As I was in there, it suddenly dawned on me: Pitchers are just unlike everyone else in the sense that what they do is so physically violent, that they have to do what is called “prehab” just to reduce the likelihood (or in reality, delay) injury.  

Its pretty much a fact that if a pitcher doesn’t do regular rotator cuff, scapula, and forearm work (basically the whole pitching arm), he is doomed to inevitable, catastrophic arm injury.  Doing prehab doesn’t guarantee health by any means, as tons of diligent pitchers still injure themselves regularly, but its our insurance policy, and at the very least gives us a better chance of not being injured.Other athletes don’t do this.  Soccer players play soccer, and when they get hurt, they do rehab and return to action.  Lacrosse, football, tennis, you name it, these sports all allow their athletes to play, with nothing intrinsic in the sport that injures them.  Sure, football and martial arts are violent and injurious, but the injuries are general and not caused by any specific physical act.

Baseball position players are also allowed to play.  Sure, they come down with the occasional arm problem, but with not nearly the regularity as the pitchers. 

No, pitchers are the only athletes that aren’t just allowed to just play their sport.  They simply can’t show up at the ballpark and leave when they are done.  They have to spend extra time strengthening and stretching their throwing arm just so it’s less likely to rip itself out of the socket.  Ever seen a pitcher’s arm lay back, parallel to the ground in external rotation?  Try replicating that in your living room, and you’ll start to understand…

The pitching motion is just ungodly stressful and unnatural for the human body.  Its  interesting how in the entire athletic community, this one position in one sport is so different from the rest.  Sure, all athletes have to strengthen their bodies to compete at a high level, but none but the pitcher are at such an injury risk where they must go above and beyond just to have a chance at longevity, and even then it’s often a losing battle.  

The only other trends like this are in knees of female athletes and football linemen.  Women are predisposed to ACL injury due to their natural body shape and unique biomechanics, and have an ACL injury rate something like 10x that of men.  A good friend of mine just tore hers for the second time.  Football linemen are so heavy and get pushed around so much that they suffer a similar fate.  

I, for one, am ready for titanium ligament replacements.  Maybe one day that will be possible.  I’ll gladly call myself a cyborg if it allows me 20 more good years.  

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.

So next time out I did the same thing, and this time it was 65-68.  An improvement, but still terrible, and it still felt like I was throwing as hard as I could.  Everyone else said it looked like I wasn’t trying, but I sure felt like I was.

This was how the next month or two went.  I would feel like I was throwing my hardest, but I really wasn’t recruiting much of my arm or body.  Velocity crept up in each bullpen, and I gained 3-4 mph per session for a couple of weeks.

But even as velocity crept up, I felt so far away from throwing the way I used to. After seeing 75 mph leave my hand and feeling like it was the best I could muster, I couldn’t believe how I ever used to throw a ball 90, or would again.

I still suffered from that months later, and I had been sitting in the upper 80s for about 2 weeks.  The velocity has been stabilizing in my outings, but I still wasn’t where I once was.  So I wondered, had I finally plateaued?  Everyone said no.

At that time I was doing nothing but pitch from a mound, and I had no idea how little extension I was getting until I finally long-tossed.  What a difference.

Since I was throwing so much on my rehab program, I also had no idea how fatigued my arm had gotten. It wasn’t until I took 5 days off that I realized, again, what a fresh arm felt like. What a difference.

Those little victories came and went, and over such a long time of throwing and rehabbing I had forgotten the little nuances of my delivery, such as really reaching out, and how to schedule my throwing, including when to rest up.  I finally broke through my plateau and started throwing a few ticks harder because of it.  It just took a new stimulus and a little rest.

Little plateaus will happen, and it’s hard to not get frustrated when you wonder if its finally THE plateau at the end of the recovery, when the new you is finally fully baked.  I’m still not there yet, even 13 months later, because I had a 2 month battle with forearm tendinitis.   I decided after taking care of that and going to a tryout, I was gonna take my off-season rest, which I am currently enjoying.

