Preventing Arm Injuries as a Pitcher

There’s a concept in psychology called Maslow’s Hierarchy of Needs which lays out all of the basic needs humans require to survive and thrive. After years of rehabbing and maintaining pitchers’ injuries and healthy arms, I’ve adapted the hierarchy of needs and apply it with athletes here at PRO Athlete PT: Blue and White Funnel Chart Presentation

Other healthcare providers can (and likely will) pick knits at this “model” but you’ll have a hard time convincing me that following scientific principles doesn’t help prevent pitchers from sustaining arm injuries.

You’re probably wondering when I’ll get into fancy exercises and cutting edge maintenance programs. That will come. But I can't emphasize enough how often I see pro athletes who need a crash course on this stuff first. Let’s dive in.

Sleep, Nutrition, and Hydration

These needs are the building blocks to preventing injuries in pitchers (and every athlete, really).

Nutrition

Disclaimer: Nutrition is a topic that can depend on many factors. If you’re reading this, please check with your doctor before applying these principles.

When it comes to nutrition and hydration, the principles are straight forward. While training, a general recommendation for athletes is to eat between 1.5 and 2 grams of protein per kilogram of body weight. Carbohydrates and fats in things like whole grains/vegetables and nuts/avocados are important as well. However protein is paramount to development and growth.

Here’s an example for a 19 year old pitcher who weighs 160 lbs and training regularly:

→ 160lbs/2.2 = 73 kilograms

→ 73x1.5 = 110 grams of protein per day

Hydration

As far as hydration goes, the general rule of thumb for water is to drink at least 1 cup for every 20 minutes of exercise. Also make sure to eat plenty of fruits and vegetables and a well balanced diet to maintain electrolyte balance. Generally speaking, drinks like gatorade and electrolyte supplements can be reserved for extreme heat training and/or training sessions longer than 90 minutes.

For more absolutely killer (and FREE) nutrition advice, I recommend Wendi Irlbeck who is a Registered Dietician and certified sports nutritionist. Below is an example of her advice.

Wendi Irlbeck Advice

Sleep

Here are the scientific facts:

7-9 hours of sleep is recommended for adults 18-25
Sleeping fewer than 7 hours per night increases an athlete’s injury risk by 1.7x
The average amount of sleep elite athletes get is 6.7 hours
Sleep influences mental processing/appetite/mood/reaction time and so much more

Here’s what to do. Track your sleep for a period of a week and change nothing else about your training or habits. Journal it. At the end of the week rate how rested you feel on a scale from 1-6 with 6 being very rested. Then rate how satisfied you are from 1-10 with 10 being very satisfied and adjust from there.

The biggest competitive edge almost no athlete is exploiting is sleep. Want to prevent injury? The answer isn’t just in foam rolling, postural exercises or massage. Those things have a place but a good night’s sleep is absolutely essential for any of your training to matter. Just ask Usain Bolt.

Usain Bolt on Sleep

Mental Health and Communication

Mental Health

Here’s the bottom line: If the grind doesn't stop, neither does your brain.

Mental health is a vague buzzword but the reality for athletes is that facing adversity in sport becomes way harder when your nervous system is overloaded before you step foot in the gym or on the field/court. Things like family troubles, financial stress, making the roster and other life stressors are going to happen.

But the goal is not and should not be to eliminate these completely. Instead, finding healthy coping strategies and communicating with your coaches/support staff is absolutely key. If there are enough stressors in your life that sports aren’t in the cards at this moment, that’s okay. Find a trained mental health professional that can help you come to that conclusion.

Contact: 988 if you’re in crisis.

Communication

Want 2 truths about performance and preventing arm injuries as a pitcher?

Closed mouths don’t get fed.
“The single biggest problem in communication is the illusion that it has taken place”. - George Bernard Shaw

A Pitcher’s Arm Injury Story

The best way to drive this section home is with a story.

During my time in pro ball, I helped rehab a pitcher after Tommy John Surgery. We spent a ton of time together and he eventually confessed to me that his elbow didn’t feel right…for months.

Then he blew out.

He had been feeling pain and tightness after every outing. Did he communicate with his athletic trainer about this?

Not once.

Now, could this have saved him from a year plus of rehab? It’s impossible to say. But the bottom line is that despite having every resource at his fingertips to stay healthy and give himself a fighting chance, it didn’t happen. Why?

Because closed mouths don’t get fed.

Don’t wait until you’re in pain. Talk to your athletic trainer and/or a physical therapist you trust. Communicate to your skill coaches how much you think you can do. Talk to your S&C coaches about modifications. Take initiative and understand you need to have the long game in mind.

