There are those who didn’t require a crystal ball to predict that Strasburg would have Tommy John surgery lurking in the shadows of his future.  With youth on his side though, most probably felt he’d buy more time.  Strasburg’s unorthodox delivery coupled with the extraordinary pace of his pitches is thought by many to have made his elbow more vulnerable.  Let’s not forget that Strasburg also missed three weeks of starts earlier this summer with shoulder inflammation.  The kid is breaking down.  A piece by Bill Conlin (posted to Philly.com Sports on August 30^th) details issues with Strasburg’s delivery and the possible repercussions that we may be witnessing.  If you are interested in more on this topic, take a look.

What exactly is the UCL & what is Tommy John Surgery?

Ligaments attach one bone to another and provide much of the stability at a joint.  A partial or complete tear of the ulnar collateral ligament (UCL) of the elbow results in the need for the Tommy John procedure in order to reconstruct this medial ligament. A higher incidence of severe elbow injuries in overhead athletes is partly due to players’ increased size and strength as well as the tremendous forces generated, particularly when pitching.  More frequent use of the slider and split-finger fastball is thought to be another reason.  Advances in medicine have led to an increase in Tommy John surgeries due to better reporting of injuries, an improvement in the ability to diagnose the problem and greater expertise in performing the procedure.

There is a great deal of stress on the inner aspect of the elbow during the throwing motion. A very high velocity (speed) is required to extend (straighten) the elbow, and maximum stress on the inner elbow ligament occurs just after the cocking phase of pitching, when the arm just begins to descend.  In fact, at a 90-degree angle, the ulnar collateral ligament provides at least 54% of the stability of the elbow joint (figures from 54% up to 70% have been reported). Acceleration during the throwing motion also places significant stress on the ligament, while compression forces and a high level of muscular activity are also present.  You can see why the ulnar collateral is so important and why it is so often damaged.

Normal range of motion for a pitcher’s shoulder and elbow is different than that for an average person or even an average player.  Likewise, pitchers are much more developed on their dominant side, enabling them to exert with greater force on that side.  A UCL tear results in pain and a loss of throwing speed.  The instability caused by a tear such as Strasburg’s may also result in a stretching (traction) of the ulnar nerve, causing nerve related symptoms.  The ulnar nerve is the one you provoke when you hit your “funny bone”.

Dr. Frank Jobe pioneered the Tommy John Procedure in 1974.  Studies currently show an extremely high success rate, now at about 90%, while the non-surgical success rate of treating a partial tear is about 45-50%.  Various studies show that major leaguers generally return to action between 9.8 and 11.2 months post-operatively, though their rehab begins to include a low-level throwing program at about the four-month mark.  Even after returning to play however, a pitcher generally is not thought to regain full form for up to two years.  As a result, many reports list the return to play in the 12-18 month range.

Strasburg’s tender age should help with respect to his ability to heal and return to form.  However, it remains to be seen whether his coaches and doctors will encourage him to modify that form in order to protect himself from further injury.

 Types of Stretching

• Static (passive)
• Active Isolation (static)
• Active (dynamic)
• Contract – Relax (PNF)
• Strain – Counterstrain – Positional Release

 Static Stretching (Passive)
Static stretching is the most traditional way to stretch and remains a viable and popular option.  A muscle is put in a position of stretch over its entire length and held in its lengthened position (hence the name static) for a period of 30 seconds.  Research has demonstrated that the best results are achieved by repeating a static stretch four times.   Static stretches can be performed independently or with a partner.  There are a variety of positions in which muscles can be put on stretch, and some are more desirable than others.  For example, the hamstrings (in the back of the thigh) connect to the pelvis (at the ischial tuberosity – often referred to as the sit bone) and to the lower leg (just below both sides of the back of the knee).  The actions of the hamstring (when it contracts) are to extend the hip and flex (bend) the knee.  Therefore, to stretch the hamstring over its entire length, one must do the opposite – flex the hip and extend (straighten) the knee.  A good way to do this is to lie on your back and use your hands to draw your leg toward your chest, keeping the knee as straight as possible.  After you’ve taken up all the slack in the muscle and feel a stretch, hold the position for 30 seconds.  You will likely stretch a little further with each subsequent repetition.  

Not every passive stretch is a good one however.  Hamstring stretching positions that cause you to round your back as you lean forward go beyond the slack in the hamstring and stress the low back.  These are not advisable unless the forward bending comes exclusively from the hips and your back remains in a neutral position.  That also rules out hoisting your foot onto a very high surface and bending forward.  Try elevating your foot on a low stool instead (or sitting on the edge of a chair with your leg stretched in front of you) and bend forward from the hip with a straight back.  The result?  Less effort, better stretch, reduced potential for injury.