Doctors and trainers say that a lot of times it takes that first off-season before the new elbow reaches its full, and hopefully greater, potential.  As much as seeing the changes throughout rehab was exciting, man, it feels nice to not worry about it for a little while, and focus on myself in other ways.  To be continued.

Yet despite it’s popularity, the YTWL circuit is often done improperly, and actually contains some movement patterns that aren’t useful: specifically, the W.

My shoulder routine has consisted of the YTWL for a few years, coupled with an additional standing shoulder/rotator cuff circuit.  However, for the YTWL, it is time for a upgrade, and that is why I have made the switch to the YTLP.

My friend Nick Tumminello at Performance University has been evaluating the YTWL for a while now, and has done a series of videos on how to perform his newly developed L-Y-T-P circuit perfectly, many of which are featured below.  Read some of his other great training articles on this page.

Nick has made a lot of changes to the circuit, which I am going to highlight in this article.  The biggest is a call to eliminate the W pattern, which he swaps for the (P)ivot Prone.  Rest assured, adopting the new circuit is going to give you stronger shoulders and more scapular stability than you’ve ever had before, even if you’ve already been doing the YTWL.

Before you get going…

Go in order: The order in which you perform these exercises matters!  LYTP is ideal because it progresses from most difficult to least difficult, thus allowing you to face the hardest exercises when you are fresh.

Choose your posture: you can perform this circuit a few different ways:

-laying prone on a flat bench, training table or the floor

-standing with knees bent and a flat back (as if doing an RDL)

-with knees bent and stomach on a stability ball

-standing with your back bent to 45° (this is good as a way to work the same muscles on a new angle).

-prone on an incline bench, at any angle up to 45°. (Again, to alter work angle)

The following video goes deeper into the issue of posture:

Gimme a L

The L is the first exercise.  To perform, lay prone with arms hanging down. Pinch your blades together as you pull your arms straight back, keeping your elbows at 90°.  Then externally rotate them back to finish.  Lower them in the reverse sequence.

Finish Position of L-Raise

Gimme a Y

The Y is next.  Rather than rehash, watch the video below for full instructions:

Gimme a T

Third in line is the T.  Again, we have a good video to explain:

Gimme a P

And we will end with the pivot prone, which represents our P.  As Nick explains in the following video, the pivot prone reinforces a developmental movement pattern that we are all born with.

What’s that spell?

LYTP!  Well maybe it’s not that exciting, and it’s certainly doesn’t spell anything, but it will do wonders for your shoulders and scapular stability.

As a pitcher, I usually perform these with 2-4 lbs, for 2-3 sets of 12-15 reps, 2-3 times per week.  Each rep is done with a 1-3 second pause at the top.  If you’re a beginner, start without weight, get a good pause at the top, and then progress with weight as strength increases.

I can remember doing these without weight for 20-25 minutes a day a few years ago, trying to correct for a condition called SICK scapula. I got stronger in a hurry, and have had healthy shoulders since. The LYTP is a great circuit to get that bullet-proof rotator cuff.

That first throw was pretty scary, but I knew I was ready for it, and it went fine.  It felt just like it used to. I started out at 30 feet, progressing to 40 feet x 60 throws by the month’s end.  Month two moved me back to 50 feet, and month three to 60. Midway through month three, however, I switched to a different throwing program because I was progressing faster than my throwing program would allow.  

I talked earlier about falling on my arm when I was running and how important that was in trusting my arm.  The first day I let a ball go on a line was another such moment.  After every single throw was on a soft arc, letting one go on a line was one of the first tests of my new ligaments.  I can remember that first throw, and how liberated I felt when I did it without pain.  I only uncorked a few of these per session, but they always provided me with a release from the tension of wondering if my elbow was really strong enough to get me back to where I once was.  

In the middle of my third throwing month I jumped into Dr. Andrews’ throwing program, which my training staff had a copy of from a previous TJ patient.  It called to move up in distance and in throwing volume every time a stage was completed twice without discomfort.  On this program, one can move as fast as his arm is able, and if he has pain, he just backs off and slows down.  I moved through this program without a hitch until a month into the mound phase.