Pro Pitcher After Arm Injury Rehab

In this 3 chapter series on preventing arm injuries as a pitcher, I can’t emphasize enough how important sleep and nutrition are as a foundation. Even pro athletes need this education at times. So if you aren’t a professional pitcher yet, congratulations! You’re already ahead of the game.

Chapter 1 Summary

To prevent arm injuries as a pitcher, here’s where to start:

Sleep enough. Generally, at least 8 hours a night is where to start.
Eat a balanced diet with enough protein (1.5 - 2 grams of protein per kilo of body weight)
Understand your mental load outside of just ball and talk to a professional if needed
If you start to feel physically off do not ignore it. Talk to your athletic trainer or give us a call for free at (720) 248-7515 to see if we can be of assistance.

Remember this is just part 1 of this series. Next week we’ll discuss workloads, how to structure training and why a routine is important. Then in part 3 we’ll finally address mobility and strength and a proper arm care routine to prevent injuries as a pitcher.

In the meantime, stay safe out there.

Chapter 2

In chapter 2 we’ll discuss workloads and how to structure throwing/training in order to reduce your risk of arm injuries. Then in chapter 3 we’ll finally get into specific mobility and strength drills within a proper arm care routine to further protect against baseball injuries.

Here’s chapter 2 of how to prevent the most common baseball injuries:

For reference, when I say “common injuries in baseball” here’s the data to validate the claim. A whopping 49% of injuries to big leaguers were to the arm! Here are the most common arm injuries in baseball according to one source:

Shoulder - 35%
Elbow - 31%
Hand - 14%

This data is a physical therapist’s nightmare. So let’s get into how your training structure and workload management can reduce your injury risk.Managing Workloads

You only get one workload “bucket”. Everything that you do on a daily basis from walking to the car to high intensity sprints that day goes into your bucket. That’s why just working hard is not the recipe to prevent arm injuries in baseball. You’ll burn yourself out and eventually get injured. That’s the reality.

Fill my bucket by-1

What else goes into that bucket?

You guessed it. Pitch counts.

Welp, the digital friendship was good while it lasted. Hope to see ya around!

Pitch Counts

The science isn’t new. Throwing too much - especially as a young baseball player - leads to bad things. Pitchers who throw more than 100 pitches in a game are more likely to sustain shoulder and elbow injuries.

That’s why 25% of 12 to 16 year old baseball players sustain some sort of arm injury. You don’t want to end up in a physical therapist’s office, right?

Here at PRO Athlete Physical Therapy, we support pitch counts in 98% of cases. Why? Because in most instances not only are pitchers blowing past pitch counts, they’re also spending the rest of the weekend playing catcher throwing even more.

Here’s what MLB recommends. Keep in mind they know the most common baseball injuries and are trying to help:

Here’s a list of things the research has told us about what causes arm injuries in baseball other than violating pitch counts. As a physical therapist, these are things I want to manage right away when athletes come into my office:

History of injury
Training > 16 hours per week (in youth athletes)
High pitch velocity
Bad shoulder range of motion
Bad shoulder strength
Bad throwing mechanics

Work Harder and Smarter

Listen, I get it. You want to outwork the competition but the bottom line is that one more bullpen or one more set of plyos or one more cage session is probably doing more harm than good. Especially if you’re already fatigued and especially if you already have physical limitations like bad shoulder/elbow strength and mobility.

Sidebar: Want a customized maintenance plan to prevent injuries in the first place? Call us to set up an injury prevention program designed jus for you.

Now, does that mean you should never work hard? Of course not.

Research shows that tolerating extremely high workloads - uncomfortable levels of hard work - for a brief period can be a good thing. But your training program should be designed in a way that exposes you to hard work safely.

How?

Physical therapist, Dr. Mike Reinold, and his team created this throwing program for MLB pitchers with arm injuries. They did so by following the 0.7 to 1.3 principle. These numbers come from years of workload-related research in many other sports. Long story short, big swings in workloads can lead to nearly double the injury risk among athletes.

Workload management to prevent common baseball injuries

This study is hot off the presses by a baseball physical therapist and thought leader Mike Reinold:

These graphs show daily throw count and overall workloads over time. You’ll notice that the trend is smooth and never takes a sharp turn in either direction. This is the most logical way to attempt to prevent common baseball injuries in baseball players.

Example

A professional reliever is rehabbing from a shoulder injury and is now in week 1 of his mound progression. In the first week on the mound, he’s scheduled to throw 2 bullpens for a total of 44 pitches.