Studies have shown that a short-term effect of static stretching is the diminished force output of the stretched muscle.  This is one reason that some now eschew it as a warm-up prior to strenuous activity. 

Active Isolation Stretching – Static
Active Isolation stretching is exactly what its name implies – a muscle is stretched by actively contracting its opposing muscle.  Studies have demonstrated that the result of contracting one muscle (termed the agonist) is the relaxation of that muscle’s opposite, or antagonist.  Let’s use the hamstrings as an example once again.  Contracting your quadriceps (the muscle group in the front of the thigh whose action is to straighten your knee and assist in flexing your hip), will result in the relaxation of your hamstrings (in the back of your thigh).  Proponents of Active Isolation recommend holding the end position for only a few seconds.  Many athletes endorse this type of stretching and it has been shown to be very effective.

Active Stretching – Dynamic
Active Dynamic Stretching entails movements that put muscles on stretch.  Because they involve movement, these stretches are said to increase muscle temperature and prepare muscles for activity.  Dynamic stretches are also said to put joints through their full ranges of motion, though that is not likely because a joint can only be moved to its end range when the muscles crossing that joint are on slack (relaxed) rather than on stretch.   Examples of active/dynamic stretches include motions such as a lunge, which puts the hip flexors (in front of the hip/groin) on stretch, and the Inch Worm in which one creeps forward while maintaining a Downward Facing Dog yoga position (on the hands and feet with the butt high), which stretches the hamstrings.

If you like Active Dynamic Stretches I would not rely on them as the sole means of increasing your flexibility.  Because muscles are stretched in combination – for instance the calf along with the hamstring in the Inch Worm exercise – if one of those muscles is particularly tight, it will limit your ability to stretch the other.  Also, as with ballistic stretching, care must be taken to avoid setting off a stretch reflex due to the quick stretch that movement may elicit.

Contract – Relax (PNF)
PNF stands for Proprioceptive Neuromuscular Facilitation.  This is a broad classification that includes both strengthening and flexibility exercises.  PNF strengthening entails a variety of effective exercises that involve multiple muscle groups working in combination in functional cross-planar motions (working in diagonal patterns rather than strengthening individual muscles in isolation). 

PNF stretching is better known as Contract – Relax (C-R) and it has long been employed by physical therapists and athletic trainers to assist clients in developing increased flexibility.  Contract – Relax has both active and static components.  This type of stretching is based on research demonstrating that tension in a muscle is relaxed in the aftermath of contracting that same muscle.  This is quite different than the principle already described for active isolation stretching which shows that a muscle also relaxes with the contraction of its opposing muscle. 

C-R is most easily performed with a partner.  Using the hamstrings to illustrate once again: the hamstrings are held in a position of mild stretch (with the knee extended – straight – and the hip maintained in flexion) and are asked to contract gently.  This contraction is sub-maximal (only a mild force is exerted) and it is isometric (no movement is allowed).  This isometric hamstring contraction (to extend the hip) is held for several seconds, while the position of end range hip flexion with the knee straight is maintained with the aid of a partner.  Following the contraction there is a relax phase, during which the partner attempts to move the hip into greater flexion, thereby further stretching the hamstring.  The sequence is: contract (actively) – hold the contraction – relax/stretch (passively).  Several repetitions are performed with the ending position of each rep becoming the starting position of the next.  As a result, significant gains can be seen.

Strain – Counterstrain (Positional Release)
Another staple in physical therapy clinics, Strain – Counterstrain (S-CS) is a technique to release a muscle rather than stretch it, but the end result is more flexibility.  By passively maintaining a muscle in its fully contracted position for 90 seconds it has been shown that the muscle will relax, subsequently allowing it to stretch further.  Though often done with the assistance of a partner or health professional, Strain – Counterstrain positions can be maintained independently (as with holding the knees to the chest for the hip flexors) or with the help of pillows (as when releasing the hip abductors (outer thigh) in side-lying by elevating the upper thigh on pillows).  You may want to follow Strain – Counterstrain positioning with static stretching to capitalize on newly gained flexibility.

Conclusion
Just as we work to achieve balance in our lives, we also benefit from working toward a balance within our bodies.   Having normal flexibility is an important component of this balanced ideal and one that will help to prevent the stresses and strains that result in overuse injuries.