I started having some slight pain in my forearm once I was throwing about 3/4 speed from the mound.  It was only initiated through pressure on my fingertips, however, and not really with throwing, which assured me that it wasn’t a ligament problem, and was probably just one of those minor complications that accompany the surgery.  It only slowed me for a few days, and it later subsided.  My doctor told me it wasn’t something that I need to worry about, since I stopped having pain with it while throwing.  

I threw some long toss days in with the program, as long toss always helped my arm feel good and it keeps me in good mechanical timing.  The thing I realized most was that the throwing program was just a guide for incremental progression. Progressing continually was the key, and whatever I wanted to do was fine as long as it stayed within the confines of moving up in small steps.  Long tossing to 300 feet one workout after only long tossing to 240 feet before would not be OK, because that’s a big jump in the throwing load.  But from 240 to 270 is a better choice, and one after which your arm won’t hate your guts.  

You'll get there, one at a time

I wish I had a copy of the throwing program to post, but I don’t.  At first, I wanted to adhere to it 100%, and any deviation from it made me feel afraid that I might hurt myself.  But the farther I got in my rehab the more I learned that my arm would tell me what it could and could not handle, and that just moving progressively but prudently was what really mattered.

One major adaptation of the pitcher is in shoulder range of motion (ROM). Pitchers have incredible, otherworldly external rotation.  The average person couldn’t dream of contorting his arm in such a way.

My buddy Andrew Germuth showing off his external rotation

My buddy Andrew Germuth showing off his external rotation

And what price do we pitchers pay for enjoying such lavish external rotation?  You guessed it! A tight rotator cuff and a subsequent deficiency of internal rotation. (there is always a catch!)

So what?  Does it matter if a pitcher has poor shoulder range of motion internally?

The answer to this question is unequivocally “yes.” Any trainer or physical therapist will tell you that a lack of ROM in any joint is pathological and indicative of underlying problems.  Normal ROM should exist in all one’s joints, and if not, there is a probably a problem as to why.  In many populations these imbalances in flexibility might not impair day-to-day functioning, but for athletes and especially pitchers, inflexibility poses major problems.

Dr. Craig Morgan and colleagues are researching the link between elbow pain (up to and including full blown ligament tears requiring Tommy John surgery) and internal rotation.  What he is finding (as he found in me) is that a huge amount of pitchers coming to him have significant GIRD (glenohumeral internal rotation deficiency), and once that GIRD is reduced to an amount within 20 degrees of the internal rotation of the non-throwing shoulder, the pitchers very often return to throwing without pain.  Internal rotation deficits are caused by posterior shoulder capsule tightness, which can be alleviated using the sleeper stretch.  Restore your internal rotation ROM and you will be throwing healthier and harder.

The Sleeper Stretch

The basic form is as follows: lay on your hip with knees bent, with ankles in line with your spine.  Prop your head (or don’t if you like being uncomfortable) under a towel or pillow, your glove or whatever.  Extend your throwing arm out in front of you at 90°.  Keep your chest out and don’t lean back.

Sleeper Stretch Starting Position

Next you need to pinch your shoulder blades together, hard, and hold them that way throughout the stretch. This is crucial, and the stretch is useless without pinched blades because your shoulder will be in improper position.

The WRONG Way – Blades not pinched, shoulders misaligned

The CORRECT way - blades pinched, shoulders in better alignment

CORRECT – blades pinched, shoulders in better alignment

I held a pencil in the middle of my back for effect – think about holding something there while you perform the stretch.

Once your blades are held together, take your other hand and GENTLY push your arm toward the ground.  Don’t force it, just give it enough of a push to feel a stretch. I have to stretch mine 3 times daily to keep it loose, and from the beginning it will take a few weeks to really loosen up.  Forcing it won’t help, it will just cause more problems.