By Week 5, that means, ideally, he doesn’t surpass ~58 total pitches from the bump (AKA no more than 30% of the volume from week 1).

And,

By Week 5, that means, ideally, he doesn’t throw any less than ~35 total pitches from the mound (AKA at least 70% of the volume from week 1).

Now, there are approximately one million considerations here that this mini example doesn’t take into account. Here are a few:

Athlete age
Warmup throws/rehab work
Injury history
In-game max velocity
Perceived effort
Elbow torque
Build up volume to bullpen
Self recovery reports
Objective strength/mobility data
Diet/hydration
Sleep quality
Outside stressors
Player goals
Team goals
Alternative pitches
Time of year
Strength and conditioning program and goals

As you can guess, this is a very, very watered down version of a complex topic but athletes with minimal to no resources should follow these general workload rules:

Workload Rules

1. Don’t do too much too soon (no more than 30% of the previous 4 weeks)

2. Don’t let activity dip below a baseline level (at least 70% of the previous 4 weeks)

3. Ramp up at a pace that gradually increases your work

Structure and Routine

Another area of concern for sports physical therapists when it comes to an athlete’s structure and routine is the athlete not having any at all. While I was a PT with the Twins, I saw this issue arise consistently. Guys had no idea how many throws/swings they would rack up in a day or week. What’s worse, they had no concept of relative intensity. The result?

Spoiler: they’d spend a chunk of the season in rehab with me treating some of the most common baseball injuries.

But what does relative intensity even mean? Relative intensity means alternating the amount of stress/work in any given training day. The scientific term for this is undulation.

Example

Imagine a professional pitcher building up for the season. Instead of throwing a max effort bullpen every day, many professional relievers structure their week like this:

“Day before” (a light day in preparation for the heavy day)
“Day of” (bullpen or heavy day)
“Day after” (a medium intensity recovery day)

Below is a very basic template of how a pro reliever structures his work week coming back from an arm injury. This obviously depends on several factors - especially the rotation - but the idea is to separate work days into light/medium/heavy intensity. As with everything there are caveats and exceptions. However this is generally how to get the most out of training and prevent the most common injuries in baseball:

This applies to position players, too. You should not be long-tossing and taking 300 swings on one day, lifting heavy the next day, then playing in a double-header on the third day.

Undulation prevents injury and improves performance because it allows for your tissues to heal and for your brain to process new skills. Your training should be like a predictable roller coaster - not a never ending NASCAR race.

What’s the Point?

You may be thinking “Edwin, all of this research is based on injured guys. I’m healthy.”

Exactly.

When a baseball player is injured, physical therapists and athletic trainers follow all of these concepts to get them back on the field. Why wait until you’re injured to take advantage of all this knowledge?

Chapter 1 and 2 Summary

Get at least 8 hours of sleep
Eat 1.5-2 grams of protein per kilogram of body weight
Drink about 1 cup of water for every 20 minutes of exercise
Find good mental headspace and talk to a professional if you need to
Structure your work week in a way that alternates between low/medium/high intensity
Create a predictable roller coaster-like routine with throwing and swinging

Chapter 3

So where does arm care come in? If you remember the pyramid from part 1, congratulations! It’s time to talk about that.

Now it’s time to start thinking about a specific shoulder/arm care routine to prevent common baseball injuries. Remember these 3 risk factors from earlier?

Bad shoulder range of motion
Bad shoulder strength
Bad throwing mechanics

Turns out that’s our wheelhouse as physical therapists! In the final installment of this 3 part series on preventing common baseball injuries, I’ll get into my process of assessing a baseball player as a physical therapist. That process leads to an individualized arm care routine.

If Athlete Pyramid of Needs

If you or somebody you know would like a FREE 15 minute phone call to begin an arm care routine, call us today!

The Secret Sauce

Here’s the secret sauce to prevent shoulder pain as a pitcher: there is no secret sauce. An individualized and complete evaluation specific to a baseball player is the goal.

If you’re going somewhere else other than PRO Athlete for rehab as a baseball player, here are 3 questions to ask your PT or AT to ensure you’re getting the most out of your time:

Will we be looking at shoulder strength today? If so, which ranges?
Will we be looking at shoulder range of motion today? If so, what is your opinion on “GIRD”?
Will we be assessing the rest of my body like my mid back and lower body for issues that could increase my risk of injury?

Let’s walk through what part of an evaluation at PRO Athlete Physical Therapy looks like with an example. Keep in mind every rehab professional has a different process and there’s not one right or wrong way to do, well, anything. But there is a way that addresses risk factors to reduce the risk of common baseball injuries.

