It’s not uncommon for a Baseball or Softball player to have medial elbow tightness due to soft tissue restrictions limiting the amount of elbow extension they have causing pain. The athlete may even feel a “locking out” sensation in the elbow joint when performing normal daily activities. What should an athlete do if this happens? How does their training protocol change as there are lots of factors that is actually causing this to happen.
Take a look at the image below. Do you think this athlete is a right hand thrower or left hand thrower? I’ll give you a hint. He’s not a righty! Again, it’s not uncommon to see this in throwers. As they get older and throw more, it’s just an adaptation to the bone structure and muscle tissue. Does this mean there’s an injury directly to the elbow? Not necessarily. Let’s dig deeper.
There’s a number of elements that can contribute to this tightness and limitation; Yes, throwing for 10 plus years will do this to an athlete, but there are also some other elements that can contribute to the tightness, elbow extension limitation and pain; pectoralis tightness, bicep and brachioradialis tightness, rounded shoulders and/or inefficient throwing mechanics.
I recently spoke to Paul Lee, Owner & Director of Peak Fitness Workouts in Worcester, MA about the tightness and limitation problem. Paul is a PT and has worked at some of the best outpatient/sports rehabilitation facilities in central Massachusetts. These are his thoughts.
“Typically when I hear about lack of extension in the elbow, my first thought is usually tightness of the bicep and brachioradialis causing the limitation. However, when they are associated with decreased grip strength, pain with supination and there are postural deficiencies coming from above the joint (forward and rounded shoulders) we have to look at the biomechanics of the throwing motion and how it relates to the shoulder and elbow complexes.”
What’s the first thing that has to happen?
Paul recently performed an evaluation on a college infielder who had limited elbow extension, decreased grip strength and pain with elbow flexion, extension, pronation and supination. This was his approach.
“First we look at what happens with poor posture in the throwing motion. Forward shoulders would limit the external rotation and horizontal abduction needed to get the arm into the proper loaded position and the kyphosis that comes with the rounded shoulders would limit the thoracic extension and rotation needed in a good throwing pattern.”
“In order to get to these positions, the body would stress the next joint down (in this case, the elbow) in order to get more motion. Add the tremendous forces traveling down the arm in a high level throwing athlete and you can see how the elbow joint can become irritated and inflamed which over a prolonged period of time, would cause decreased range of motion both in the soft tissue and the joint.”
Strength Measurements
It is important to get strength values of the Rotator Cuff and Scap Stabilizing Musculature. If there’s a weakness somewhere, you will be able to see it or feel it, depending on the test performed. The idea is to try and recreate pain or weakness to better understand what’s happening. Also, grip strength and finger strength is an important factor in determining if it’s muscular or nerve related.
Active Movements
Have the athlete actively move their shoulder, elbow or wrist in specific positions. This will show possible limitations which will give you a better idea of what is happening.
The particular athlete Paul recently performed an eval on had a “hard end feel” limiting his elbow ROM. Knowing that the head of the radius retracts superiorly with supination he looked at mobilizing the radial head with and without movement.
What About Addressing Soft Tissue Restrictions?
We had to address the soft tissue restrictions that would come with the loss of ROM at the elbow joint. Doing myofascial massage and some ART to the extensor group released the radial nerve entrapment that was causing the decreased grip strength. When addressing the bicep and brachioradialis with the same techniques, the athlete gained noticeable extension in the elbow and no pain with supination.
Next, we moved up into the shoulder and T-spine to look at what muscles were tight and possibly restricting proper movement. There were definitely restrictions at pec major/minor insertions as well as at latissimus dorsi and serratus anterior which was verified by a simple prone scap squeeze test and checking the ROM in flexion with just GH joint (less than 120 degrees) and then allowing the scapula to move (approx. 160 degrees).
Prior to any manual work, the athlete could not pull the head of the humerus past neutral by retracting and depressing the scapula due to increase tightness through the anterior shoulder from the pec inserts.
After several minutes of pin and move and myofascial release at the pec insert and lateral scap border, we retested and the athlete was then able to retract the head of the humerus past neutral and achieve retraction/depression through the scapula. He was also able to gain close to 120 of GH flexion and close to full ROM with scapula movement allowed.
The athlete was able to throw without pain and felt he had better ROM after a 15 minute treatment of the above techniques was received. In order to continue to improve, these soft tissue treatments would have to continue to be implemented.
Chiropractic intervention to help increase T-spine mobility along with scap strengthening and posterior rotator cuff strengthening would also help correct the postural issues. Examples of proper strengthening exercises and soft tissue exercises are listed. There will be video of each exercise in a following post.
- Lat Pull down
- Band Rows
- Extensions w/ Bands
- Isometric Extension w/ Body Movement
- 90/90 ER with Bands
- Ts, Ys & Is
- Doorway Pec Stretch & Bicep Stretch
- Foam Roll T-Spine
- Wrist Extensor Stretch (emphasis on Radial Nerve)
- Triceps & Forearm Bar Rolling
- Scalenes Release w/ PiriSphere
- Pec Release w/ Football
- Subscapularis Foam Roll Release
Exercises to minimize or take out completely would be anterior focused exercises such as:
- Bench Press or DB Press
- Pec Fly
- Curls
- Wrist Extensor Curls
These exercises should be limited until the head of the humerus can be held in a neutral position throughout the exercise. As the strength increases, these anterior exercises should be re-implemented with the posterior exercises at a 40/60 ratio anterior to posterior.
Final Thoughts
Training individuals just to train them is one thing. Training individuals with the knowledge of structure/function, injury prevention/pre-habilitation, functional strength movements and energy system protocols, the training now becomes a completely different ball game!
This is where guys like Paul Lee stand out. Paul’s PeakFitnessWorkouts are different from other CrossFit Gyms and Boot Camp facilities because of his knowledge of the human body and his ability to assess an inefficiency in a client and fix it.
This is what he did with the College Baseball Player. He understood the mechanism of injury and knew how to assess it and fix it in a short amount of time. Other Boot Camp or CrossFit gyms may not have access to someone like Paul. This is why his training is invaluable!
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