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Dr. Andrews and Dr. Fleisig Do Not Understand Why Baseball Pitchers Rupture their Ulnar Collateral Ligaments.1075. On October 05, 2004, Dr. Fleisig published an article that he titled: Biomechanics of Elbow Injuries During Throwing (Pathomechanics). In this article, he explained what he believes causes baseball pitchers to ruptured their Ulnar Collateral Ligaments. I disagree with what he says causes the Ulnar Collateral Ligament to rupture. To find that article, readers should: 01. Click on: American Sports Medicine Institute 02. In the Google Search box for asmi.org, type in: Pathomechanics of elbow injuries 03. Click on: Pathomechanics of elbow injuries -------------------------------------------------- Pathomechanics Biomechanics of Elbow Injuries During Throwing By Dr. Glenn Fleisig Elbow injuries in pitchers can be divided into three types, based upon their location within the joint. All three types of elbow injuries are related to the large rotational force - called "torque" - needed to slow down the cocking of the arm and accelerate the forearm, hand, and ball forward. Elbow torque is greatest when the arm is in its maximum cocked position. Medial Elbow Injuries – The Ulnar Collateral Ligament From the cocked position, the ulnar collateral ligament (UCL) pulls the forearm forward with the rotating upper arm. The tremendous tension produced in the relatively small UCL is close to its limit. When improper mechanics are used or arm muscles become fatigued, the load placed on the UCL may be increased to more than it can withstand, causing small "micro"-tears in the UCL. Microtears in muscles or ligaments can heal when given enough recovery time. In fact, microtears during exercise followed by healing is how muscles become bigger and stronger. However, when a pitcher continues to tear his UCL without allowing enough time for it to heal, the microtears add up to be one large tear in the ligament. Pitchers with UCL injuries often describe feeling or hearing a "pop" in the elbow on one particular pitch. These types of stories lead many people to believe that a pitcher blows out his UCL on one bad pitch – such as the first pitch on a cold day or a poorly thrown breaking pitch. Really, this is usually not the case. Quite frequently the one bad pitch was really just "the straw that broke the camel’s back" and was the final microtear that led a series of microtears to become a large tear. Lateral Elbow Injuries At the same time the medial elbow is under tension, the lateral side of the elbow is compressed. The compression between the forearm’s bone (the radius) and the upper arm’s bone (the humerus) helps the forearm stop cocking back and start rotating forward. This large crushing force on tiny bone surfaces sometimes results in small bone chips breaking off. These bone chips float in the elbow joint and may result in pain, loss of elbow motion, and diminished pitching performance. Posterior Elbow Injuries – "Valgus Extension Overload" From the arm-cocked position, the arm rapidly rotates forward at the shoulder and straightens out at the elbow. The elbow straightens out so fast that it takes less than a tenth of a second (0.1 sec) to go from the 90-degree bent position to the nearly straight position at ball release. The combination of this rapid elbow extension and the large torque generated to rotate the arm forward can cause a grinding injury in the posterior-medial elbow (the "funny bone" area of the elbow). Small bone chips can break off and float in the elbow joint, which may result in pain, loss of motion, and diminished pitching performance. -------------------------------------------------- My Comments: In this article, Dr. Fleisig clearly claims that when baseball pitchers inwardly rotate their pitching upper arm at very high velocities, they tear their Ulnar Collateral Ligament. I wish that I knew how to put this article, photographs and all, on my website. The title of this article is 'Pathomechanics.' Remember 'Pathomechanics." Remember the Red Sox rehabilitation coordinator Mike Reinold? He is the guy that the Boston Red Sox hired from Dr. Andrews rehabilitation team to eliminate pitching injuries. In a September 2008 article about Dr. James Andrew on Fastcompany.com, writer Chuck Salter wrote the following: "When Jonathan Papelbon, the virtually unhittable closer for the Boston Red Sox, hurls a baseball at nearly 100 mph, his right arm becomes a fantastic and ferocious blur, rotating at about 7,500 degrees per second. If it were to keep going, spinning like a pinwheel, his limb would complete nearly 21 revolutions in the time it takes to say "Jonathan Papelbon." The 'rotating at 7,500 degrees per second' to which he referred is inward rotation of