Objective Measures and a Routine is Key

History

Let’s say that there’s a baseball pitcher named Pete returning for his 2nd visit on a maintenance plan at PRO Athlete. Here are the bare essentials we already know from his previous visit:

It is Week 3 of the baseball season
Pete’s last outing was four days ago (4 live-game innings) and his next outing is two days from now
Pete had medium to high intensity throwing day yesterday along with a heavy lift
Pete has no injury or surgery history but says by mid-season he just feels “wound up and tight”
Pete has gotten heavy interest from the MLB as a free agent so longevity is his goal

For new pitchers looking to prevent arm injuries, we measure/assess all of the following:

Shoulders/Shoulder blades
Low back
Hips
Ankles
Trunk
Neck
Elbows
Wrists

For the purposes of this example though, the key areas of focus for Pete due to his history are:

Feeling overall recovered and ready for his next outing
Total shoulder range of motion on his throwing side
Upper/mid back joint and muscle tightness

Observation

The physical exam will include a quick visual scan to see if Pete has any new abnormalities or asymmetries (another spoiler: there probably will be).

Mobility

What’s normal vs. abnormal range of motion? There are general rules of thumb but the reality is together we’ll find what feels and should be normal for Pete.

A Quick note on Shoulder “GIRD”

A specific worry for many athletes and coaches is shoulder “GIRD or Glenohumeral Internal Rotation Deficit. There are common myths about GIRD that could be an entire blog series by itself. So in the name of brevity, just know that losing shoulder internal rotation motion after throwing is normal, does not automatically mean you’ll injure your arm and is certainly not a death sentence. For more on “GIRD” myths, shoot me an email at edwin@proathletept.com. I’ll send some resources to you.

After objectively assessing Pete’s shoulder total arc range of motion of both shoulders (below) with specialized tools and the rest of his body’s mobility, we’ll jump into strength testing.

Shoulder Total Arc Range of Motion

Strength

What do we measure?

We use a tool called a dynamometer to see how many pounds of force Pete’s body can utilize and go from there. We’ll start by testing his shoulder internal rotation and external rotation of both arms.

We’ll also measure Pete’s grip strength on both sides now using a handheld dynamometer.

Findings

Here’s what we found with Pete:

A big decrease in total shoulder range of motion compared to his opposite side and a big loss of internal rotation specifically compared to his last visit
A loss of mid back mobility on his left side
A big “knot’ and soreness to the back of his shoulder muscles and upper back joints
A decrease in grip strength on both sides

Now What?

So, what to do with Pete? One outing and let’s be honest, he’s toast!

We’ll start by checking in on how he’s sleeping.

You can guess how this is gonna go - since he last pitched he’s been up every night playing Roblox until 1:00AM. Then he gets up at 7:00AM for school, work and training. Otherwise he’s been eating enough protein and “sort of hydrating” but another issue is he hasn’t made time to do his maintenance exercises.

This is not the way to prevent arm injuries as a pitcher.

These are probably the main drivers of why Pete is having a hard time recovering and probably why his grip strength is down. So we remind him how important the basics are and he agrees.

Mobility Work

Next, Pete has had success in the past with the use of dry needling. So to reduce the muscle tightness in the back of his shoulder, that’s where we go:

Shoulder Dry Needling

But we can’t just end on needles - we need to work that new motion. So we load it with this:

Shoulder ER Strength

That pesky internal rotation was still limited, though. So now what? We hit ‘em with a few rounds of these:

To address the rest of his mid back joint restriction, we work on Pete's spine with some manual therapy and he learns this drill for upper back stiffness:

Next, he begins diaphragmatic breathing + a thread the needle exercise and after the session, he ends with 15 minutes of medium intensity Airdyne biking.

The Result

Pete’s session is a a grand slam.

After the session Pete reports still feeling tired from not sleeping enough but his grip strength on both sides improved slightly. He also saw a big change in his mid back mobility and his total shoulder arc range of motion is almost back to baseline.

Not every case is this simple but after spending hundreds of hours with elite baseball players, I can nearly guarantee that following the basics can get you these results.

I hope this series and final example helped tie it all together for you so you can prevent the most common injuries in baseball. If you’re interested in working with us at PRO Athlete, give us a call today!

We'll talk soon.

Tags:

arm injuries, baseball injuries, shoulder pain

Post by Edwin Porras
May 8, 2024 6:01:57 PM

How to Prevent Arm Injuries as a Pitcher: Part 3

6 min read

What is Load Management in Sports?

2 min read

Preventing Arm Injuries for Baseball Players

Preventing Arm Injuries as a Pitcher

Table of Contents:

Chapter 1