A good sleeper stretch

A good sleeper stretch

Notice how much internal rotation I have in the above picture: about 45 degrees. Once I go through this I gain about 10° more, but that’s it.  Watch what happens when I don’pinch and hold my blades together:

The WRONG way. If you look like this, your shoulder blades are not pinched

The WRONG way. If you look like this, your shoulder blades are not pinched.

If you see someone at the field doing the sleeper with their palm almost on the ground, correct them, because they are doing it wrongly.  Try it the right and wrong way so you feel the difference.  In proper position with blades pinched, if you have 45 degrees like I do, then you are looking great.  When I go in for checkups I measure symmetrical to my left. Everyone has a different setpoint, but no one can put their palm to the floor. It looks about the same, though, which is why players so often do it incorrectly.

Variations and Reps

So now you’ve mastered the form in the 90° position.  The three positions from which you will stretch are 90°, 70°, and 110° from your shoulder to your body. Stretch your arm for 3 sets of 30 seconds at each position.  Even at 70 and 110, keep a 90° angle with your forearm and upper arm.

Correct angle between forearm and upper arm

 Correct angle between forearm and upper arm

INCORRECT angle between forearm and upper arm

INCORRECT angle between forearm and upper arm

Proper stretch at 70 degrees from body

Proper stretch at 70 degrees from body

Proper stretch at 110 degrees from body

Proper stretch at 110 degrees from body

The orientation of muscle fibers in your rotator cuff varies, which is why stretching three positions is recommended.

So do your sleepers daily, and do them correctly.  If you do, you’ll be taking a huge step toward both keeping yourself injury-free, and picking up some MPHs. Flexibility plays a big role in velocity, and I picked up 3-4 from increasing my ROM in my shoulder and in my hips.

Additionally, check out my great new article and video on Sleeper Stretch Variations!

Update – Here is a video from the Morgan-Kalman clinic, where I was taught this stretch. Watch it!

**I am a strength coach and pitching instructor in the Central Illinois area. Personal training, pitching lessons, and custom training programs are among my available services. If you liked this post, please subscribe to my monthly newsletter – you will receive member-only tips, tricks and/or special offers on services and products.**
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Thanks for reading! -Dan Blewett

The first 3 months post-op were exciting in the sense that everything was new and changes were dramatic.  Things returned to normal rather quickly, and it was all building up to that fateful day when I would chuck that pill again, even if it was only for 30 feet at first.

Surgery Day

I was in and out of the O.R. in about 75 minutes, and I had minimal pain and wasn’t overly groggy or out of it.  I had a prescription for Vicodin and a sling on my arm that I was to keep on for two days.  I was told I could move my hand and arm around in any way I wanted, and I could squeeze a soft ball.  I went home and did all of the above, though I only had the strength of an infant with low blood-sugar.

I was worried about my arm not being immobilized, as I had previously mentioned, but I dealt with it, and I was quite nice after those two days passed and I had only an Ace bandage left covering my incision.

Week 1

I was given 4 different Thera-Bands  at my 7 day post-op visit and was instructed to perform 4 exercises with them every day.  I was to start light and move up once I could perform 2 sets of 20 reps with each exercise. The four, which I still do daily 9 months later, are: Wrist Flexion, Extension, Supination and Pronation.  I also continued to squeeze a soft ball.

Weeks 2 to 3

My other goal, beside strengthening my forearm, was to extend my arm.  As soon as the brace was off I was on my own to do this as tolerated.  All day I would just flex and extend, flex and extend, flex and extend.  The first 150 degrees or so of extension came within about 2 weeks, but the last 30 and then 15 degrees were tough to get.  By about 3 weeks I could fully extend my arm, but upon awakening It would usually be a little less than straight until a week or two later.

Since Dr. Morgan views glenohumeral internal rotation deficiency (GIRD) as a chief factor in elbow problems, I was instructed to resumed sleeper stretches and hip flexibility exercises at week 3.  Addressing and correcting flexibility problems before throwing was a necessity.

One of the most helpful exercises in getting my arm to extend was to prop a pillow under my tricep and hold a 1 lb dumbell in my hand, allowing gravity and the weight to extend it.

