Stop Looking For Diagnosis and Cause and Start Looking For Dysfunction and Contributors
Yesterday we had a 17 year-old right-handed pitcher in from Colorado for a Precision Strike 1 Day Evaluation and Training Session. We’ll call him Cole.
Cole loves pitching. He’s pretty good, according to his mom, and his dream is to pitch in college some day. But last, January, he began to experience severe, debilitating biceps pain.
As usual, the immediate response from the medical professionals was to shut down all throwing and rest. After resting for 6 weeks, he started throwing again, and of course, his arm started hurting again.
He spent the summer getting MRIs of his shoulder and elbow, and going to physical therapy, but still he was unable to throw.
Every doctor he saw gave him a different diagnosis.
Here is a list of the various diagnoses he received.
Labrum tearNo labrum tear, just normal fraying
Biceps tendon tear and finally…
A few weeks ago he had an Ultrasound study on his biceps and was diagnosed with entrapment of the musculocutaneous nerve… That’s the one the doctors had ultimately settled on, and I had to admit, it was the first I had seen it.
The musculocutaneous nerve emerges between the biceps and the brachialis muscle.
You can see it in the following pictures:
His mom is a trauma nurse and is highly involved in his care. She had consulted with best doctors in he the Denver area and had joined her son for every appointment. She and her son were clearly frustrated. She fought back tears and cuss words as she explained the goat rope she and her son had endured over the past 10 months.
“I just want to find the cause and get it fixed,” she said with exasperation.
After listening intently and taking notes on everything she said, I paused and said,
“Listen, I think we need to stop looking for a ‘’diagnosis and a ‘cause’ and start looking for dysfunction and contributors. You see, in my experience arm injury is rarely due to one specific thing, but instead a collection of contributing factors come together in the perfect storm to create an environment where injury can occur.”
She sat back in her chair, and with a sigh of relief she said, “You’re right. So what do we do?”
I outlined the entire process.
“We’ll start with a brief presentation on the design of our unique motor learning process and the principles of a connected durable, and powerful delivery. Then we’ll conduct a head-to toe physical assessment of his scapular mobility and stability, his shoulder and thoracic mobility, hip mobility, ankle mobility, trunk stability and functional movement patterns. We’ll warm-up and make a few throws for the high-speed video after which we’ll sit down and analyze the video looking to identify any of 13 different disconnections that could be contributing to his pain. From there we’ll design a series of corrective throwing drills for the disconnections we find, and we’ll give him hands-on instruction on the correct performance of those drills. Once that is done, we’ll show him all the necessary mobility exercises to correct the constraints we find, and then we’ll meet back here and wrap it all up with a comprehensive written training plan.”
Cole and his mom smiled, and we got to work.
The significant findings of the physical exam were:
Scapular control: Caution (slight winging and decreased eccentric control)
Shoulder Internal Rotation: Acceptable (he had been working with a PT on this)
Thoracic Rotation: Caution
Thoracic Extension: Significant Opportunity*
Active Straight Leg Raise: Caution
Hip flexors: Significant Opportunity*
Quads: Significant Opportunity*
Hip Internal Rotation: Significant Opportunity *
Glute Activation: Caution*
Deep Squat: Caution*
Ankle Mobility: Caution*
The movement pattern analysis revealed:
Forearm Play: Significant Opportunity*
Early Torso Rotation: Significant Opportunity
Glove Side Tuck: Significant Opportunity
Lead Leg Disconnection: Significant Opportunity*
Postural Disconnection to Glove Side: Significant Opportunity*
Internal Rotation of Shoulder Into Launch: Significant Opportunity *
Continued Rotation Around Front Hip: Significant Opportunity*
All of the asterisked items listed above interplayed like this: (hang with me here)
Because of his tight ankles, quad and hip flexors, and his inability to perform a deep squat, his first move was to shift to the ball of his foot, projecting him toward the on deck circle on the 3rd base side.
Severely limited hip internal rotation (which may or may not be due to hip retroversion for all the PTs out there) prohibited him from internally rotating his back hip for adequate lower half efficiency, and caused his lead leg to drift open prematurely.
Since he did not have adequate thoracic extension to arch his back for a course correction, as his front leg opened caused his torso to rotate open too soon an released any elastic assistance he might have gotten to attenuate the stresses on his arm. This also caused him to lean heavily toward his glove side in an attempt to correct his directional error, catapulting his arm further away from his head and adding to the stress on the biceps
When he reached the high cock position with his arm, his front foot had not landed, so to buy time he directed his shoulder into premature external rotation creating a bang on the his UCL and anterior sheer on his labrum.
His lack of hip internal rotation precluded him from adequately rotating his back hip into the forward move, and his subsequent premature trunk rotation projected his arm outward toward the 3rd base dugout instead of in what Dr. Mike Marshall called the “driveline” with his arm path going directly toward the hitter.
The centrifugal force created by the out and around arm action had to be eccentrically resisted by his biceps. (This alone can lead to biceps pain, biceps hypertrophy from the increased load could compress the musculocutaneous nerve, and micro tears in the biceps could produce bleeding that would result in scarring that could tether the musculocutaneous nerve).
After launching the ball early (even with his his head), his tight hip internal rotation precluded him from rotating around his front hip, thus producing a linear finish in which his shoulder never internally rotated and his forearm did not roll into passive pronation (thumb down).
This move had to also be eccentrically resisted by his biceps, which could also be a contributor to the pain and microtrauma described above.
Interestingly, his work in physical therapy had produce excellent passive internal rotation of his shoulder, but he still exhibited a linear deceleration pattern in his shoulder. This could be attributable to the lack of internal rotation in both hips, but upon further investigation, he revealed that he had done a lot of towel drills early in his pitching development. This would explain the engrained liner motor pattern lack of end range motor control even though he had adequate passive motion.
With all this data in hand, my Director of Player Development, Josh Wagner and I went to work on systematically eliminating every possible contributor to his pain.
We found that he could throw in the DurathroTM Training Sock, a 1 pound Indian Club, and a 2 pound weighted ball without pain. We used those instruments and a TBR connection ball in position 2 to perform a blend of 10 different corrective throwing drills, all of which he was able to complete without pain.
Josh took him through his corrective mobility/stability exercises, while I retired to the office to write a specific 30-day return to throwing plan that gradually weaned him form the use of the corrective instruments and back to full throwing.
Our SCC, Lisa Church, PTA jumped in for some soft tissue work on his pecs and a dose of ScaptivationTM. When the session was complete (about 4 hours), we met back in the office to wrap it all up and to review the written plan of attack he would execute at home for the next 30 days.
The smile on his face was priceless as he marveled, “I can’t believe I finally threw without pain!”
This time Mom couldn’t hold back the tears.
We hugged and I said, “We got this. You’re going to get better and you’re going to pitch in college someday.”
As they left, I turned to Josh and Lisa and said, “Guys… THAT is why we exist. THAT is who we are… THAT is what we do.”
We all shared a group hug and got back to work.
If you’re having arm pain, there is only one place for you to be. Call us at 866-STRIKE3 (866-787-4533) and schedule a Precision Strike One Day Evaluation and Training Session.
We’ll help you solve your pain and get you back to pursuing your dreams in the game you love.
See you at The Ranch
Randy Sullivan, MPT
CEO, Florida Baseball Ranch