these exercises regularly.

These exercises can be done with dumbbells or a flat or tubular Thera-band (Flat is preferred). You can find Thera-Bands here: Thera-Bands 6 Yard Box (6 in. wide)

Pronation, supination and ulnar deviation are best done with a ban, mini-sledge hammer or baseball bat (though they are shown below with a dumbbell).

Forearm Flexion

Forearm Extension Read the rest of this entry »

Most good things in life can arise from something bad.  So is the case with Tommy John surgery. TJ is unique among major  arm surgeries in that it potentially provides a greater than 100% recovery.   Getting to 100% or above, however, is a matter of capitalizing on the time off, and making the most of a bad situation.

So here I’ve compiled a list of the top 5 good things one can get out of a little elbow-slicing action… Read the rest of this entry »