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.

So set some goals.  If you don’t, it will be much harder to stay on track this winter as the weather turns sour, school starts to wear on you, and your comfy bed calls your name.

Get there.

I like to set my goals at the upper limit of what’s realistic, and I don’t worry too much if I don’t reach them, as long as I come close.  Many people need to do the opposite, and set many smaller, more manageable goals to act as stepping stones toward a final, better product.  To each his own.  But, no matter your method, there needs to be a finish line somewhere and the vision to reach it.

So for my winter, which lasts from now until March, my strength goals are the following:

-Reach 195 pounds while staying below 8% bodyfat.

-Deadlift 450×5

-8 Reps Rock Ring Chin-Ups with 45lb added

-Develop the core of a gymnast

My assault on these milestones is going to be pretty complex, so brace yourself: I’m going to:

-Deadlift, chin-up, and lift my ass off

-Eat like a man twice my size

-Only eat carbs for breakfast, and pre and post-workout

-Eat more vegetables than a vegan hippy

I also have pitching-specific goals, but they are more broad, not worth sharing, and really just sum up to: be the most polished, healthy and powerful pitcher I can be. That’s every pitcher’s goal, anyway.

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

1. A well conditioned arm

      -Doing the rehab is necessary for a full recovery, but will also leave one with a very well conditioned arm, assuming the shoulder is well taken care of as well. This is the reason many pitchers throw harder when rehab is complete.

2. Time to reinvent pitching mechanics

      -Especially if one is a college pitcher, it is hard to get enough time off to break down and completely berid oneself of bad mechanical habits.  Pitching all fall, spring and summer typically makes this difficult.  The time off during rehab can allow one to start back up as a clean slate.

3. Time to address flexibility/mobility problems

      -It is tough to get rid of joint mobility problems and tightness when one is playing year-round the sport that causes those problems.  Time off mixed with a little yoga and a dedicated stretching program can make tightness a thing of the past. Getting a functional movement screen from a trainer is a must.

4. Time to get stronger

      -Trying to be fresh for outings can prevent one from focusing fully on strength training.  The time off from surgery gives one a chance to focus on specific weaknesses and lay down a really good base of strength, which can be maintained once returned to action. 

5. A work ethic

      -People undergo surgery with varying degrees of commitment, and some finish rehab with a different perspective on what it means to take care of their arm and body.  As previously said, the reason many throw harder after surgery is because they take care of it for the first time.  Hopefully that result provides incentive to continue on a path of physical furtherance.  

The Common Theme?

Time.  You can do the required 20 daily minutes of  rehab and throwing, and spend the other 23:40 bullshitting, or you can use those months off to (re)build a better you. If you make the most of it, that arm injury can turn out to be a blessing.

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.

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.

[youtube=http://www.youtube.com/watch?v=chuNZAcagCE]

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!