Weeks 3-6

At the week 3 check-up I was given the green light to start conditioning again, as my incision was closed and sweat would no longer cause an infection risk.  So I started running, doing Bikram yoga, and lifting weights to the extent I could without using my right arm.  I also started with light scapula exercises, which I also performed with Thera-Bands.

Slightly Swollen Elbow at Week 3

I was able to squat using a Top Squat attachment, and I did a lot of sled dragging with a harness, and body weight and weighted vest exercises.  I was happy to be active again.

Weeks 6-12

I was cleared to lift weights to my heart’s content at week 6, but again, I had to start light.  I started with wall pushups and worked up (or down) to floor pushups. Holding a 15 pound weight  would make my forearm nearest the elbow pretty tired, but over time that effect would only occur with heavier and heavier weights, until around week 10 I could hold 50s in each hand with no problem.  Most of my upper-body work was done with light dumbbells and bands until my strength was back up.  It was crucial to get my overall body strength up before the throwing phase started at week 12.

I also resumed my rotator cuff circuit at week 6.  This was the Orioles shoulder workout and is very extensive.  It takes about 30 minutes to complete 2 cycles.  I credit this with the fact that my shoulder has been perfect and very strong since.  Many pitchers return from elbow surgery just to tear a labrum or rotator cuff afterward because they neglect their shoulders while rehabbing their elbows.  While injuries are never totally controllable and preventable, I did everything I could to avoid any further arm problems.

What the doctor told me was that my elbow was fine, and that I could lift and run around and fall on it if I wanted.  I didn’t really believe this, but an important event took place around week 8 when I started running agilities and sprints with the team.  Within ten minutes in the first session of agilities I clipped a cone, slipped, and caught myself as I fell with my throwing arm.  I got up, finished the drilled, looked down at my arm, and let out a big sigh of relief.  It was a big moment, because I didn’t really trust my arm before that fall.  But fall I did, and nothing happened.  No pain, no soreness, no stiffness, nothing.  It was a blessing in disguise, and I trusted my arm from that point on.

At week 10 it was swelling-free and ready to go

At Week 10 I was feeling pretty strong, with full range of motion and no swelling left in my arm.  It felt normal and ready to go.

At week 12 I had another check-up and was cleared to start throwing.  It was exciting yet nerve-racking at the same time.  It was the next step, and I was physically ready for it, but mentally was a slightly different story…

Keep in mind that I’m not a doctor or physical therapist, and my intention with this post is to create some body awareness and help people understand how their body may be feeling, and whether or not their expression of those feelings are in tune.

Call it Pain

Pain is typified by, and this probably is not news to anyone, sharp, short and sudden sensations that accompany a certain activity.  Pain draws our attention strongly and immediately to certain areas of the body.  

Now, pain is different in type and intensity for everyone, and being in tune with one’s body is important for reading into it.  I know which pains, when throwing or pitching, are incidental and aren’t telling me anything about the health of my arm or body.  These I largely ignore, because experience has taught me that they never manifest into anything pathological.  Pitchers commonly have little pains here and there that are just a natural part of the violent act of throwing.  Listening to one’s body and having experience with it is important, because one cannot become consumed with every little ache or pain that crops up.  It’s too stressful.

But some pain is an indicator of present injury or developing injury, and these need to be attended to.  These are usually stronger and don’t go away in a day or two, and may not respond to pain medication, therapy, ice, or other treatments.  If they do respond, then they will probably work themselves out with therapy, but they should not be ignored, and the activity should be backed off.  

During my rehab I have had little pains appear at different times and in different places.  Some of them I ignore, and they go away, and others I have had to back off my throwing or training until my arm could catch up and recover.  The key is understanding your body, and listening to it, and always being prudent about things.  Hammering away is not going to solve things when your body needs rest.