the pitching upper arm. Remember in his misguided response to my criticism of the questions that he used for his biomechanical analysis of my four baseball pitchers where Dr. Fleisig said that I needed to worry about the excessive inward rotation of their pitching upper arms that my baseball pitchers achieved? He wrongly believes that baseball pitchers rupture their Ulnar Collateral Ligaments when they inwardly rotate their pitching upper arm. Back to the Salter article: "Adhering to the baseball adage that pitching wins games, the Red Sox have spent more than $43 million this season on Papelbon and other enviable arms. The team has been keenly aware of another adage as well: Pitching is a game of attrition. Over the grueling 162-game season, bending the arm way back and accelerating it forward, the fastest recorded human motion, is hard on shoulders and elbows. In fact, pitchers make up half of major-league rosters yet account for 7 in 10 injuries. To protect and maximize its investments, Boston has adopted a startlingly different approach. It originated off the field, 1,176 miles from Fenway Park, in the operating room of Dr. James Andrews, a groundbreaking orthopedic surgeon in Alabama. The idea is this: Prevent injuries by predicting them. The program, which Boston guards closely as a competitive advantage, is built upon a multitude of biomechanical breakthroughs from Andrews's practice. Red Sox pitching coach John Farrell, rehabilitation coordinator Mike Reinold, and their staff apply science to a realm long defined by hunches. "Instead of saying, 'He looks tight' or 'He looks loose,' we measure everything," says Reinold, who joined Boston in 2007 after eight years with Andrews. He and Farrell prescribe each pitcher a customized routine based on quantifying strength, fatigue, and flexibility; Papelbon and starter Josh Beckett focus on different muscles, because their bodies and pitching mechanics differ." Remember the last sentence. They prescribed a personalized training routine for Josh Beckett based on strength, fatigue and flexibility. Again, back to the Salter article. "The Red Sox, who also send young pitchers to the lab, are further along. Reinold, the team's rehab specialist and a Wilk protégé, is applying what he learned in Birmingham to Boston's pitching staff, creating a new kind of insurance. Through "pathomechanics," Reinold studies Papelbon and his teammates' deliveries to determine the points of maximum force, which are most vulnerable to injury. That's where each pitcher focuses on building strength and stamina. The data also allow the coaches to deploy pitchers in a game partly based on test scores, not guesswork. To determine the points of maximum force that are most vulnerabel to injury, Reinold thoroughly studied Josh Beckett's baseball pitching motion. Again, again, back to the Salter article. "The methodology is still evolving, and the Sox are one of the few to embrace the high-tech analysis, so they won't divulge too much. Suffice it to say, they believe they have an advantage on their hands. Literally. The proof, Reinold says, is "the large ring I'm wearing on my finger." The inscription: 2007 World Series Champions." Are they now wearing a ring that says, because Josh Beckett pitched with injury, we did not win the 2008 American League championship? In article on the ASMI website, Dr. Fleisig discusses what causes injuries to the pitching elbow. He is wrong about everything that he says. Perhaps that explains why they could not help Mr. Beckett with his pitching elbow injury. Dr. Fleisig labels the first photograph as showing the 'Maximum Arm-Cocked Position.' Actually, the photograph shows the moment in the acceleration phase immediately before the powerful inward rotation of the pitching upper arm. The photograph shows a 'traditional' baseball pitcher after his glove foot has landed, where his pitching upper arm is perpendicular to the driveline to home plate and the pitching forearm lies horizontally behind the pitching elbow. Dr. Fleisig claims that rotational force (torque) causes the injuries to the medial, posterior and lateral sides of the pitching elbow when 'traditional' baseball pitchers accelerate their pitching forearm, hand and baseball forward. In his specific discussion about injuries to the medial side of the pitching elbow, Dr. Fleisig says that, when the pitching upper arm rotates (inwardly), the Ulnar Collateral Ligament (UCL) pulls the pitching forearm forward. WRONG! The Ulnar Collateral Ligament that holds the medial side of the Humerus bone of the pitching upper arm to the medial side of the Ulna bone of the pitching forearm. Ligaments have no contractile property. Ligaments do not apply any force. Therefore, ligaments do not pull anything. Ligaments simply