Call it Soreness

Soreness is present usually after a hard workout following a long period of inactivity, or an unusually stressful workout.  Its not the same as pain, though some people will claim that a part of their body “hurts” and they need to rest.  Soreness can indicate a developing injury, but more often it is probably the result of a new and taxing physical stimulus.  Soreness is typified by that burning feeling that encompasses larger areas of the body, and is usually very general and not pinpoint in nature.  

I have found that the best cure for my soreness is to keep the exercise regular.  If I am sore after a hard workout I won’t take off until it fades away, which could be up to a week, but rather will continue my regimen.  The soreness seems to get flushed out by this and usually recedes much faster than if I were to rest it.

After a start early in the season I will be sore, but will still lightly throw the next day and then increase my workload the subsequent days.  Rest is probably indicated when one can barely move from it, but other than that I have found that getting some exercise, or throwing a little for pitchers, is usually beneficial.

Call it Fatigue

Fatigue isn’t like the other two, because there isn’t usually a concrete sensation to go with it, other than aches and deadness.  Sharp or burning sensations aren’t there, but rather the muscles just don’t want to go.  

For pitchers this is a situation that calls for rest, because the arm is depleted and it just needs to recharge.  The hazard with throwing hard when fatigued is that mechanics get sloppy, and biomechanical laxity can cause more stress on all of your soft tissues.  You always want to be strong enough, when throwing hard, to maintain the highest quality mechanics possible.  Throw through fatigue too hard and too often, and some pain and soreness are going to appear, making things worse.

Call it Correctly

The important message here is to understand what your body is telling you, and to know it well enough to take the appropriate action.  All too often young pitchers will say their arms hurt when they are sore, or are sore when they are hurt, and the indicated paths to recovery for both are quite different.  Little pains and big pains are different, and should always be monitored, but may or may not lead to injury.  

When rehabbing from an injury there is often accompanying pains and tightnesses and sorenesses, and they, like all others, have to be analyzed to see if they are part of the healing process (which they often are) or a sign that progression is beyond the limits of the body.  But overall, people usually have an intuitive sense of when something is wrong, but over-analyzation of every pain can make for one neurotic and sleepless athlete.  The key is learning to know thyself.

…Standard MRIs are garbage.  When I felt my elbow go in the game, I was fairly sure that I was going to need surgery.  When I got my MRI a week later, however, my doctor could get a very accurate picture of my ligament on the films.  The regular MRI was just not clear enough in showing my ligament, and as such he recommended rehab and flexibility work, which had worked for me in the past.   Teammates of mine had had MRIs with a dye injection, which makes diagnoses much easier.  After 8 weeks of rest and rehab, I tried to pitch but couldn’t do it without pain.  My elbow felt loose when releasing the pitch, as if my ulna really wasn’t attached to my humerus.

So I went back and got an MRI with a dye injection, and it was clear as day that my ligament was torn.  My recommendation for others is to get a dye-injected MRI the FIRST time.  Ask for it and see if the doctor will prescribe it.

Your Elbow is What You Eat

So under the knife we went.  Surgery took only 70 minutes, and I was on my way home before I knew it.  It felt very surreal to have had the surgery that I so dreaded, but I was now on my way to having a clean, fresh elbow and career.  

Diet was the first thing I could control, and I’m a huge believer in good nutrition.  I believe the American diet is terrible and compromises the body’s ability to heal itself.  That said, I made it my quest to stuff as many vegetables and fruits down my throat as I could.  If the average person healed in 9 months, then I felt I could heal in 8 just because my body had every nutrient it needed to heal itself.  My rehab went very smoothly, and while I can’t say for sure that my diet helped, I know that I am organically healthier for the way I ate, and currently eat.  I took calcium supplements and a multivitamin, and always had tons of omega-3s from fish and flax oil in my system.  It is said that post-surgery energy needs are increased as well, so I made sure I was eating enough (although that has never been a problem for me).  

Some Like it Hot

Another thing I did that was out of the box for most was Bikram Yoga.  I had done Bikram Yoga, which is a 90 yoga minute class performed in a 105 degree room, in the past and enjoyed the increased flexibility that it afforded me.  So much heat is generated in the classes that bloodflow is through the roof, and it seems to speed healing and promote good health.  So I went twice a week for about 10 weeks after my incision was closed and I was cleared to sweat and exercise. The green light to exercise was given to me after 2 weeks, so I was happy to get back out running and into the Yoga studio.  Another goal of my rehab was to reinvent myself mechanically and make myself physically stronger and more athletic.  I had very tight hips and quads, and the Bikram Yoga helped so much to loosen me up and get me on track to maintain my flexibility outside of the yoga studio.  After about 10 weeks I had had it, and couldn’t invest the time anymore to make it to yoga.  On top of my running, rehab and lifting, it was too much to fit it in anymore.  My friends Eddie and Emily at Bikram Yoga Baltimore were wonderful in helping me recover.

Pump That Off-Arm

There is a human phenomenon known as bilateral transfer, which is the body’s desire to keep paired muscles balanced in size and strength.  When one side is worked more than the other, the less-used side will still get the same growth hormones and bloodflow as the worked side, which will result in similarity bilaterally.

In rehab this is useful because you can work out your non-surgical side and still get the benefits in your surgical side.  As long as the incision is close and sweat and infection is not an issue, working out the non-surgical side can be very useful in preventing atrophy and weakness in your surgically repaired arm.  

So with these three tactics of excellent nutrition, Bikram Yoga and bilateral transfer, I felt I was able to get ahead in my rehabilitation and heal to the best of my body’s ability.  I never had any tricep tightness, a common symptom of the surgery, and my flexibility was excellent all through my recovery, both of which I attribute to working hard and doing the extras early on.

My next installment will cover the doctor-prescribed rehab protocol up to the throwing stage

From March on I was having forearm and elbow problems, and could barely recover between starts. But I got through it and didn’t miss time, and made it through 5 2/3 innings of my last start of the year.   I was actually starting to feel better by time it finally went.  

So anyway, I figured I would put together some of the findings of this journey, of which I am almost through (8 months post-op and at 90% of previous velocity)

Today’s Topic: Doctor Discrepancies

Now, I got surgery from Dr. Craig Morgan in Wilmington Delaware.  I had heard good things about him, seeing as how is world-renowned, and I trusted him above all others with my pitching future.  

Five teammates of mine had this same surgery during my career, and there were differences in all five rehab protocols.  And this is interesting, because everyone seems to make it to the finish line just the same.  Thus, the question arises- which protocol is the best? If you’re not familiar with the tommy john procedure, check out the link in my About Me page.

That question is hard to answer but from my own experiences, I do have an opinion. I base this opinion on what I went through, what others went through, and what seems to intuitively make sense about the human body and its ability to heal.

First: We Need a Tendon

 I received a gracilis tendon allograft from a cadaver.  This means that the tendon used in my elbow was harvested from a deceased donor and installed into my elbow.  Advantages: only one site to rehabilitate, and a better success rate (so says my doctor).  Most doctors use the palmaris longus tendon from the same forearm, and some use one’s own gracilis tendon, which is from an the adductor muscle by the same name in the medial thigh.  

Getting the palmaris taken from the forearm is the industry standard, but I was thankful to only have to rehabilitate one surgery site.  My buddy had his tendon taken from his gracilis, and that harvest hurt him more than the elbow did for the first month or so.  He hobbled around much more than seemed necessary.  This was done only because he didn’t have a palmaris longus in his throwing arm, which is reasonably common. (The palmaris longus serves little function in the forearm, which is why many people lack it with no lack in capability).

Getting the cadaver tendon graft was advantageous to me because I was able to jump into rehab very quickly, as is discussed later on in this article.

Second: To brace or not to brace?

Every other player I know who has had Tommy John was in an adjustable metal brace which allowed controlled advances in range of motion. Dr. Andrews, Dr. Cosgarea, Dr. Baugher, the Mets’ team doctor (don’t know the name) all prescribed braces post-op, usually for at least a few weeks.