hold two bones together. That is all that ligaments do. Muscles contract. Therefore, muscles pull the pitching forearm forward. To be precise, the muscles that arise from the medial epicondyle of the Humerus bone of the pitching upper arm pull the pitching forearm forward. To be precise, the Pronator Teres, Flexor Carpi Radialis, Palmaris Longus, Flexor Carpi Ulnaris and a portion of the Flexor Digitorum Superficialis muscles pull the pitching forearm forward. That Dr. Fleisig does not understand muscle action explains why he does not understand what causes pitching injuries. The numbers that his questionable biomechanical analyses do not explain muscle action. Without understanding what muscles do what when, it is impossible to understand the causes of pitching injuries. In this case, the muscles of the medial epicondyle hold the medial side of the Humerus bone to the medial side of the Ulna bone. In fact, when baseball pitchers take the baseball out of their glove with the palm of their pitching hand under that baseball and pendulum swing the pitching arm to driveline height in one smooth, continuous movement to arrive when their glove foot lands, it is possible for baseball pitchers with ruptured Ulnar Collateral Ligaments to pitch very powerfully. I have even heard of a major league baseball pitcher who was born without an Ulnar Collateral Ligament. However, I have not verified the information. But, if the information is true, then that baseball pitcher is the best evidence that the muscles of the medial epicondyle protect the Ulnar Collateral Ligament from injury, even microscopic injury. I believe that his name is D. A. Dickey. Check him out and let me know. Now that we know that 'traditional' baseball pitchers do not microscopically tear their Ulnar Collateral Ligament when they powerfully inward rotate their pitching upper arm during the acceleration phase, let me explain when they do microscopically tear the Ulnar Collateral Ligament with every maximum intensity pitch that they throw. I call the moment when 'traditional' baseball pitchers microscopically tear their Ulnar Collateral Ligament, 'Reverse Pitching Forearm Bounce.' In Q14 of the report that I wrote, 'Does the American Sports Medicine Institute Increase or Decrease Pitching Injuries,' I explain in great detail what causes 'traditional' baseball pitchers to rupture their Ulnar Collateral Ligament. It is too bad that Dr. Fleisig refuses to read this report. If he does, then maybe, rather than perpetuating pitching injuries, he will do something that will help me eliminate pitching injuries. ------------------------------------------------- As a sub-classification ‘Throwing Shoulder External Rotation’ under the main classification ‘Throwing Arm Position,’ the ASMI protocol asks: Q14: Is your forearm rotated to a semi-cocked position? To determine ‘throwing shoulder external rotation,’ ASMI measures the angle between the pitching forearm line and the forward direction of the trunk. The report says that, when their glove foot lands, the degrees of outward rotation of the pitching upper arm of their Elite group ranged between 24 and 79 degrees to the forward direction of their trunk. Therefore, ASMI recommends that, when their glove foot lands, all baseball pitchers have outwardly rotated their pitching upper arm between 24 and 79 degrees to the forward direction of their trunk. ------------------------------------------------ My Comments: To understand throwing shoulder external rotation (outward rotation), we have to understand the position from which the pitching upper arm should be maximally outwardly rotated. 01. In the proper maximum outward rotation position for baseball pitching, baseball pitchers should have their pitching upper arm vertically beside their head, their pitching forearm horizontally behind their pitching elbow and their pitching forearm pointing straight toward second base. 02. In the maximum inward rotation position for baseball pitching, baseball pitchers should have their entire pitching arm pointed at home plate with their pitching hand aimed into the strike zone. ‘Traditional’ baseball pitchers take the baseball out of their glove with the palm of their pitching hand on top of the baseball. Therefore, when they take their pitching arm backwards, they raise their pitching upper arm to shoulder height before they raise their pitching forearm, wrist, hand, fingers and baseball to shoulder height. With their pitching upper arm stuck at shoulder height and their pitching forearm pointing forward and downward, ‘traditional’ baseball pitchers have to raise their pitching forearm, wrist, hand, fingers and baseball straight upward. I call this action, ‘Late Pitching Forearm Turnover.’ At some moment during their ‘Late Pitching Forearm Turnover,’ their glove foot lands. ASMI reports that, when the glove foot of their Elite group lands, they have their pitching forearm between 24 and 79 degrees above the forward direction of their trunk. Therefore, before their glove foot lands, not one of the Elite group raised their pitching forearm to vertical. The maximum functional inward rotation range of motion starts with the pitching forearm, wrist, hand, fingers and baseball horizontally extended the full length of their pitching forearm behind their pitching elbow. Therefore, after their glove foot lands, those members of ASMI’s Elite group have outwardly rotated their pitching forearm to only 24 above horizontal. Therefore, to get their pitching forearm, wrist, hand, fingers and baseball to vertical, they still have to outwardly rotate the Humerus bone of their pitching upper arm 66 more degrees. Then, to get their pitching forearm, wrist, hand, fingers and baseball to horizontally behind their pitching elbow, they have to outwardly rotate their pitching upper arm 90 more degrees. As a result, after their glove foot lands, these Elite baseball pitches have to outwardly rotate their pitching upper arm total of 156 degrees more. However, when their glove foot lands, ‘traditional’ baseball pitchers immediately start to forwardly rotate their shoulders and pitching upper arms. Therefore, ‘traditional’ baseball pitchers very little time to properly reposition their pitching forearm, wrist, hand, fingers and baseball horizontally behind their pitching elbow. During this brief moment in time, ‘traditional’ baseball pitchers have two forces operating on their pitching forearm, wrist, hand, fingers and baseball. 01. To reposition their pitching forearm horizontally behind their pitching elbow, ‘traditional’ baseball pitchers actively outwardly rotate their pitching upper arm. 02. To accelerate their pitching hand toward home plate, ‘traditional’ baseball pitchers also powerfully forwardly rotate their shoulders and pitching upper arm. Therefore, while their pitching forearm, wrist, hand, fingers and baseball are moving upward and backward, their pitching upper arm is explosively moving forward. As a result, the force of the forward movement of their pitching upper arm forward accelerates the outward rotation of the pitching upper arm moving upward and backward. At the end of the outward rotation of their pitching upper arm, their pitching upper arm has to stop moving backward and downward and start moving forward. I call this moment, ‘Reverse Pitching Forearm Bounce.’ To actively outwardly rotate their pitching upper arm, ‘traditional’ baseball pitchers use their Teres Minor, Infraspinatus and Supraspinatus muscles. To move their pitching forearm with their pitching upper arm, ‘traditional’ baseball pitchers use the Brachioradialis muscle. As a result, when their pitching forearm, wrist, hand, fingers and baseball suddenly stop moving backward and downward, their Ulnar Collateral Ligament receives the full force of the ‘Reverse Pitching Forearm Bounce.’ Unfortunately, during ‘Late Pitching Forearm Turnover,’ ‘traditional’ baseball pitchers leave their Ulnar Collateral Ligament unprotected by their Pronator Teres muscle. As a result, ‘traditional’ baseball pitchers microscopically tear the connective tissue fibers of their Ulnar Collateral Ligament. When ‘traditional’ baseball pitchers tear sufficient numbers of the connective tissue fibers in their Ulnar Collateral Ligament, they rupture their Ulnar Collateral Ligament. Therefore, it is critical that the biomechanical analysis of the baseball pitching motion includes calculating the force of the ‘Reverse Pitching Forearm Bounce’ on the unprotected Ulnar Collateral Ligament. Unfortunately, the biomechanical analysis protocol that the American Sports Medicine Institute uses does not calculate this critical value. Force equals mass multiplied by acceleration. Therefore, to calculate the force of ‘Reverse Pitching Forearm Bounce,’ the biomechanical analysis protocol needs to determine the mass of the pitching forearm and the angle of the pitching forearm line to the pitching upper arm line, the final outward rotation velocity and the initial outward rotation velocity of the pitching arm when the glove foot lands divided by the time period for the changes in position to take place. Do you remember the example from their Elite group, where some of the Elite group have to almost instantaneously outwardly rotate their pitching upper arm an additional 156 degrees and they have to do this almost instantaneously? During this instantaneous 156 degrees of outward rotation, the Ulnar Collateral Ligament is the only tissue holding the Ulna bone to the Humerus bone. Therefore, with every competitive pitch that ‘traditional’ baseball pitchers throw, they microscopically tear the connective tissue fibers of their Ulnar Collateral Ligament. I have no idea how many connective tissue fibers that these Elite baseball pitchers microscopically tear with every competitive pitch that they throw. I also have no idea how much time their body needs to repair these tears. I also have no idea how many connective tissue fibers need to tear before they rupture their Ulnar Collateral Ligament. However, I do know that eventually all ‘traditional’ baseball pitchers with ‘Reverse Pitching Forearm Bounce’ will rupture their Ulnar Collateral Ligament. Therefore, when ASMI recommends that, when their glove foot lands, all baseball pitchers have outwardly rotated their pitching upper arm between 24 and 79 degrees above horizontal, ASMI injures the Ulnar Collateral Ligament. I teach my baseball pitchers to take the baseball out of their glove with the palm of their pitching hand under the baseball. I teach my baseball pitchers to smoothly and continuously pendulum swing their pitching arm downward, backward and upward to driveline height to arrive at the same time that their glove foot lands. As a result, when their glove foot lands, my baseball pitchers are moving the baseball straight forward toward home plate. Because, when their glove foot lands, my baseball pitchers are moving the baseball straight forward toward home plate, they are contracting the muscles that inwardly rotate their pitching upper arm. To move with their pitching upper arm, my baseball pitchers are also contracting the five critical baseball pitching muscles that attach to the medial epicondyle of the Humerus bone of their pitching upper arm. The Ulnar Collateral Ligament holds the medial epicondyle of the Humerus bone of the pitching upper arm to the coronoid process of the Ulna bone of the pitching forearm. Therefore, when these five critical baseball pitching muscles that arise from the medial epicondyle contract, they protect their Ulnar Collateral Ligament. In fact, when they contract these five muscles, even baseball pitchers without Ulnar Collateral Ligaments can pitch. ------------------------------------------------ In his discussion of the injuries to the lateral side of the pitching elbow, Dr. Fleisig claims that compression between the head of the Radius bone of the pitching forearm and the Capitular end of the Humerus bone of the pitching upper arm causes 'small bone chips' to break off. While that is an interesting theory, he failed to produce any scientific evidence to support his theory. However, with regard to injuries to the head of the Radius bone, the research on youth baseball pitchers in San Bernadino, CA in the early 1960s might provide some information. To learn what Dr. Joel Adams found, I recommend that you open the X-rays of Youth Baseball Pitchers section of my Baseball Pitching Instructional Video file. In it, I show a surgical photograph the grossly enlarged head of the Radius bone of a youth baseball pitcher that Dr. Adams had to remove. The head of this Radius bone did not enlarge because the Capitular end of the Humerus bone of the pitching upper arm compressed against the head of Radius bone of the pitching forearm. Instead, the head of the Radius bone enlarged because of repeated collisions between the head of the Radius bone and the Capitular end of the Humerus bone. In youth baseball pitchers, bones are still growing. Therefore, when collision forces impact on them, to withstand the insults, the head of the Radius bone to grossly enlarged. I believe that, rather than grinding together, collisions between the head of Radius bone and the Capitulum occur after baseball pitchers release their pitches and the head of the Radius bone rebounds back into the Capitulum. If Dr. Fleisig provided surgical photographs that show pieces of the hyaline cartilage that covers the head of the Radius bone and the Capitular end of the Humerus bone are missing, then he would at least have scientific evidence that these two bones contributed to the 'bone chips' floating in the elbow joint of the pitching arm. However, I believe that the collision of the Olecranon Process with its Olecranon Fossa causes pieces of hyaline cartilage to break off and float in the elbow joint of the pitching elbow. Nevertheless, both the lateral and posterior compartments of the pitching elbow could contribute to these 'bone chips.' In Dr. Fleisig's discussion of injuries to the posterior elbow, Dr. Fleisig says that the 'funny bone' area of the pitching elbow grinds with something to produce 'bone chips.' The 'funny bone' is not a bone, it is the Ulnar Nerve. The Ulnar Nerve travels through a groove behind the medial epicondyle of the Humerus bone of the pitching upper arm. It does not