None of Dr. Morgan’s Tommy John patients wear braces.  Ever.  I was in a sling for two days and was then free, with only an ace bandage covering my incision.  If it sounds scary compared to the heavily braced alternative, that’s because it kind of is.  Thing is, though, it does inspire in you the notion that your elbow really has been made stronger, even from day one.  

I asked Dr. Morgan, “What if i roll over on it, or trip and fall and catch myself on it, or get bumped into by someone? I’ll be OK?”  He responded that my elbow was stronger now than the day I was born (keep in mind I had just been revived from anesthesia when I asked these questions).  

So I slept on it that night.  I moved it around in whatever way I wanted. When I was out of my sling two days later I was really, really free.  It was crazy, and I wondered, why does everyone else brace their patients up when my doctor doesn’t, and his success rate is through the roof?  I think the only answer is that the new ligament really is, as he said, strong as hell as soon as the last stitch is closed.

Third: Strengthening Protocols 

My strength training protocol was administered by my physical therapy team at school, but I was given the go-ahead to start forearm strengthening just one week after surgery.  It was quick.  Obviously, I could do this because I was not in brace.  Braced players have to wait until the brace is off, and then maybe an additional few weeks or month(s) to start forearm training.  Part of the reason I was able to do this I’m sure was because of my graft, which allowed me minimal surgical trauma.

After forearm strengthening was underway, I was able to start running and doing other conditioning at three weeks, and I could lift weights starting light from I think 6 weeks post-op.  My elbow was always up to the challenge, and progressed quickly through it all. Above all I never felt rushed, and always felt reasonably capable for the new additions to my rehab.  The pace felt right, not going too fast, and not stagnating or plateauing at any one thing.

Fourth: Throw Now, or Throw Later?

I started throwing (lightly tossing) at three months post-op.  So do Dr. Andrews’ patients.  Two other teammates started throwing at four months, and one started at six months.  My protocol said that one is ready to throw when the arm has adequate strength, no swelling and full range of motion.  For me, I got to start at three months, right on schedule.  

So why the discrepancy in starting date?  This is something that makes little sense to me, especially when many prominent doctors have great success starting their patients at three months.  If so many patients start at three months and have success, why wait?  Is there any research that says to wait? I can’t answer these questions, but there is a lot of discontinuity between doctors, even in such a well established surgery as UCL reconstruction.  

Fifth: Throwing Progression

 I went in stages, getting a large base of throwing and generally moving up in distance once per month for the first three months.  The number of throws increased during each month, and I got comfortable throwing again after about a month.  the fourth month moved me from 60 feet to 120 feet in only two weeks, and from then on the program got more rapidly moving.  I threw from the mound after 3 1/2 months of throwing, and moved through 1/2 speed to 3/4 speed in about another month.  

My program was less progressive than the Andrews’ program is, which pushes the pitcher faster through the program, to allow him to return to form faster if he is able. The pretense is that if one can complete each step twice without pain he can move up to the next step. If pain crops up, then the program is backed off as tolerated.  It makes sense and allows the elbow, which heals at different rates in each player, to call the shots about what it can handle.  Encountering pain is normal, and not at all a big deal. The elbow is fixed, and with reasonable prudence nothing will re-injure it.  I had pain here and there, and it always cleared up, even if I didn’t back off.  Very slight pain often just indicates that the elbow is dealing with a new stress, which is part of the progression, though it should never be ignored.  

The finish line is there just the same

What I have gathered from my amateur analysis of all this surgery nonsense is that each rehab journey is going to be different, depending on the doctor, but the finish line will be reached just the same in each one.  The surgery is not easy, as it is mentally draining at times, but each different method converges to the same end.  I wonder, though, why there is such discontinuity between doctors and their protocols.  It appears as though the successes of some and the data gathered are not shared across practices.  Certainly there is never one right way of doing something, but at the same time, if a longer recovery time is not necessary, then why prescribe it?

In Part 2 I will discuss my early recovery and how my elbow progressed in the first months before throwing began. Stay Tuned, Kids!