come into contact with anything. Therefore, it does not grind against anything. However, when 'traditional' baseball pitchers throw their cut fastballs, sliders, slurves and curves, they are susceptible to slamming the Olecranon Process of their pitching elbow into the Olecranon Fossa of their pitching elbow. These repeated collisions cause the hyaline cartilage of the Olecranon Fossa to calcify. As a result, 'traditional' baseball pitchers lose the ability to completely straighten their pitching arm. The more that I read what Dr. Fleisig believes, the more ignorant and dangerous I believe that he is. Certainly, he is not a part of the solution to eliminating pitching injuries. As such, we have to group him with all the others we need to ignore and eliminate from the discussion. -------------------------------------------------- In the spirit of transparency and collegial constructive criticism, I immediately sent a copy of the above material to Dr. Fleisig. To his credit, I received the following response. -------------------------------------------------- Mike, Thank you for reaching out to me again. I am glad that we tried to cooperate this year. However, after collecting and analyzing some data together, I think that we have reached different conclusions about the effectiveness of your pitching technique versus traditional technique. I wish you a Happy Thanksgiving and the best of luck in the future. Glenn -------------------------------------------------- To which I responded. Dear Glenn, Obviously, we disagree on the effectiveness of how I teach my baseball pitchers to apply force to their pitches. However, I am not interested in whether, with regard to force application techniques, you agree with my baseball pitching motion. I am only interested in eliminating pitching injuries. I believe that we can develop a biomechanical analysis protocol that will show baseball pitchers how to eliminate pitching injuries. To do this, we have to identify the injurious flaws in the 'traditional' baseball pitching motion that causes pitching injuries. The first injurious flaw on which we must agree is what causes baseball pitchers to rupture their Ulnar Collateral Ligament. At this point, we could not disagree more. You believe that baseball pitchers rupture their Ulnar Collateral Ligament when they inwardly rotate their pitching upper arm during the moment where they are starting their acceleration phase before they have finished moving their pitching arm to driveline height. I believe that baseball pitchers rupture their Ulnar Collateral Ligament when they outwardly rotate their pitching upper arm during the moment where they are starting their acceleration phase before they have finished moving their pitching arm to driveline height. I believe that, with face to face meetings, we can come to agreements on the cause of this pitching injury and all the rest. At that time, we can design a biomechanical analysis protocol that determines how susceptible baseball pitcher are to injuries and what they need to do to prevent them. Sincerely, Dr. Mike Marshall The next day, I received the following email from Dr. Fleisig. -------------------------------------------------- Mike, I think we actually might be in AGREEMENT about UCL injuries. Regardless of the pitching technique, a pitcher "outwardly rotate" (or "externally rotates") his arm into a cocked position and then "inwardly rotates" (or "internally rotates") or accelerates. I think you and I agree that the greatest tension in the UCL is when the arm is cocked back at the end of the outward rotation and the beginning of the internal rotation. I think that we both gree that UCL ruptures are likely to occur near this time. Glenn -------------------------------------------------- To which I responded: -------------------------------------------------- Dear Glenn, I agree with the first part of your next to the last sentence. "I think you and I agree that the greatest tension in the UCL is when the arm is cocked back at the end of the outward rotation..." However, because the muscles that attach tot he medial epicondyle are contracting at the "beginning of the internal rotation," they prevent any damage to the Ulnar Collateral Ligament. This is why I teach my baseball pitchers to inwardly rotate their pitching upper arms as powerfully as they can. Unfortunately, even with superior inward rotation numbers, because they do not have the high fast-twitch muscle fiber percentages, they cannot achieve superior release velocities. Nevertheless, they do get closer to their genetic maximum release velocity. Sincerely, Dr. Mike Marshall ----------------------------------------------------------------------------------------------- |
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